Congressional Record, Volume 142 Issue 137 (Saturday, September 28, 1996)

[Congressional Record Volume 142, Number 137 (Saturday, September 28, 1996)]
[Senate]
[Pages S11642-S11658]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

VETERANS' HEALTH CARE ELIGIBILITY REFORM ACT OF 1996

Mr. NICKLES. Madam President, I ask unanimous consent that the
Veterans Affairs Committee be discharged from further consideration of
H.R. 3118, and that the Senate proceed to its consideration.
The PRESIDING OFFICER. Without objection, it is so ordered.
The clerk will report.
The assistant legislative clerk read as follows:.

A bill (H.R. 3118) to amend title 38 of the U.S. Code to
reform eligibility for health care provided by the Department
of Veterans Affairs.

The PRESIDING OFFICER. Is there objection to the immediate
consideration of the bill?
There being no objection, the Senate proceeded to consider the bill.

Amendment No. 5414

(Purpose: To provide a substitute)

Mr. NICKLES. Madam President, Senator Simpson has a substitute
amendment at the desk. I ask for its immediate consideration.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:

The Senator from Oklahoma [Mr. Nickles], for Mr. Simpson,
for himself and Mr. Rockefeller, Mrs. Hutchison, Mr. Akaka,
Mr. Murkowski, and Mr. Wellstone, proposes an amendment
numbered 5414.

Mr. NICKLES. Madam President, I ask unanimous consent that reading of
the amendment be dispensed with.
The PRESIDING OFFICER. Without objection, it is so ordered.
(The text of the amendment is printed in today's Record under
``Amendments Submitted.'')
Mr. SIMPSON. Madam President, the legislation now before this body
may be one of the most significant veterans' bills of the last few
years. In agreeing to this bill, the Congress will make, under the
rubric of health care ``eligibility reform'', changes in the nature

[[Page S11643]]

of our Nation's health care commitment to veterans that are more far-
reaching than any decision since the end of World War II.
The Congress faces the issue of setting priorities for VA care
because all 26 million veterans are eligible for VA health care.
However, VA care is not an entitlement. VA provides as much care to as
many veterans as resources allow.
Our Nation's historic commitment to veterans is to care for the
wounds of war, that is, to care for service-connected disabilities. The
VA hospital system was created to fulfill that obligation. And, having
created a network of hospitals--now numbering 173--it made good sense
to put it to use caring for non-service-connected veterans when space
was available. That is how VA got into the business of caring for non-
service-connected conditions and veterans.
As so often happens, the world changed over time, while VA and the
laws that govern VA lagged behind. Over time, the non-service-connected
tail began to wag the service-connected dog. Today, 89 percent of VA's
medical workload is care for non-service-connected conditions. VA built
a hospital system at a time when the terms ``hospital care'' and
``medical care'' were synonymous. Today, American medical care is
rapidly moving out of hospitals and into the outpatient arena. VA is
also moving in that direction. But, VA's movement has been hampered by
statutory ``eligibility'' rules which set priorities reflecting VA's
hospital-based infrastructure. VA medical centers are underutilized and
VA has excess beds.
This fact is reflected in the eligibility rules which give a large
number of veterans, perhaps 10 million, priority access to inpatient
hospitalization.
Outpatient care is the bottleneck in the VA system and only a small
number of veterans, about 500,000, have guaranteed access to a complete
continuum of care. In addition, 2.2 million veterans receive whatever
care is needed for their service-connected disabilities, and other
veterans have conditional access to outpatient care.
The eligibility rules set by Congress are really a way to ration care
by setting priorities. They allow VA to live within its resources.
However, they have two major faults: first, they are very complex.
Second, they stand modern medical practice on its head by making it
easier to provide inpatient care than outpatient care.
The easy to describe--and from a medical point of view, desirable--
fix would be to simply eliminate the distinction between inpatient and
outpatient care and direct VA to provide care in the most cost-
effective therapeutically appropriate manner.
There are two ways to do this. We could direct VA to provide complete
care--including outpatient--to all of the veterans now ``mandatory''
for inpatient care. However, giving new access to outpatient care,
including virtually free prescription drugs and prosthetic devices such
as hearing aids, to millions of additional veterans could be very
expensive.
Or, the Congress could direct VA to provide complete care, but only
to the number of veterans who could be served with a budget equal to
VA's current funding level. This would make VA's rules simple and allow
the most cost-effective care. However, $17.1 billion may not fund a
full continuum of care for all of the veterans who are now
``mandatory'' for inpatient care. If the Congress takes this course, we
could be accused of ``taking away a veterans' benefit'' from those
veterans excluded under the new rules.

There are savings to be realized by moving treatment out of hospitals
and into less expensive ambulatory care. However, CBO costed
unconstrained bills directing that course as being in the billions of
dollars.
As I read the CBO estimates, improved and expanded health care
benefits will draw new veteran patients who do not now use VA care and
the cost of their care would more than offset the savings of moving
some inpatient care into the outpatient arena. For Federal budget
purposes, VA health care is ``discretionary'' rather than ``mandatory''
spending. CBO cost estimates show how much it will cost to provide the
care which ``eligibility reform'' proposals would authorize. Since VA
health care spending is ``discretionary'', this is not a ``pay-go''
cost for which offsets must be found. However, appropriators are bound
by a ceiling on discretionary spending and they could fund the
``promised'' care only if they reduced other discretionary programs,
unless eligibility reform legislation imposes its own limits on the
obligations of the taxpayer to fund VA health care.
VA, the Veterans Service Organizations, (VSO's), and others dispute
CBO's analysis. They have stated that if the Congress reforms the rules
under which VA operates the resulting efficiencies will pay for, or
perhaps even more than pay for, the cost of the additional care. The
Veterans' Affairs Committee has taken them at their word. The
legislation we now bring before the Senate caps VA medical care
spending at $17.250 billion for 1997 and $17.9 billion in 1998. I
expect those caps to be extended into the future at a level reflecting
any increases in the cost of providing health care and taking into
account the declining veteran population.
Current eligibility rules do really stand modern medicine on its head
by making it easier to treat a veteran on an inpatient basis than in a
non-hospital, outpatient setting. Many advocates for eligibility reform
point to the need for changes in the law in order to allow VA the
freedom to bring itself up to date. I note, however that VA has
informed the Committee that it is moving rapidly to a primary care
model for medical care under the current rules. VA's Under-Secretary
for Health, Dr. Kenneth Kizer,--one splendid administrator--in a May
10, 1996 letter to the Veterans' Committee's distinguished ranking
minority member, Senator Rockefeller, deemphasized sound medicine as a
reason for seeking ``eligibility reform''. He instead said that he
needs eligibility reform in order to instill respect for the law
(asserting that VA clinicians feel they must evade rather than follow
statutory criteria), in order to provide a mechanism for him to hold
the field management accountable to the taxpayers, and to allow him to
design an efficient system of care.
Madam President, these are all worthy and desirable goals. I support
them. But they are goals driven by sound public administration, not a
crisis. The legislation now before the Senate will allow the able Dr.
Kizer to pursue those goals.
This legislation makes some real choices and I expect its enactment
to have real consequences.
Current priorities for VA health care favor veterans who are service-
connected, or poor, or who are members of special groups (former POW's,
World War I, exposed to radiation, agent orange, Persian Gulf).
Changing these priorities requires a Congressional decision as to the
Nation's health care obligation to veterans. When care was rationed by
hospital bed availability it was easy to set limits. If we move to
ambulatory care, constrained only by funding, and do not want to, or
can not, create a new entitlement, it will be necessary to set explicit
limits on who will be served.
In approving this legislation, the Congress will answer questions as
basic as:
First, Should VA care for all disability and illness for service-
connected veterans, or just the service-connected conditions? If yes,
for all service-connected veterans or just some of them? If just some
of them, which ones?

Second, Should VA serve as a social safety net for ``poor'' veterans?
If yes, how poor?
Third, Should VA provide the same general medical services as the
private sector or should it focus on providing veterans with services
not generally available in the private sector (such as long term
psychiatric care, or lifetime treatment of spinal cord dysfunction?
Madam President, reform even opens the door to the question of VA's
role as a direct care provider. Should VA continue to provide care
itself or should it fund private sector care for eligible veterans?
Madam President, I would like to take a moment to describe the
eligibility reform provisions of the bill and then discuss how the bill
answers the questions this issue puts before the Congress and the
implications of some of those answers.
First, and most importantly, the bill eliminates the distinction
between inpatient and outpatient care. VA is directed to provide
hospital care and

[[Page S11644]]

medical services in the most clinically appropriate setting for the
veterans it treats. However, and this is important, the fully
discretionary nature of eligibility for nursing home care remains
unchanged. In addition, VA is required to maintain special programs
(such as treatment for spinal cord dysfunction, blind rehabilitation,
amputation, and mental illness) at least at the current level. On a per
capita basis, these services are expensive to provide and it is not the
intent of the Committee to allow VA to reduce them in order to pay for
other kinds of routine care. This decision means that VA will be forced
to reduce the number of veterans it treats for routine conditions and
diseases in order to sustain its effort for the unique services it
provides. In many cases, VA is a national leader for these services
and, in this regard, VA is truly a national asset.
Second, the legislation does not create an entitlement to health care
for veterans. Funding for veterans' health care has always been
considered discretionary spending and the benefits provided by this
bill are explicitly subject to the availability of appropriations. As I
noted earlier, the amount of appropriations authorized is capped at
about the current level of effort, $17.25 billion for 1997 and $17.9
billion for 1998.
Third, VA is directed to manage access to its health care system by
enrolling veterans according to the following priorities:
First, veterans with service-connected disabilities evaluated 50
percent and greater.
Second, veterans with service-connected disabilities evaluated at 30
percent and 40 percent disabling.
Third, former POW's and veterans with 10 percent and 20 percent
service-connected disabilities.
Fourth, catastrophically disabled veterans and veterans in receipt of
increased non-service-connected disability pension because they are
housebound or in need of the aid and attendance of another person to
accomplish the activities of daily life.
Fifth, veterans unable to defray the cost of medical care, as
prescribed by VA in regulation.
Sixth, all other veterans in the so-called ``core'' group including
veterans of WWI, and veterans with a priority for care based on
presumed environmental exposure.
Seventh, all other veterans.
VA will be authorized to establish subdivisions for enrollment within
priority groups. 1997 and 1998 will be a transition period with
enrollment required for treatment after September 30, 1998. VA will, of
course, continue to treat service-connected conditions (and veteran
service-connected 50 percent and higher) without regard to enrollment.
Other veterans will need to be enrolled if they are to receive VA care
and VA will enroll only the number of veterans it will be able to treat
with the resources available to it.
Madam President, this bill will change the way VA does business and
it has the potential to change the characteristics of the veterans in
our States who will have a realistic expectation of receiving VA care.
Veterans with non-compensable service-connected disabilities will no
longer have an automatic priority for care. However, by giving a high
priority for enrollment to all veterans with compensable service-
connected disabilities we will create a population of 2.2 million
veterans who can expect VA to provide a complete continuum of care,
including such services as free or virtually free prescriptions, which
are not covered by Medicare. If this expansion of services draws large
numbers of these veterans to the VA system, then veterans with a low
priority for care, including the low-income veterans who now make up a
large proportion of VA's patients, may not receive full care. The
alternative to this would have been to give a low priority to veterans
with minor service-connected disabilities, but that option was not
acceptable to the members negotiating the legislation. This outcome is
made more likely by the decision to freeze VA's level of effort in its
special, but expensive, services. A possible outcome of this bill will
be a VA system that primarily treats service-connected veterans for
their non-service-connected conditions and veterans whose disabilities
or illnesses make them candidates for treatment in one of VA's
specialized programs. Of course, this outcome will not come about if VA
and the Veterans Service Organizations are correct and the efficiencies
this bill will allow VA to realize are adequate to pay for the
additional services provided to veterans newly attracted to the VA
system. We will see veterans turned away if the Congressional Budget
Office and General Accounting Office are correct and liberalized rules
lead to dramatic numbers of new veterans seeking free VA care.
Madam President, I also ask my colleagues to be aware of the effect
of the increased VA efficiencies necessary if it is to continue to
treat its current low income patients. Because VA's resources will
remain constrained, we can expect VA to accelerate the already underway
process of reevaluating the desirability of continuing to support
underutilized and inefficient ``infrastructure''. In a word, we will
see some hospitals closed and mission changes for many others. To his
clear credit, VA's Under Secretary for Health, Dr. Ken Kizer, has
already made more progress in this direction than any other Under
Secretary or Chief Medical Director in my time in Congress. And, I
believe he would continue that process with or without this
legislation. He deserves our highest praise for that. However, I think
it safe to predict that every unpopular decision to close a hospital,
or limit or redirect a service, will be attributed to this legislation.
Since those changes will be the very changes needed to transform VA
from a 1945 system of hospitals into a twenty-first century health care
system, we should thank those who often point their fingers in our
direction--for giving us the credit. If Veterans' Service Organizations
in our States voice complaints about the outcome of this legislation,
we should remind them of the old saying about being careful what you
ask for because you may get it!
Madam President, this amendment goes beyond reform of the rules
governing access to VA medical care, and I will take a few minutes to
summarize some of the major provisions for the benefit of my
colleagues.
It extends VA's authority to treat Persian Gulf veterans with
disabling symptoms, but for which no disease can be diagnosed. It also
extends to December 31, 1998 VA's authority to provide health
examinations to the families of Persian Gulf veterans. This authority
originally ended September 30, 1996, but unless the deadline is
extended, delays in putting the program into effect would result in a
substantially shorter time frame for VA to provide these exams than was
contemplated by the Congress when the authority was originally enacted.
In addition, it extends VA's authority to care for veterans presumed
to have been exposed to Agent Orange or radiation, and also takes a
necessary step to exclude from that treatment authority those diseases
for which there is evidence that exposure is not the cause.
The amendment, authorizes the construction of 18 major construction
projects. I am pleased that we have made the turn away from VA's past
emphasis on the construction of inpatient hospital facilities and are
beginning to expand the proportion of scarce resources allocated to
ambulatory care. I urge my successors to reenforce this shift in
emphasis as ambulatory care is the bottleneck in the VA system and the
``eligibility reform'' provisions of this bill will bring VA even more
veterans seeking care on an ambulatory care basis.
The bill authorizes ambulatory care projects in Honolulu, HI ($43 m),
Brockton, MA ($13.5 m); Shreveport, LA ($25 m); Lyons, NJ ($21.1 m);
Tomah, WI ($12.7 m); Asheville, NC ($26.3 m); Temple, TX: ($9.8 m);
Tucson, AZ ($35.5 m); and Leavenworth, KS ($27.75 m). In addition, it
authorizes patient environment improvement projects in Lebanon, PA
($9.5 m); Marion, IL: ($11.5 m); Omaha, Neb. ($7.7 m); Pittsburgh, PA:
($17.4 m); Waco, TX ($26 m); Marion, IN ($17.3 m); Perry Point, MD
($15.1 m); and Salisbury, NC ($18.2 m). It also authorizes correction
of seismic deficiencies at Palo Alto, CA ($20.8 m) and leases of
outpatient clinics in Allentown, PA ($2.159 m); Beaumont, TX ($1.940
m); Boston, MA ($2.358 m); San Antonio, TX ($2.256 m), (also includes a
VBA office); Toledo, OH ($2.223 m); and a parking facility in
Cleveland, OH ($1.3 m).
In other construction provisions, the amendment directs VA to submit
an

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annual report with a 5-year strategic plan showing each of the 22
Veterans Integrated Service Network's (VISN) facility needs and plans
for meeting those needs, and a listing of VA's 20 highest priority
construction projects with the category, priority score and priority
rank for each. Additional information will also be required in the
prospectus for each project, especially on projected workload and
costs. The threshold separating minor from major construction increased
from $3 million to $4 million. The ``grandfathered'' authorization of
projects already in the works when the authorization requirement was
established will be eliminated. Future construction projects will
require an affirmative authorization by the Congress. VA will also be
required to give the Congress 30 days notice before obligating more
than $500,000 for advance planning.
Eligibility reform will call upon VA to break out of the mold created
by its historic dependence on its physical infrastructure. This
amendment will assist in that process by expanding the types of
providers with which, as well as the types of services for which, VA
would be able to enter into sharing agreements. The amendment would
also allow VA to use a simplified procedure for complying with Federal
procurement processes when contracting with commercial providers.
The amendment would also make permanent VA's authority for CHAMPUS
sharing agreements, an authority now expiring September 30, 1996.
The ``notice and wait'' period for VA reorganizations is reduced from
90 to 45 days, 30 of which must occur while Congress is in session.
The bar on VA contracting for patient care (which is now suspended
through 1998) is deleted, with a requirement that VA report to Congress
in advance of any contracting proposal.
The amendment has significant provisions relating to medical services
for women veterans. It would require accreditation of VA mammography
programs and require VA to adopt and enforce mammography quality
control and quality assurance standards. Since VA is already in
compliance with these provisions, their enactment will have the effect
of codifying VA's current policy and practice. In addition, VA would be
directed to survey its facilities in order to identify privacy
deficiencies and to incorporate a correction plan into its construction
planning process. VA would also be directed to assess the use, and
barriers to use, of VA services by women veterans and to report on its
findings, recommendations, and the correctional steps it has taken in
response to those findings.
The Readjustment Counseling Service program administered through
community based ``Vet Centers'' would be updated. Mandatory counseling
eligibility would be limited to combat theater veterans (with
nontheater Vietnam-era veterans ``grandfathered'' in if they become Vet
Center clients before January 1, 2000). The Advisory Committee on the
Readjustment of Veterans would be given statutory recognition. VA would
be directed to report to the Congress on the feasibility and
desirability of collocating Vet Centers and outpatient clinics or
providing some medical services at Vet Centers.

VA would be directed to establish up to five Mental Illness Education
Research and Clinical Centers [MIRECCs]. The centers established would
be chosen from proposals through a peer review process. They would be
located in various geographic regions, at sites linking tertiary care
and primarily psychiatric VA Medical Centers [VAMCs]. In addition, the
Committee on Care of Severely Chronically Mentally Ill Veterans would
be made a statutory committee and VA would be required to forward its
reports to the Congress.
VA would be directed to conduct research evaluating the most cost
effective and efficient way to provide hospice care to veterans, with a
report due to the Congress by April 1, 1998.
VA would be authorized to make construction grants to modify State
homes to provide adult day care and to pay per diem to State homes for
veterans receiving adult day care.
VAMCs would be allowed a new window of opportunity to create research
corporations for the purpose of accepting gifts and grants from the
private sector for funding VA medical research. This authority would
sunset on December 31, 2000. These corporations would be required to
report to Congress on the sources and expenditures of their funds.
The Office of the Under Secretary for Health be required to be
staffed so as to ensure that the Under Secretary has the benefit of the
expertise and policy guidance of: First, VA's specialized programs
(e.g. blind rehabilitation, spinal cord dysfunction, mental illness,
etc.) and, second, readjustment counseling. The amendment would also
eliminate the current requirement that the Associate Deputy Under
Secretary be an MD.
In addition, the amendment would eliminate current ``moonlighting''
restrictions imposed on full time VA health care professionals. The
recovery of special pay incentives would be suspended for doctors and
dentists while they pursue additional residency training if they return
to VA employment. VA would also be given more flexibility in payment
arrangements for residents and interns.
And, finally, land transfers at VAMCs Milwaukee and Cheyenne would be
approved and the VA Medical Center at Mountain Home, TN, would be named
after Congressman James H. Quillen. That name change would take effect
at the beginning of the 105th Congress or when Congressman Quillen
ceases to be a Member of Congress.
Madam President, this amendment is a major legislative
accomplishment. And, as we all know, such an accomplishment requires
hard work on the part of everyone involved. We would not be where we
are today without the active and sincere involvement and interest of
the distinguished ranking minority member of the Committee on Veterans'
Affairs, Senator Jay Rockefeller. In addition to recognizing his hard
work and that of the Committee's minority staff director and chief
counsel, Jim Gottlieb, I must acknowledge the tireless effort and broad
expertise of Bill Brew. Bill Brew took me by the hand and ``showed me
the ropes'' when I first came to the Committee on Veterans' Affairs as
a junior member of the committee. Now years later, and when I am in the
last days of my chairmanship of the committee, I find that Bill is
still indispensable to the committee's operations. They don't make many
like Bill, and veterans everywhere are very fortunate that he has
chosen to put his talent to work on the committee staff.
And then my dear friend, Sonny Montgomery. What a man. The present
ranking minority member of the House Committee on Veterans' Affairs.
Sometimes it seems to us all that there hasn't been a piece of
veterans' legislation that has gone through this body since before the
war (and I'll let you decide which war) that didn't carry the
fingerprints of that fine and noble gentleman. He is leaving the
legislative arena this year. But we shall all remember the unquenchable
flame powering his singular focus on the men and women whose uniformed
service has kept this Nation free for so long. And he has played an
unmatched role in the development and enactment of the amendment now
before this body. He is a very dear friend. Chairman Bob Stump of the
House committee takes second place to no one when it comes to veterans'
legislation and so it has been in the evolution of this bill. He is
steady and courageous and I am proud to be his friend also. I thank him
for his constructive role and acknowledge his indispensable efforts to
transform the commitment of the Congress to America's veterans into
effective and generous benefits and services.

Madam President, I suspect that Congressmen Stump and Montgomery
would be the first to acknowledge their debt to their dedicated staff.
Carl Commentator, Kingston Smith and JoAnn Webb of the majority staff,
and Pat Ryan and Ralph Ibsen of the minority staff have worked
tirelessly to implement the policy direction of their bosses.
And lastly, Tom Harvey, my chief counsel and staff director, and his
crew on the Senate Veterans' Committee staff have done yeoman service
over the last 2 years. Tom has long been the absolutely indispensable
voice of reason to whom I have turned for advice so many times when the
topic turned to veterans. And he has ``saved my bacon'' many a time,
especially with the Veterans' service organizations. A more loyal,
savvy, protective friend I

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could never have. For the last 2 years, I have slept less fitfully
knowing he is in full charge of the committee staff. Chris Yoder, as a
fine professional staff member, has been responsible for health care
issues, and has shepherded this amendment from it's origin as a cluster
of ideas on a ``to do'' list through the legislative product now before
this body. Bill Tuerk, the committee's general counsel, has played an
indispensable and strong role in the development of this amendment and
has committed more time and energy to its enactment than it is
reasonable to ask of someone unless they work for love of country as
well as for sustenance. Their efforts were well supported by Deputy
Staff Director Dave Balland, Dat Tran, Bill Foster, Stephanie Foster,
Dr. Sally Satel, Dennis Doherty, Rosie Ducosin, Linda Reamy, and
Dolores Moorehead. All very wonderful people. The Members of this body,
as well as America's 26 million veterans, are all deeply indebted to
all of them for their consistent hard work and commitment.
Madam President, I urge my colleagues to join me in support of this
legislation and I thank the Chair.
I ask unanimous consent that a joint explanatory statement be printed
in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

JOINT EXPLANATORY STATEMENT FOR H.R. 3118, THE PROPOSED VETERANS'
HEALTH CARE ELIGIBILITY REFORM ACT OF 1996

H.R. 3118, the proposed ``Veterans' Health Care Eligibility
Reform Act of 1996'' reflects a compromise agreement that the
Senate and House of Representatives Committees on Veterans'
Affairs have reached on a number of bills considered in the
Senate and House during the 104th Congress, including: a
construction authorization bill, ordered reported by the
Senate Committee on Veterans' Affairs on July 24, 1996,
[hereinafter, Senate Construction Authorization Bill]; an
eligibility reform bill, ordered reported by the Senate
Committee on Veterans' Affairs on July 24, 1996,
[hereinafter, Senate Eligibility Reform Bill]; and a health
care bill, ordered reported by the Senate Committee on
Veterans' Affairs on July 24, 1996, [hereinafter, Senate
Health Care Bill]; H.R. 1384, ordered reported on June 15,
1995, and passed by the House on October 10, 1995; H.R. 3376,
ordered reported on May 8, 1996, and passed by the House on
June 4, 1996; H.R. 3118, ordered reported on May 8, 1996, and
passed by the House on July 30, 1996; and H.R. 3643, ordered
reported on June 20, 1996, and passed by the House on July
16, 1996.
The Committees on Veterans' Affairs have prepared the
following explanation of H.R. 3118 (hereinafter referred to
as ``compromise agreement''). Differences between the
provisions contained in the compromise agreement and the
related provisions in the bills listed above are noted in
this document, except for clerical corrections and conforming
changes made necessary by the compromise agreement, and minor
drafting, technical, and clarifying changes.

Title I--Eligibility Reform

ELIGIBILITY FOR CARE

Current law
Provisions of law governing eligibility for VA care, set
forth in chapter 17 of title 38 U.S. Code, are complex and
are not uniform across levels of care. All veterans are
``eligible'' for hospital care and nursing home care, but
``eligibility'' does not in itself assure access. Existing
law draws a broad distinction, for purposes of all levels of
care, between two categories. The first is a ``multi-tiered''
cohort (``category A'') of veterans who have been recognized
through a series of acts of Congress as having a priority to
VA care, including service-connected veterans, those
considered unable to defray the expenses of necessary care,
and several special-eligibility subgroupings. The second
category, which has a lower priority for VA care,
encompasses all other veterans who have no special
eligibility and whose income exceeds means-test thresholds
set in law.
With respect to hospital care, the law states that VA
``shall'' provide needed care to all category A veterans,
while VA ``may'' provide those same veterans nursing home
care. Eligibility for outpatient care is more fragmented.
Only limited groups of veterans are eligible for
comprehensive outpatient care. The VA ``shall'' furnish such
care to those who are 50% or more service-connected, and
``may'' furnish it to former prisoners of war, World War I
veterans, and certain profoundly disabled veterans. Current
law imposes specific limitations on certain other veterans.
Those not eligible for comprehensive services are limited
generally to treatment ``to obviate a need of hospital
admission'' or to complete treatment initiated on an
inpatient basis. Veterans undergoing treatment based on a
need to obviate hospitalization are specifically not eligible
to receive prosthetic supplies.
A provision of existing law, which sunsets on December 31,
1996, provides special eligibility for health care services
for veterans exposed to toxic or hazardous substances during
their service.
9House bills
H.R. 3118: Section 2 would provide that, within
appropriations, VA shall provide all needed hospital care and
medical services (including preventive health services), and
may provide all needed nursing home care to veterans in
category A (other than veterans with a non-compensable
disability). VA shall ensure that a service-connected veteran
is provided all benefits under chapter 17 for which the
veteran was eligible prior to enactment of the bill. Section
3 would authorize VA to furnish needed prosthetic items for a
veteran otherwise receiving care or services under chapter
17; in addition, it would require VA to develop guidelines
applicable to provision of hearing aids and eyeglasses.
Section 4 would establish a new section 1705 which would
require that VA manage provision of hospital care and medical
services under new section 1710 through a system of annual
patient enrollment. Enrollment of veterans is to be managed
in accordance with specified priorities in the following
order:
Veterans with service-connected disabilities rated 30% or
higher;
Former POW's and veterans with service-connected
disabilities rated 10% and 20%;
Veterans in receipt of increased pension based on need of
aid and attendance or housebound status, and other veterans
who are catastrophically disabled (such as the spinal cord
injured);
Veterans unable to defray the cost of care; and
All other ``category A'' veterans.
In designing an enrollment system, the Secretary would be
authorized to establish additional priorities within the
priority groupings and to provide for exceptions to the
specified priorities where dictated by compelling medical
reasons, but would be required to ensure that the system is
managed in a manner to ensure that the provision of care to
enrollees is timely and acceptable in quality.
Section 4 would also establish a new section 1706,
applicable to managing the provision of hospital care and
medical services, which would:
Require VA, to the extent feasible, to design, establish
and manage health care programs so as to promote cost-
effective delivery of care in the most clinically appropriate
setting;
Authorize VA to contract for hospital care and medical
services when VA facilities could not furnish such care
economically, and to establish such acquisition policies and
procedures as appropriate to provide the needed services; and
Require VA to maintain its capacity to provide for the
specialized treatment and rehabilitation needs of disabled
veterans so as to afford those veterans reasonable access,
and ensure that overall capacity is not reduced below its
capacity to provide those services as of the date of
enactment of the section.
The bill would also authorize appropriations for the
medical care account, for the purposes specified for that
account in the most recent VA/HUD appropriations act,
including the cost of providing care under the amendments
made by section 2, not to exceed $17.25 billion for fiscal
year 1997 and not to exceed $17.9 billion for fiscal year
1998.
The bill would also include a detailed report on
implementation and operation applicable to sections 2, 3, and
4.
H.R. 3643: Section 1 would extend special eligibility
provisions applicable to veterans exposed to toxic or
hazardous substances and, with respect to herbicide-and
ionizing radiation-exposed veterans, revise such eligibility,
as follows:
Extend the special eligibility provision applicable to
service in the Persian Gulf until December 31, 1998;
Provide with respect to herbicide-exposed veterans, that VA
for a two-year period shall provide care for diseases (1) for
which the National Academy of Sciences in a report issued in
accordance with section 2 of the Agent Orange Act of 1991 has
determined (or subsequently determines) that there is either
some evidence of, or insufficient evidence to permit a
conclusion as to, an association between occurrence of the
disease in humans and exposure to a herbicide agent, and (2)
which the Secretary, based on peer-reviewed research
published within a specified period after the most recent
Academy report, determines there is credible evidence
suggestive of such an association;
Limit the treatment of veterans exposed to ionizing
radiation to treatment of those diseases listed in 38 USC
sec. 1112(c)(2) and those as to which VA determines there is
credible evidence of a positive association between disease
occurrence and radiation exposure; and
Provide that, as to veterans who received care under the
special eligibility provisions being amended, such provisions
shall continue in effect for continued care of the disability
for which such care was furnished before the date of
enactment.
Section 1 would also expand eligibility for health care
applicable to the Persian Gulf War to veterans who served in
Israel or Turkey during the period August 2, 1990 through
July 31, 1991.
Senate health care reform bill
Section 2 would amend section 1701 of title 38 to add
definitions for the terms ``health care'' and ``respite
care''.
Section 3 generally conditions eligibility for health care
to a requirement that a veteran enroll for VA care. It would
provide that VA--

[[Page S11647]]

Shall furnish health care to any veteran for a service-
connected disability, and any veteran who is 50% or more
service-connected disabled, a former prisoner of war, or a
veteran of World War I or the Mexican border; and shall
furnish hospital care for the treatment of any disability of
a veteran with a compensable disability;
Shall, to the extent resources and facilities are
available, furnish health care to all other category A
veterans (other than veterans with a non-compensable
disability); and
May furnish health care, subject to copayment requirements,
to any other veteran.
The section recodifies existing law on eligibility for
nursing home care and domiciliary care, but generally
conditions such eligibility on a requirement that a veteran
enroll for such care. The section would also recodify into
new section 1710, without substantive change, other
eligibility provisions of current section 1712.
The section would exempt veterans who are 50% or more
service-connected disabled and veterans in need of care for a
service-connected condition from the requirement that a
veteran enroll to receive VA care, and provide that VA shall
automatically enroll such veterans upon application for care.
Section 3 would extend through December 31, 1997, existing
law governing special eligibility for veterans exposed to
toxic or hazardous substances.
Section 4 would require that VA manage provision of care
under new section 1710 through a system of annual patient
enrollment, with enrollment of veterans (who are not
automatically enrolled) to be managed in accordance with
specified priorities in the order listed, from veterans with
service-connected disabilities rated 50 percent or greater
having the highest priority and category C veterans the
lowest. In designing an enrollment system, the Secretary
would be authorized to establish additional priorities within
the priority groupings, and to provide for exceptions to the
specified priorities where dictated by compelling medical
reasons.
Section 5 would make conforming and clerical amendments.
Section 6 would authorize appropriations for the Department
for FY 1997 of $17,068,447,000 for the purposes of the
provision of VA medical care. It would authorize increases in
appropriations in subsequent fiscal years in the amount of
the consumer price index.
Compromise agreement
Sections 101, 103, 104, 105, and 106 are derived
substantially from H.R. 3118, with revisions, based primarily
on the Senate bill, to include the following:
Addition of a requirement that, effective on October 1,
1998, VA may not provide hospital care or medical services
unless the veteran enrolls with VA;
Revision in the list of priorities for enrollment to
provide highest priority to any veteran who has a service-
connected disability rated 50% or greater, and second
priority to veterans 30% or 40% service-connected disabled:
Deletion of proposed amendments to section 1703 of title 38
that would have established broad authority to contract for
hospital care and medical services; and
With respect to the requirement that VA maintain its
special disability program capacity, inclusion of a report
requirement and establishment of a consultative role for
special VA committees in assisting the Secretary in carrying
out this provision.
Section 102 would extend special eligibility provisions
applicable to veterans exposed to toxic or hazardous
substances and, with respect to herbicide- and ionizing
radiation-exposed veterans, revise such eligibility. With
respect to the special eligibility provisions associated with
ionizing radiation and Persian Gulf War service, the section
follows section 1 of H.R. 3643 (with the exception of the
proposed expansion to Israel and Turkey, which is not
contained in the compromise). The revisions applicable to
herbicide-exposed veterans are partially derived from H.R.
3643, and would:
Extend the special eligibility provision (applicable to
herbicide-exposed veterans) in existing law until December
31, 2002, but provide that VA shall not furnish care (under
this special eligibility authority) for diseases for which
the National Academy of Sciences, in a report issued in
accordance with section 2 of the Agent Orange Act of 1991,
has determined that there is evidence that is (at least)
suggestive of the lack of a positive association between
occurrence of the disease in humans and exposure to a
herbicide agent; and
Provide that, as to veterans who received care under the
special eligibility provisions being amended (for herbicides
and ionizing radiation), such provisions shall remain in
effect for continued care of the disability for which
treatment was furnished before the date of enactment.

Title II--Construction Authorization

AUTHORIZATION OF MAJOR MEDICAL FACILITY PROJECTS

Current law
Section 8104(a)(2) of title 38 provides that no funds may
be appropriated for any fiscal year, and the Secretary of
Veterans Affairs may not obligate or expend funds (other than
for advance planning and design), for any major medical
facility project unless funds for that project have been
specifically authorized by law.
House Bill
Section 101(a) of H.R. 3376 would authorize the Secretary
to carry out the following ambulatory care projects: Dallas,
TX, $19.9 million; Brockton, MA, $13.5 million; Shreveport,
LA, $25 million; Lyons, NJ, $21.1 million; Tomah, WI, $12.7
million; Asheville, NC, $28.8 million; Temple, TX, $9.8
million; and Tucson, AZ, $35.5 million.
Section 101(b) of H.R. 3376 would authorize the Secretary
to carry out the following environmental improvement
projects: Lebanon, PA, $9.5 million; Marion, IL, $11.5
million; Atlanta, GA, $28.2 million; Battle Creek, MI, $22.9
million; Omaha, NE, $7.7 million; Pittsburgh, PA, $17.4
million; Waco, TX, $26 million; Marion, IN, $17.3 million;
Perry Point, MD, $15.1 million; and Salisbury, NC, $18.2
million.
Section 101(c) would authorize the Secretary to carry out
the following seismic correction projects: Palo Alto, CA, $36
million; Long Beach, CA, $20.2 million; and San Francisco,
CA, $26 million.
Senate construction authorization bill
Section 101 would authorize the Secretary to carry out
identical ambulatory care projects except for the following:
Projects not authorized: Dallas, TX; Lyons, NJ; and Tucson,
AZ. Projects authorized at modified amounts: Shreveport, LA,
$25.4 million; Asheville, NC, $28.5 million; and Temple, TX,
$9.5 million. Additional projects authorized in the Senate
Amendment: Honolulu, HI, $43 million; Wilkes Barre, PA, $42.7
million; and Leavenworth, KS; $27.75 million.
Section 101 would also authorize the Secretary to carry out
identical environmental improvement projects except for the
following: Atlanta, GA; Battle Creek, MI; and Waco, TX, which
are not authorized.
The bill would not authorize the Secretary to carry out any
seismic correction projects.
Compromise Agreement
The projects authorized in the Compromise Agreement are
derived from both measures. The Senate agrees to the addition
of projects at Waco, TX; Lyons, NJ; Tucson, AZ; and scaled-
down seismic work at Palo Alto, CA. The House agrees to the
addition of ambulatory care projects at Honolulu, HI and
Leavenworth, KS. It also contains a modified authorization of
$26.3 million for Asheville, NC, and the House recedes from
its proposed inclusion of projects at Dallas, TX; Atlanta,
GA; Battle Creek, MI; Long Beach, CA; and San Francisco,
CA.

AUTHORIZATION OF MAJOR MEDICAL FACILITY LEASES

Current Law
Section 8104(a)(2) of title 38 provides that no funds may
be appropriated for any fiscal year, and the Secretary of
Veterans Affairs may not obligate or expend funds (other than
for advance planning and design), for any major medical
facility lease unless funds for that lease have been
specifically authorized by law.
House bill
Section 102 of H.R. 3376 would authorize the Secretary to
carry out the following leases of satellite outpatient
clinics: Allentown, PA, $2.159 million; Beaumont, TX, $1.94
million; Boston, MA, $2.358 million; and Toledo, OH, $2.223
million.
Section 102 of H.R. 3376 would authorize the Secretary to
carry out a lease of a parking facility in Cleveland, OH, for
$1.3 million.
Section 102 of H.R. 3376 would authorize the Secretary to
carry out a lease of a satellite outpatient clinic and a VBA
field office in San Antonio, TX, for $2.256 million. Senate
Construction Authorization Bill
Section 102 contains the same lease authorizations as the
House bill, and would also authorize the lease of an
outpatient facility in Ft. Myers, FL.
Compromise agreement
Section 202 follows the House Bill.

AUTHORIZATION OF APPROPRIATIONS

[[Page S11648]]

Section 103(b) is substantively identical to the House
provision in section 103(b).
Compromise agreement
Section 203(a) authorizes to be appropriated to the
Secretary of Veterans Affairs for fiscal year 1997 and fiscal
year 1998 (1) $358.15 million for the authorized major
medical facility projects; and (2) $12.236 million for the
authorized major medical facility leases.
Section 203(b) follows the House and Senate provisions
except that it provides that projects in section 201 are
authorized for funding in fiscal years 1997 and 1998.

STRATEGIC PLANNING

Current law
Section 8107(a) of title 38 requires the Secretary to
submit to the Senate and House Committees on Veterans'
Affairs an annual report detailing VA's five-year medical
facility construction plans, to include a list of the VA's
highest priority hospital construction projects.
House bill
Section 201 would repeal the report requirement in section
8107(a) and require a broader annual report on long-range
health planning. The new annual report would be required to
include (a) a strategic plan for provision of care (including
provision of services for the specialized treatment and
rehabilitative needs of disabled veterans) through networks
of VA medical facilities operating within prescribed
geographic service delivery areas; (b) a description of how
such networks will coordinate their planning efforts; and (c)
a profile of each network.
The network profile would be intended to identify (a) the
mission of each medical facility, or proposed facility; (b)
any planned change in any facility's mission and the
rationale for the change; (c) data regarding the population
of veterans served by the network and anticipated changes
both in demographics and in health-care needs; (d) pertinent
data by which to assess the progress made toward achieving
relative equivalency in the availability of services per
patient in each network; (e) opportunities for providing
veterans services through contract arrangements; and (f)
five-year construction plans for facilities in each network.
The report would also be required to include information
with respect to each VA medical care facility regarding
progress toward instituting identified, planned mission
changes; implementing managed care; and establishing new
services to provide veterans alternatives to institutional
care.
The report would also be required to include (a) the 20
most highly ranked major medical construction projects (by
category of project) and the relative rank and priority score
for each; (b) a description of the specific factors that
account for the project's ranking in relation to other
projects within the same category; and (c) a description of
the reasons for any change in the ranking from the last
report.
Senate construction authorization bill
The Senate Bill contains no comparable provision.
Compromise agreement
Section 204 follows the House Bill.

REVISION TO PROSPECTUS REQUIREMENTS

Current law
Section 8104(b) of title 38 requires the Secretary to
submit to the Senate and House Committees on Veterans'
Affairs a prospectus for any medical facility proposed by the
President or the Secretary. The prospectus is required to
include a detailed description and a cost estimate of the
proposed medical facility.
House bill
Section 202 of H.R. 3376 would expand the requirements of
each prospectus under section 8104(b) to include (a)
demographic data applicable to the project; (b) current and
projected workload and utilization data; (c) current and
projected operating costs of the facility; (d) the priority
score assigned to the project under VA's prioritization
methodology (and if a project is proposed for funding ahead
of a higher-scored project, an explanation of the factors
underlying that funding decision); and (e) a listing of each
alternative to construction of the facility that has been
considered.
Senate bill
No comparable provision.
Compromise agreement
Section 205 follows the House bill.

CONSTRUCTION AUTHORIZATION REQUIREMENTS

Current law
Under section 8104(a)(3)(A) of title 38, the term ``major
medical facility project'' means a project for the
construction, alteration or acquisition of a medical facility
involving a total expenditure of more than $3 million, but
such term does not include an acquisition by exchange.
Under section 301(b) of the Veterans' Medical Programs
Amendments of 1992, Public Law 102-405, major medical
construction projects for which funds were appropriated prior
to Public Law 102-405 are exempted from the requirement of
congressional authorization.
There is no provision in current law expressly requiring
the Secretary to report to the Senate and House Committees on
Veterans' Affairs prior to obligating funds from the Advance
Planning Fund (APF) or toward design or development of a
major medical facility project.
House bill
Section 203(a) would increase the funding threshold for
major medical facility projects from $3 million to $5
million.
Section 203(b) would provide that, effective as to fiscal
year 1998, the ``grandfather clause'' in section 301(b) of
Public Law 102-405 shall have no application.
Section 203(c) would require the Secretary to report in
advance on plans to obligate APF funds in excess of $500,000
on any project.
Senate construction authorization bill
The Senate bill contains no comparable provisions.
Compromise agreement
Section 206(a) increases the funding threshold for major
medical facility projects from $3 million to $4 million.
Section 206(b) follows the House bill.
Section 206(c) follows the House bill.

TERMINOLOGY CHANGES

Compromise agreement
Section 207 would make technical changes in terminology in
sections 8101 and 8109 of title 38 regarding elements of the
construction process.

Title III--Health Care and Administration

Subtitle A--Health Care Sharing and Administration

REVISION OF AUTHORITY TO SHARE MEDICAL FACILITIES, EQUIPMENT AND
INFORMATION

Current law
Subchapter IV of chapter 81 of title 38 authorizes VA to
enter into agreements with specified health care entities for
the mutual use or exchange of use of ``specialized medical
resources,'' a narrowly defined term. VA is only authorized
to enter into ``sharing agreements'' involving specialized
medical resources with health care facilities, research
centers or medical schools. VA has broader authority under
section 8153 to ``share'' any health care resource only
with State veterans homes.
House bill
Section 6 of H.R. 3118 would (a) expand both the range of
health care resources which can be the subject of mutual use
or exchange of use contracts, and the kind of entities with
which VA may so contract; (b) provide that VA may execute
such contracts involving any health care resource, and may
contract with any individual or entity, including a health
plan; (c) provide greater flexibility as to when a VA
facility may enter into such a contract, and what payment
requirements it may negotiate in selling services, while
conditioning the circumstances under which VA furnishes
services to non-veterans [only when such an arrangement (1)
would not result in delay or denying veterans' care and (2)
would result in improving the care of veterans, or is
necessary to maintain an acceptable level or quality of
service at that facility]; and (d) clarify that VA is to be
reimbursed when it provides services under a ``sharing
agreement'' to a Medicare-covered patient.
Senate health care bill
Section 101 of S. 1359 contains provisions substantively
similar to the provisions described in (a) and (b) of the
House bill.
The Senate bill contains no provisions pertaining to the
provisions described in (c) and (d) of the House bill
Compromise agreement
Section 301 is derived from provisions of both the House
and Senate bills. As provided for under the Senate bill, the
section would revise the statement of purpose in 38 USC sec.
8151 to reflect a broader sharing mandate, and revise the
definitional provisions applicable to the broader scope of
the new authority. Amendments to section 8153 are primarily
derived from the House bill and are intended to encourage
increased efficiencies, applicable to sharing hospital care
and medical services (as those terms are defined in chapter
17 of title 38), supplies, and any other health-care service,
support, or administrative resource. The measure is subject
to the limitation that VA may furnish services to non-
veterans under this section only if veterans will receive
priority under such an arrangement and that arrangement
either is needed to maintain an acceptable level and quality
of service or will result in improved services to eligible
veterans. Section 301 would also provide that in instances
where the health-care resource is a commercial service, the
use of medical equipment or space, or research, and is to be
acquired from an institution affiliated with the VA,
including medical practice groups, blood banks, organ banks
or research centers, the acquisition may be accomplished
on a sole source basis. Where the health care resource is
to be obtained from other commercial sources, it would be
obtained in accordance with simplified procurement
procedures developed by the Secretary that would permit
all responsible sources to compete for the resources being
obtained.

improved efficiency in health care resource management

Current law
Title II of Public Law 102-585 authorized an expansion of
the cooperative arrangements between VA and DoD facilities
instituted

[[Page S11649]]

under Public Law 97-174. Public Law 102-585 authorized the
Departments to enter into agreements under which VA
facilities could provide medical services to beneficiaries of
DoD's CHAMPUS program. Under this authority, VA has begun to
provide care to dependents of active-duty members and
retirees. Section 204 of Public Law 102-585 ``sunsets'' this
expanded authority on September 30, 1996.
House bill
Section 5 of H.R. 3118 would repeal section 204 of Public
Law 102-585 and extend indefinitely VA's authority to provide
care and services through contract arrangements to DoD
beneficiaries under chapter 55 of title 10, United States
Code. Section 5 would also clarify VA's authority to recover
or collect from the insurance plans (including so-called
``CHAMPUS supplemental'' plans) of CHAMPUS beneficiaries
cared for by VA to the same extent as DoD recovers for care
rendered to these beneficiaries in its facilities. This
section would also direct that all funds received by VA from
insurance plans of CHAMPUS beneficiaries be credited to the
VA facility that furnished the care.
Senate health care bill
Section 212 of S. 1359 would extend for two years, from
October 1, 1996 to December 31, 1998, VA's authority to
provide care and service through contract arrangements to DoD
beneficiaries.
The Senate Amendment contains no comparable provision
relating to VA's authority to recover from insurance plans of
CHAMPUS beneficiaries or to VA's authority to credit the VA
facility that furnished such care.
Compromise agreement
Section 302 follows the House bill. It also provides that
any services provided under agreements entered into under
section 201 of Public Law 102-585 during the period beginning
on October 1, 1996, and ending on the date of enactment of
the Act are ratified.

personnel furnishing shared resources

Current law
Section 712 of title 38 established a requirement for
minimum numbers of employees in the Department of Veterans
Affairs. As implemented, however, this provision has resulted
in the establishment of employment ceilings. Such ceilings
potentially create a dilemma with respect to medical facility
staffing in that they may force a choice between dedicating
staff solely to internal service delivery, regardless of the
level of efficiency of such service, or to providing as well
some level of service delivery to other entities under the
auspices of efficiency-driven ``sharing agreements''. Faced
with such a choice, facility directors might opt not to
embark on any new ``sharing agreements'' or may question the
merits of maintaining those in place.
House bill
Section 7 of H.R. 3118 would provide that for purposes of
determining the minimum number of positions to be maintained
at VA during a fiscal year, the number of positions at VA in
any fiscal year (to be reduced under existing law by
reference to specified categories of positions) would be
further reduced by the number of positions in that fiscal
year held by persons involved in providing health care
resources under ``sharing agreements'' executed under section
8111 of title 38 (as expanded by section 201 of Public Law
102-585) or section 8153 of title 38.
Senate health care bill
The Senate bill contains no comparable provision.
Compromise agreement
The Compromise Agreement follows the House Bill.

waiting period for administrative reorganizations

Current law
Section 510 of title 38 authorizes the Secretary to
reorganize the functions of the Administrations, offices,
facilities or activities in VA. Prior to implementing such a
reorganization, the Secretary must submit to the House and
Senate Committees on Veterans' Affairs a report containing a
detailed plan and justification for the change. The
reorganization may not be started until 90 days after the
Congressional committees have received the Secretary's
report.
House bill
The House bill contains no provision relating to this
matter.
Senate health care bill
Section 102 would change the waiting period from 90 days to
45 days, thirty days of which Congress shall have been in
continuous session.
Compromise agreement
Section 304 follows the Senate Health Care Bill.

repeal of limitations on contracting outpatient care activities

Current law
Section 8110(c) of title 38 prohibits contracting out of
direct patient care activities or activities ``incident to''
direct care, and permits contracting out other activities at
VA health-care facilities only on the basis of a VA-conducted
cost-comparison study carried out in accordance with the
provisions of that subsection. Under section 1103 of Public
Law 103-446, the provisions of section 8110(c) have no effect
through fiscal year 1999.
House bill
The House bill contains no provision relating to this
matter.
Senate health care bill
Section 103 would repeal section 8110(c).
Compromise agreement
Section 305 incorporates the Senate provisions and adds an
annual reporting requirement.

Subtitle B--Care of Women Veterans

mammography quality standards

Current law
Section 354 of the Public Health Service Act, as added by
Public Law 102-539, relates to the certification by the
Secretary of Health and Human Services of facilities which
perform mammograms. This section does not apply to VA health
care facilities.
House bill
Section 8 of H.R. 3643 would add a new section 7319 to
title 38 which would (a) require VA facilities to be
accredited by a private nonprofit organization to perform
mammography testing; (b) require VA to prescribe quality
assurance standards for the performance and interpretation of
mammograms and the use of mammography equipment by
facilities, that these standards be prescribed by the
Secretary of Veterans Affairs in consultation with the
Secretary of Health and Human Services, and that they are to
be as stringent as those prescribed under the Public Health
Services Act; (c) provide for annual inspection of equipment
and facilities used by and in Department health care
facilities for the performance of mammograms; (d) require
that any outside facility performing mammography services for
VA under contract must meet the requirements issued by the
Secretary of Health and Human Services. Section 8 would also
require the Secretary of Veterans Affairs to prescribe
standards under section 7319(b) not later than 120 days after
enactment. It would also require an implementation report to
be submitted to the House and Senate Committees on Veterans'
Affairs within 120 days after the Secretary prescribes
quality standards or the date of enactment, whichever comes
later.
Senate health care bill
Title V contains substantially similar provisions.
Compromise agreement
Section 321 contains this provision.

patient privacy for women patients

Current law
There is no express provision in current law relating to
patient privacy issues for women patients.
House bill
Section 9 of H.R. 3643 would require VA to (a) survey each
of its medical centers to identify deficiencies relating to
the personal privacy of women patients; (b) ensure that plans
to correct deficiencies identified in the survey are
developed and incorporated into VA's construction planning
processes and given high priority; (c) compile an annual
inventory of those deficiencies and remedial plans; and (d)
report to Congress annually through 1999 on such deficiencies
and include the inventory compiled by the Secretary, the
proposed corrective plans and the status of such plans in the
report.
Senate health care bill
The Senate bill contains no comparable provisions.
Compromise agreement
Section 322 generally follows the House Bill. The
Compromise Agreement limits the construction requirement to
projects where it is cost efficient to do so.

assessment of use by women veterans of va health services

Current law
Section 318 of title 38 provides for a Center for Women
Veterans at VA. The Center's director serves as the principal
adviser to the Secretary on the adoption and implementation
of policies and programs affecting women veterans. The
Secretary includes in documents submitted to Congress in
support of the President's budget for each fiscal year the
following: (1) detailed information on the budget for the
Center; (2) the Secretary's opinion as to whether the
resources proposed in the budget are adequate for the Center;
and (3) a report on the activities of the Center for the
preceding fiscal year.
House bill
Section 7 of H.R. 3643 would (a) require the Center for
Women Veterans, in consultation with the Advisory Committee
on Women Veterans, to assess the use by women veterans of VA
health services, including counseling for sexual trauma and
mental health services; (b) require the Center to submit to
the Under Secretary for Health a report by April 1, 1997,
1998 and 1999 on the extent to which women veterans eligible
for VA health care fail to seek or face barriers in seeking
health services at VA and recommendations for encouraging
greater use of such services; (c) require the Secretary to
submit a report to the House and Senate Committees on
Veterans' Affairs by July 1, 1997, 1998, and 1999 containing
the most recent report of the Center, the views of the Under
Secretary for Health on the Center's report findings and
recommendations, and a description of the steps being taken
by the Secretary to remedy any problems described in the
report.
Senate health care bill
The Senate bill contains no comparable provision.
Compromise agreement
Section 323 follows the House bill.

[[Page S11650]]

REPORTING REQUIREMENTS

Current law
Section 107 of Public Law 102-585, which expired in 1995,
required the Secretary to submit annual reports on the
provision of health care services and the conduct of research
relating to women veterans carried out by, or under the
jurisdiction of, the Secretary to the Committees on Veterans'
Affairs.
House bill
Section 6 of H.R. 3643 would (a) extend through January 1,
1998, the annual reporting requirements of section 107 of
Public Law 102-585; and (b) add to the reporting requirements
information on the number of inpatient stays and outpatient
visits by women veterans and a description of the Secretary's
action to foster and encourage research on women veterans.
Senate health care bill
The Senate bill contains no similar provision.
Compromise agreement
Section 324 follows the House bill.

Subtitle C--Readjustment Counseling and Mental Health Care

ELIGIBILITY FOR READJUSTMENT COUNSELING SERVICES

Current law
Section 1712A requires VA to provide, at the request of any
eligible veteran, counseling to assist such veteran in
readjusting to civilian life. Under current law, eligible
veterans include Vietnam-era veterans and in-theater veterans
of post-Vietnam hostilities, such as Lebanon, Grenada, Panama
and the Persian Gulf.
House bill
The House bill contains no provision relating to this
matter.
Senate health care bill
Section 202 would make the following changes in current
eligibility for readjustment counseling: it would require VA
to furnish such counseling to in-theater Vietnam-era
veterans; in-theater combat veterans for periods prior to the
Vietnam era; and Vietnam-era veterans who seek such
counseling before January 1, 2000, or who have been furnished
such counseling before that date. It would also authorize VA
to furnish such counseling to any other veteran. The measure
would require the Secretary to provide bereavement counseling
to the surviving parents, spouse and children of certain
veterans and grant the Secretary the discretion to provide
bereavement counseling to the surviving parents, spouse and
children of other certain veterans; and (d) authorize the
Secretary to contract for bereavement counseling under this
section in the same manner in which it contracts for medical
services for veterans with total service-connected
disabilities under sections 1712(a)(1)(B) and 1703(a)(2).
Compromise agreement
Section 331 is derived from the Senate Health Care Bill. It
modifies existing law as follows: it requires VA to furnish
such counseling to in-theater Vietnam-era veterans and
Vietnam-era veterans who seek such counseling before January
1, 2000, or who have been furnished such counseling before
that date. It also authorizes VA to furnish such
counseling to any veteran who had served in a theater of
combat operations prior to the Vietnam-era. Section 331
does not contain any provision relating to the provision
of, or contracting for, bereavement counseling.

reports relating to vet centers

Current law
Current law contains no specific authorization for VA to
provide medical services at Vet Centers.
House bill
The House bill contains no provision relating to this
matter.
Senate health care bill
Section 204 would require the Secretary to submit to the
Senate and House Committees on Veterans' Affairs a report,
not later than six months after enactment, on the feasibility
and desirability of collocating Vet Centers and VA outpatient
clinics as current leases for such centers and clinics
expire. Section 205 would require the Secretary to submit to
the Senate and House Committees on Veterans' Affairs a
report, not later than six months after enactment, on the
feasibility and desirability of providing a limited battery
of health care services, including ambulatory services and
health care screening services, to veterans at VA
readjustment counseling centers.
Compromise agreement
Section 332 incorporates the two report provisions of the
Senate Amendment and adds language stating that nothing in
the section is intended to preclude the Secretary from
providing limited health care services at Vet Centers during
the period before submission of the reports.

advisory committee on the readjustment of veterans

Current law
There is no statutory requirement for VA to establish an
Advisory Committee on the Readjustment of Veterans.
House bill
The House bill contains no provision relating to this
matter.
Senate health care bill
Section 203 would (a) add a new section 545 to title 38,
which would establish in VA the Advisory Committee on the
Readjustment of Veterans, consisting of 18 members to be
appointed by the Secretary; (b) provide that a term of
service on the Committee may not exceed 2 years and that the
Secretary may reappoint any member for additional terms of
service; (c) require the Committee to submit a report to the
Secretary, which shall be submitted to Congress, on the
programs and activities of VA that relate to the readjustment
of veterans to civilian life; and (d) provide that the
original members of the Committee shall be the members of the
present, administratively established Advisory Committee on
the Readjustment of Vietnam and Other War Veterans.
Compromise agreement
Section 333 follows the Senate bill.

centers for mental illness research, education and clinical activities

Current law
There is no provision in current law relating to the
establishment of centers for mental illness research,
education and clinical activities.
House bill
Section 3 of H.R. 3643 would add a new section 7320 to
title 38, which would (a) require the Secretary to designate
not more than five VA centers of excellence in mental illness
research, education and clinical care activities (MIRECCs);
(b) require centers to be established and operated
collaboratively (through a formal governance structure) by a
VA facility (or facilities) with a mission centered on care
of the mentally ill and a VA facility in the same geographic
area with a mission of providing tertiary medical care; (c)
require that no less than 50 percent of the funds for the
center for care, research and education shall be provided to
the collaborating facility or facilities with a mission
centered on care of the mentally ill; (d) require one of the
participating facilities to be affiliated with a medical or
other school which provides mental illness training,
attracts clinicians and investigators with a clear and
focused clinical mental health research mission and
maintains an advisory committee; (e) require, as a
prerequisite to selection of any MIRECC ``center'' that a
peer review panel has determined that any such proposed
center meets the highest competitive standards of
scientific and clinical merit; and (f) require that at
least three of the five centers emphasize the development
of community-based alternatives to institutional treatment
of mental illness.
The purpose of the MIRECCs would be to facilitate the
improvement of health care services for veterans suffering
from mental illness--especially from conditions which are
service-related--and to develop improved models for the
furnishing of clinical services. The centers would do this
through research, education and training of health personnel
and development of improved models of clinical services. The
aim is to channel the interests and expertise of VA tertiary
medicine to work toward improving mental health care at VA's
often unaffiliated psychiatric hospitals and developing
improved models of mental health care delivery. Such
collaboration in the case of proposed MIRECCs would entail
establishing a dual-sited (or even multi-sited) ``center''
which involves the two (or more) VA institutions forming a
collaborative program encompassing mental health research,
education and clinical care.
Section 3 would authorize appropriations for centers
through 2001, and require annual reports to the Senate and
House Committees on Veterans' Affairs not later than February
1, 1998, 1999, and 2000. Section 3 would also require the
Secretary to designate at least one center not later than
January 1, 1998.
Senate health care bill
Section 301 contains a similar provision, differing
primarily in that it imposes no requirement for collaborative
operation and establishment of a MIRECC by two or more VA
facilities. It would authorize appropriations for centers
through 2000, require designation of at least one MIRECC by
January 1, 1997, and require annual reporting until 1999.
Compromise agreement
Section 334 generally follows the House bill.

committee on care of severely chronically mentally ill veterans

Current law
There is no provision in current law relating to the
establishment of an Advisory Committee on Severely
Chronically Mentally Ill Veterans.
House bill
Section 2 of H.R. 3643 would (a) require VA to establish a
Committee on Care of Severely Chronically Mentally Ill
Veterans to assess VA's capability to meet the treatment
needs of veterans, including women veterans, with severe and
chronic mental illness; (b) require that Committee members be
VA employees with expertise in the care of the chronically
mentally ill; (c) require the Committee to advise and make
recommendations to the Under Secretary for Health regarding
policies for the care of chronically mentally ill veterans;
and (d) require the Secretary to submit to the Senate and
House Committees on Veterans' Affairs annual reports on the

[[Page S11651]]

recommendations of the committee on VA's need for improving
care for the chronically mentally ill. The first report would
be due not later than April 1, 1997, and subsequent annual
reports would be due not later than February 1, 1998, 1999,
2000, and 2001.
Senate health care bill
Section 214 would require the Secretary, not later than 60
days after receipt, to submit to the Senate and House
Committees on Veterans' Affairs any report submitted to the
Under Secretary for Health by the Special Committee for the
Seriously Mentally Ill Veteran as in existence on July 1,
1996.
Compromise agreement
Section 335 follows the House bill.

hospice care study

Current law
Current law provides no express authority relating to VA's
provision of hospice care to terminally ill veterans.
However, many VAMCs currently provide hospice or palliative
care in some form, including: (a) on-site hospice care
consultation teams; (b) caregiver counseling; (c) the
provision of pain management and other services to terminally
ill veterans; and (d) inpatient hospice care units,
freestanding buildings or separate units where a home like
atmosphere is created.
House Bill
The House bill contains no provision relating to this
matter.
Senate health care bill
Title IV of S. 1359 would add a new subchapter VII to
chapter 17 of title 38, ``Hospice Care Pilot Program; Hospice
Care Services''. Title IV would require VA to conduct a five-
year pilot program from October 1, 1996, to December 31,
2001, to assess the desirability of furnishing hospice care
services and to evaluate the best way to provide hospice
care.
VA would be required to set up demonstration projects at 15
to 30 VA sites (selected in a manner that provides a broad
spectrum of experience with regard to facility size, location
and range of affiliations) at which terminally ill veterans
receive care by (a) a hospice operated by a VAMC; (b) a non-
VA hospice under contract with a VAMC pursuant to which any
necessary inpatient care would be furnished at VA facilities;
or (c) a non-VA hospice under contract with a VAMC with any
necessary inpatient care to be furnished at non-VA
facilities. As to each such program model, VA is to furnish
care under the pilot in at least five VAMCs.
The bill would require that in contracting for hospice
care, VA would follow the Medicare policy in setting
reimbursement rates. Contract hospice rates would generally
be capped at the Medicare rates. However, exceptions could be
made in cases in which the Secretary determines that the
Medicare rate would not compensate a non-VA hospice for
providing a veteran with necessary care. The intended effect
of this provision would be to ensure that veterans for whom
care is extraordinarily expensive due to the nature of their
condition would not be excluded from the program.
VA would also be required to include at least 10 VAMCs that
offer palliative care to terminally ill veterans. As part of
the evaluation, the comparison group would be intended to
help the Committee determine whether furnishing a less
comprehensive range of services constitutes a viable
alternative to VAMCs in which the numbers of veterans
desiring such services may not be sufficient to justify a
full-scale hospice program.
Not later than August 1, 2000, VA would be required to
submit to the Senate and House Committees on Veterans'
Affairs a detailed report containing an evaluation and
assessment by the Under Secretary for Health of the hospice
care pilot program and the furnishing of hospice care
services.
In order to ensure that VA patient care is not compromised
by this pilot program, the bill would expressly provide that
VA would not be precluded from furnishing hospice care
services at VAMCs not participating in the pilot program or
the comparison group.
The bill would authorize appropriations of $1.2 million for
fiscal year 1997, $2.5 million for fiscal year 1998, $2.2
million for fiscal year 1999 and $100,000 for fiscal year
2000.
Compromise agreement
Section 341 would (a) require the Secretary to conduct a
research and evaluation study to determine the desirability
of furnishing hospice care to terminally ill veterans at VA
facilities and to evaluate the most cost effective and
efficient way to do so; (b) require the Secretary to conduct
the study using VA resources and personnel; and (c) require
the Secretary to submit to the Senate and House Veterans'
Affairs Committees a report on the research study not later
than April 1, 1998. The Committees intend that such study
would be conducted by the Management Decision and Research
Center of the Health Services Research and Development
Service.

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

Current law
There is no authority in current law for VA to make per
diem payments to State Veterans Homes in connection with the
furnishing of adult day health care. There is no authority in
current law relating to VA's program of assistance to States
in connection with the construction of facilities to furnish
care to veterans to provide assistance in connection with the
construction of facilities to furnish adult day health care.
House bill
The House bill contains no provision relating to this
matter.
Senate health care bill
Section 211 would (a) amend section 1741 to authorize VA to
provide per diem payments to State Veterans Homes, at a rate
set by VA, for adult day health care; and (b) amend
subchapter III of chapter 81 to authorize construction grant
support to States for expansion, remodeling or alteration of
existing buildings to permit the provision of adult day
health care.
Compromise agreement
Section 342 follows the Senate Health Care Bill.

research corporation

Current law
Subchapter IV of chapter 73 previously authorized VA to
establish nonprofit corporations at individual VA medical
centers in order to facilitate and foster the conduct of VA
medical research. The establishment of such corporations was
intended to create mechanisms which could accept public and
private grants and administer funds for support of VA-
approved research. These corporations have served as flexible
mechanisms to enable VA clinicians to carry out research
projects for which funding might not be available through
VA's own research appropriation. The more than 80
corporations are self sustaining and require no
appropriation. VA's authority to establish additional
research corporations expired in 1992. Consequently, a
significant number of VA facilities, including several major
VA medical centers, do not have a research corporation to
support their research programs.
House bill
Section 304 of H.R. 3376 would renew VA's authority to
establish additional research corporations and extend that
authority until December 31, 2000.
Senate health care bill
Section 302 contains a substantially similar provision. It
would also make a technical change in citations to the tax
code to clarify that research corporations shall be tax-
exempt entities without regard to the specific provision of
the code under which they achieve that status. It would also
expand the annual reporting requirements applicable to the
corporations to require the Secretary to report to the
Committees with respect to each corporation on amounts
received from governmental entities, tax-exempt entities, and
all other sources; information on the source of contributions
in the case of amounts greater than $25,000 received from
entities other than governmental or tax-exempt sources; and
with respect to expenditures, amounts expended for salary for
research and support staff, for direct support of research,
and with respect to expenditures exceeding $10,000,
information that identifies the recipient of such payment.
Compromise agreement
Section 343 is generally derived from the Senate bill. It
would renew VA's authority to establish additional research
corporations and extend that authority through December 31,
2000; delete references to ``section 501(c)(3)'' of the
tax code in sections 7361 and 7363 of title 38, United
States Code. It would expand reporting requirements,
generally as provided for in the Senate bill except (to
conform more closely with reporting requirements set by
the Internal Revenue Service) that it omits any
requirement to isolate amounts received from tax-exempt
entities, and requires identification with respect to
payees only where the amount expended exceeds $35,000. The
provision would also clarify section 7366(b) by specifying
that corporations must obtain an audit performed by an
independent auditor. In the case of a corporation with
annual revenue greater than $300,000, the corporation
shall be audited annually. In the case of a corporation
with annual revenues between $10,000 and $300,000, the
measure requires that an audit be conducted at least once
every three years. Finally, the compromise includes an
amendment to simplify administration of the requirement
that corporation directors and employees are aware of and
comply with conflict-of-interest laws and regulations.

veterans health administration headquarters

Current law
Subchapter I of chapter 73 of title 38 requires specified
clinical service positions in the Veterans Health
Administration and the Office of the Under Secretary for
Health.
House bill
Section 205 of H.R. 3376 would (a) repeal certain statutory
requirements regarding the organization and staffing of the
Office of the Under Secretary for Health; (b) authorize the
Under Secretary to include such professional and other
services as deemed necessary; and (c) ensure that the Office
is sufficiently staffed to provide expertise in clinical care
disciplines generally as well as in the unique, specialized
VA programs such as blind rehabilitation, prosthetics, spinal
cord dysfunction, mental illness and geriatrics and long-term
care.
Senate health care bill
Section 201 of S. 1359 would provide that the Secretary may
not alter or revise the organizational or administrative
structure of the Readjustment Counseling Service.
Compromise agreement
Section 344 is derived primarily from the House provision.
The Committees recognize,

[[Page S11652]]

however, the importance of ensuring that the Under
Secretary's office be staffed so as to have a broad range of
clinical expertise and, particularly, expertise in VA's
special disability programs. Section 344, accordingly, would
require that in organizing the Office, the Under Secretary
shall ensure that the office is staffed in a manner such that
a designated clinician from the appropriate discipline serve
as a principal policy adviser with respect to (1) the VA's
unique special disability programs; and (2) the VA's
readjustment counseling program. With respect to the latter
program, it would require that the Under Secretary ensure
that a clinician with appropriate expertise is responsible
for the management of that program.
The Compromise Agreement does not contain the statutory
repeals proposed in the House Bill. That legislation was
derived in part from of legislative proposal submitted by the
Department of Veterans Affairs, aimed at providing the Under
Secretary of Health greater flexibility to manage a modern
health care system. The Committees do not disagree with the
view underlying that proposal, that current law is unduly
prescriptive and that its centralized management model
impedes VA's ability to operate most effectively in a dynamic
health care environment. The loss of this provision in no way
diminishes support of the Under Secretary's efforts to
implement a field management structure which advocates
decentralization of authority, programmatic accountability,
and flexibility in organizational design and management. The
failure to include a provision revising sections 7305 and
7306 of title 38, U.S. Code, should not be construed as an
expression of agreement that those provisions any longer
represent a sound legislative policy.

DISBURSEMENT AGREEMENTS RELATING TO MEDICAL RESIDENTS AND INTERNS

Current law
Section 7406(c) authorizes the use of disbursement
agreements which provide pay and other employee benefits to
residents and interns who train at VA hospitals. Current law
makes no specific provision for such agreements for residents
and interns who train at VA outpatient clinics, nursing homes
or other Department medical facilities.
House bill
Section 4 of H.R. 3643 would permit disbursement agreements
to be arranged for residents and interns who train at any VA
health care facility.
Senate health care bill
Section 111 contains an identical provision.
Compromise agreement
Section 345 contains this provision.

AUTHORITY TO SUSPEND SPECIAL PAY AGREEMENTS FOR PHYSICIANS AND DENTISTS
WHO ENTER RESIDENCY TRAINING PROGRAMS

Current law
Subchapter III of chapter 74 authorizes ``special pay'' in
addition to basic pay to assist in physician recruitment and
retention. To receive special pay, a physician must enter
into a special pay agreement that carries certain service
obligations. Failure to complete that obligation triggers
refund liabilities. Under current law, employees incur a
refund liability any time they leave voluntarily. A waiver
can be granted only when the employee's breach of an
agreement is for reasons beyond their control, as provided by
section 7432(b)(2) of title 38. A physician or dentist who
enters a residency training program is converted to a special
appointment category that is excluded from receipt of special
pay. Entering a residency training position constitutes a
breach of the agreement and triggers the obligation to repay
the special pay that the physician or dentist received during
that year, thereby imposing adverse financial consequences on
those individuals entering residency training programs.
House bill
Section 5 of H.R. 3643 would temporarily suspend the
special pay agreement during residency training and allow the
return of the physician or dentist to VA employment without
incurring a special pay refund obligation.
Senate health care bill
Section 113 contains an identical provision.
Compromise agreement
Section 346 contains this provision.

REMUNERATED OUTSIDE PROFESSIONAL ACTIVITIES BY VETERANS HEALTH
ADMINISTRATION PERSONNEL

Current law
Section 7423(b)(1) prohibits full-time title 38 employees
from obtaining outside employment which involves assuming
responsibility for providing patient care.
House bill
H.R. 1384 would free registered professional nurses,
physician assistants, and expanded-duty dental auxiliaries of
this restriction on outside employment.
Senate health care bill
Section 112 would eliminate this restriction as to all
title 38 employees.
Compromise Agreement
Section 347 follows the Senate bill.

MODIFICATION OF RESTRICTIONS ON REAL PROPERTY, MILWAUKEE COUNTY,
WISCONSIN

Current law
The terms of a conveyance of a parcel of land from the VA
to Milwaukee County, Wisconsin, as authorized by statute in
1954, provided that such land was to be used for recreational
and other purposes, and that if the county were to attempt to
transfer title to a third party, title would automatically
revert back to VA. Unlike two other adjacent parcels of land
previously transferred from VA to the county, the deed of
conveyance made no provision for reversion ``at the option of
the United States''. Financing requirements associated with
planned construction of a baseball stadium on the tract now
require a transfer of title to the State. Legislation is
clearly needed to enable the county to transfer the 28-acre
tract, which would otherwise revert to the United States, to
the State of Wisconsin.
VA has advised, with respect to its authority to weigh the
option of reversion, that it will not exercise the option in
favor of reversion back to the United States so long as the
existing statutory restrictions on use are followed. VA has
further advised that in the event that legislation is
introduced to modify the deed restrictions, the VA would not
object to releasing the properties from the restriction
against alienation.
House bill
Section 10 of H.R. 3643 would modify VA's reversionary
interest in the land which it had previously conveyed to
Milwaukee County and authorize VA to execute instruments to
permit the County to grant all or part of such land to
another party with a condition on such grant that the grantee
use the land only for civic and recreational purposes. It
would also provide that the conditions under which title to
all or any part of the land reverts to the United States are
stated so that any such reversion would occur at the option
of the United States.
Senate bill
There is no comparable provision in a Senate bill.
Compromise agreement
Section 348 follows the House Bill.

MODIFICATION OF RESTRICTIONS ON REAL PROPERTY, CHEYENNE, WYOMING

Current law
Public Law 89-345 transferred VA-owned land adjacent to the
VA Medical and Regional Office Center (VAMROC) in Cheyenne,
WY, to the City of Cheyenne for park and recreational use.
The instrument of transfer provides that title to the land
will automatically revert to VA in the event the land is no
longer used for park and recreational purposes.
The First Cheyenne Federal Credit Union in Cheyenne, WY,
proposes to build a building on the land previously
transferred to the City of Cheyenne for park and recreational
use. The City of Cheyenne, and VA, agree that such a transfer
would benefit VA, VA employees, and VA beneficiaries.
However, the statutory restriction on the use of the land,
and the reverter provision in the transfer instrument prevent
such a change in land use without authorizing legislation.
House bill
The House had no provision relating to this matter.
Senate construction authorization bill
Section 202 of the Senate bill would authorize VA to modify
the conditions under which the land would revert to VA, and
thereby authorize the transfer of the land from the City to
the First Cheyenne Federal Credit Union for the purpose of
constructing a building to house its operations.
Compromise Agreement
Section 349 follows the Senate provision.

EVALUATION OF HEALTH STATUS OF SPOUSES AND CHILDREN OF PERSIAN GULF WAR
VETERANS

Current law
Section 107 of the Persian Gulf War Veterans' Benefits Act
(Public Law 103-446) requires the Secretary to conduct a
study to evaluate the health status of spouses and children
of Persian Gulf War veterans. Such study requires VA to
arrange for diagnostic testing and medical examinations of
such individuals through September 30, 1996.
House bill
The House bill contains no provision relating to this
matter.
Senate health care bill
The Senate bill would extend the program from September 30,
1996 to December 31, 1998.
Compromise agreement
The Compromise Agreement contains this provision in section
352(a). Section 352(b) would provide that any testing and
examinations conducted for the purposes specified in section
107 of Public Law 103-446 during the period beginning on
October 1, 1996, and ending on the date of enactment of the
Act are ratified.

report on health care needs of veterans in east central florida

Current law
Two years ago, Congress appropriated construction funds to
convert the former Orlando Naval Training Center Hospital
(which was transferred to VA) into a nursing home. VA
currently operates an outpatient clinic at that facility, but
has not begun construction on the nursing home care unit.
Congress appropriated $17.2 million for the design of a 470-
bed medical center and 120-bed nursing home in Brevard
County, Florida. That project, developed and proposed by VA,

[[Page S11653]]

called for 230 psychiatric beds, 60 intermediate care beds,
an ambulatory care clinic and a number of surgical and
intermediate medicine beds. The Conference Report on the
Fiscal Year 1996 VA/HUD Appropriations bill, however, called
for allotting that design money, along with $7.8 million in
new funds, to design and construct a comprehensive outpatient
clinic in Brevard County.
House Bill
Section 104(a) would require the Secretary to report to the
Veterans' Affairs Committees not later than 60 days after the
date of enactment of this Act, on the health care needs of
veterans in east central Florida, and to include in that
report the Secretary's views as to the best means of meeting
such needs (and particularly their needs for psychiatric and
long-term care).
Section 104(b) would limit the Secretary's authority to
obligate funds, other than for working drawings, for the
conversion of the former Orlando Naval Training Center in
Orlando, Florida, to a nursing home care unit until 45 days
after the date on which the report required in section 104(a)
is submitted.
Senate construction authorization bill
The Senate bill contains no comparable provision.
Compromise agreement
The Committees attach a high priority to meeting the needs
of veterans in Florida. With respect to outpatient care, the
Committees believe that construction of an outpatient clinic
in Brevard County should begin as soon as possible. While the
Conference Report on FY 1996 VA/HUD Appropriations addresses
Florida veterans' outpatient needs, it makes no provision for
meeting inpatient care needs that were to have been addressed
by the Brevard project, particularly the lack of long-term
psychiatric beds in the State of Florida.
In light of the unresolved questions surrounding inpatient
needs, the Committees believe that a reassessment of the
health care needs of veterans in east central Florida is
needed. Section 351 of the bill would require the Secretary
to report to the Committees on how these veterans' needs
could best be met. It would specifically require the
Secretary to include in that report his views on how those
needs could best be met using existing facilities in east
central Florida. The Secretary's analysis should also include
a re-examination of other uses of the Orlando facility in
light of the changing needs of central Florida's veterans
population.

renaming of the va medical center in johnson city, tennessee

Current law
The name of the VA medical center in Johnson City, TN, is
the Mountain Home Department of Veterans Affairs Medical
Center.
House bill
Section 302 of H.R. 3376 would rename the VA medical center
the ``James H. Quillen Department of Veterans Affairs Medical
Center'' on January 3, 1997.
Senate bill
There was no similar Senate provision.
Compromise agreement
Section 350 generally follows the House bill.

renaming of the va nursing care center in aspinwall, pennsylvania

Current law
The name of the VA nursing home in Aspinwall, PA, is the
Aspinwall VA Nursing Care Center.
House bill
Section 303 of H.R. 3376 would rename the nursing home in
Aspinwall, PA the ``H. John Heinz, III Department of Veterans
Affairs Nursing Care Center.''
Senate bill
There was no similar Senate provision.
Compromise Agreement
The Compromise contains no provision relating to the
renaming of the Aspinwall VA Nursing Care Center.

additional matters: west los angeles vamc

The Department of Veterans Affairs is directed to
appropriately preserve for the Department's future needs, the
land on the grounds of the West Los Angeles Medical Center
bounded on the north by the VA property boundary, on the
south by Wilshire Boulevard, on the east by Sepulveda
Boulevard, and on the west by Bonsall Street. The Committee
supports uses such as the development of an interim park as a
memorial to veterans, or such other use as the Secretary may
determine to be consistent with needs of the Department. The
Committees understand that local community organizations are
willing to work with the Department to raise the private
funds to develop the land into a Veterans Memorial Park and
to maintain the Park until such time as funds may be
appropriated to convert the park to other uses consistent
with the mission of the Department that the Secretary
determines are in the best interest of the United States,
such as cemetery expansion. The Secretary is free to use the
property for events which provide benefit to veterans until
its development into the Veterans' Memorial Park. The
Department is directed not to dispose of the property or to
use it for commercial development not in furtherance of the
mission of the Department.
Mr. ROCKEFELLER. Madam President, as the Ranking Minority Member of
the Committee on Veterans' Affairs, I am enormously pleased that the
Senate is considering H.R. 3118, a bill that would, among other things,
reform current law relating to eligibility for VA health care. I urge
my colleagues to give their unanimous support to this measure as it
will be amended with a final compromise developed by the two Veterans'
Affairs Committees.
Madam President, before I discuss the content of this legislation, I
will provide a brief procedural history so that those seeking to
understand the background of the measure as it comes before the Senate
today will be able to do so.
H.R. 3118, as it will be amended, which I will refer to as the
compromise agreement, includes a number of provisions in three titles.
Title I of the bill contains the provisions which revise the law
setting forth the criteria for eligibility for VA health care. The
provisions in title I are a compromise between H.R. 3118 as passed by
the House on July 30, 1996, and an original bill which the Senate
Veterans' Affairs Committee ordered reported on July 24 of this year.
Unfortunately, the committee was unable to complete and file its report
on this legislation prior to today's action, so there is no formal
record of our committee's efforts on this vital issue, a result I
deeply regret. I will endeavor to provide some background on our
committee's efforts later in my statement.
Title II of the compromise agreement addresses VA medical
construction matters, including providing authorization for specific
projects. These provisions are a compromise between H.R. 3376, passed
by the House on June 4, 1996, and an original bill ordered reported by
the Senate Veterans' Affairs Committee on July 24. As with the
eligibility reform legislation, the committee was not able to complete
and file a report on this legislation prior to today's consideration by
the Senate, so there is no formal record of our actions.
Title III of the compromise agreement addresses a range of VA health
care programs and services, including several that I have been
particularly interested in for a number of years. These provisions are
a compromise between a number of House bills--H.R. 1384, passed by the
House on October 10, 1995; H.R. 3643, passed on July 16, 1996; and H.R.
3118 and H.R. 3376--and a comprehensive Senate bill, S. 1359, as
ordered reported by the Senate Veterans' Affairs Committee on July 24.
The committee's report on that legislation, which was filed on
September 26, describes the various bills which were combined in the
bill as reported.
Madam President, because a description of all of the provisions of
the compromise agreement are set forth in the explanatory statement
which Senator Simpson will place in the Record, I will just discuss
some of the issues which are of particular interest to me. The
explanatory statement was developed in cooperation with the House
Committee on Veterans' Affairs and that committee's chairman, Rep.
Stump, will insert the same explanatory statement in the Record when
the House considers this measure.

Eligibility Reform

While I supported the Senate committee's action in ordering reported
eligibility reform legislation and I support the inclusion of
provisions derived from that measure in the compromise agreement, I do
so with some significant reluctance. My reluctance is twofold--first, I
remain unconvinced that there is a compelling need for this action at
this time; and second, it is unclear that the course of action we are
pursuing is the most appropriate.
Before discussing these concerns, I will outline briefly the
legislative history of this legislation, and most particularly the
activity in the Senate Committee on Veterans' Affairs. As I noted
earlier, although eligibility reform legislation was ordered reported
by our committee on July 24, a report was never filed. I believe it is
important to provide some background on our committee's role in this
effort.
Madam President, the current drive for eligibility reform
legislation--that is, legislation which would amend those provisions of
title 38, United States Code, which set forth which veterans are
eligible to receive what care from VA--dates back to at least 1985, my
first year in the Senate. Late that

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year, in the context of reconciliation legislation, both Houses passed
legislation which would have amended the then-current law on access to
VA care. The differences between those measures were resolved and the
final compromise, which set forth a hierarchy of veterans as to whom VA
was required to furnish inpatient care, was enacted in title XIX of
Public Law 99-272, the Consolidated Omnibus Budget Reconciliation Act
of 1985.
That first attempt at setting forth in law exactly which veterans
should be guaranteed what care from VA was limited to inpatient care
because of significant differences between the House and Senate over
the potential impact of providing such a guarantee for outpatient and
other care, concerns that have persisted through to this Congress and
that, as I will discuss later in my statement, remain largely
unresolved. Indeed, there is some suggestion that those concerns cannot
be resolved without some specific data-gathering initiative. And while
it is not the sort of data-generating undertaking that I would prefer,
what we are doing in the pending measure may be the way in which the
Congress finally gets the information we need about demand for VA care
and VA's ability to meet that demand within currently available
resources.

Following the enactment of COBRA, the next step in the effort to
modify the law relating to access to VA care came in 1988 with the
enactment, in Public Law 100-322, of legislation which set forth those
groups of veterans who would be guaranteed certain access to outpatient
care. Because of ongoing concerns about the demand for outpatient care
and VA's ability to meet that demand in a timely fashion, the universe
of veterans described in the law as guaranteed access to outpatient
care was smaller than the universe with access to inpatient care and,
within that group, only a small portion was guaranteed unlimited access
to ambulatory care.
Thus, under the law as it has been in effect since 1988, only a very
small percentage of the veteran population--those with service-
connected disabilities rated at 50 percent or more disabling, a number
less than 470,000 out of a total service-connected population of 2.2
million--have comprehensive access to both VA inpatient and outpatient
care. For the rest of the eligible veteran population, the greatest
access to care is provided for inpatient care, with access to
outpatient care much more restricted.
Since 1988, there have been various efforts to amend the law. Last
Congress, under my chairmanship, the committee made significant
progress toward that goal. However, our efforts were carried out as
part of the national health care reform effort. When that larger effort
died, so too did the work of our committee.
This Congress the issue was again before us and a number of events
led up to our markup in July to consider eligibility reform
legislation.
For example, beginning early in 1995, I worked with the four veterans
service organizations that prepare the Independent Budget--AMVETS,
Disabled American Veterans, Paralyzed Veterans of America, and Veterans
of Foreign Wars--to develop a draft eligibility reform bill based on
those groups' testimony before our committee. Senator Simpson and I
introduced this bill, S. 1563, in February of this year as a ``by
request'' bill. In so doing, we both indicated that we were not
endorsing the bill but merely making it available for consideration by
the committee.
Last September, VA submitted eligibility reform legislation to the
Congress which Senator Simpson introduced, by request, as S. 1345 on
October 18, 1995. Also last September, The American Legion, during its
annual legislative presentation, presented its eligibility reform
proposal.
Finally, late in the first session, the House Committee on Veterans'
Affairs included eligibility reform provisions as part of the
legislation which that committee ordered reported to comply with
reconciliation. These provisions were very similar to VA's proposal.
Although the reconciliation measure passed the House with the
eligibility reform provisions included, those provisions were not
included in the conference report on that legislation. This session,
the House again passed the eligibility reform provisions in H.R. 3118,
which passed the House on July 30, 1996.

Against this backdrop of activity and strong expressions of support
from VA and the veterans community for committee action on eligibility
reform legislation, our committee held two hearings on the issue. The
first, on March 20, 1996, heard testimony from the General Accounting
Office and a number of veterans organizations. The second, on May 8,
1996, took testimony from VA and the Congressional Budget Office.
Following those hearings and significant work to develop a proposal
which could gain the support of the committee, the committee met on
July 24 and ordered reported an original measure. It was that measure
which became the basis for the compromise agreement which is before the
Senate today.
Our committee's action was premised on the position that whatever
legislation we endorsed would have to eliminate the complexity and
confusion in current law about which veterans would receive what care,
but do so in a budget-neutral manner.
To that end, the committee started from an approach similar to that
incorporated in the VA and House bills, both of which sought to
eliminate differences in the law on eligibility for inpatient and
outpatient care and differences among groups of veterans in the access
to types of outpatient care. In an attempt to achieve budget
neutrality, both of those approaches made access to all care for all
groups of veterans ``subject to appropriations,'' a limitation not
included in current law. In addition, the House bill included a
provision requiring VA to utilize an enrollment system to manage care.
However, that provision did not appear to limit care to those veterans
who participated in the enrollment system.
The bill our committee ordered reported added three elements to the
general format of the VA and House bills. I am pleased to note that
provisions derived from two of those changes are included in the
compromise agreement, and I regret that the third element is not
included.
The first change that our committee incorporated in the bill we
ordered reported related to the way in which veterans' access to care
is described in the law. As I just noted, both the House bill and the
VA proposal use the phrase ``shall, subject to appropriations'' to
describe access to care for all veterans. Under current law, the word
``shall,'' with no limitation, is used to describe the access to care
of those veterans who are included in what is known as the mandatory or
``category A'' group, and the word ``may'' is used to describe the
access of those veterans in what is known as the discretionary
category. While there is some disagreement about the full meaning or
scope of the word ``shall'' in the context of access to health care, it
is important to note that it is not otherwise limited in current law.
The bill ordered reported by the committee did not go as far as the
House or VA bills, nor did we insist on maintaining current law.
Instead, we took a middle ground. The bill we ordered reported provided
that access to VA care for four subsets of the veterans' population--
veterans with service-connected disabilities rated at 50 percent or
greater for any disability, all veterans with service-connected
disabilities seeking care for those disabilities, former prisoners of
war, and veterans of the Mexican border period and World War I--would
remain as in current law, that is, by using ``shall'' without any
limitation. For all others in the mandatory or category A
classification, the ``shall, subject to appropriations'' approach of
the House and VA bills was used.

The approach adopted by our committee was designed to ensure that
those veterans who have the highest claim on VA resources--veterans
seeking care for their service-connected conditions and those more
seriously disabled veterans for the treatment of any disability, as
well as two categories of veterans whose service distinguishes them--
receive the care they need, with no reference to any external
limitation. As a practical matter, that result should be ensured by
other provisions of the legislation relating to priorities for care,
but it was my view, shared by others on the committee, that the
Congress should not be cutting back on the promise of current

[[Page S11655]]

law as to those veterans with the greatest claim on the system.
Unfortunately, Mr. President, this effort to ensure that access to
care is not compromised for these veterans for whom the system was
established is not reflected in the compromise agreement. Initially,
there was agreement that the compromise agreement would follow the
Senate bill as to two of the four groups in the Senate bill--the more
seriously disabled veterans and for the treatment of service-connected
disabilities--and would apply the ``subject to appropriations''
limitation to all other category A veterans.
However, very late in the process of developing the compromise
agreement, the Congressional Budget Office, which had previously
expressed no concerns about the approach in the Senate bill, suggested
that the use of ``shall'' as to these veterans would create an
entitlement to care and that, as a result, spending for such purposes
would be mandatory spending, rather than discretionary spending as VA
health care funding has always been treated. This, of course, raised
budget problems for the legislation.
One way to have avoided this problem would have been to drop the
``subject to appropriation'' language and restore the approach found in
current law. However, this approach did not enjoy unanimous support
from the Members working on the compromise agreement. While I feel very
strongly that appearing to cut back on the guarantee for care for these
most deserving veterans is not the course we should be following, I
realized that my insistence on either the Senate approach or a return
to the phrasing of current law could well jeopardize the enactment of
this legislation in this legislative session. Thus, I reluctantly
agreed to the use of the ``subject to appropriation'' language as to
all veterans. As I noted earlier, as a practical matter, these veterans
will still be guaranteed first access to VA care as a result of the
priority scheme in the compromise agreement.

The second key difference between the bill our committee ordered
reported and H.R. 3118 as passed by the House is the requirement that
VA establish a rigorous enrollment system, rather than the apparently
nonbinding system incorporated in the House bill. Under the approach in
the Senate bill, only those who enroll, with certain exceptions, would
be able to receive VA care. The purpose of this enrollment requirement
is to create a mechanism that will ensure that those who desire VA care
will know with some measure of certainty whether they will or will not
receive such care within a particular enrollment period, which I
anticipate will run for a year.
Madam President, I am pleased that this enrollment provision has been
included in the compromise agreement. So as to give VA the opportunity
to prepare to implement this enrollment system, the requirement that
veterans enroll in order to receive care will not take effect until
October 1, 1998. It is my expectation that, in the coming year, VA will
begin to implement an enrollment process so as to gain experience with
this system, but will not deny care to any veteran because of a failure
to have enrolled.
The third difference between the bill our committee ordered reported
and the House bill, at least as it was reported by the House Committee
on Veterans' Affairs, was the inclusion in the Senate bill of a cap on
the fiscal year 1997 appropriations so as to remove any doubt about the
budget neutrality of the bill. This limitation is designed to avoid any
suggestion that, if new demand for VA care is generated by the changes
in access to care, additional appropriations will follow to meet the
demand in the absence of specific authorization.
The House bill was amended prior to House passage to include a
similar cap, so there is no longer any substantive difference between
the bills on this provision.
Madam President, that is a brief outline of our committee's efforts
on eligibility reform legislation. I regret that a more complete
discussion is not available in a committee report, but I hope this
discussion will shed some light on what our committee did and how we
reached the final compromise agreement.
Earlier I noted that my support for both the Senate committee's
action and the pending final compromise is reluctant, at best. I will
turn now to an explanation of my position, not so as to highlight my
personal concerns but rather to note what I believe are pitfalls in
what we are doing and as to which we must be aware as the eligibility
reforms are put in place.
At the outset, I note that I understand the concerns that many have
expressed about the existing rules which set forth which veterans are
eligible to receive what types of care from VA. The criticism that many
raise about the complexity of these rules is certainly justified, as is
the position that these eligibility rules do not reflect current trends
in how and where health care is furnished.

Madam President, I note one ironic aspect about this current effort
to amend the VA eligibility law, namely that, as VA facilities convert
to a primary care model under which veterans are assigned to primary
care teams which manage how and when care is furnished, there is less
and less attention being paid at the facility level to the limitations
in the law on who is eligible for specific care. In fact, it might
fairly be said that, at least as to those veterans who are already
receiving VA care, eligibility reform is already taking place.
In any event, while a case can be made that the current eligibility
system is complex and difficult to defend, it has evolved as an
appropriate response to demand and resources constraints over time and
may have, to the extent it continues to be observed, a couple of
advantages.
First, it is a known system, and facilities and veterans across the
system understand its implications in any given locale. Changing it,
especially if the changes appear to broaden access to care, as the
compromise agreement surely does, can easily create false expectations.
The second advantage, related to the first, is that the current
eligibility system is working to ration care. Facilities know when to
use its restrictions--most especially on access to ambulatory care--to
cut back on access so as to stay within budget. Replacing this system
with an untested approach that relies on providing VA facilities with
an unspecified authority to deny some veterans access to care is
difficult to defend as a step forward.
The current system's role in rationing care seems particularly
important in this time of fiscal constraint. In past years, when the
issue of eligibility for VA care has been debated, there were those who
expressed the belief that any increased demand resulting from a change
in eligibility would be addressed by increased appropriations. No one
appears to hold that view today. Thus, it seems clear that some form of
rationing will continue to be needed if the population of those
veterans who are eligible for VA care is not adjusted to meet VA's
capacity to provide care.
Having said that, however, I note that my concerns about the
compromise agreement bill do not stem from a view that the current
eligibility rules must remain inviolate. Rather, my reluctance about
this legislation is grounded in my belief that the Congress has a more
involved role to play in determining the scope of VA health care than
is reflected in the bill the Senate ordered reported or in the
compromise agreement.
Madam President, throughout our committee's efforts on this
legislation, I have held to the premise, on which I think there is
general agreement, that whichever veterans are made eligible for VA
care should be able to receive all the care they need, of whatever
sort, with the possible exception of long-term care, because of the
costs of that care. It certainly could be otherwise--that is, certain
groups of veterans could be given access only to certain care--but that
seems to be directly contrary to the spirit of eligibility reform.

With that as a guiding premise, and my certainty that VA will not
receive any significant infusion of resources for health care at any
time in the foreseeable future, it has been my view throughout the
debate on eligibility reform that we, the Congress, should expressly
set forth in law the population of veterans who are to receive
comprehensive care from VA so that there would be no need for VA to
make rationing decisions at the facility or other management level.
However, as

[[Page S11656]]

the debate progressed, it became increasingly clear that developing
such an approach was highly unlikely, both because we lacked data on
which we might base a more comprehensive action and because reaching
consensus on the specifics of such an approach was highly improbable.
During the eligibility reform debate, the key questions as to which I
have sought answers have been:
First, in crafting legislation to define which veterans are to
receive what care from VA, can we guarantee that those who are told
they are eligible for care will be able to get that care without
extensive delay?
Second, if we assume that we should expand access to outpatient
care--and I do--but that there will be no significant increase in VA's
medical care appropriation, will the demand for care, and the costs
associated with that demand, increase, remain static, or decrease? Who
should make the inevitable rationing decisions?
Third, and finally, do we have the necessary information to make
informed decisions on these issue?
While I acknowledge that these are difficult questions, without easy
solutions, I have been greatly disappointed in the lack of answers that
I have received, particularly from VA. While I believe that I have
gained some further insight into some of these issues, much remains far
from clear.
For example, nothing VA has said has given me any satisfaction that
the proposed eligibility reform proposals will help veterans or VA
health care professionals answer with certainty the question of which
veterans will receive care in a given time period.
Likewise, nothing VA has provided sheds any light on the likely
demand for care that will follow from the enactment of this reform
package and the almost certain publicity about that will follow which
will lead many veterans to believe that they now are eligible for
comprehensive care from VA.
However, as I noted earlier, one clear benefit of our action is that
there will finally be an opportunity to see what happens when apparent
access to VA care is expanded with no concomitant increase in
resources. Once eligibility reform actually takes place, there will
finally be some hard information on the impact of changing the
definition of which veterans receive what care. This, in turn, will
finally enable us to develop some understanding of whether those who
believe that VA can furnish more care to more veterans within existing
resources, or whether, as other believe, that eligibility reform
legislation will generate significant new demand for care.

Madam President, during our committee's consideration of eligibility
reform we heard some very different views on this issue. Some,
including CBO and GAO, believe that amending the law to provide such
expanded access to VA care will result in a significant increase in
demand, which either would be met through increased funding or, if new
funding is not provided, will lead to delays in getting care or
outright denial of care which in turn will generate significant unrest
in the veteran community. Others believe that there is little, if any,
suppressed demand for VA care and therefore do not believe that
eligibility reform will result in any significant increased costs.
Indeed, some who testified in support of eligibility reform expressed
the belief that it is possible that changing the law will result in a
net decrease in the cost of VA care because veterans will be able to be
treated in the most appropriate setting, rather than being forced into
inpatient care because that is the extent of their current eligibility.
At this point, even after our hearings and all the followup actions
associated with them, little more than speculation and best guesses
support any of these positions.
What is known is that VA has been appropriated just over $17 billion
for medical care in fiscal year 1997. It may be that, operating under
revised eligibility criteria, the Department will be able to furnish
more care to a larger cohort of veterans at that funding level. But, in
any event, that will be all the funds that will be available, come what
may.
Madam President, I am confident that the two committees and the
Congress will be vigilant in our oversight of VA's implementation of
this proposal, and, should it prove unsuccessful at matching scarce
resources to demand for care, it will be modified in the years ahead.
Madam President, I have a final thought on this issue before I turn
to other parts of the bill. During this debate on eligibility reform,
VA expressed the view that any eligibility reform legislation should
meet six objectives:
First, the eligibility system should be one that both the persons
seeking care and those providing the care are able to understand.
Second, the eligibility system should ensure that VA is able to
furnish patients the most appropriate care and treatment that is
medically needed, cost effectively and in the most appropriate setting.
Third, veterans should retain eligibility for those benefits they are
now eligible to receive.
Fourth, VA management should gain the flexibility needed to manage
the system effectively.
Fifth, the proposal should be budget neutral.
Sixth, the proposal should not create any new and unnecessary
bureaucracy.
Were I to grade the compromise agreement against this list, I'd say
the only element that is clearly met is the fifth one--the measure is
budget neutral. And while there can be some discussion about some of
the others, the one that I think the bill fails to meet most
dramatically is the first. Nothing in what we are doing, without a
great deal more experience with the new eligibility criteria, will
result in a system that can be understood by patients and providers
alike.
In fact, I believe that just the opposite is true--we are setting in
place a system that no one will be able to predict or, at least in the
near future, understand. Since it is clear that whatever changes are to
take place must occur with no additional resources, it is a virtual
certainty that VA will still need to ration care and to make decisions
about how to do that. While this bill may, in time, yield a flexible,
streamlined bureaucracy that establishes clear rules about which
veterans are to get what care, that result is far from guaranteed. In
the early years of this new system, it is far more likely that more
resources will have to be dedicated to making decisions about who gets
what care, resulting in a confusing, labor-intensive system.
Madam President, despite my misgivings, it is clear that there is
widespread support for our action on this issue. I intend to watch very
closely as it goes forward and will be prepared to support any
amendatory legislation needed as VA moves into this new era.

Contracting Authority

Madam President, the compromise agreement contains two separate
provisions relating to VA's authority to contract for health care
services--section 301, which amends subchapter IV of chapter 81 of
title 38, relating to VA's authority to share medical resources with
non-VA entities; and section 304, which amends section 8110(c) of title
38 relating to VA's authority to contract with outside entities for the
conversion of VA activities to private activities. Taken separately,
these two provisions both break substantial new ground in terms of
giving VA greater latitude to provide services other than through in-
house resources. Together, the enactment of these provisions represents
a potential sea change in how VA meets its health care mission.
Madam President, I want to be very clear that the enactment of these
provisions is meant to give VA managers greater flexibility to operate
the VA health care system in the most effective manner available,
consistent with meeting the obligation to furnish quality medical care
to those veterans who are eligible for VA care and who seek such
services and benefits. I intend to monitor very closely VA use of this
new flexibility and will not hesitate to seek to reimpose limitations
on the Department's contracting authority if it appears that either
authority is being used in a manner that impinges on veterans' access
to care in the name of fiscal restraint. I invite input from
the veterans organizations, veteran patients, VA employees and their
representatives, those organizations which represent groups of VA
professionals, and others with an interest in the integrity of the VA
health care system.

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MIRECC'S

Madam President, I am very pleased that a longstanding Senate
initiative dating back nearly a decade--the establishment of VA centers
of excellence in mental health research--is included in the compromise
agreement. The provision in the compromise agreement is derived
directly from legislation I originally introduced in S. 425 on February
15, 1995, with the cosponsorship of committee member Senators Akaka,
Dorgan, Wellstone, Murkowski, and Campbell.
Madam President, this provision requires VA to establish up to five
centers of excellence in the area of mental illness at existing VA
health care facilities. These centers, to be known as Mental Illness
Research, Education, and Clinical Centers [MIRECC's] will be a vitally
important and integral link in VA's efforts in the areas of research,
education, and provision of clinical care to veterans suffering from
mental illness.
As I noted at the time I introduced S. 425, the need to improve
services to mentally ill veterans has been recognized for a number of
years. For example, the October 20, 1985, report of the special
purposes committee to evaluate the Mental Health and Behavioral
Sciences Research Program of the VA, chaired by Dr. Seymour Kety--
generally referred to as the Kety Committee--concluded that research on
mental illness and training for psychiatrists and other mental health
specialists at VA facilities were totally inadequate. The Kety report
noted that about 40 percent of VA beds are occupied by veterans who
suffer from mental disorders, yet less than 10 percent of VA's research
resources are directed toward mental illness.
Little has changed since that report. The percentage of VA patients
suffering from mental illness continues to hover over the same 40
percent rate found by the Kety Committee, and little has changed with
respect to VA's research on mental illness.
VA provides mental health services to more than one-half to three-
quarters of a million veterans each year, yet in the years between the
time the Kety Committee began its work and now, there has not been a
significant effort to focus VA's resources on the needs of mentally ill
veterans. Among the recommendations of the Kety Committee was one that
VA centers of excellence be established to develop first-rate
psychiatric research programs within VA. Such centers, in the view of
the Kety Committee, would provide state-of-the-art treatment, increase
innovative basic and clinical research opportunities, and enhance and
encourage training and treatment of mental illness.
Based on the recommendations of the Kety Committee, the Committee on
Veterans' Affairs began efforts nearly 10 years ago to encourage
research into mental illnesses and to establish centers of excellence.
For example, on May 20, 1988, Public Law 100-322 was enacted which
included a provision to add an express reference to mental illness
research in the statutory description of VA's medical research mission
which is set forth in section 7303(a)(2) of title 38.

At that time, the committee urged VA to establish three centers of
excellence, or MIRECC's, as proposed by the Kety Committee.
Unfortunately, VA has done little to implement the recommendations of
the Kety Committee.
I also note that the January 1991 final report of the blue ribbon VA
Advisory Committee for Health Research Policy recommended the
establishment of MIRECC's as a means of increasing opportunities in
psychiatric research and encouraging the formulation of new research
initiatives in mental health care, as well as maintaining the
intellectual environment so important to quality health care. The
report stated that these ``centers could provide a way to deal with the
emerging priorities in the VA and the Nation at large.''
In light of VA's failure to act administratively to establish these
centers of excellence, our committee has developed legislation to
accomplish this objective. The proposed MIRECCs legislation is
patterned after the legislation which created the very successful
Geriatric Research, Education, and Clinical Centers [GRECC's], section
302 of Public Law 96-330, enacted in 1980. The MIRECC's would be
designed first, to congregate at one facility clinicians and research
investigators with a clear and precise clinical research mission, such
as PTSD, schizophrenia, or drug abuse and alcohol abuse; second, to
provide training and educational opportunities for students and
residents in psychiatry, psychology, nursing, social work, and other
professions which treat individuals with mental illness; and third, to
develop new models of effective care and treatment for veterans with
mental illnesses, especially those with service-connected conditions.
The establishment of MIRECC's should encourage research into outcomes
of various types of treatment for mental illnesses, an aspect of mental
illness research which, to date, has not been fully pursued, either by
VA or other researchers. This provision will promote the sharing of
information regarding all aspects of MIRECC's activities throughout the
Veterans Health Administration by requiring the Under Secretary for
Health to develop continuing education programs at regional medical
education centers.
Madam President, the VA for too long has made inadequate efforts to
improve research and treatment of mentally ill veterans and to foster
educational activities designed to improve the capabilities of VA
mental health professionals. The establishment of MIRECC's will be a
significant step forward in improving care for some of our neediest
veterans. I am hopeful that this long recognized need will become more
than a forgotten want item for veterans who suffer, in many cases, in
silence.

Hospice Care

Madam President, I am pleased that the compromise agreement includes
a provision, section 341, which directs VA to carry out a research
study on the desirability of VA furnishing hospice care services to
terminally ill veterans and the most cost effective and efficient way
to furnish such services. This provision is derived from legislation I
authored which was included in S. 1359 as considered by the Senate
committee. That legislation was in turn based on legislation dating
back to the 102d Congress.
Madam President, I have been pursuing an effort for a number of years
to have VA closely examine the area of hospice care so as to have a
basis for deciding the Department's role in meeting the needs of
terminally ill veterans.
In my view, it is important that VA develop the most cost-effective
methods of providing treatment to those groups of veterans, especially
those older veterans, who are most likely to seek VA services in the
coming years. Among the methods that can meet the needs of an older
population are a wide variety of community-based, noninstitutional
services, including hospice care, which provides a compassionate
alternative to customary curative care for terminally ill persons.
During the Veterans' Affairs Committee's pursuit of this issue, there
have been a number of hearings and submission of reports by VA. While
the record before the committee on hospice care, including hearings in
1991, 1993, and 1995, indicates that there is some focus on hospice
care within VA, I am convinced that VA has moved ahead too cautiously
to establish programs which achieve the goals of hospice care. For
example, while VA, on April 30, 1992, issued a directive that required
all VA medical centers [VAMC's] to implement hospice programs, that
directive provided only vague guidelines, regarding the manner in which
VAMC's should provide hospice care. As a result, significant variations
now exist in the manner in which hospice care is provided at VAMC's.
VA reports that all VA medical centers now have hospice consultation
teams, consisting of at least a physician, nurse, social worker, and
chaplain, and 56 out of 171 VAMC's have inpatient hospice units,
freestanding buildings or separate units where a home-like atmosphere
is created.
While this is an increase in the total number of inpatient units in
recent years, it is not clear that it demonstrates a significant change
in the overall effort in support of hospice care. In answer to
posthearing questions on its hospice programs, VA noted that ``most VA
inpatient hospice units are small with an average size of 7 beds.''
Other VAMC's provide pain management and other services to terminally
ill veterans in units in which hospice rooms are adjacent to rooms in
which other patients are administered

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curative care. Still other VAMC's only provide some hospice services
such as caregiver counseling and pain management.
Unfortunately, many VAMC's hospice efforts offer only an assessment
of a terminally ill veteran's needs and referral to a non-VA hospice.
While such referrals may benefit some veterans, they are of little
value to the many veterans who are not entitled to Medicare or Medicaid
or lack health insurance coverage for hospice care. Because VA has no
authority under current law to contract with non-VA hospices, these
veterans are left with the difficult choice of foregoing hospice care
or using their own resources to pay for that care.
Although I am convinced that VA should provide hospice care, I am not
certain as to the best way for the Department to provide such care.
Some assert that the only bona fide form of hospice care is through a
program in which palliative care--noncurative care focusing on
alleviating pain and other symptoms--and support services to meet the
psychological, social, and spiritual needs of patients and their
families are available in both home and inpatient settings. Others
believe that equally effective care can be furnished by integrating
hospice concepts into customary care. Similarly, there is considerable
disagreement as to whether veterans who wish to receive hospice care
are best served by VA hospice programs or through contracts with non-VA
providers.
Because I am satisfied that VA, to this point, has not carried out
sufficient research to determine with any degree of certainty the most
appropriate way in which to furnish hospice care, I have proposed
legislation that would require VA to study the ways in which hospice
care can successfully be furnished to veterans. That is what the
provision in the compromise agreement calls for, and I look forward to
VA's efforts to carry out this research and to the results of that
study.
Given the growing numbers of VA patients who are elderly or have
fatal diseases who could benefit from hospice care, demand for VA
hospice care is likely to increase. Research related to the provision
of hospice care is critical not only to VA health care professionals,
many of whose patients cannot rely on friends and family to provide all
of the care they require, but also to other health care providers who
will soon have to accommodate a great increase in the number of aging
patients comparable to that which VA is presently providing care.

Mammography Quality Standards

Madam President, I am delighted that the compromise agreement
includes a provision, section 321, which seeks to ensure that women
veterans are guaranteed that they will receive safe and accurate
mammograms from or through VA. This provision is derived from
legislation, S. 548, which I introduced last year.
At present, under the Mammography Quality Standards Act of 1992,
Public Law 102-539, all health care facilities--hospitals, outpatient
departments, clinics, physicians' offices, or mobile units--are
required to be certified by the Secretary of Health and Human Services
as meeting specified standards for mammography in equipment, personnel,
and quality assurance. That law, however, does not apply to VA
facilities that operate their own mammography equipment.

It is my strong opinion that women veterans who use VA facilities
should have the same assurances as other women that their mammography
tests will be performed properly and yield reliable information. The
Secretary of Veterans Affairs agrees. In a letter to me, dated July 12,
1993, Secretary Jesse Brown wrote, ``It is my intent that VA will
comply with standards equal to those set forth in the Mammography
Quality Standards of 1992 for all mammography done within VA facilities
and require that all contracts and sharing agreements for mammography
include a provision for compliance.''
More recently, at the committee's October 25, 1995, hearing, Dr.
Kenneth Kizer, VA's Under Secretary for Health, updated Secretary
Brown's commitment, noting that ``VA policy now requires compliance
with the requirements of the 1992 Mammography Quality Standards Act.
Moreover, all VA facilities furnishing mammography services are
currently using the FDA's guidelines.''
Section 321 of the compromise agreement would ensure that the goal of
giving women veterans safe and accurate mammograms continues to be met
by requiring the Secretary to promulgate quality assurance and quality
control regulations for VA facilities that furnish mammography that are
no less stringent than the Department of Health and Human Services
regulations to which other mammography providers are subject under the
Mammography Quality Standards Act of 1992. VA facilities that contract
with non-VA facilities would be required to contract only with
facilities that comply with that act.

Outside Employment

Madam President, I am pleased that the compromise agreement includes
a provision, section 347, relating to the limitation in current law on
certain VA health care personnel's ability to work outside of VA--the
so-called ``moonlighting'' bar. Under current law, full-time VA
professionals in seven professions--physicians, dentists, podiatrists,
optometrists, nurses, physician assistants, and expanded-function
dental auxiliaries--are not permitted to work in their professions
during their non-duty times at VA.
This provision was reported by our committee in S. 1359 after it was
amended in committee in response to a concern of mine. As originally
introduced in S. 1752, VA-proposed legislation, the legislation lifted
the bar to outside work for only three of the seven professions listed
in current law. In response to my concerns, the provisions removed the
existing limitation as to all seven of the title 38 professions,
including physicians, and not just to a portion of that population.

CONCLUSION

Madam President, in closing, I acknowledge the work of my colleagues
in the House, Chairman Bob Stump and the ranking minority member, Sonny
Montgomery, and our committee's chairman, Senator Simpson, in
developing the comprehensive legislation.
Madam President, I thank the staff who have worked extremely long and
hard on this compromise--Ralph Ibson, Lori Fertal, Pat Ryan, JoAnn
Webb, Sloan Rappoport, and others on the House Committee, and Bill
Brew, Jim Gottlieb, Bill Tuerk, Chris Yoder, and Tom Harvey with the
Senate committee. I also thank Bob Cover and Charlie Armstrong of the
House and Senate Offices of Legislative Counsel for their excellent
assistance and support in drafting the compromise agreement.
Mr. NICKLES. Madam President, I ask unanimous consent that the
amendment be agreed to, the bill be deemed read a third time and
passed, the amendment to the title be agreed to, the motion to
reconsider be laid upon the table, and that any statements relating to
the bill appear at the appropriate place in the Record.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendment (No. 5414) was agreed to.
The bill (H.R. 3118), as amended, was deemed read a third time and
passed.
The title was amended so as to read: ``An act to amend title 38,
United States Code, to reform eligibility for health care provided by
the Department of Veterans Affairs, to authorize major medical facility
construction projects for the Department, to improve administration of
health care by the Department, and for other purposes.''

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