[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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