[Congressional Record Volume 140, Number 67 (Wednesday, May 25, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: May 25, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
            VETERANS HEALTH PROGRAMS IMPROVEMENT ACT OF 1993

  Mr. MITCHELL. Mr. President, I ask unanimous consent that the Senate 
proceed to the immediate consideration of calendar No. 193, S. 1030 
relating to veterans programs.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       A bill (S. 1030) to amend chapter 17 of title 38 United 
     States Code, to improve the Department of Veterans Affairs 
     program of sexual trauma counselling for veterans, and to 
     improve certain Department of Veterans Affairs programs for 
     women veterans.

  The PRESIDING OFFICER. Is there objection to the immediate 
consideration of the bill?
  There being no objection, the Senate proceeded to consider the bill 
which had been reported from the Committee on Veterans' Affairs with an 
amendment to strike all after the enacting clause and inserting in lieu 
thereof the following: which had been reported from the Committee on 
Veterans' Affairs, with an amendment to strike all after the enacting 
clause and inserting in lieu thereof the following:

                                S. 1030

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Veterans 
     Health Programs Improvement Act of 1993''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

                        TITLE I--WOMEN VETERANS

Sec. 101. Department of Veterans Affairs sexual trauma services 
              program.
Sec. 102. Reports relating to determinations of service connection for 
              sexual trauma.
Sec. 103. Coordinators of women's services.
Sec. 104. Women's health services.
Sec. 105. Expansion of research relating to women veterans.
Sec. 106. Mammography quality standards.

                 TITLE II--GENERAL HEALTH CARE SERVICES

Sec. 201. Extension of period of eligibility for medical care for 
              exposure to dioxin or ionizing radiation.
Sec. 202. Authority to provide priority health care to veterans of the 
              Persian Gulf War.
Sec. 203. Programs for furnishing hospice care to veterans.
Sec. 204. Rural health-care clinic program.
Sec. 205. Payment to States of per diem for veterans receiving adult 
              day health care.

                        TITLE III--MISCELLANEOUS

              Subtitle A--Education Debt Reduction Program

Sec. 301. Short title.
Sec. 302. Program of assistance in the payment of education debts 
              incurred by certain Veterans Health Administration 
              employees.

                      Subtitle B--Other Provisions

Sec. 311. Extension of authority of Advisory Committee on Education.
Sec. 312. Extension of authority to maintain regional office in the 
              Philippines.
                        TITLE I--WOMEN VETERANS

     SEC. 101. DEPARTMENT OF VETERANS AFFAIRS SEXUAL TRAUMA 
                   SERVICES PROGRAM.

       (a) Authority To Provide Services for Sexual Trauma.--(1) 
     Subsection (a)(1) of section 1720D of title 38, United States 
     Code is amended--
       (A) by inserting ``(A)'' before ``During the period''; and
       (B) by adding at the end the following:
       ``(B) During the period referred to in subparagraph (A), 
     the Secretary may provide appropriate care and services to a 
     veteran for an injury, illness, or other psychological 
     condition which the Secretary determines to be the result of 
     a physical assault, battery, or harassment referred to in 
     that subparagraph.''.
       (2) Subsection (c)(1) of such section is amended to read as 
     follows:
       ``(1) The Secretary shall give priority to the 
     establishment and operation of the program to provide 
     counseling and care and services under subsection (a). In the 
     case of a veteran eligible for counseling and care and 
     services under subsection (a)(1), the Secretary shall ensure 
     that the veteran is furnished counseling under this section 
     in a way that is coordinated with the furnishing of such care 
     and services under this chapter.''.
       (3) Subsection (d) of such section is amended by inserting 
     ``and care and services'' after ``counseling'' each place it 
     appears.
       (b) Authority To Provide Services by Contract.--Subsection 
     (a)(3) of such section is amended--
       (1) by inserting ``(A)'' before ``In furnishing'';
       (2) in subparagraph (A), as so designated--
       (i) by striking out ``(A)'' and inserting in lieu thereof 
     ``(i)''; and
       (ii) by striking out ``(B)'' and inserting in lieu thereof 
     ``(ii)''; and
       (3) by adding at the end the following:
       ``(B) The Secretary may provide care and services to a 
     veteran under paragraph (1)(B) pursuant to a contract with a 
     qualified non-Department health professional or facility if 
     Department facilities are not capable of furnishing such care 
     and services to that veteran economically because of 
     geographic inaccessibility.''.
       (c) Extension of Authority To Provide Sexual Trauma 
     Services.--Subsection (a) of such section, as amended by 
     subsections (a) and (b) of this section, is further amended--
       (1) by striking out ``December 31, 1995,'' in paragraph 
     (1)(A) and inserting in lieu thereof ``December 31, 1998,''; 
     and
       (2) by striking out ``December 31, 1994,'' in paragraph (3) 
     and inserting in lieu thereof ``December 31, 1998,''.
       (d) Period of Eligibility To Seek Services.--(1) Such 
     subsection, as amended by subsections (a), (b), and (c) of 
     this section, is further amended--
       (A) by striking out paragraph (2); and
       (B) by redesignating paragraph (3) as paragraph (2).
       (2) Section 102(b) of the Veterans Health Care Act of 1992 
     (Public Law 102-585; 106 Stat. 4946; 38 U.S.C. 1720D note) is 
     repealed.
       (e) Repeal of Limitation on Period of Receipt of 
     Services.--Section 1720D of title 38, United States Code (as 
     amended by subsections (a) through (d) of this section), is 
     further amended--
       (1) by striking out subsection (b); and
       (2) by redesignating subsections (c), (d), and (e) as 
     subsections (b), (c), and (d), respectively.
       (f) Increased Priority of Care.--Section 1712(i) of title 
     38, United States Code, is amended--
       (1) in paragraph (1)--
       (A) by inserting ``(A)'' after ``To a veteran''; and
       (B) by inserting ``, or (B) who is eligible for counseling 
     and care and services under section 1720D of this title, for 
     the purposes of such counseling and care and services'' 
     before the period at the end; and
       (2) in paragraph (2)--
       (A) by striking out ``, (B)'' and inserting in lieu thereof 
     ``or (B)''; and
       (B) by striking out ``, or (C)'' and all that follows 
     through ``such counseling''.
       (g) Program Revision.--(1) Section 1720D of title 38, 
     United States Code (as amended by subsections (a) through (e) 
     of this section), is further amended--
       (A) by striking out ``woman'' in subsection (a)(1)(A);
       (B) by striking out ``women'' in subsection (b)(2)(C) and 
     in the first sentence of subsection (c); and
       (C) by striking out ``women'' in subsection (c)(2) and 
     inserting in lieu thereof ``individuals''.
       (2)(A) The heading of such section is amended to read as 
     follows:

     ``Sec. 1720D. Counseling, care, and services for sexual 
       trauma''.

       (B) The item relating to such section in the table of 
     sections at the beginning of chapter 17 of such title is 
     amended to read as follows:

``1720D. Counseling, care, and services for sexual trauma.''.

       (h) Information on Counseling by Telephone.--(1) Paragraph 
     (1) of section 1720D(c) of title 38, United States Code, as 
     redesignated by subsection (d) of this section, is amended by 
     striking out ``may'' and inserting in lieu thereof ``shall''.
       (2) In providing information on counseling available to 
     veterans through the information system required under 
     section 1720D(c)(1) of title 38, United States Code, as 
     amended by this section, the Secretary of Veterans Affairs 
     shall ensure--
       (A) that the telephone system described in such section is 
     operated by Department of Veterans Affairs personnel who are 
     trained in the provision to persons who have experienced 
     sexual trauma of information about the counseling and care 
     and services relating to sexual trauma that are available to 
     veterans in the communities in which such veterans reside, 
     including counseling and care and services available under 
     programs of the Department (including the care and services 
     available under section 1720D of such title) and from non-
     Department agencies or organizations;
       (B) that such personnel are provided with information on 
     the counseling and care and services relating to sexual 
     trauma that are available to veterans and the locations in 
     which such care and services are available;
       (C) that such personnel refer veterans seeking such 
     counseling and care and services to appropriate providers of 
     such counseling and care and services (including counseling 
     and care and services that are available in the communities 
     in which such veterans reside);
       (D) that the telephone system is operated in a manner that 
     protects the confidentiality of persons who place telephone 
     calls to the system; and
       (E) that the telephone system operates at all times.
       (3) The Secretary shall ensure that information about the 
     availability of the telephone system is visibly posted in 
     Department medical facilities and is advertised through 
     public service announcements, pamphlets, and other means.
       (4) Not later than 18 months after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the operation of the telephone system required 
     under section 1720D(c)(1) of title 38, United States Code (as 
     so amended). The report shall set forth the following:
       (A) The number of telephone calls placed to the system 
     during the period covered by the report, with a separate 
     display of (i) the number of calls placed to the system from 
     each State (as such term is defined in section 101(20) of 
     title 38, United States Code) during that period, and (ii) 
     the number of persons who placed more than one call to the 
     system during that period.
       (B) The types of sexual trauma described to personnel 
     operating the system by persons placing calls to the system.
       (C) A description of the difficulties, if any, experienced 
     by persons placing calls to the system in obtaining 
     counseling and care and services for sexual trauma in the 
     communities in which such persons live, including counseling 
     and care and services available from the Department and from 
     non-Department agencies and organizations.
       (D) A description of the training provided to the personnel 
     operating the system.
       (E) The recommendations and plans of the Secretary for the 
     improvement of the system.
       (5) The Secretary shall commence operation of the telephone 
     system required under section 1720D(c)(1) of title 38, United 
     States Code (as so amended), not later than 180 days after 
     the date of the enactment of this Act.

     SEC. 102. REPORTS RELATING TO DETERMINATIONS OF SERVICE 
                   CONNECTION FOR SEXUAL TRAUMA.

       (a) Report.--(1) The Secretary of Veterans Affairs shall 
     submit to the Committees on Veterans' Affairs of the Senate 
     and House of Representatives a report containing the 
     Secretary's assessment of--
       (A) the difficulties that veterans encounter in obtaining 
     from the Department of Veterans Affairs determinations that 
     disabilities relating to sexual trauma resulting from events 
     that occurred during active duty are service-connected 
     disabilities; and
       (B) the extent to which Department personnel fail to make 
     determinations that such disabilities are service-connected 
     disabilities.
       (2) The Secretary shall include in the report the 
     Secretary's recommendations for actions to be taken to 
     respond in a fair manner to the difficulties described in the 
     report and to eliminate failures to make determinations that 
     such disabilities are service-connected disabilities.
       (3) The report required by this subsection shall be 
     submitted not later than June 30, 1994.
       (b) Follow-Up Reports.--Not later than June 30 of each of 
     1995 and 1996, the Secretary shall submit to the committees 
     referred to in paragraph (1) of subsection (a) a report on 
     the actions taken by the Secretary to implement the 
     recommendations referred to in paragraph (2) of that 
     subsection.
       (c) Definition.--In this section, the term ``sexual 
     trauma'' means the immediate and long-term physical or 
     psychological trauma resulting from rape, sexual assault, 
     aggravated sexual abuse (as such term is described in section 
     2241 of title 18, United States Code), sexual harassment, or 
     other act of sexual violence.

     SEC. 103. COORDINATORS OF WOMEN'S SERVICES.

       (a) Requirement of Full-time Service.--Section 108 of the 
     Veterans Health Care Act of 1992 (Public Law 102-585; 106 
     Stat. 4948; 38 U.S.C. 1710 note) is amended--
       (1) by inserting ``(a)'' before ``The Secretary''; and
       (2) by adding at the end the following:
       ``(b) Each official who serves in the position of 
     coordinator of women's services under subsection (a) shall so 
     serve on a full-time basis.''.
       (b) Additional Responsibilities.--Subsection (a) of such 
     section (as designated by subsection (a) of this section) is 
     further amended--
       (1) by redesignating paragraph (5) as paragraph (6); and
       (2) by inserting after paragraph (4) the following new 
     paragraph (5):
       ``(5) Facilitating communication between women veterans 
     coordinators under the jurisdiction of such regional 
     coordinator and the Under Secretary for Health and the 
     Secretary.''.
       (c) Support for Women's Services Coordinators.--The 
     Secretary of Veterans Affairs shall take appropriate actions 
     to ensure that--
       (1) sufficient funding is provided to each Department of 
     Veterans Affairs facility in order to permit the coordinator 
     of women's services to carry out the responsibilities of the 
     coordinator at the facility;
       (2) sufficient clerical and communications support is 
     provided to each such coordinator for that purpose; and
       (3) each such coordinator has direct access to the Director 
     or Chief of Staff of the facility to which the coordinator is 
     assigned.

     SEC. 104. WOMEN'S HEALTH SERVICES.

       (a) Women's Health Services.--Section 1701 of title 38, 
     United States Code, is amended--
       (1) in paragraph (6)(A)(i), by inserting ``women's health 
     services,'' after ``preventive health services,''; and
       (2) by adding at the end the following:
       ``(10) The term `women's health services' means health care 
     services provided to women, including counseling and services 
     relating to the following:
       ``(A) Papanicolaou tests (pap smear).
       ``(B) Breast examinations and mammography.
       ``(C) Comprehensive reproductive health care, including 
     pregnancy-related care.
       ``(D) The management of infertility.
       ``(E) The management and prevention of sexually-transmitted 
     diseases.
       ``(F) Menopause.
       ``(G) Physical or psychological conditions arising out of 
     acts of sexual violence.''.
       (b) Contracts for Women's Health Services.--Section 1703(a) 
     of such title is amended by adding at the end the following:
       ``(9) Women's health services for veterans on an ambulatory 
     or outpatient basis.''.
       (c) Repeal of Superseded Authority.--Section 106 of the 
     Veterans Health Care Act of 1992 (Public Law 102-585; 38 
     U.S.C. 1710 note) is amended--
       (1) by striking out subsection (a); and
       (2) by striking out ``(b) Responsibilities of Directors of 
     Facilities.--'' before ``The Secretary''.
       (d) Report on Health Care and Research.--Section 107(b) of 
     such Act (38 U.S.C. 1710 note) is amended--
       (1) in paragraph (1), by inserting ``and women's health 
     services (as such term is defined in section 1701(10) of 
     title 38, United States Code)'' after ``section 106 of this 
     Act'';
       (2) in paragraph (2), by striking out ``and (B)'' and 
     inserting in lieu thereof ``(B) the type and amount of 
     services provided by such personnel, including information on 
     the numbers of inpatient stays and the number of outpatient 
     visits through which such services were provided, and (C)'';
       (3) by redesignating paragraph (4) as paragraph (7);
       (4) by adding after paragraph (3) the following new 
     paragraphs:
       ``(4) A description of the personnel of the Department who 
     provided such services to women veterans, including the 
     number of employees (including both the number of individual 
     employees and the number of full-time employee equivalents) 
     and the professional qualifications or specialty training of 
     such employees and the Department facilities to which such 
     personnel were assigned.
       ``(5) A description of any actions taken by the Secretary 
     to ensure the retention of the personnel described in 
     paragraph (4), and any actions undertaken to recruit 
     additional such personnel or personnel to replace such 
     personnel.
       ``(6) An assessment by the Secretary of any difficulties 
     experienced by the Secretary in the furnishing of such 
     services and the actions taken by the Secretary to resolve 
     such difficulties.''; and
       (5) by adding after paragraph (7), as redesignated by 
     paragraph (3) of this subsection, the following:
       ``(8) A description of the actions taken by the Secretary 
     to foster and encourage the expansion of such research.''.

     SEC. 105. EXPANSION OF RESEARCH RELATING TO WOMEN VETERANS.

       (a) Health Research.--Section 109(a) of the Veterans Health 
     Care Act of 1992 (Public Law 102-585; 38 U.S.C. 7303 note) is 
     amended--
       (1) by inserting ``(1)'' before ``The Secretary'';
       (2) in paragraph (1), as so designated, by striking out 
     ``veterans who are women'' and inserting in lieu thereof 
     ``women veterans''; and
       (3) by adding at the end the following:
       ``(2) In carrying out this section, the Secretary shall 
     consult with the following:
       ``(A) The Director of the Nursing Service.
       ``(B) Officials of the Central Office assigned 
     responsibility for women's health programs and sexual trauma 
     services.
       ``(C) The members of the Advisory Committee on Women 
     Veterans established under section 542 of title 38, United 
     States Code.
       ``(D) Members of appropriate task forces and working groups 
     within the Department of Veterans Affairs (including the 
     Women Veterans Working Group and the Task Force on Treatment 
     of Women Who Suffer Sexual Abuse).
       ``(3) The Secretary shall foster and encourage research 
     under this section on the following matters as they relate to 
     women:
       ``(A) Breast cancer.
       ``(B) Gynecological and reproductive health, including 
     gynecological cancer, infertility, sexually-transmitted 
     diseases, and pregnancy.
       ``(C) Human Immunodeficiency Virus and Acquired Immune 
     Deficiency Syndrome.
       ``(D) Mental health, including post-traumatic stress 
     disorder and depression.
       ``(E) Diseases related to aging, including menopause, 
     osteoporosis, and Alzheimer's Disease.
       ``(F) Substance abuse.
       ``(G) Sexual violence and related trauma.
       ``(H) Exposure to toxic chemicals and other environmental 
     hazards.
       ``(4) The Secretary shall, to the maximum extent 
     practicable, ensure that personnel of the Department of 
     Veterans Affairs engaged in the research referred to in 
     paragraph (1) include the following:
       ``(A) Personnel of the geriatric research, education, and 
     clinical centers designated pursuant to section 7314 of title 
     38, United States Code.
       ``(B) Personnel of the National Center for Post-Traumatic 
     Stress Disorder established pursuant to section 110(c) of the 
     Veterans Health Care Act of 1984 (Public Law 98-528; 98 Stat. 
     2692).
       ``(5) The Secretary shall, to the maximum extent 
     practicable, ensure that personnel of the Department engaged 
     in research relating to the health of women veterans are 
     advised and informed of such research engaged in by other 
     personnel of the Department.''.
       (b) Population Study.--Section 110(a) of such Act (38 
     U.S.C. 1710 note) is amended--
       (1) in paragraph (1), by striking out the second sentence; 
     and
       (2) by amending paragraph (3) to read as follows:
       ``(3)(A) Subject to subparagraph (B), the study shall be 
     based on--
       ``(i) an appropriate sample of veterans who are women and 
     of women who are serving on active military, naval, or air 
     service; and
       ``(ii) an examination of the medical and demographic 
     histories of the women comprising such sample.
       ``(B) The sample referred to in subparagraph (A) shall, to 
     the maximum extent practicable, constitute a representative 
     sampling (as determined by the Secretary) of the ages, the 
     ethnic, social and economic backgrounds, the enlisted and 
     officer grades, and the branches of service of all veterans 
     who are women and women who are serving on such duty.
       ``(C) In carrying out the examination referred to in 
     subparagraph (A)(ii), the Secretary shall determine the 
     number of women of the sample who have used medical 
     facilities of the Department, nursing home facilities of or 
     under the jurisdiction of the Department, and outpatient care 
     facilities of or under the jurisdiction of the Department.''.

     SEC. 106. MAMMOGRAPHY QUALITY STANDARDS.

       (a) Performance of Mammograms.--Mammograms may not be 
     performed at a Department of Veterans Affairs facility unless 
     that facility is accredited for that purpose by a private 
     nonprofit organization designated by the Secretary of 
     Veterans Affairs. The organization designated by the 
     Secretary under this subsection shall meet the standards for 
     accrediting bodies established by the Secretary of Health and 
     Human Services under section 354(e) of the Public Health 
     Service Act (42 U.S.C. 263b(e)).
       (b) Quality Standards.--(1)(A) The Secretary of Veterans 
     Affairs shall prescribe quality assurance and quality control 
     standards relating to the performance and interpretation of 
     mammograms and use of mammogram equipment and facilities by 
     personnel of the Department of Veterans Affairs. Such 
     standards shall be no less stringent than the standards 
     prescribed by the Secretary of Health and Human Services 
     under section 354(f) of the Public Health Service Act.
       (B) In prescribing such standards, the Secretary of 
     Veterans Affairs shall consult with the Secretary of Health 
     and Human Services.
       (2) The Secretary of Veterans Affairs shall prescribe such 
     standards not later than 120 days after the Secretary of 
     Health and Human Services prescribes quality standards under 
     such section 354(f).
       (c) Inspection of Department Equipment.--(1) The Secretary 
     of Veterans Affairs shall, on an annual basis, inspect the 
     equipment and facilities utilized by and in Department of 
     Veterans Affairs health-care facilities for the performance 
     of mammograms in order to ensure the compliance of such 
     equipment and facilities with the standards prescribed under 
     subsection (b). Such inspection shall be carried out in a 
     manner consistent with the inspection of certified facilities 
     by the Secretary of Health and Human Services under section 
     354(g) of the Public Health Services Act.
       (2) The Secretary of Veterans Affairs may not delegate the 
     responsibility of such secretary under paragraph (1) to a 
     State agency.
       (d) Application of Standards to Contract Providers.--The 
     Secretary of Veterans Affairs shall ensure that mammograms 
     performed for the Department of Veterans Affairs under 
     contract with any non-Department facility or provider conform 
     to the quality standards prescribed by the Secretary of 
     Health and Human Services under section 354 of the Public 
     Health Service Act.
       (e) Report.--(1) The Secretary shall submit to the 
     Committees on Veterans' Affairs of the Senate and House of 
     Representatives a report on the quality standards prescribed 
     by the Secretary under subsection (b)(1).
       (2) The Secretary shall submit the report not later than 
     180 days after the date on which the Secretary prescribes 
     such regulations.
       (f) Definition.--In this section, the term ``mammogram'' 
     shall have the meaning given such term in section 354(a)(5) 
     of the Public Health Service Act (42 U.S.C. 263b(a)).
                 TITLE II--GENERAL HEALTH CARE SERVICES

     SEC. 201. EXTENSION OF PERIOD OF ELIGIBILITY FOR MEDICAL CARE 
                   FOR EXPOSURE TO DIOXIN OR IONIZING RADIATION.

       Section 1710(e)(3) of title 38, United States Code, is 
     amended by striking out ``December 31, 1993'' and inserting 
     in lieu thereof ``December 31, 2003''.

     SEC. 202. AUTHORITY TO PROVIDE PRIORITY HEALTH CARE TO 
                   VETERANS OF THE PERSIAN GULF WAR.

       (a) Authorized Inpatient Care.--(1) Section 1710(a)(1)(G) 
     of title 38, United States Code, is amended by striking out 
     ``or radiation'' and inserting in lieu thereof ``, radiation, 
     or environmental hazard''.
       (2) Section 1710(e) of such title is amended--
       (A) by inserting at the end of paragraph (1) the following 
     new subparagraph:
       ``(C) Subject to paragraphs (2) and (3) of this subsection, 
     a veteran who the Secretary finds may have been exposed while 
     serving on active duty in the Southwest Asia theater of 
     operations during the Persian Gulf War to a toxic substance 
     or environmental hazard (including petrochemicals, the fumes 
     of burning landfills or petrochemicals, pharmaceuticals or 
     other chemical agents administered by the Department of 
     Defense, indigenous diseases, pesticides, and inhalation or 
     ingestion of depleted uranium or wounds caused by depleted 
     uranium) is eligible for hospital care and nursing home care 
     under subsection (a)(1)(G) of this section for any 
     disability, notwithstanding that there is insufficient 
     medical evidence to conclude that such disability may be 
     associated with such exposure.'';
       (B) in paragraph (2), by striking out ``subparagraph (A) or 
     (B)'' and inserting in lieu thereof ``subparagraph (A), (B), 
     or (C)''; and
       (C) in paragraph (3), by striking out the period at the end 
     and inserting in lieu thereof ``, or, in the case of care for 
     a veteran described in paragraph (1)(C), after September 30, 
     2003.''.
       (b) Authorized Outpatient Care.--Section 1712(a) of such 
     title is amended--
       (1) in paragraph (1)--
       (A) by striking out ``and'' at the end of subparagraph (B);
       (B) by striking out the period at the end of subparagraph 
     (C) and inserting in lieu thereof ``; and''; and
       (C) by adding at the end the following:
       ``(D) during the period before October 1, 2003, for any 
     disability in the case of a veteran who served on active duty 
     in the Southwest Asia theater of operations during the 
     Persian Gulf War and who the Secretary finds may have been 
     exposed to a toxic substance or environmental hazard 
     (including petrochemicals, the fumes of burning landfills or 
     petrochemicals, pharmaceuticals or other chemical agents 
     administered by the Department of Defense, indigenous 
     diseases, pesticides, and inhalation or ingestion of depleted 
     uranium or wounds caused by depleted uranium) during such 
     service, notwithstanding that there is insufficient medical 
     evidence to conclude that the disability may be associated 
     with such exposure.''; and
       (2) by adding at the end the following new paragraph:
       ``(7) Medical services may not be furnished under paragraph 
     (1)(D) with respect to a disability that is found, in 
     accordance with guidelines issued by the Under Secretary for 
     Health, to have resulted from a cause other than an exposure 
     described in that paragraph.''.
       (c) Effective Date.--(1) The amendments made by subsections 
     (a) and (b) shall take effect as of August 2, 1990.
       (2) The Secretary of Veterans Affairs shall, upon request, 
     reimburse any veteran who paid the United States an amount 
     under section 1710(f) or 1712(f) of title 38, United States 
     Code, as the case may be, for hospital care, nursing home 
     care, or outpatient services, as the case may be, furnished 
     by the Secretary to the veteran before the date of the 
     enactment of this Act as a result of the exposure of the 
     veteran to a toxic substance or environmental hazards during 
     the Persian Gulf War. The amount of the reimbursement shall 
     be the amount paid by the veteran for such care or services 
     under such section 1710(f) or 1712(f).

     SEC. 203. PROGRAMS FOR FURNISHING HOSPICE CARE TO VETERANS.

       (a) Establishment of Programs.--Chapter 17 of title 38, 
     United States Code, is amended by adding at the end the 
     following:


  ``subchapter vii--hospice care pilot program; hospice care services

     ``Sec. 1761. Definitions

       ``For the purposes of this subchapter--
       ``(1) The term `terminally ill veteran' means any veteran--
       ``(A) who is (i) entitled to receive hospital care in a 
     medical facility of the Department under section 1710(a)(1) 
     of this title, (ii) eligible for hospital or nursing home 
     care in such a facility and receiving such care, (iii) 
     receiving care in a State home facility for which care the 
     Secretary is paying per diem under section 1741 of this 
     title, or (iv) transferred to a non-Department nursing home 
     for nursing home care under section 1720 of this title and 
     receiving such care; and
       ``(B) who has a medical prognosis (as certified by a 
     Department physician) of a life expectancy of six months or 
     less.
       ``(2) The term `hospice care services' means (A) the care, 
     items, and services referred to in subparagraphs (A) through 
     (H) of section 1861(dd)(1) of the Social Security Act (42 
     U.S.C. 1395x(dd)(1)), and (B) personal care services.
       ``(3) The term `hospice program' means any program that 
     satisfies the requirements of section 1861(dd)(2) of the 
     Social Security Act (42 U.S.C. 1395x(dd)(2)).
       ``(4) The term `medical facility of the Department' means a 
     facility referred to in section 1701(4)(A) of this title.
       ``(5) The term `non-Department facility' means a facility 
     (other than a medical facility of the Department) at which 
     care to terminally ill veterans is furnished, regardless of 
     whether such care is furnished pursuant to a contract, 
     agreement, or other arrangement referred to in section 
     1762(b)(1)(D) of this title.
       ``(6) The term `personal care services' means any care or 
     service furnished to a person that is necessary to maintain a 
     person's health and safety within the home or nursing home of 
     the person, including care or services related to dressing 
     and personal hygiene, feeding and nutrition, and 
     environmental support.

     ``Sec. 1762. Hospice care: pilot program requirements

       ``(a)(1) During the period beginning on October 1, 1993, 
     and ending on December 31, 1998, the Secretary shall conduct 
     a pilot program in order--
       ``(A) to assess the feasibility and desirability of 
     furnishing hospice care services to terminally ill veterans; 
     and
       ``(B) to determine the most efficient and effective means 
     of furnishing such services to such veterans.
       ``(2) The Secretary shall conduct the pilot program in 
     accordance with this section.
       ``(b)(1) Under the pilot program, the Secretary shall--
       ``(A) designate not less than 15 nor more than 30 medical 
     facilities of the Department at or through which to conduct 
     hospice care services demonstration projects;
       ``(B) designate the means by which hospice care services 
     shall be provided to terminally ill veterans under each 
     demonstration project pursuant to subsection (c);
       ``(C) allocate such personnel and other resources of the 
     Department as the Secretary considers necessary to ensure 
     that services are provided to terminally ill veterans by the 
     designated means under each demonstration project; and
       ``(D) enter into any contract, agreement, or other 
     arrangement that the Secretary considers necessary to ensure 
     the provision of such services by the designated means under 
     each such project.
       ``(2) In carrying out the responsibilities referred to in 
     paragraph (1) the Secretary shall take into account the need 
     to provide for and conduct the demonstration projects so as 
     to provide the Secretary with such information as is 
     necessary for the Secretary to evaluate and assess the 
     furnishing of hospice care services to terminally ill 
     veterans by a variety of means and in a variety of 
     circumstances.
       ``(3) In carrying out the requirement described in 
     paragraph (2), the Secretary shall ensure, to the maximum 
     extent feasible, that--
       ``(A) the medical facilities of the Department selected to 
     conduct demonstration projects under the pilot program 
     include facilities located in urban areas of the United 
     States and rural areas of the United States;
       ``(B) the full range of affiliations between medical 
     facilities of the Department and medical schools is 
     represented by the facilities selected to conduct 
     demonstration projects under the pilot program, including no 
     affiliation, minimal affiliation, and extensive affiliation;
       ``(C) such facilities vary in the number of beds that they 
     operate and maintain; and
       ``(D) the demonstration projects are located or conducted 
     in accordance with any other criteria or standards that the 
     Secretary considers relevant or necessary to furnish and to 
     evaluate and assess fully the furnishing of hospice care 
     services to terminally ill veterans.
       ``(c)(1) Subject to paragraph (2), hospice care to 
     terminally ill veterans shall be furnished under a 
     demonstration project by one or more of the following means 
     designated by the Secretary:
       ``(A) By the personnel of a medical facility of the 
     Department providing hospice care services pursuant to a 
     hospice program established by the Secretary at that 
     facility.
       ``(B) By a hospice program providing hospice care services 
     under a contract with that program and pursuant to which 
     contract any necessary inpatient services are provided at a 
     medical facility of the Department.
       ``(C) By a hospice program providing hospice care services 
     under a contract with that program and pursuant to which 
     contract any necessary inpatient services are provided at a 
     non-Department medical facility.
       ``(2)(A) The Secretary shall provide that--
       ``(i) care is furnished by the means described in paragraph 
     (1)(A) at not less than five medical facilities of the 
     Department; and
       ``(ii) care is furnished by the means described in 
     subparagraphs (B) and (C) of paragraph (1) in connection with 
     not less than five such facilities for each such means.
       ``(B) The Secretary shall provide in any contract under 
     subparagraph (B) or (C) of paragraph (1) that inpatient care 
     may be provided to terminally ill veterans at a medical 
     facility other than that designated in the contract if the 
     provision of such care at such other facility is necessary 
     under the circumstances.
       ``(d)(1) Except as provided in paragraph (2), the amount 
     paid to a hospice program for care furnished pursuant to 
     subparagraph (B) or (C) of subsection (c)(1) may not exceed 
     the amount that would be paid to that program for such care 
     under section 1814(i) of the Social Security Act (42 U.S.C. 
     1395f(i)) if such care were hospice care for which payment 
     would be made under part A of title XVIII of such Act.
       ``(2) The Secretary may pay an amount in excess of the 
     amount referred to in paragraph (1) (or furnish services 
     whose value, together with any payment by the Secretary, 
     exceeds such amount) to a hospice program for furnishing care 
     to a terminally ill veteran pursuant to subparagraph (B) or 
     (C) of subsection (c)(1) if the Secretary determines, on a 
     case-by-case basis, that--
       ``(A) the furnishing of such care to the veteran is 
     necessary and appropriate; and
       ``(B) the amount that would be paid to that program under 
     section 1814(i) of the Social Security Act would not 
     compensate the program for the cost of furnishing such care.

     ``Sec. 1763. Care for terminally ill veterans

       ``(a) During the period referred to in section 1762(a)(1) 
     of this title, the Secretary shall designate not less than 10 
     medical facilities of the Department at which hospital care 
     is being furnished to terminally ill veterans to furnish the 
     care referred to in subsection (b)(1).
       ``(b)(1) Palliative care to terminally ill veterans shall 
     be furnished at the facilities referred to in subsection (a) 
     by one of the following means designated by the Secretary:
       ``(A) By personnel of the Department providing one or more 
     hospice care services to such veterans at or through medical 
     facilities of the Department.
       ``(B) By personnel of the Department monitoring the 
     furnishing of one or more of such services to such veterans 
     at or through non-Department facilities.
       ``(2) The Secretary shall furnish care by the means 
     referred to in each of subparagraphs (A) and (B) of paragraph 
     (1) at not less than five medical facilities designated under 
     subsection (a).

     ``Sec. 1764. Information relating to hospice care services

       ``The Secretary shall ensure to the extent practicable that 
     terminally ill veterans who have been informed of their 
     medical prognosis receive information relating to the 
     eligibility, if any, of such veterans for hospice care and 
     services under title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.).

     ``Sec. 1765. Evaluation and reports

       ``(a) Not later than September 30, 1994, and on an annual 
     basis thereafter until October 1, 1999, the Secretary shall 
     submit a written report to the Committees on Veterans' 
     Affairs of the Senate and House of Representatives relating 
     to the conduct of the pilot program under section 1762 of 
     this title and the furnishing of hospice care services under 
     section 1763 of this title. Each report shall include the 
     following information:
       ``(1) The location of the sites of the demonstration 
     projects provided for under the pilot program.
       ``(2) The location of the medical facilities of the 
     Department at or through which hospice care services are 
     being furnished under section 1763 of this title.
       ``(3) The means by which care to terminally ill veterans is 
     being furnished under each such project and at or through 
     each such facility.
       ``(4) The number of veterans being furnished such care 
     under each such project and at or through each such facility.
       ``(5) An assessment by the Secretary of any difficulties in 
     furnishing such care and the actions taken to resolve such 
     difficulties.
       ``(b) Not later than August 1, 1997, the Secretary shall 
     submit to the committees referred to in subsection (a) a 
     report containing an evaluation and assessment by the 
     Director of the Health Services Research and Development 
     Service of the hospice care pilot program under section 1762 
     of this title and the furnishing of hospice care services 
     under section 1763 of this title. The report shall contain 
     such information (and shall be presented in such form) as 
     will enable the committees to evaluate fully the feasibility 
     and desirability of furnishing hospice care services to 
     terminally ill veterans.
       ``(c) The report shall include the following:
       ``(1) A description and summary of the pilot program.
       ``(2) With respect to each demonstration project conducted 
     under the pilot program--
       ``(A) a description and summary of the project;
       ``(B) a description of the facility conducting the 
     demonstration project and a discussion of how such facility 
     was selected in accordance with the criteria set out in, or 
     prescribed by the Secretary pursuant to, subparagraphs (A) 
     through (D) of section 1762(b)(3) of this title;
       ``(C) the means by which hospice care services care are 
     being furnished to terminally ill veterans under the 
     demonstration project;
       ``(D) the personnel used to furnish such services under the 
     demonstration project;
       ``(E) a detailed factual analysis with respect to the 
     furnishing of such services, including (i) the number of 
     veterans being furnished such services, (ii) the number, if 
     any, of inpatient admissions for each veteran being furnished 
     such services and the length of stay for each such admission, 
     (iii) the number, if any, of outpatient visits for each such 
     veteran, and (iv) the number, if any, of home-care visits 
     provided to each such veteran;
       ``(F) the direct costs, if any, incurred by terminally ill 
     veterans, the members of the families of such veterans, and 
     other individuals in close relationships with such veterans 
     in connection with the participation of veterans in the 
     demonstration project;
       ``(G) the costs incurred by the Department in conducting 
     the demonstration project, including an analysis of the 
     costs, if any, of the demonstration project that are 
     attributable to (i) furnishing such services in facilities of 
     the Department, (ii) furnishing such services in non-
     Department facilities, and (iii) administering the furnishing 
     of such services; and
       ``(H) the unreimbursed costs, if any, incurred by any other 
     entity in furnishing services to terminally ill veterans 
     under the project pursuant to section 1762(c)(1)(C) of this 
     title.
       ``(3) An analysis of the level of the following persons' 
     satisfaction with the services furnished to terminally ill 
     veterans under each demonstration project:
       ``(A) Terminally ill veterans who receive such services, 
     members of the families of such veterans, and other 
     individuals in close relationships with such veterans.
       ``(B) Personnel of the Department responsible for 
     furnishing such services under the project.
       ``(C) Personnel of non-Department facilities responsible 
     for furnishing such services under the project.
       ``(4) A description and summary of the means of furnishing 
     hospice care services at or through each medical facility of 
     the Department designated under section 1763(a)(1) of this 
     title.
       ``(5) With respect to each such means, the information 
     referred to in paragraphs (2) and (3).
       ``(6) A comparative analysis by the Director of the 
     services furnished to terminally ill veterans under the 
     various demonstration projects referred to in section 1762 of 
     this title and at or through the designated facilities 
     referred to in section 1763 of this title, with an emphasis 
     in such analysis on a comparison relating to--
       ``(A) the management of pain and health symptoms of 
     terminally ill veterans by such projects and facilities;
       ``(B) the number of inpatient admissions of such veterans 
     and the length of inpatient stays for such admissions under 
     such projects and facilities;
       ``(C) the number and type of medical procedures employed 
     with respect to such veterans by such projects and 
     facilities; and
       ``(D) the effectiveness of such projects and facilities in 
     providing care to such veterans at the homes of such veterans 
     or in nursing homes.
       ``(7) An assessment by the Director of the feasibility and 
     desirability of furnishing hospice care services by various 
     means to terminally ill veterans, including an assessment by 
     the Director of the optimal means of furnishing such services 
     to such veterans.
       ``(8) Any recommendations for additional legislation 
     regarding the furnishing of care to terminally ill veterans 
     that the Secretary considers appropriate.''.
       (b) Clerical Amendment.--The table of sections at the 
     beginning of such chapter is amended by adding at the end the 
     following:


   ``subchapter vii--hospice care pilot program; hospice care services

``1761. Definitions.
``1762. Hospice care: pilot program requirements.
``1763. Care for terminally ill veterans.
``1764. Information relating to hospice care services.
``1765. Evaluation and reports.''.
       (c) Authority To Carry Out Other Hospice Care Programs.--
     The amendments made by subsection (a) may not be construed as 
     terminating the authority of the Secretary of Veterans 
     Affairs to provide hospice care services to terminally ill 
     veterans under any program in addition to the programs 
     required under the provisions added by such amendments.
       (d) Authorization of Appropriations.--Funds are authorized 
     to be appropriated for the Department of Veterans Affairs for 
     the purposes of carrying out the evaluation of the hopice 
     care pilot programs under section 1765 of title 38, United 
     States Code (as added by subsection (a)), as follows:
       (1) For fiscal year 1994, $1,200,000.
       (2) For fiscal year 1995, $2,500,000.
       (3) For fiscal year 1996, $2,200,000.
       (4) For fiscal year 1997, $100,000.

     SEC. 204. RURAL HEALTH-CARE CLINIC PROGRAM.

       (a) Program.--(1) Chapter 17 of title 38, United States 
     Code, is amended by adding at the end of subchapter II the 
     following:

     ``Sec. 1720E. Rural health-care clinics: pilot program

       ``(a) During the three-year period beginning on October 1, 
     1993, the Secretary shall conduct a rural health-care clinic 
     program in States where significant numbers of veterans 
     reside in areas geographically remote from existing health-
     care facilities (as determined by the Secretary). The 
     Secretary shall conduct the program in accordance with this 
     section.
       ``(b)(1) In carrying out the rural health-care clinic 
     program, the Secretary shall furnish medical services to the 
     veterans described in subsection (c) through use of--
       ``(A) mobile health-care clinics equipped, operated, and 
     maintained by personnel of the Department; and
       ``(B) other types of rural clinics, including part-time 
     stationary clinics for which the Secretary contracts and 
     part-time stationary clinics operated by personnel of the 
     Department.
       ``(2) The Secretary shall furnish services under the rural 
     health-care clinic program in areas--
       ``(A) that are more than 100 miles from a Department 
     general health-care facility; and
       ``(B) that are less than 100 miles from such a facility, if 
     the Secretary determines that the furnishing of such services 
     in such areas is appropriate.
       ``(c) A veteran eligible to receive medical services 
     through rural health-care clinics under the program is any 
     veteran eligible for medical services under section 1712 of 
     this title.
       ``(d) The Secretary shall commence operation of at least 
     three rural health-care clinics (at least one of which shall 
     be a mobile health-care clinic) in each fiscal year of the 
     program. The Secretary may not operate more than one mobile 
     health-care clinic under the authority of this section in any 
     State in any such fiscal year.
       ``(e) Not later than 120 days after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the Secretary's plans for the implementation of 
     the pilot program required under this section.
       ``(f) Not later than December 31, 1997, the Secretary shall 
     submit to Congress a report containing an evaluation of the 
     program. The report shall include the following:
       ``(1) A description of the program, including information 
     with respect to--
       ``(A) the number and type of rural health-care clinics 
     operated under the program;
       ``(B) the States in which such clinics were operated;
       ``(C) the medical services furnished under the program, 
     including a detailed specification of the cost of such 
     services;
       ``(D) the veterans who were furnished services under the 
     program, setting forth (i) the numbers and percentages of the 
     veterans who had service-connected disabilities, (ii) of the 
     veterans having such disabilities, the numbers and 
     percentages who were furnished care for such disabilities, 
     (iii) the ages of the veterans, (iv) taking into account the 
     veterans' past use of Department health-care facilities, an 
     analysis of the extent to which the veterans would have 
     received medical services from the Department outside the 
     program and the types of services they would have received, 
     and (v) the financial circumstances of the veterans; and
       ``(E) the types of personnel who furnished services to 
     veterans under the program, including any difficulties in the 
     recruitment or retention of such personnel.
       ``(2) An assessment by the Secretary of the cost-
     effectiveness and efficiency of furnishing medical services 
     to veterans through various types of rural clinics (including 
     mobile health-care clinics operated under the pilot program 
     conducted pursuant to section 113 of the Veterans' Benefits 
     and Services Act of 1988 (Public Law 100-322; 38 U.S.C. 1712 
     note)).
       ``(3) Any plans for administrative action, and any 
     recommendations for legislation, that the Secretary considers 
     appropriate.
       ``(g) For the purposes of this section, the term 
     `Department general health-care facility' has the meaning 
     given such term in section 1712A(i)(2) of this title.''.
       (2) The table of sections at the beginning of such chapter 
     is amended by inserting after the item relating to section 
     1720D the following new item:

``1720E. Rural health-care clinics: pilot program.''.

       (b) Authorization of Appropriations.--(1) There is 
     authorized to be appropriated for the Department of Veterans 
     Affairs to carry out the rural health-care clinics program 
     provided for in section 1720E of title 38, United States Code 
     (as added by subsection (a)), the following:
       (A) For fiscal year 1994, $3,000,000.
       (B) For fiscal year 1995, $6,000,000.
       (C) For fiscal year 1996, $9,000,000.
       (2) Amounts appropriated pursuant to such authorization may 
     not be used for any other purpose.
       (3) No funds may be expended to carry out the rural health-
     care clinics program provided for in such section 1720E 
     unless expressly provided for in an appropriations Act.

     SEC. 205. PAYMENT TO STATES OF PER DIEM FOR VETERANS 
                   RECEIVING ADULT DAY HEALTH CARE.

       (a) Payment of Per Diem for Veterans Receiving Adult Day 
     Care.--Section 1741 of title 38, United States Code, is 
     amended--
       (1) by inserting ``(1)'' after ``(a)'';
       (2) by redesignating paragraphs (1) and (2) as 
     subparagraphs (A) and (B), respectively; and
       (3) by adding at the end the following new paragraph (2):
       ``(2) The Secretary may pay each State per diem at a rate 
     determined by the Secretary for each veteran receiving adult 
     day health care in a State home, if such veteran is eligible 
     for such care under laws administered by the Secretary.''.
       (b) Assistance to States for Construction of Adult Day Care 
     Facilities.--(1) Section 8131(3) of title 38, United States 
     Code, is amended by inserting ``adult day health,'' before 
     ``or hospital care''.
       (2) Section 8132 of such title is amended by inserting 
     ``adult day health,'' before ``or hospital care''.
       (3) Section 8135(b) of such title is amended--
       (A) in paragraph (2)(C), by inserting ``or adult day health 
     care facilities'' after ``domiciliary beds''; and
       (B) in paragraph (3)(A), by inserting ``or construction 
     (other than new construction) of adult day health care 
     buildings'' before the semicolon.
                        TITLE III--MISCELLANEOUS
              Subtitle A--Education Debt Reduction Program

     SEC. 301. SHORT TITLE.

       This subtitle may be cited as the ``Department of Veterans 
     Affairs Health Professionals Education Debt Reduction Act''.

     SEC. 302. PROGRAM OF ASSISTANCE IN THE PAYMENT OF EDUCATION 
                   DEBTS INCURRED BY CERTAIN VETERANS HEALTH 
                   ADMINISTRATION EMPLOYEES.

       (a) Program.--(1) Chapter 76 of title 38, United States 
     Code, is amended by adding at the end the following:

           ``SUBCHAPTER VI--EDUCATION DEBT REDUCTION PROGRAM

     ``Sec. 7661. Authority for program

       ``(a) The Secretary shall carry out an education debt 
     reduction program under this subchapter. The program shall be 
     known as the Department of Veterans Affairs Education Debt 
     Reduction Program (hereafter in this chapter referred to as 
     the `Education Debt Reduction Program'). The purpose of the 
     program is to assist personnel serving in health-care 
     positions in the Veterans Health Administration in reducing 
     the amount of debt incurred by such personnel in completing 
     educational programs that qualify such personnel for such 
     service.
       ``(b)(1) Subject to paragraph (2), assistance under the 
     Education Debt Reduction Program shall be in addition to the 
     assistance available to individuals under the Educational 
     Assistance Program established under this chapter.
       ``(2) An individual may not receive assistance under both 
     the Education Debt Reduction Program and the Educational 
     Assistance Program for the same period of service in the 
     Department.

     ``Sec. 7662. Eligibility; application

       ``(a) An individual eligible to participate in the 
     Education Debt Reduction Program is any individual (other 
     than a physician or dentist) who--
       ``(1) serves in a position in the Veterans Health 
     Administration under an appointment under section 7402(b) of 
     this title;
       ``(2) serves in an occupation, specialty, or geographic 
     area for which the recruitment or retention of an adequate 
     supply of qualified health-care personnel is especially 
     difficult (as determined by the Secretary);
       ``(3) has pursued or is pursuing, as the case may be--
       ``(A) a two-year or four-year course of education or 
     training at a qualifying undergraduate institution which 
     course qualified or will qualify, as the case may be, the 
     individual for appointment in a position referred to in 
     paragraph (1); or
       ``(B) a course of education at a qualifying graduate 
     institution which course qualified or will qualify, as the 
     case may be, the individual for appointment in such a 
     position; and
       ``(4) owes any amount of principal or interest under a loan 
     or other obligation the proceeds of which were used or are 
     being used, as the case may be, by or on behalf of the 
     individual to pay tuition or other costs incurred by the 
     individual in the pursuit of a course of education or 
     training referred to in paragraph (3).
       ``(b) Any eligible individual seeking to participate in the 
     Education Debt Reduction Program shall submit an application 
     to the Secretary relating to such participation.

     ``Sec. 7663. Agreement

       ``(a) The Secretary shall enter into an agreement with each 
     individual selected to participate in the Education Debt 
     Reduction Program. The Secretary and the individual shall 
     enter into such an agreement at the beginning of each year 
     for which the individual is selected to so participate.
       ``(b) An agreement between the Secretary and an individual 
     selected to participate in the Education Debt Reduction 
     Program shall be in writing, shall be signed by the 
     individual, and shall include the following provisions:
       ``(1) The Secretary's agreement to provide assistance on 
     behalf of the individual under the program upon the 
     completion by the individual of a one-year period of service 
     in a position referred to in section 7662(a) of this title 
     which period begins on the date of the signing of the 
     agreement (or such later date as is jointly agreed upon by 
     the Secretary and the individual).
       ``(2) The individual's agreement that the Secretary shall 
     pay any assistance provided under the program to the holder 
     (as designated by the individual) of any loan or other 
     obligation of the individual referred to in section 
     7662(a)(4) of this title in order to reduce or satisfy the 
     unpaid balance (including principal and interest) due on such 
     loan or other obligation.
       ``(3) The individual's agreement that assistance shall not 
     be paid on behalf of the individual under the program for a 
     year unless and until the individual completes the one-year 
     period of service referred to in paragraph (1).
       ``(4) The individual's agreement that assistance shall not 
     be paid on behalf of the individual under the program for a 
     year unless the individual maintains (as determined by the 
     Secretary) an acceptable level of performance during the 
     service referred to in paragraph (3).

     ``Sec. 7664. Amount of assistance

       ``(a) Subject to subsection (b), the amount of assistance 
     provided to an individual under the Education Debt Reduction 
     Program for a year may not exceed $4,000 (adjusted in 
     accordance with section 7631 of this title).
       ``(b) The total amount of assistance received by an 
     individual under the Education Debt Reduction Program may not 
     exceed $12,000 (as so adjusted).''.
       (2) The table of sections at the beginning of such chapter 
     is amended by adding at the end the following:

           ``SUBCHAPTER VI--EDUCATION DEBT REDUCTION PROGRAM

``7661. Authority for program.
``7662. Eligibility; application.
``7663. Agreement.
``7664. Amount of assistance.''.

       (b) Conforming Amendments.--Section 7631 of title 38, 
     United States Code, is amended--
       (1) in subsection (a), by striking out ``and the maximum 
     Selected Reserve member stipend amount'' and inserting in 
     lieu thereof ``the maximum Selected Reserve stipend amount, 
     and the education debt reduction amount and limitation''; and
       (2) in subsection (b)--
       (A) by redesignating paragraph (4) as paragraph (5); and
       (B) by inserting after paragraph (3) the following new 
     paragraph (4):
       ``(4) The term `education debt reduction amount and 
     limitation' means the maximum amount of assistance, and the 
     limitation applicable to such assistance, for a person 
     receiving assistance under subchapter VI of this chapter, as 
     specified in section 7663 of this title and as previously 
     adjusted (if at all) in accordance with this subsection.''.
       (c) Regulations.--The Secretary of Veterans Affairs shall 
     prescribe regulations necessary to carry out the Education 
     Debt Reduction Program established under subchapter VI of 
     chapter 76 of title 38, United States Code (as added by 
     subsection (a)). The Secretary shall prescribe such 
     regulations not later than 90 days after the date of the 
     enactment of this Act.
       (d) Report.--Section 7632 of title 38, United States Code, 
     is amended--
       (1) in the matter above paragraph (1), by inserting ``and 
     the Education Debt Reduction Program'' before the period at 
     the end;
       (2) in paragraph (1)--
       (A) by inserting ``and the Education Debt Reduction 
     Program'' after ``Educational Assistance Program'';
       (B) by striking out ``Program and'' and inserting in lieu 
     thereof ``Program,''; and
       (C) by inserting ``, and the Education Debt Reduction 
     Program'' before ``separately'';
       (3) in paragraph (3), by striking out ``the Educational 
     Assistance Program (or predecessor program) has'' and 
     inserting in lieu thereof ``each of the Educational 
     Assistance Program (or predecessor program) and the Education 
     Debt Reduction Program have'';
       (4) in paragraph (4)--
       (A) by striking out ``and per'' and inserting in lieu 
     thereof ``, per''; and
       (B) by inserting ``, and per participant in the Education 
     Debt Reduction Program'' before the period at the end.
       (e) Exemption From Taxation.--Section 7636 of title 38, 
     United States Code, is amended--
       (1) by inserting ``(a)'' before ``Notwithstanding''; and
       (2) by adding at the end the following:
       ``(b) Notwithstanding any other law, any payment on behalf 
     of a participant in the Education Debt Reduction Program for 
     the tuition or other costs referred to in section 7662(a)(4) 
     of this title shall be exempt from taxation.''.
       (f) Authorization of Appropriations.--(1) There is 
     authorized to be appropriated for the Department of Veterans 
     Affairs $10,000,000 for each of fiscal years 1994 through 
     1998 to carry out the Education Debt Reduction Program.
       (2) No funds may be used to provide assistance under the 
     program unless expressly provided for in an appropriations 
     Act.
       (g) Exemption From Limitation.--Section 523(b) of the 
     Veterans Health Care Act of 1992 (Public Law 102-585; 38 
     U.S.C. 7601 note) shall not apply to the Education Debt 
     Reduction Program.
                      Subtitle B--Other Provisions

     SEC. 311. EXTENSION OF AUTHORITY OF ADVISORY COMMITTEE ON 
                   EDUCATION.

       Section 3692(c) of title 38, United States Code, is amended 
     by striking out ``December 31, 1993'' and inserting in lieu 
     thereof ``December 31, 1997''.

     SEC. 312. EXTENSION OF AUTHORITY TO MAINTAIN REGIONAL OFFICE 
                   IN THE PHILIPPINES.

       Section 315(b) of title 38, United States Code, is amended 
     by striking out ``March 31, 1994'' and inserting in lieu 
     thereof ``September 30, 1995''.


                           Amendment No. 1747

 (Purpose: To revise the services covered by the term ``women's health 
service'', to make discretionary the requirement that the Secretary of 
     Veterans Affairs establish smoking areas in facilities of the 
        Department of Veterans Affairs, and for other purposes)

  Mr. MITCHELL. Mr. President, on behalf of Senator Rockefeller I send 
an amendment to the desk and ask for its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative cleark read as follows:

       The Senator from Maine [Mr. Mitchell], for Mr. Rockefeller, 
     proposes an amendment numbered 1747:

       On page 10, strike out ``1993'' and insert in lieu thereof 
     ``1994''.
       On page 21, strike out line 11 and all that follows through 
     page 21, line 20, and insert in lieu thereof the following:
       ``(A) Papanicolaou tests (pap smears).
       ``(B) Breast examinations and mammography.
       ``(C) Maternity care, including pre-natal care, delivery, 
     and post-natal care.
       ``(D) Menopause.''.
       On page 30, line 7, strike out ```December 31, 1993''' and 
     insert in lieu thereof ```June 30, 1994'''.
       On page 30, strike out line 9 and all that follows through 
     page 33, line 7, and insert in lieu thereof the following:

     SEC. 202. EXTENSION OF PERIOD OF ELIGIBILITY FOR PRIORITY 
                   HEALTH CARE FOR VETERANS OF THE PERSIAN GULF 
                   WAR.

       (a) Inpatient Care.--Section 1710(e)(3) of title 38, United 
     States Code, is amended by striking out ``after December 31, 
     1994'' and inserting in lieu thereof ``after September 30, 
     2003''.
       (b) Outpatient Care.--Section 1712(a)(1)(D) of such title 
     is amended by striking out ``before December 31, 1994'' and 
     inserting in lieu thereof ``before October 1, 2003''.
       On page 52, between lines 11 and 12, insert the following:

     SEC. 206. REVISION OF AUTHORITY ON USE OF TOBACCO PRODUCTS IN 
                   DEPARTMENT FACILITIES.

       Section 526(a) of the Veterans Health Care Act of 1992 
     (Public Law 102-585; 38 U.S.C. 1715 note) is amended--
       (1) in paragraph (1), by striking out ``establishes and 
     maintains--'' and inserting in lieu thereof ``may establish 
     and maintain--''; and
       (2) in paragraph (2), by striking out ``provides access'' 
     and all that follows through ``paragraph (1)'' and inserting 
     in lieu thereof ``if such an area is established, provides 
     access to the area''.
       On page 60, line 7, strike out ```December 31, 1993''' and 
     insert in lieu thereof ```December 31, 1994'''.
       On page 60, line 12, strike out ```March 31, 1994''' and 
     insert in lieu thereof ```December 31, 1994'''.
  The PRESIDING OFFICER. If there is no objection, the amendment is 
agreed.
  So the amendment (No. 1747) was agreed to.
  Mr. ROCKEFELLER. Mr. President, as the chairman of the Committee on 
Veterans' Affairs, I urge my colleagues to support the passage of the 
pending measure, S. 1030, the proposed Veterans Health Programs 
Improvement Act of 1994, as reported by the Committee on September 8, 
1993 and as it will be amended by an amendment I will offer.
  This is a vitally important bill that encompasses many different 
programs, which will help millions of veterans.
  Mr. President, the proposed ``Veterans Health Programs Improvement 
Act of 1994'' has three titles: Women Veterans; General Health Care 
Services; and Miscellaneous, which has two subtitles, Educational Debt 
Reduction and Other Provisions.
  Mr. President, I refer my colleagues to the committee's report 
accompanying S. 1030 (Senate Report 103-136). Because the provisions of 
the legislation are described in detail in that report, I will now 
highlight the provisions of the bill as it will be amended.

                        TITLE I--WOMEN VETERANS


     department of veterans affairs sexual trauma services program

       Mr. President, the provisions in title I relating to sexual 
     trauma services are derived, in part, from S. 2973 of the 
     102nd Congress that was ultimately enacted as the Veterans 
     Health Care Act of 1992 (Public Law 102-585), an omnibus 
     veterans health measure.
       Mr. President, this legislation would extend the entire 
     sexual trauma counseling program within VA. Under current 
     law, VA's authority to carry out this program would expire on 
     December 31, 1995. VA needs more time to reach the veterans 
     who need these services.
       In addition, this legislation would repeal the restriction 
     in current law that requires women veterans to seek sexual 
     trauma counseling within two years of discharge from active 
     duty, and it would also repeal the one year time limit during 
     which a veteran could receive VA care for sexual trauma.
       Women veterans have served with dignity and courage in all 
     battles since the American Revolution, and we must ensure 
     that if a veteran is raped or sexually assaulted while 
     serving on active duty, he or she must be able to seek care 
     at any point after leaving the service and get care for as 
     long as is necessary.


  reports relating to determinations of service connection for sexual 
                                 trauma

       S. 1030 would also require the Secretary to complete a 
     study on the difficulties veterans encounter in obtaining VA 
     determination that disabilities resulting from sexual trauma 
     are service connected and the extent to which VA personnel 
     fail to make such determinations.


                    coordinators of women's services

       S. 1030 would improve the women veterans coordinator 
     program. The bill would require that each coordinator serve 
     on a full-time basis; that each regional coordinator 
     facilitate communcation between women veterans coordinators 
     at VAMCs and VA officials; and require VA to provide to 
     coordinators adequate clerical and communications support.


                        women's health services

       S. 1030, as amended, would expand the list of women's 
     health services offered by VA from that enacted last 
     Congress. Under current law, VA is authorized to provide pap 
     smears, mammograms, very limited reproductive services, and 
     services for menopause. Under S. 1030 as amended, this list 
     would replace limited reproductive services (which does not 
     include maternity services) with maternity services, which is 
     defined as prenatal care, delivery services, and postnatal 
     care. The modification would require VA to furnish, directly 
     or by contract, all of these services to women veterans who 
     are eligible for them. S. 1030 makes no change in existing 
     law with regard to abortion.


            expansion of research relating to women veterans

       S. 1030 would amend provisions in Public Law 102-585 in 
     order to further improve and expand VA research relating to 
     women veterans' health care needs. The proposed bill provides 
     more specific direction to the Secretary with regard to VA's 
     responsibility to foster and encourge medical research 
     relating to the health care needs of women veterans.


                     mammography quality standards

       The proposed bill would attempt to ensure that women 
     veterans will receive safe and accurate mammograms. The bill 
     requires the Secretary to promulgate quality assurance and 
     quality control regulations for VA facilities that furnish 
     mammography that are no less stringent than regulations to 
     which other mammography providers are subject under the 
     Mammography Quality Standards Act of 1992.

                 Title II--General Health Care Services


  extension of period of eligibility for medical care for exposure to 
                      dioxin or ionizing radiation

       Mr. President, I am also pleased that this legislation 
     includes provisions relating to eligibility for medical care 
     for exposure to dioxin or ionizing radiation.
       This bill extends--from June 30 of this year to September 
     31, 2003--health care eligibility for veterans exposed to 
     Agent Orange or other herbicides in Vietnam or exposed to 
     radiation during participation in the nuclear weapons testing 
     program or the American occupation of Hiroshima or Nagasaki, 
     Japan, even if there is insufficient medical evidence to 
     prove service-connection.
       These provisions also symbolize Congress' resolve to help 
     veterans who were poorly informed or misinformed about their 
     exposures to chemicals or atomic radiation. In essence, we 
     will be telling these veterans that Congress is committed to 
     providing the needed health care, even if the nature of their 
     exposure makes it difficult to establish scientific proof 
     that their exposures caused specific illnesses.


 extension of authority to provide priority health care to veterans of 
                          the Persian gulf war

       Mr. President, our feelings of victory after the Persian 
     Gulf War have been tempered because of concerns about the 
     health of Desert Shield and Desert Storm veterans. Although 
     it may take years to determine all the causes of the 
     mysterious illnesses experienced by our Persian Gulf War 
     veterans, we must move quickly to provide medical care to 
     those veterans who are suffering from these illnesses.
       In this regard, the pending measure includes a provision 
     extending--from December 31, 1994 until September 30, 2003--
     VA's authority to provide priority health care to veterans of 
     the Persian Gulf War. The provision is based on an amendment 
     proposed by Committee members Tom Daschle and James Jeffords 
     at our July 1, 1993, markup of S. 1030.


            programs for furnishing hospice care to veterans

       S. 1030 would require VA to set up demonstration projects 
     at 15 to 30 VA sites to evaluate the best way to provide 
     hospice care.


                    rural health-care clinic program

       S. 1030 would require VA to establish and evaluate three 
     different types of programs for furnishing health care 
     services to veterans living in areas geographically remote 
     from VA facilities. Provisions relating to the rural health-
     care clinic program are identical to S. 452, which was 
     originally introduced by Senator Conrad.


 payment to states of per diem for veterans receiving adult day health 
                                  care

       S. 1030 would authorize VA to make per diem payments, at a 
     rate determined by the Secretary, for each eligible veteran 
     receiving adult day health care in a State Home. Further, 
     this bill would authorize VA to provide grants to States to 
     help with the cost of expanding or remodeling State Veterans 
     Home facilities for the purpose of furnishing adult day 
     health care. Provisions relating to state veterans home 
     facilities are identical to S. 852, which was introduced by 
     Senator Conrad.

                        Title III--Miscellaneous

              Subtitle A--Education Debt Reduction Program

       Mr. President, the proposed ``Veterans Health Programs 
     Improvement Act of 1994'' would establish a student loan 
     repayment program for certain VA health care professionals 
     who have completed or are completing a 2-year or 4-year 
     course of training at an undergraduate institution or a 
     course of training at a graduate institution, which qualifies 
     them to serve in occupations, specialities, or geographic 
     areas where it is difficult to recruit and retain qualified 
     employees. Provisions relating to the education debt 
     reduction program are derived from S. 1122, which was 
     introduced by Senator Mikulski and modified by an amendment 
     by Senator Rockefeller.

                      Subtitle B--Other Provisions


       extension of authority of advisory committee on education

       The proposed bill would extend VA's authority to maintain a 
     Veterans' Advisory Committee on Education for 3 years, from 
     December 31, 1994, to December 31, 1997.


 extension of authority to maintain regional office in the philippines

       The proposed bill would extend VA's authority to maintain a 
     regional office in the Republic of the Philippines from 
     December 31, 1994, to September 30, 1995.


                     smoking areas in va hospitals

       As amended, S. 1030 would modify existing law--section 
     526(a) of Public Law 102-585--to make the establishment of 
     smoking areas in VA hospitals subject to the discretion of 
     the Secretary of Veterans Affairs. However, it would maintain 
     mandatory provisions relating to access and ventilation for 
     those smoking areas that are established.


                               conclusion

       Mr. President, in closing, I thank our Committee's Ranking 
     Republican Member, Senator Murkowski, for his cooperation and 
     help with this bill. I am also grateful to many other members 
     of the Committee for their support on this measure.
       In addition, with regard to the women's health provisions, 
     I also want to express my gratitude to Senators Barbara 
     Boxer, Barbara Mikulski, and Patty Murray, for their 
     unwavering support for women veterans, and for all American 
     women.
       The Committee believes that this bill is an important step 
     forward, especially in the area of women's health services. I 
     believe that VA will need to significantly broaden its 
     services to provide comprehensive health care services for 
     men and women, if it is to successfully compete under health 
     care reform, and if it is to meet the needs of all American 
     veterans.
       Thank you, Mr. President.
  Ms. MIKULSKI. Mr. President, many services, especially primary care 
and preventive services, are not currently available at all VA medical 
facilities. I would like to have the views of my colleague, the 
committee chairman [Mr. Rockefeller], on how this bill fits in with his 
plans regarding legislative reform of the VA medical system.
  Mr. ROCKEFELLER. Mr. President, as my good friend, the chair of the 
VA-HUD Subcommittee on Appropriations, appreciates better than most, 
the VA medical system does not provide comprehensive health care 
services to either men or women. This bill is an important step, but 
must not be the only step, toward making essential health care services 
available to all veterans, including those women who served our country 
so well but have not been well served by the VA.
  Ms. MIKULSKI. Mr. President, all American women, including women 
veterans, deserve a basic benefits package that includes the wide range 
of services needed to keep them well, to prevent diseases as well as 
treat them, and to provide services to treat and manage heart disease, 
mental illness, and respiratory problems, to provide comprehensive 
reproductive services, including pregnancy-related services, and to 
treat menopause, osteoporosis, and many other health problems. I know 
my friend from West Virginia agrees. My concern, Mr. President, is 
whether this bill in any way undermines efforts to provide such 
services to veterans under health care reform.
  Mr. ROCKEFELLER. Mr. President, on the contrary, I am convinced that 
this bill will help prepare the VA for the more comprehensive services 
that health care reform will require. This bill will require the VA to 
provide essential services that will save women's lives--services that 
the VA has not always provided in the past. If the VA is to survive and 
thrive under health care reform, VA health plans must provide the same 
basic package of services that will be available to all other 
Americans. I share the strong commitment of my good friend from 
Maryland that we pass a health care reform bill that provides a truly 
comprehensive basic benefit package for all Americans, and that for the 
first time gives every veteran the opportunity to obtain comprehensive 
health care services through the VA medical system or through other 
health care providers. I will do everything I can to make that happen.
  Mr. MURKOWSKI. Mr. President, I would like to have the views of my 
colleague, the committee chairman [Mr. Rockefeller], regarding the 
impact of provisions in the pending bill relating to health care for 
women veterans in VA facilities. First, I am interested in knowing 
whether he believes that the provision that would authorize VA to 
furnish maternity care to women veterans would authorize VA to provide 
neonatal care to the child of a woman veteran?
  Mr. ROCKEFELLER. Mr. President, the legislation would authorize VA to 
furnish maternity care to women veterans, but would not authorize VA to 
furnish neonatal care to the children of these veterans. Without 
express authority to furnish such care, VA would have no basis for 
caring for a veteran's child.
  Mr. President, the purpose of the provision in the bill is that a 
woman veteran receive prenatal, delivery, and postnatal care. Given 
VA's history of not furnishing such care, I fully expect that delivery 
services will be contracted out to non-VA facilities--such as DOD 
facilities and medical school affiliates of VA medical centers. This 
would ensure that, while there will be no disruption of care between 
the time of delivery and neonatal care, VA's obligation to pay for the 
delivery can and will be segregated from the cost of the child's care.
  Mr. MURKOWSKI. Mr. President, I am also concerned about the 
possibility that VA would spend its limited construction funds to build 
delivery suites and to open obstetrical and gynecological clinics to 
provide the services we are authorizing, and I am interested in the 
chairman's views on that.
  Mr. ROCKEFELLER. Mr. President, that is not our intention. Instead, 
as I just noted, we fully expect VA to contract with other conveniently 
located and high quality facilities to provide delivery services, such 
as DOD facilities and medical school affiliates.
  Mr. President, under health care reform, VA will rely very heavily on 
contract agreements with other providers in their service area to 
provide services in closer proximity to the veteran and for services 
for which they do not have the expertise, such as pediatrics. This will 
be an opportunity for VA to further enhance these key relationships.
  Mr. MURKOWSKI. Finally, Mr. President, does the inclusion of 
authority to furnish delivery services in title 38 provide new 
authority for abortion procedures in VA hospitals?
  Mr. ROCKEFELLER. Mr. President, no, these provisions would have no 
effect on current law regarding abortion procedures for veterans.
  Mr. MITCHELL. Mr. President, I ask unanimous consent, the amendment 
having been agreed to, that the committee substitute, as amended, be 
agreed to, the bill read a third time, passed, the motion to reconsider 
be laid upon the table; that the title amendment be agreed to and that 
any statements appear at the appropriate place in the Record.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  So the bill (S. 1030), as amended, was passed, as follows:

                                S. 1030

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Veterans 
     Health Programs Improvement Act of 1994''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

                        TITLE I--WOMEN VETERANS

Sec. 101. Department of Veterans Affairs sexual trauma services 
              program.
Sec. 102. Reports relating to determinations of service connection for 
              sexual trauma.
Sec. 103. Coordinators of women's services.
Sec. 104. Women's health services.
Sec. 105. Expansion of research relating to women veterans.
Sec. 106. Mammography quality standards.

                 TITLE II--GENERAL HEALTH CARE SERVICES

Sec. 201. Extension of period of eligibility for medical care for 
              exposure to dioxin or ionizing radiation.
Sec. 202. Extension of period of eligibility for priority health care 
              for veterans of the Persian Gulf War.
Sec. 203. Programs for furnishing hospice care to veterans.
Sec. 204. Rural health-care clinic program.
Sec. 205. Payment to States of per diem for veterans receiving adult 
              day health care.
Sec. 206. Revision of authority on use of tobacco products in 
              department facilities.

                        TITLE III--MISCELLANEOUS

              Subtitle A--Education Debt Reduction Program

Sec. 301. Short title.
Sec. 302. Program of assistance in the payment of education debts 
              incurred by certain Veterans Health Administration 
              employees.

                      Subtitle B--Other Provisions

Sec. 311. Extension of authority of Advisory Committee on Education.
Sec. 312. Extension of authority to maintain regional office in the 
              Philippines.
                        TITLE I--WOMEN VETERANS

     SEC. 101. DEPARTMENT OF VETERANS AFFAIRS SEXUAL TRAUMA 
                   SERVICES PROGRAM.

       (a) Authority To Provide Services for Sexual Trauma.--(1) 
     Subsection (a)(1) of section 1720D of title 38, United States 
     Code is amended--
       (A) by inserting ``(A)'' before ``During the period''; and
       (B) by adding at the end the following:
       ``(B) During the period referred to in subparagraph (A), 
     the Secretary may provide appropriate care and services to a 
     veteran for an injury, illness, or other psychological 
     condition which the Secretary determines to be the result of 
     a physical assault, battery, or harassment referred to in 
     that subparagraph.''.
       (2) Subsection (c)(1) of such section is amended to read as 
     follows:
       ``(1) The Secretary shall give priority to the 
     establishment and operation of the program to provide 
     counseling and care and services under subsection (a). In the 
     case of a veteran eligible for counseling and care and 
     services under subsection (a)(1), the Secretary shall ensure 
     that the veteran is furnished counseling under this section 
     in a way that is coordinated with the furnishing of such care 
     and services under this chapter.''.
       (3) Subsection (d) of such section is amended by inserting 
     ``and care and services'' after ``counseling'' each place it 
     appears.
       (b) Authority To Provide Services by Contract.--Subsection 
     (a)(3) of such section is amended--
       (1) by inserting ``(A)'' before ``In furnishing'';
       (2) in subparagraph (A), as so designated--
       (i) by striking out ``(A)'' and inserting in lieu thereof 
     ``(i)''; and
       (ii) by striking out ``(B)'' and inserting in lieu thereof 
     ``(ii)''; and
       (3) by adding at the end the following:
       ``(B) The Secretary may provide care and services to a 
     veteran under paragraph (1)(B) pursuant to a contract with a 
     qualified non-Department health professional or facility if 
     Department facilities are not capable of furnishing such care 
     and services to that veteran economically because of 
     geographic inaccessibility.''.
       (c) Extension of Authority To Provide Sexual Trauma 
     Services.--Subsection (a) of such section, as amended by 
     subsections (a) and (b) of this section, is further amended--
       (1) by striking out ``December 31, 1995,'' in paragraph 
     (1)(A) and inserting in lieu thereof ``December 31, 1998,''; 
     and
       (2) by striking out ``December 31, 1994,'' in paragraph (3) 
     and inserting in lieu thereof ``December 31, 1998,''.
       (d) Period of Eligibility To Seek Services.--(1) Such 
     subsection, as amended by subsections (a), (b), and (c) of 
     this section, is further amended--
       (A) by striking out paragraph (2); and
       (B) by redesignating paragraph (3) as paragraph (2).
       (2) Section 102(b) of the Veterans Health Care Act of 1992 
     (Public Law 102-585; 106 Stat. 4946; 38 U.S.C. 1720D note) is 
     repealed.
       (e) Repeal of Limitation on Period of Receipt of 
     Services.--Section 1720D of title 38, United States Code (as 
     amended by subsections (a) through (d) of this section), is 
     further amended--
       (1) by striking out subsection (b); and
       (2) by redesignating subsections (c), (d), and (e) as 
     subsections (b), (c), and (d), respectively.
       (f) Increased Priority of Care.--Section 1712(i) of title 
     38, United States Code, is amended--
       (1) in paragraph (1)--
       (A) by inserting ``(A)'' after ``To a veteran''; and
       (B) by inserting ``, or (B) who is eligible for counseling 
     and care and services under section 1720D of this title, for 
     the purposes of such counseling and care and services'' 
     before the period at the end; and
       (2) in paragraph (2)--
       (A) by striking out ``, (B)'' and inserting in lieu thereof 
     ``or (B)''; and
       (B) by striking out ``, or (C)'' and all that follows 
     through ``such counseling''.
       (g) Program Revision.--(1) Section 1720D of title 38, 
     United States Code (as amended by subsections (a) through (e) 
     of this section), is further amended--
       (A) by striking out ``woman'' in subsection (a)(1)(A);
       (B) by striking out ``women'' in subsection (b)(2)(C) and 
     in the first sentence of subsection (c); and
       (C) by striking out ``women'' in subsection (c)(2) and 
     inserting in lieu thereof ``individuals''.
       (2)(A) The heading of such section is amended to read as 
     follows:

     ``Sec. 1720D. Counseling, care, and services for sexual 
       trauma''.

       (B) The item relating to such section in the table of 
     sections at the beginning of chapter 17 of such title is 
     amended to read as follows:

``1720D. Counseling, care, and services for sexual trauma.''.
       (h) Information on Counseling by Telephone.--(1) Paragraph 
     (1) of section 1720D(c) of title 38, United States Code, as 
     redesignated by subsection (d) of this section, is amended by 
     striking out ``may'' and inserting in lieu thereof ``shall''.
       (2) In providing information on counseling available to 
     veterans through the information system required under 
     section 1720D(c)(1) of title 38, United States Code, as 
     amended by this section, the Secretary of Veterans Affairs 
     shall ensure--
       (A) that the telephone system described in such section is 
     operated by Department of Veterans Affairs personnel who are 
     trained in the provision to persons who have experienced 
     sexual trauma of information about the counseling and care 
     and services relating to sexual trauma that are available to 
     veterans in the communities in which such veterans reside, 
     including counseling and care and services available under 
     programs of the Department (including the care and services 
     available under section 1720D of such title) and from non-
     Department agencies or organizations;
       (B) that such personnel are provided with information on 
     the counseling and care and services relating to sexual 
     trauma that are available to veterans and the locations in 
     which such care and services are available;
       (C) that such personnel refer veterans seeking such 
     counseling and care and services to appropriate providers of 
     such counseling and care and services (including counseling 
     and care and services that are available in the communities 
     in which such veterans reside);
       (D) that the telephone system is operated in a manner that 
     protects the confidentiality of persons who place telephone 
     calls to the system; and
       (E) that the telephone system operates at all times.
       (3) The Secretary shall ensure that information about the 
     availability of the telephone system is visibly posted in 
     Department medical facilities and is advertised through 
     public service announcements, pamphlets, and other means.
       (4) Not later than 18 months after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the operation of the telephone system required 
     under section 1720D(c)(1) of title 38, United States Code (as 
     so amended). The report shall set forth the following:
       (A) The number of telephone calls placed to the system 
     during the period covered by the report, with a separate 
     display of (i) the number of calls placed to the system from 
     each State (as such term is defined in section 101(20) of 
     title 38, United States Code) during that period, and (ii) 
     the number of persons who placed more than one call to the 
     system during that period.
       (B) The types of sexual trauma described to personnel 
     operating the system by persons placing calls to the system.
       (C) A description of the difficulties, if any, experienced 
     by persons placing calls to the system in obtaining 
     counseling and care and services for sexual trauma in the 
     communities in which such persons live, including counseling 
     and care and services available from the Department and from 
     non-Department agencies and organizations.
       (D) A description of the training provided to the personnel 
     operating the system.
       (E) The recommendations and plans of the Secretary for the 
     improvement of the system.
       (5) The Secretary shall commence operation of the telephone 
     system required under section 1720D(c)(1) of title 38, United 
     States Code (as so amended), not later than 180 days after 
     the date of the enactment of this Act.

     SEC. 102. REPORTS RELATING TO DETERMINATIONS OF SERVICE 
                   CONNECTION FOR SEXUAL TRAUMA.

       (a) Report.--(1) The Secretary of Veterans Affairs shall 
     submit to the Committees on Veterans' Affairs of the Senate 
     and House of Representatives a report containing the 
     Secretary's assessment of--
       (A) the difficulties that veterans encounter in obtaining 
     from the Department of Veterans Affairs determinations that 
     disabilities relating to sexual trauma resulting from events 
     that occurred during active duty are service-connected 
     disabilities; and
       (B) the extent to which Department personnel fail to make 
     determinations that such disabilities are service-connected 
     disabilities.
       (2) The Secretary shall include in the report the 
     Secretary's recommendations for actions to be taken to 
     respond in a fair manner to the difficulties described in the 
     report and to eliminate failures to make determinations that 
     such disabilities are service-connected disabilities.
       (3) The report required by this subsection shall be 
     submitted not later than June 30, 1994.
       (b) Follow-Up Reports.--Not later than June 30 of each of 
     1995 and 1996, the Secretary shall submit to the committees 
     referred to in paragraph (1) of subsection (a) a report on 
     the actions taken by the Secretary to implement the 
     recommendations referred to in paragraph (2) of that 
     subsection.
       (c) Definition.--In this section, the term ``sexual 
     trauma'' means the immediate and long-term physical or 
     psychological trauma resulting from rape, sexual assault, 
     aggravated sexual abuse (as such term is described in section 
     2241 of title 18, United States Code), sexual harassment, or 
     other act of sexual violence.

     SEC. 103. COORDINATORS OF WOMEN'S SERVICES.

       (a) Requirement of Full-time Service.--Section 108 of the 
     Veterans Health Care Act of 1992 (Public Law 102-585; 106 
     Stat. 4948; 38 U.S.C. 1710 note) is amended--
       (1) by inserting ``(a)'' before ``The Secretary''; and
       (2) by adding at the end the following:
       ``(b) Each official who serves in the position of 
     coordinator of women's services under subsection (a) shall so 
     serve on a full-time basis.''.
       (b) Additional Responsibilities.--Subsection (a) of such 
     section (as designated by subsection (a) of this section) is 
     further amended--
       (1) by redesignating paragraph (5) as paragraph (6); and
       (2) by inserting after paragraph (4) the following new 
     paragraph (5):
       ``(5) Facilitating communication between women veterans 
     coordinators under the jurisdiction of such regional 
     coordinator and the Under Secretary for Health and the 
     Secretary.''.
       (c) Support for Women's Services Coordinators.--The 
     Secretary of Veterans Affairs shall take appropriate actions 
     to ensure that--
       (1) sufficient funding is provided to each Department of 
     Veterans Affairs facility in order to permit the coordinator 
     of women's services to carry out the responsibilities of the 
     coordinator at the facility;
       (2) sufficient clerical and communications support is 
     provided to each such coordinator for that purpose; and
       (3) each such coordinator has direct access to the Director 
     or Chief of Staff of the facility to which the coordinator is 
     assigned.

     SEC. 104. WOMEN'S HEALTH SERVICES.

       (a) Women's Health Services.--Section 1701 of title 38, 
     United States Code, is amended--
       (1) in paragraph (6)(A)(i), by inserting ``women's health 
     services,'' after ``preventive health services,''; and
       (2) by adding at the end the following:
       ``(10) The term `women's health services' means health care 
     services provided to women, including counseling and services 
     relating to the following:
       ``(A) Papanicolaou tests (pap smears).
       ``(B) Breast examinations and mammography.
       ``(C) Maternity care, including pre-natal care, delivery, 
     and post-natal care.
       ``(D) Menopause.''.
       (b) Contracts for Women's Health Services.--Section 1703(a) 
     of such title is amended by adding at the end the following:
       ``(9) Women's health services for veterans on an ambulatory 
     or outpatient basis.''.
       (c) Repeal of Superseded Authority.--Section 106 of the 
     Veterans Health Care Act of 1992 (Public Law 102-585; 38 
     U.S.C. 1710 note) is amended--
       (1) by striking out subsection (a); and
       (2) by striking out ``(b) Responsibilities of Directors of 
     Facilities.--'' before ``The Secretary''.
       (d) Report on Health Care and Research.--Section 107(b) of 
     such Act (38 U.S.C. 1710 note) is amended--
       (1) in paragraph (1), by inserting ``and women's health 
     services (as such term is defined in section 1701(10) of 
     title 38, United States Code)'' after ``section 106 of this 
     Act'';
       (2) in paragraph (2), by striking out ``and (B)'' and 
     inserting in lieu thereof ``(B) the type and amount of 
     services provided by such personnel, including information on 
     the numbers of inpatient stays and the number of outpatient 
     visits through which such services were provided, and (C)'';
       (3) by redesignating paragraph (4) as paragraph (7);
       (4) by adding after paragraph (3) the following new 
     paragraphs:
       ``(4) A description of the personnel of the Department who 
     provided such services to women veterans, including the 
     number of employees (including both the number of individual 
     employees and the number of full-time employee equivalents) 
     and the professional qualifications or specialty training of 
     such employees and the Department facilities to which such 
     personnel were assigned.
       ``(5) A description of any actions taken by the Secretary 
     to ensure the retention of the personnel described in 
     paragraph (4), and any actions undertaken to recruit 
     additional such personnel or personnel to replace such 
     personnel.
       ``(6) An assessment by the Secretary of any difficulties 
     experienced by the Secretary in the furnishing of such 
     services and the actions taken by the Secretary to resolve 
     such difficulties.''; and
       (5) by adding after paragraph (7), as redesignated by 
     paragraph (3) of this subsection, the following:
       ``(8) A description of the actions taken by the Secretary 
     to foster and encourage the expansion of such research.''.

     SEC. 105. EXPANSION OF RESEARCH RELATING TO WOMEN VETERANS.

       (a) Health Research.--Section 109(a) of the Veterans Health 
     Care Act of 1992 (Public Law 102-585; 38 U.S.C. 7303 note) is 
     amended--
       (1) by inserting ``(1)'' before ``The Secretary'';
       (2) in paragraph (1), as so designated, by striking out 
     ``veterans who are women'' and inserting in lieu thereof 
     ``women veterans''; and
       (3) by adding at the end the following:
       ``(2) In carrying out this section, the Secretary shall 
     consult with the following:
       ``(A) The Director of the Nursing Service.
       ``(B) Officials of the Central Office assigned 
     responsibility for women's health programs and sexual trauma 
     services.
       ``(C) The members of the Advisory Committee on Women 
     Veterans established under section 542 of title 38, United 
     States Code.
       ``(D) Members of appropriate task forces and working groups 
     within the Department of Veterans Affairs (including the 
     Women Veterans Working Group and the Task Force on Treatment 
     of Women Who Suffer Sexual Abuse).
       ``(3) The Secretary shall foster and encourage research 
     under this section on the following matters as they relate to 
     women:
       ``(A) Breast cancer.
       ``(B) Gynecological and reproductive health, including 
     gynecological cancer, infertility, sexually-transmitted 
     diseases, and pregnancy.
       ``(C) Human Immunodeficiency Virus and Acquired Immune 
     Deficiency Syndrome.
       ``(D) Mental health, including post-traumatic stress 
     disorder and depression.
       ``(E) Diseases related to aging, including menopause, 
     osteoporosis, and Alzheimer's Disease.
       ``(F) Substance abuse.
       ``(G) Sexual violence and related trauma.
       ``(H) Exposure to toxic chemicals and other environmental 
     hazards.
       ``(4) The Secretary shall, to the maximum extent 
     practicable, ensure that personnel of the Department of 
     Veterans Affairs engaged in the research referred to in 
     paragraph (1) include the following:
       ``(A) Personnel of the geriatric research, education, and 
     clinical centers designated pursuant to section 7314 of title 
     38, United States Code.
       ``(B) Personnel of the National Center for Post-Traumatic 
     Stress Disorder established pursuant to section 110(c) of the 
     Veterans Health Care Act of 1984 (Public Law 98-528; 98 Stat. 
     2692).
       ``(5) The Secretary shall, to the maximum extent 
     practicable, ensure that personnel of the Department engaged 
     in research relating to the health of women veterans are 
     advised and informed of such research engaged in by other 
     personnel of the Department.''.
       (b) Population Study.--Section 110(a) of such Act (38 
     U.S.C. 1710 note) is amended--
       (1) in paragraph (1), by striking out the second sentence; 
     and
       (2) by amending paragraph (3) to read as follows:
       ``(3)(A) Subject to subparagraph (B), the study shall be 
     based on--
       ``(i) an appropriate sample of veterans who are women and 
     of women who are serving on active military, naval, or air 
     service; and
       ``(ii) an examination of the medical and demographic 
     histories of the women comprising such sample.
       ``(B) The sample referred to in subparagraph (A) shall, to 
     the maximum extent practicable, constitute a representative 
     sampling (as determined by the Secretary) of the ages, the 
     ethnic, social and economic backgrounds, the enlisted and 
     officer grades, and the branches of service of all veterans 
     who are women and women who are serving on such duty.
       ``(C) In carrying out the examination referred to in 
     subparagraph (A)(ii), the Secretary shall determine the 
     number of women of the sample who have used medical 
     facilities of the Department, nursing home facilities of or 
     under the jurisdiction of the Department, and outpatient care 
     facilities of or under the jurisdiction of the Department.''.

     SEC. 106. MAMMOGRAPHY QUALITY STANDARDS.

       (a) Performance of Mammograms.--Mammograms may not be 
     performed at a Department of Veterans Affairs facility unless 
     that facility is accredited for that purpose by a private 
     nonprofit organization designated by the Secretary of 
     Veterans Affairs. The organization designated by the 
     Secretary under this subsection shall meet the standards for 
     accrediting bodies established by the Secretary of Health and 
     Human Services under section 354(e) of the Public Health 
     Service Act (42 U.S.C. 263b(e)).
       (b) Quality Standards.--(1)(A) The Secretary of Veterans 
     Affairs shall prescribe quality assurance and quality control 
     standards relating to the performance and interpretation of 
     mammograms and use of mammogram equipment and facilities by 
     personnel of the Department of Veterans Affairs. Such 
     standards shall be no less stringent than the standards 
     prescribed by the Secretary of Health and Human Services 
     under section 354(f) of the Public Health Service Act.
       (B) In prescribing such standards, the Secretary of 
     Veterans Affairs shall consult with the Secretary of Health 
     and Human Services.
       (2) The Secretary of Veterans Affairs shall prescribe such 
     standards not later than 120 days after the Secretary of 
     Health and Human Services prescribes quality standards under 
     such section 354(f).
       (c) Inspection of Department Equipment.--(1) The Secretary 
     of Veterans Affairs shall, on an annual basis, inspect the 
     equipment and facilities utilized by and in Department of 
     Veterans Affairs health-care facilities for the performance 
     of mammograms in order to ensure the compliance of such 
     equipment and facilities with the standards prescribed under 
     subsection (b). Such inspection shall be carried out in a 
     manner consistent with the inspection of certified facilities 
     by the Secretary of Health and Human Services under section 
     354(g) of the Public Health Services Act.
       (2) The Secretary of Veterans Affairs may not delegate the 
     responsibility of such secretary under paragraph (1) to a 
     State agency.
       (d) Application of Standards to Contract Providers.--The 
     Secretary of Veterans Affairs shall ensure that mammograms 
     performed for the Department of Veterans Affairs under 
     contract with any non-Department facility or provider conform 
     to the quality standards prescribed by the Secretary of 
     Health and Human Services under section 354 of the Public 
     Health Service Act.
       (e) Report.--(1) The Secretary shall submit to the 
     Committees on Veterans' Affairs of the Senate and House of 
     Representatives a report on the quality standards prescribed 
     by the Secretary under subsection (b)(1).
       (2) The Secretary shall submit the report not later than 
     180 days after the date on which the Secretary prescribes 
     such regulations.
       (f) Definition.--In this section, the term ``mammogram'' 
     shall have the meaning given such term in section 354(a)(5) 
     of the Public Health Service Act (42 U.S.C. 263b(a)).
                 TITLE II--GENERAL HEALTH CARE SERVICES

     SEC. 201. EXTENSION OF PERIOD OF ELIGIBILITY FOR MEDICAL CARE 
                   FOR EXPOSURE TO DIOXIN OR IONIZING RADIATION.

       Section 1710(e)(3) of title 38, United States Code, is 
     amended by striking out ``June 30, 1994'' and inserting in 
     lieu thereof ``December 31, 2003''.

     SEC. 202. EXTENSION OF PERIOD OF ELIGIBILITY FOR PRIORITY 
                   HEALTH CARE FOR VETERANS OF THE PERSIAN GULF 
                   WAR.

       (a) Inpatient Care.--Section 1710(e)(3) of title 38, United 
     States Code, is amended by striking out ``after December 31, 
     1994'' and inserting in lieu thereof ``after September 30, 
     2003''.
       (b) Outpatient Care.--Section 1712(a)(1)(D) of such title 
     is amended by striking out ``before December 31, 1994'' and 
     inserting in lieu thereof ``before October 1, 2003''.

     SEC. 203. PROGRAMS FOR FURNISHING HOSPICE CARE TO VETERANS.

       (a) Establishment of Programs.--Chapter 17 of title 38, 
     United States Code, is amended by adding at the end the 
     following:


  ``subchapter vii--hospice care pilot program; hospice care services

     ``Sec. 1761. Definitions

       ``For the purposes of this subchapter--
       ``(1) The term `terminally ill veteran' means any veteran--
       ``(A) who is (i) entitled to receive hospital care in a 
     medical facility of the Department under section 1710(a)(1) 
     of this title, (ii) eligible for hospital or nursing home 
     care in such a facility and receiving such care, (iii) 
     receiving care in a State home facility for which care the 
     Secretary is paying per diem under section 1741 of this 
     title, or (iv) transferred to a non-Department nursing home 
     for nursing home care under section 1720 of this title and 
     receiving such care; and
       ``(B) who has a medical prognosis (as certified by a 
     Department physician) of a life expectancy of six months or 
     less.
       ``(2) The term `hospice care services' means (A) the care, 
     items, and services referred to in subparagraphs (A) through 
     (H) of section 1861(dd)(1) of the Social Security Act (42 
     U.S.C. 1395x(dd)(1)), and (B) personal care services.
       ``(3) The term `hospice program' means any program that 
     satisfies the requirements of section 1861(dd)(2) of the 
     Social Security Act (42 U.S.C. 1395x(dd)(2)).
       ``(4) The term `medical facility of the Department' means a 
     facility referred to in section 1701(4)(A) of this title.
       ``(5) The term `non-Department facility' means a facility 
     (other than a medical facility of the Department) at which 
     care to terminally ill veterans is furnished, regardless of 
     whether such care is furnished pursuant to a contract, 
     agreement, or other arrangement referred to in section 
     1762(b)(1)(D) of this title.
       ``(6) The term `personal care services' means any care or 
     service furnished to a person that is necessary to maintain a 
     person's health and safety within the home or nursing home of 
     the person, including care or services related to dressing 
     and personal hygiene, feeding and nutrition, and 
     environmental support.

     ``Sec. 1762. Hospice care: pilot program requirements

       ``(a)(1) During the period beginning on October 1, 1993, 
     and ending on December 31, 1998, the Secretary shall conduct 
     a pilot program in order--
       ``(A) to assess the feasibility and desirability of 
     furnishing hospice care services to terminally ill veterans; 
     and
       ``(B) to determine the most efficient and effective means 
     of furnishing such services to such veterans.
       ``(2) The Secretary shall conduct the pilot program in 
     accordance with this section.
       ``(b)(1) Under the pilot program, the Secretary shall--
       ``(A) designate not less than 15 nor more than 30 medical 
     facilities of the Department at or through which to conduct 
     hospice care services demonstration projects;
       ``(B) designate the means by which hospice care services 
     shall be provided to terminally ill veterans under each 
     demonstration project pursuant to subsection (c);
       ``(C) allocate such personnel and other resources of the 
     Department as the Secretary considers necessary to ensure 
     that services are provided to terminally ill veterans by the 
     designated means under each demonstration project; and
       ``(D) enter into any contract, agreement, or other 
     arrangement that the Secretary considers necessary to ensure 
     the provision of such services by the designated means under 
     each such project.
       ``(2) In carrying out the responsibilities referred to in 
     paragraph (1) the Secretary shall take into account the need 
     to provide for and conduct the demonstration projects so as 
     to provide the Secretary with such information as is 
     necessary for the Secretary to evaluate and assess the 
     furnishing of hospice care services to terminally ill 
     veterans by a variety of means and in a variety of 
     circumstances.
       ``(3) In carrying out the requirement described in 
     paragraph (2), the Secretary shall ensure, to the maximum 
     extent feasible, that--
       ``(A) the medical facilities of the Department selected to 
     conduct demonstration projects under the pilot program 
     include facilities located in urban areas of the United 
     States and rural areas of the United States;
       ``(B) the full range of affiliations between medical 
     facilities of the Department and medical schools is 
     represented by the facilities selected to conduct 
     demonstration projects under the pilot program, including no 
     affiliation, minimal affiliation, and extensive affiliation;
       ``(C) such facilities vary in the number of beds that they 
     operate and maintain; and
       ``(D) the demonstration projects are located or conducted 
     in accordance with any other criteria or standards that the 
     Secretary considers relevant or necessary to furnish and to 
     evaluate and assess fully the furnishing of hospice care 
     services to terminally ill veterans.
       ``(c)(1) Subject to paragraph (2), hospice care to 
     terminally ill veterans shall be furnished under a 
     demonstration project by one or more of the following means 
     designated by the Secretary:
       ``(A) By the personnel of a medical facility of the 
     Department providing hospice care services pursuant to a 
     hospice program established by the Secretary at that 
     facility.
       ``(B) By a hospice program providing hospice care services 
     under a contract with that program and pursuant to which 
     contract any necessary inpatient services are provided at a 
     medical facility of the Department.
       ``(C) By a hospice program providing hospice care services 
     under a contract with that program and pursuant to which 
     contract any necessary inpatient services are provided at a 
     non-Department medical facility.
       ``(2)(A) The Secretary shall provide that--
       ``(i) care is furnished by the means described in paragraph 
     (1)(A) at not less than five medical facilities of the 
     Department; and
       ``(ii) care is furnished by the means described in 
     subparagraphs (B) and (C) of paragraph (1) in connection with 
     not less than five such facilities for each such means.
       ``(B) The Secretary shall provide in any contract under 
     subparagraph (B) or (C) of paragraph (1) that inpatient care 
     may be provided to terminally ill veterans at a medical 
     facility other than that designated in the contract if the 
     provision of such care at such other facility is necessary 
     under the circumstances.
       ``(d)(1) Except as provided in paragraph (2), the amount 
     paid to a hospice program for care furnished pursuant to 
     subparagraph (B) or (C) of subsection (c)(1) may not exceed 
     the amount that would be paid to that program for such care 
     under section 1814(i) of the Social Security Act (42 U.S.C. 
     1395f(i)) if such care were hospice care for which payment 
     would be made under part A of title XVIII of such Act.
       ``(2) The Secretary may pay an amount in excess of the 
     amount referred to in paragraph (1) (or furnish services 
     whose value, together with any payment by the Secretary, 
     exceeds such amount) to a hospice program for furnishing care 
     to a terminally ill veteran pursuant to subparagraph (B) or 
     (C) of subsection (c)(1) if the Secretary determines, on a 
     case-by-case basis, that--
       ``(A) the furnishing of such care to the veteran is 
     necessary and appropriate; and
       ``(B) the amount that would be paid to that program under 
     section 1814(i) of the Social Security Act would not 
     compensate the program for the cost of furnishing such care.

     ``Sec. 1763. Care for terminally ill veterans

       ``(a) During the period referred to in section 1762(a)(1) 
     of this title, the Secretary shall designate not less than 10 
     medical facilities of the Department at which hospital care 
     is being furnished to terminally ill veterans to furnish the 
     care referred to in subsection (b)(1).
       ``(b)(1) Palliative care to terminally ill veterans shall 
     be furnished at the facilities referred to in subsection (a) 
     by one of the following means designated by the Secretary:
       ``(A) By personnel of the Department providing one or more 
     hospice care services to such veterans at or through medical 
     facilities of the Department.
       ``(B) By personnel of the Department monitoring the 
     furnishing of one or more of such services to such veterans 
     at or through non-Department facilities.
       ``(2) The Secretary shall furnish care by the means 
     referred to in each of subparagraphs (A) and (B) of paragraph 
     (1) at not less than five medical facilities designated under 
     subsection (a).

     ``Sec. 1764. Information relating to hospice care services

       ``The Secretary shall ensure to the extent practicable that 
     terminally ill veterans who have been informed of their 
     medical prognosis receive information relating to the 
     eligibility, if any, of such veterans for hospice care and 
     services under title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.).

     ``Sec. 1765. Evaluation and reports

       ``(a) Not later than September 30, 1994, and on an annual 
     basis thereafter until October 1, 1999, the Secretary shall 
     submit a written report to the Committees on Veterans' 
     Affairs of the Senate and House of Representatives relating 
     to the conduct of the pilot program under section 1762 of 
     this title and the furnishing of hospice care services under 
     section 1763 of this title. Each report shall include the 
     following information:
       ``(1) The location of the sites of the demonstration 
     projects provided for under the pilot program.
       ``(2) The location of the medical facilities of the 
     Department at or through which hospice care services are 
     being furnished under section 1763 of this title.
       ``(3) The means by which care to terminally ill veterans is 
     being furnished under each such project and at or through 
     each such facility.
       ``(4) The number of veterans being furnished such care 
     under each such project and at or through each such facility.
       ``(5) An assessment by the Secretary of any difficulties in 
     furnishing such care and the actions taken to resolve such 
     difficulties.
       ``(b) Not later than August 1, 1997, the Secretary shall 
     submit to the committees referred to in subsection (a) a 
     report containing an evaluation and assessment by the 
     Director of the Health Services Research and Development 
     Service of the hospice care pilot program under section 1762 
     of this title and the furnishing of hospice care services 
     under section 1763 of this title. The report shall contain 
     such information (and shall be presented in such form) as 
     will enable the committees to evaluate fully the feasibility 
     and desirability of furnishing hospice care services to 
     terminally ill veterans.
       ``(c) The report shall include the following:
       ``(1) A description and summary of the pilot program.
       ``(2) With respect to each demonstration project conducted 
     under the pilot program--
       ``(A) a description and summary of the project;
       ``(B) a description of the facility conducting the 
     demonstration project and a discussion of how such facility 
     was selected in accordance with the criteria set out in, or 
     prescribed by the Secretary pursuant to, subparagraphs (A) 
     through (D) of section 1762(b)(3) of this title;
       ``(C) the means by which hospice care services care are 
     being furnished to terminally ill veterans under the 
     demonstration project;
       ``(D) the personnel used to furnish such services under the 
     demonstration project;
       ``(E) a detailed factual analysis with respect to the 
     furnishing of such services, including (i) the number of 
     veterans being furnished such services, (ii) the number, if 
     any, of inpatient admissions for each veteran being furnished 
     such services and the length of stay for each such admission, 
     (iii) the number, if any, of outpatient visits for each such 
     veteran, and (iv) the number, if any, of home-care visits 
     provided to each such veteran;
       ``(F) the direct costs, if any, incurred by terminally ill 
     veterans, the members of the families of such veterans, and 
     other individuals in close relationships with such veterans 
     in connection with the participation of veterans in the 
     demonstration project;
       ``(G) the costs incurred by the Department in conducting 
     the demonstration project, including an analysis of the 
     costs, if any, of the demonstration project that are 
     attributable to (i) furnishing such services in facilities of 
     the Department, (ii) furnishing such services in non-
     Department facilities, and (iii) administering the furnishing 
     of such services; and
       ``(H) the unreimbursed costs, if any, incurred by any other 
     entity in furnishing services to terminally ill veterans 
     under the project pursuant to section 1762(c)(1)(C) of this 
     title.
       ``(3) An analysis of the level of the following persons' 
     satisfaction with the services furnished to terminally ill 
     veterans under each demonstration project:
       ``(A) Terminally ill veterans who receive such services, 
     members of the families of such veterans, and other 
     individuals in close relationships with such veterans.
       ``(B) Personnel of the Department responsible for 
     furnishing such services under the project.
       ``(C) Personnel of non-Department facilities responsible 
     for furnishing such services under the project.
       ``(4) A description and summary of the means of furnishing 
     hospice care services at or through each medical facility of 
     the Department designated under section 1763(a)(1) of this 
     title.
       ``(5) With respect to each such means, the information 
     referred to in paragraphs (2) and (3).
       ``(6) A comparative analysis by the Director of the 
     services furnished to terminally ill veterans under the 
     various demonstration projects referred to in section 1762 of 
     this title and at or through the designated facilities 
     referred to in section 1763 of this title, with an emphasis 
     in such analysis on a comparison relating to--
       ``(A) the management of pain and health symptoms of 
     terminally ill veterans by such projects and facilities;
       ``(B) the number of inpatient admissions of such veterans 
     and the length of inpatient stays for such admissions under 
     such projects and facilities;
       ``(C) the number and type of medical procedures employed 
     with respect to such veterans by such projects and 
     facilities; and
       ``(D) the effectiveness of such projects and facilities in 
     providing care to such veterans at the homes of such veterans 
     or in nursing homes.
       ``(7) An assessment by the Director of the feasibility and 
     desirability of furnishing hospice care services by various 
     means to terminally ill veterans, including an assessment by 
     the Director of the optimal means of furnishing such services 
     to such veterans.
       ``(8) Any recommendations for additional legislation 
     regarding the furnishing of care to terminally ill veterans 
     that the Secretary considers appropriate.''.
       (b) Clerical Amendment.--The table of sections at the 
     beginning of such chapter is amended by adding at the end the 
     following:


  ``subchapter vii--hospice care pilot program; hospice care services

``1761. Definitions.
``1762. Hospice care: pilot program requirements.
``1763. Care for terminally ill veterans.
``1764. Information relating to hospice care services.
``1765. Evaluation and reports.''.
       (c) Authority To Carry Out Other Hospice Care Programs.--
     The amendments made by subsection (a) may not be construed as 
     terminating the authority of the Secretary of Veterans 
     Affairs to provide hospice care services to terminally ill 
     veterans under any program in addition to the programs 
     required under the provisions added by such amendments.
       (d) Authorization of Appropriations.--Funds are authorized 
     to be appropriated for the Department of Veterans Affairs for 
     the purposes of carrying out the evaluation of the hopice 
     care pilot programs under section 1765 of title 38, United 
     States Code (as added by subsection (a)), as follows:
       (1) For fiscal year 1994, $1,200,000.
       (2) For fiscal year 1995, $2,500,000.
       (3) For fiscal year 1996, $2,200,000.
       (4) For fiscal year 1997, $100,000.

     SEC. 204. RURAL HEALTH-CARE CLINIC PROGRAM.

       (a) Program.--(1) Chapter 17 of title 38, United States 
     Code, is amended by adding at the end of subchapter II the 
     following:

     ``Sec. 1720E. Rural health-care clinics: pilot program

       ``(a) During the three-year period beginning on October 1, 
     1993, the Secretary shall conduct a rural health-care clinic 
     program in States where significant numbers of veterans 
     reside in areas geographically remote from existing health-
     care facilities (as determined by the Secretary). The 
     Secretary shall conduct the program in accordance with this 
     section.
       ``(b)(1) In carrying out the rural health-care clinic 
     program, the Secretary shall furnish medical services to the 
     veterans described in subsection (c) through use of--
       ``(A) mobile health-care clinics equipped, operated, and 
     maintained by personnel of the Department; and
       ``(B) other types of rural clinics, including part-time 
     stationary clinics for which the Secretary contracts and 
     part-time stationary clinics operated by personnel of the 
     Department.
       ``(2) The Secretary shall furnish services under the rural 
     health-care clinic program in areas--
       ``(A) that are more than 100 miles from a Department 
     general health-care facility; and
       ``(B) that are less than 100 miles from such a facility, if 
     the Secretary determines that the furnishing of such services 
     in such areas is appropriate.
       ``(c) A veteran eligible to receive medical services 
     through rural health-care clinics under the program is any 
     veteran eligible for medical services under section 1712 of 
     this title.
       ``(d) The Secretary shall commence operation of at least 
     three rural health-care clinics (at least one of which shall 
     be a mobile health-care clinic) in each fiscal year of the 
     program. The Secretary may not operate more than one mobile 
     health-care clinic under the authority of this section in any 
     State in any such fiscal year.
       ``(e) Not later than 120 days after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the Secretary's plans for the implementation of 
     the pilot program required under this section.
       ``(f) Not later than December 31, 1997, the Secretary shall 
     submit to Congress a report containing an evaluation of the 
     program. The report shall include the following:
       ``(1) A description of the program, including information 
     with respect to--
       ``(A) the number and type of rural health-care clinics 
     operated under the program;
       ``(B) the States in which such clinics were operated;
       ``(C) the medical services furnished under the program, 
     including a detailed specification of the cost of such 
     services;
       ``(D) the veterans who were furnished services under the 
     program, setting forth (i) the numbers and percentages of the 
     veterans who had service-connected disabilities, (ii) of the 
     veterans having such disabilities, the numbers and 
     percentages who were furnished care for such disabilities, 
     (iii) the ages of the veterans, (iv) taking into account the 
     veterans' past use of Department health-care facilities, an 
     analysis of the extent to which the veterans would have 
     received medical services from the Department outside the 
     program and the types of services they would have received, 
     and (v) the financial circumstances of the veterans; and
       ``(E) the types of personnel who furnished services to 
     veterans under the program, including any difficulties in the 
     recruitment or retention of such personnel.
       ``(2) An assessment by the Secretary of the cost-
     effectiveness and efficiency of furnishing medical services 
     to veterans through various types of rural clinics (including 
     mobile health-care clinics operated under the pilot program 
     conducted pursuant to section 113 of the Veterans' Benefits 
     and Services Act of 1988 (Public Law 100-322; 38 U.S.C. 1712 
     note)).
       ``(3) Any plans for administrative action, and any 
     recommendations for legislation, that the Secretary considers 
     appropriate.
       ``(g) For the purposes of this section, the term 
     `Department general health-care facility' has the meaning 
     given such term in section 1712A(i)(2) of this title.''.
       (2) The table of sections at the beginning of such chapter 
     is amended by inserting after the item relating to section 
     1720D the following new item:

``1720E. Rural health-care clinics: pilot program.''.
       (b) Authorization of Appropriations.--(1) There is 
     authorized to be appropriated for the Department of Veterans 
     Affairs to carry out the rural health-care clinics program 
     provided for in section 1720E of title 38, United States Code 
     (as added by subsection (a)), the following:
       (A) For fiscal year 1994, $3,000,000.
       (B) For fiscal year 1995, $6,000,000.
       (C) For fiscal year 1996, $9,000,000.
       (2) Amounts appropriated pursuant to such authorization may 
     not be used for any other purpose.
       (3) No funds may be expended to carry out the rural health-
     care clinics program provided for in such section 1720E 
     unless expressly provided for in an appropriations Act.

     SEC. 205. PAYMENT TO STATES OF PER DIEM FOR VETERANS 
                   RECEIVING ADULT DAY HEALTH CARE.

       (a) Payment of Per Diem for Veterans Receiving Adult Day 
     Care.--Section 1741 of title 38, United States Code, is 
     amended--
       (1) by inserting ``(1)'' after ``(a)'';
       (2) by redesignating paragraphs (1) and (2) as 
     subparagraphs (A) and (B), respectively; and
       (3) by adding at the end the following new paragraph (2):
       ``(2) The Secretary may pay each State per diem at a rate 
     determined by the Secretary for each veteran receiving adult 
     day health care in a State home, if such veteran is eligible 
     for such care under laws administered by the Secretary.''.
       (b) Assistance to States for Construction of Adult Day Care 
     Facilities.--(1) Section 8131(3) of title 38, United States 
     Code, is amended by inserting ``adult day health,'' before 
     ``or hospital care''.
       (2) Section 8132 of such title is amended by inserting 
     ``adult day health,'' before ``or hospital care''.
       (3) Section 8135(b) of such title is amended--
       (A) in paragraph (2)(C), by inserting ``or adult day health 
     care facilities'' after ``domiciliary beds''; and
       (B) in paragraph (3)(A), by inserting ``or construction 
     (other than new construction) of adult day health care 
     buildings'' before the semicolon.

     SEC. 206. REVISION OF AUTHORITY ON USE OF TOBACCO PRODUCTS IN 
                   DEPARTMENT FACILITIES.

       Section 526(a) of the Veterans Health Care Act of 1992 
     (Public Law 102-585; 38 U.S.C. 1715 note) is amended--
       (1) in paragraph (1), by striking out ``establishes and 
     maintains--'' and inserting in lieu thereof ``may establish 
     and maintain--''; and
       (2) in paragraph (2), by striking out ``provides access'' 
     and all that follows through ``paragraph (1)'' and inserting 
     in lieu thereof ``if such an area is established, provides 
     access to the area''.
                        TITLE III--MISCELLANEOUS
              Subtitle A--Education Debt Reduction Program

     SEC. 301. SHORT TITLE.

       This subtitle may be cited as the ``Department of Veterans 
     Affairs Health Professionals Education Debt Reduction Act''.

     SEC. 302. PROGRAM OF ASSISTANCE IN THE PAYMENT OF EDUCATION 
                   DEBTS INCURRED BY CERTAIN VETERANS HEALTH 
                   ADMINISTRATION EMPLOYEES.

       (a) Program.--(1) Chapter 76 of title 38, United States 
     Code, is amended by adding at the end the following:

           ``SUBCHAPTER VI--EDUCATION DEBT REDUCTION PROGRAM

     ``Sec. 7661. Authority for program

       ``(a) The Secretary shall carry out an education debt 
     reduction program under this subchapter. The program shall be 
     known as the Department of Veterans Affairs Education Debt 
     Reduction Program (hereafter in this chapter referred to as 
     the `Education Debt Reduction Program'). The purpose of the 
     program is to assist personnel serving in health-care 
     positions in the Veterans Health Administration in reducing 
     the amount of debt incurred by such personnel in completing 
     educational programs that qualify such personnel for such 
     service.
       ``(b)(1) Subject to paragraph (2), assistance under the 
     Education Debt Reduction Program shall be in addition to the 
     assistance available to individuals under the Educational 
     Assistance Program established under this chapter.
       ``(2) An individual may not receive assistance under both 
     the Education Debt Reduction Program and the Educational 
     Assistance Program for the same period of service in the 
     Department.

     ``Sec. 7662. Eligibility; application

       ``(a) An individual eligible to participate in the 
     Education Debt Reduction Program is any individual (other 
     than a physician or dentist) who--
       ``(1) serves in a position in the Veterans Health 
     Administration under an appointment under section 7402(b) of 
     this title;
       ``(2) serves in an occupation, specialty, or geographic 
     area for which the recruitment or retention of an adequate 
     supply of qualified health-care personnel is especially 
     difficult (as determined by the Secretary);
       ``(3) has pursued or is pursuing, as the case may be--
       ``(A) a two-year or four-year course of education or 
     training at a qualifying undergraduate institution which 
     course qualified or will qualify, as the case may be, the 
     individual for appointment in a position referred to in 
     paragraph (1); or
       ``(B) a course of education at a qualifying graduate 
     institution which course qualified or will qualify, as the 
     case may be, the individual for appointment in such a 
     position; and
       ``(4) owes any amount of principal or interest under a loan 
     or other obligation the proceeds of which were used or are 
     being used, as the case may be, by or on behalf of the 
     individual to pay tuition or other costs incurred by the 
     individual in the pursuit of a course of education or 
     training referred to in paragraph (3).
       ``(b) Any eligible individual seeking to participate in the 
     Education Debt Reduction Program shall submit an application 
     to the Secretary relating to such participation.

     ``Sec. 7663. Agreement

       ``(a) The Secretary shall enter into an agreement with each 
     individual selected to participate in the Education Debt 
     Reduction Program. The Secretary and the individual shall 
     enter into such an agreement at the beginning of each year 
     for which the individual is selected to so participate.
       ``(b) An agreement between the Secretary and an individual 
     selected to participate in the Education Debt Reduction 
     Program shall be in writing, shall be signed by the 
     individual, and shall include the following provisions:
       ``(1) The Secretary's agreement to provide assistance on 
     behalf of the individual under the program upon the 
     completion by the individual of a one-year period of service 
     in a position referred to in section 7662(a) of this title 
     which period begins on the date of the signing of the 
     agreement (or such later date as is jointly agreed upon by 
     the Secretary and the individual).
       ``(2) The individual's agreement that the Secretary shall 
     pay any assistance provided under the program to the holder 
     (as designated by the individual) of any loan or other 
     obligation of the individual referred to in section 
     7662(a)(4) of this title in order to reduce or satisfy the 
     unpaid balance (including principal and interest) due on such 
     loan or other obligation.
       ``(3) The individual's agreement that assistance shall not 
     be paid on behalf of the individual under the program for a 
     year unless and until the individual completes the one-year 
     period of service referred to in paragraph (1).
       ``(4) The individual's agreement that assistance shall not 
     be paid on behalf of the individual under the program for a 
     year unless the individual maintains (as determined by the 
     Secretary) an acceptable level of performance during the 
     service referred to in paragraph (3).

     ``Sec. 7664. Amount of assistance

       ``(a) Subject to subsection (b), the amount of assistance 
     provided to an individual under the Education Debt Reduction 
     Program for a year may not exceed $4,000 (adjusted in 
     accordance with section 7631 of this title).
       ``(b) The total amount of assistance received by an 
     individual under the Education Debt Reduction Program may not 
     exceed $12,000 (as so adjusted).''.
       (2) The table of sections at the beginning of such chapter 
     is amended by adding at the end the following:

           ``SUBCHAPTER VI--EDUCATION DEBT REDUCTION PROGRAM

``7661. Authority for program.
``7662. Eligibility; application.
``7663. Agreement.
``7664. Amount of assistance.''.
       (b) Conforming Amendments.--Section 7631 of title 38, 
     United States Code, is amended--
       (1) in subsection (a), by striking out ``and the maximum 
     Selected Reserve member stipend amount'' and inserting in 
     lieu thereof ``the maximum Selected Reserve stipend amount, 
     and the education debt reduction amount and limitation''; and
       (2) in subsection (b)--
       (A) by redesignating paragraph (4) as paragraph (5); and
       (B) by inserting after paragraph (3) the following new 
     paragraph (4):
       ``(4) The term `education debt reduction amount and 
     limitation' means the maximum amount of assistance, and the 
     limitation applicable to such assistance, for a person 
     receiving assistance under subchapter VI of this chapter, as 
     specified in section 7663 of this title and as previously 
     adjusted (if at all) in accordance with this subsection.''.
       (c) Regulations.--The Secretary of Veterans Affairs shall 
     prescribe regulations necessary to carry out the Education 
     Debt Reduction Program established under subchapter VI of 
     chapter 76 of title 38, United States Code (as added by 
     subsection (a)). The Secretary shall prescribe such 
     regulations not later than 90 days after the date of the 
     enactment of this Act.
       (d) Report.--Section 7632 of title 38, United States Code, 
     is amended--
       (1) in the matter above paragraph (1), by inserting ``and 
     the Education Debt Reduction Program'' before the period at 
     the end;
       (2) in paragraph (1)--
       (A) by inserting ``and the Education Debt Reduction 
     Program'' after ``Educational Assistance Program'';
       (B) by striking out ``Program and'' and inserting in lieu 
     thereof ``Program,''; and
       (C) by inserting ``, and the Education Debt Reduction 
     Program'' before ``separately'';
       (3) in paragraph (3), by striking out ``the Educational 
     Assistance Program (or predecessor program) has'' and 
     inserting in lieu thereof ``each of the Educational 
     Assistance Program (or predecessor program) and the Education 
     Debt Reduction Program have'';
       (4) in paragraph (4)--
       (A) by striking out ``and per'' and inserting in lieu 
     thereof ``, per''; and
       (B) by inserting ``, and per participant in the Education 
     Debt Reduction Program'' before the period at the end.
       (e) Exemption From Taxation.--Section 7636 of title 38, 
     United States Code, is amended--
       (1) by inserting ``(a)'' before ``Notwithstanding''; and
       (2) by adding at the end the following:
       ``(b) Notwithstanding any other law, any payment on behalf 
     of a participant in the Education Debt Reduction Program for 
     the tuition or other costs referred to in section 7662(a)(4) 
     of this title shall be exempt from taxation.''.
       (f) Authorization of Appropriations.--(1) There is 
     authorized to be appropriated for the Department of Veterans 
     Affairs $10,000,000 for each of fiscal years 1994 through 
     1998 to carry out the Education Debt Reduction Program.
       (2) No funds may be used to provide assistance under the 
     program unless expressly provided for in an appropriations 
     Act.
       (g) Exemption From Limitation.--Section 523(b) of the 
     Veterans Health Care Act of 1992 (Public Law 102-585; 38 
     U.S.C. 7601 note) shall not apply to the Education Debt 
     Reduction Program.
                      Subtitle B--Other Provisions

     SEC. 311. EXTENSION OF AUTHORITY OF ADVISORY COMMITTEE ON 
                   EDUCATION.

       Section 3692(c) of title 38, United States Code, is amended 
     by striking out ``December 31, 1994'' and inserting in lieu 
     thereof ``December 31, 1997''.

     SEC. 312. EXTENSION OF AUTHORITY TO MAINTAIN REGIONAL OFFICE 
                   IN THE PHILIPPINES.

       Section 315(b) of title 38, United States Code, is amended 
     by striking out ``December 31, 1994'' and inserting in lieu 
     thereof ``September 30, 1995''.
  The title was amended so as to read:

       To amend title 38, United States Code, to improve the 
     Department of Veterans Affairs program of sexual trauma 
     services for veterans, to improve certain Department of 
     Veterans Affairs programs for women veterans, to extend the 
     period of entitlement to inpatient care for veterans exposed 
     to Agent Orange or ionizing radiation, to establish a hospice 
     care pilot program, to establish a rural health care clinics 
     program, to authorize the Secretary of Veterans Affairs to 
     provide per diem payments and construction grants to State 
     homes for adult day health care services, to establish an 
     education debt reduction program, and for other purposes.

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