[Congressional Record Volume 145, Number 88 (Monday, June 21, 1999)]
[Senate]
[Pages S7329-S7331]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. ROCKEFELLER:
  S. 1250. A bill to amend title 38, United States Code, to ensure a 
continuum of health care for veterans, to require pilot programs 
relating to long-term health care for veterans, and for other purposes; 
to the Committee on Veterans' Affairs.


          the veterans' long-term care enhancement act of 1999

  Mr. ROCKEFELLER. Mr. President, I am pleased to introduce the 
``Veterans' Long-Term Care Enhancement Act of 1999.'' There is no doubt 
that demand for long-term care--for veterans and non-veterans alike--is 
increasing. In the Department of Veterans Affairs (VA), however, we 
face an even more pressing demand.
  The numbers are staggering. About 34 percent of the total veteran 
population is 65 years or older, compared with about 13 percent of the 
total United States population. In the year 2000, the number of 
veterans aged 65 or older will peak at 9.3 million. In my state of West 
Virginia alone, we have approximately 57,000 World War II veterans.
  Because VA has already faced considerable demand for long-term care, 
it has been forced to become a leader in this field. I am proud of VA's 
work in developing geriatric evaluation teams, home-based primary care, 
and adult day health care. Our older veterans are leading richer lives 
because of these innovations. But to quote from the Report of the 
Federal Advisory Committee on the Future of VA Long-Term Care, despite 
VA's high quality and long tradition, ``VA long-term care is 
marginalized and unevenly funded.''
  Frequently I hear from families of World War II combat veterans who 
need long-term care because of a debilitating disease, such as 
Alzheimer's or Parkinson's, or a stroke. A number of these families do 
not have the money to place the veteran in a private nursing home for 
the necessary long-term care; and because of the veteran's sacrifices 
during World War II, they turn to the VA.
  Or I will get a call from a wife of an aging, sick veteran who wants 
desperately to keep her husband at home with her, but in order to do 
that she needs home health care services, so she turns to the VA.
  But when these West Virginian families are told by VA that the 
services they need are not available to them, they simply cannot 
understand how they could be denied, and they turn to me in despair.
  The challenge for all of us, of course, is to find a way to furnish 
the appropriate array of services, in a cost efficient way, to all 
those needing extended care.
  As the Senate Committee on Veterans' Affairs noted in its March 15, 
1999, letter to the Budget Committee with the Committee's views on VA's 
budget for FY 2000, ``The health care issue that VA must face over the 
intermediate term--indeed, the health care issue that the Nation must 
face over the next decade--is the need for long-term care among the 
aging World War II generation. WWII veterans saved Western 
civilization. We cannot turn our backs on them now.''
  At the outset, I want to say that my wish would be for VA to provide 
long-term care to all veterans who need and want it. While the 
legislation I am introducing today is only one step toward determining 
what VA should be doing to meet the needs of veterans for long-term 
care, I believe that it is an important step in that regard.
  There are three key elements in the bill. First, are provisions which 
clarify that long-term care is not only nursing home care, and that 
existing differences in law between eligibility for institutional long-
term care and other types of care offered by VA do not affect VA's 
ability to furnish a full array of noninstitutional long-term care 
services.
  Specifically, the provision would add ``noninstitutional extended 
care services'' to the definition of ``medical services,'' thereby 
removing any doubt about VA's authority to furnish such services to 
veterans eligible for and enrolled in VA care. The term would be 
defined to include the following: home-based primary care; adult day 
health care; respite care; palliative and end-of-life care; and 
homemaker or home health aide visits.
  Second, the bill would add clear authority for VA to furnish assisted 
living services, including to the spouses of veterans. VA already 
furnishes a form of assisted living services through its domiciliary 
care program, but the provision in the bill would provide express 
authority to furnish this modality of care to older veterans, thereby 
expanding the continuum of extended care services offered by VA.
  Third, VA would be mandated to carry out a series of pilot programs, 
over a period of three years, which would be designed to gauge the best 
way for VA to meet veterans' long-term care needs--either directly, 
through cooperative arrangements with community providers, or by 
purchasing services from non-VA providers.
  While VA has developed significant expertise in long-term care over 
the past 20-plus years, it has not done so with any mandate to share 
its learning with others, nor has it pushed its program development 
beyond that which met the current needs at the time. Some experts even 
believe that VA's expertise is gradually eroding.
  For VA's expertise to be of greatest use to others, it needs both to 
better capture what it has done and to develop new learning that would 
be most applicable to other health care entities.
  Those who would benefit by further action to develop and capitalize 
on VA's long-term care expertise include older veterans, primarily our 
honored World War II veterans; those health organizations, including 
academic medicine and research entities, with which VA is now 
connected; and finally, the rest of the U.S. health care system, and 
ultimately all Americans who will need some form of long-term care 
services.
  Each element of the pilot program would establish and carry out a 
comprehensive long-term care program, with a full array of services, 
ranging from inpatient long-term care--in intermediate care beds, in 
nursing homes, and in domiciliary care facilities--to comprehensive 
noninstitutional services, which include hospital-based home care, 
adult day health care, personal assistance services, respite care, and 
other community-base interventions.
  In each element of the pilot programs, VA would also be mandated to 
furnish case management services, to ensure that veterans participating 
in the pilot programs receive the optimal treatment and placement for 
services. Some form of assisted living services for veterans and their 
families would be provided, as well. Preventive health care services, 
such as screening and patient education, and a particular focus on end-
of-life care are also emphasized. In my view, VA must have ready access 
to all of these services.
  As part of the pilot program, VA would be encouraged to seek the 
involvement of State Veterans Homes, so

[[Page S7330]]

as to draw them into noninstitutional approaches to long-term care. Our 
State Veterans Homes are valuable assets.
  Finally, a key purpose of the pilot program would be to test and 
evaluate various approaches to meeting the long-term care needs of 
eligible veterans, both to develop approaches that could be expanded 
across VA, as well as to demonstrate to others outside of VA the 
effectiveness and impact of various approaches to long-term care. To 
this end, the pilot program within in the ``Veterans' Long-Term Care 
Enhancement Act of 1999'' would include specific data collection on 
matters such as cost effectiveness, quality of health care services 
provided, enrollee and health care provider satisfaction, and the 
ability of participants to carry out basic activities of daily living.
  From this effort, a number of things would result. First, VA would 
gain more precise information on exactly which services to offer, how 
best to coordinate those services, and the relative cost and 
effectiveness of various services. There is no doubt that our veterans 
would benefit from such findings.
  Second, there would be a concrete demonstration of the feasibility of 
furnishing a coordinated range of long-term care services, which in 
turn could lead to a greater likelihood that such an approach would be 
shared with, and replicated by, others.
  Third, the value of such an approach, measured in quality of care, 
quality of life, cost effectiveness, and patient and provider 
satisfaction would be demonstrated, thereby promoting its use by 
others.
  Mr. President, I look forward to working with the chairmen and the 
members of the Committees on Veterans' Affairs--in both the House of 
Representatives and the Senate--to advance the cause of long-term care 
in VA.
  Mr. President, I ask unanimous consent that the full text of the bill 
be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1250

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Veterans' Long-Term Care 
     Enhancement Act of 1999''.

     SEC. 2. CONTINUUM OF CARE FOR VETERANS.

       (a) Inclusion of Noninstitutional Extended Care Services in 
     Definition of Medical Services.--Section 1701 of title 38, 
     United States Code, is amended--
       (1) in paragraph (6)(A)(i), by inserting ``noninstitutional 
     extended care services,'' after ``preventive health 
     services,''; and
       (2) by adding at the end the following new paragraphs:
       ``(10) The term `noninstitutional extended care services' 
     includes--
       ``(A) home-based primary care;
       ``(B) adult day health care;
       ``(C) respite care;
       ``(D) palliative and end-of-life care; and
       ``(E) homemaker or home health aide visits.
       ``(11) The term `respite care' means hospital or nursing 
     home care which--
       ``(A) is of limited duration;
       ``(B) is furnished on an intermittent basis to an 
     individual who is suffering from a chronic illness and who 
     resides primarily at home; and
       ``(C) is furnished for the purpose of helping the 
     individual to continue residing primarily at home.''.
       (b) Assisted Living.--Subchapter II of chapter 17 of such 
     title is amended by adding at the end the following new 
     section:

     ``Sec. 1720F. Assisted living

       ``(a) The Secretary may, subject to subsection (b), provide 
     assisted living services to a veteran who is eligible to 
     receive care under section 1710 of this title and to the 
     spouse of such veteran in connection with the provision of 
     such services to such veteran.
       ``(b) The Secretary may not provide assisted living 
     services under this section to a veteran eligible to receive 
     care under section 1710(a)(3) of this title, or to a spouse 
     of any veteran, unless such veteran or spouse agrees to pay 
     the United States an amount equal to the cost, as determined 
     in regulations prescribed by the Secretary, of the provision 
     of such services.
       ``(c) For purposes of this section, the term `assisted 
     living services' means services which provide personal care, 
     activities, health-related care, supervision, and other 
     assistance on a 24-hour basis within a residential or similar 
     setting which--
       ``(1) maximizes flexibility in the provision of such care, 
     activities, supervision, and assistance;
       ``(2) maximizes the autonomy, privacy, and independence of 
     an individual; and
       ``(3) encourages family and community involvement with the 
     individual.''.
       (c) Conforming Amendments.--(1)(A) Section 1720 of such 
     title is amended by striking subsection (f).
       (B) The section heading of such section is amended by 
     striking ``; adult day health care''.
       (2) Section 1720B of such title is repealed.
       (d) Clerical Amendments.--The table of sections for chapter 
     17 of such title is amended--
       (1) in the item relating to section 1720, by striking ``; 
     adult day health care'';
       (2) by striking the item relating to section 1720B; and
       (3) by inserting after the item relating to section 1720E 
     the following new item:

``1720F. Assisted living.''.

     SEC. 3. PILOT PROGRAMS RELATING TO LONG-TERM CARE OF 
                   VETERANS.

       (a) In General.--The Secretary of Veterans Affairs shall 
     carry out three pilot programs for the purpose of determining 
     the feasibility and practicability of a variety of methods of 
     meeting the long-term care needs of eligible veterans. The 
     pilot programs shall be carried out in accordance with the 
     provisions of this section.
       (b) Locations of Pilot Programs.--(1) Each pilot program 
     under this section shall be carried out at two Veterans 
     Integrated Service Networks (VISNs) selected by the Secretary 
     for purposes of this section.
       (2) The Secretary may not carry out more than one pilot 
     program in any given Veterans Integrated Service Network.
       (c) Scope of Services Under Pilot Programs.--(1) The 
     services provided under the pilot programs under this section 
     shall include a comprehensive array of health care services 
     and other services that meet the long-term care needs of 
     veterans, including--
       (A) inpatient long-term care in intermediate care beds, in 
     nursing homes, and in domiciliary care facilities;
       (B) noninstitutional long-term care, including hospital-
     based primary care, adult day care, personal assistance 
     services, respite care, and other community-based 
     interventions and care; and
       (C) assisted living services for veterans and their 
     families.
       (2) As part of the provision of services under the pilot 
     programs, the Secretary shall also provide appropriate case 
     management services.
       (3) In providing services under the pilot programs, the 
     Secretary shall emphasize the provision of preventive care 
     services, including screening and education.
       (d) Direct Provision of Services.--Under one of the pilot 
     programs under this section, the Secretary shall provide 
     long-term care services to eligible veterans directly through 
     facilities and personnel of the Department of Veterans 
     Affairs.
       (e) Provision of Services Through Cooperative 
     Arrangements.--(1) Under one of the pilot programs under this 
     section, the Secretary shall provide long-term care services 
     to eligible veterans through a combination (as determined by 
     the Secretary) of--
       (A) services provided under cooperative arrangements with 
     appropriate public and private non-Governmental entities, 
     including community service organizations; and
       (B) services provided through facilities and personnel of 
     the Department.
       (2) The consideration provided by the Secretary for 
     services provided by entities under cooperative arrangements 
     under paragraph (1)(A) shall be limited to the provision by 
     the Secretary of appropriate in-kind services to such 
     entities.
       (f) Provision of Services by Non-Department Entities.--(1) 
     Under one of the pilot programs under this section, the 
     Secretary shall provide long-term care services to eligible 
     veterans through arrangements with appropriate non-Department 
     entities under which arrangements the Secretary acts solely 
     as the case manager for the provision of such services.
       (2) Payment for services provided to veterans under the 
     pilot programs under this subsection shall be as follows:
       (A) By the medicare program or the medicaid program, but 
     only--
       (i) if the veterans concerned are entitled to benefits 
     under such programs; and
       (ii) to the extent that payment for such services is 
     provided for under such programs.
       (B) By the Department, to the extent that payment for such 
     services is not otherwise provided for under subparagraph 
     (A).
       (g) Data Collection.--As part of each pilot program under 
     this section, the Secretary shall collect data regarding--
       (1) the cost-effectiveness of such program, including any 
     savings achieved under such program when compared with the 
     medicare program, medicaid program, or other Federal program 
     serving similar populations;
       (2) the quality of the services provided under such 
     program;
       (3) the satisfaction of participating veterans, non-
     Department, and non-Government entities with such program; 
     and
       (4) the effect of such program on the ability of veterans 
     to carry out basic activities of daily living over the course 
     of such veterans' participation in such program.
       (h) Reports.--(1) The Secretary shall annually submit to 
     Congress a report on the pilot programs under this section.
       (2) Each report under paragraph (1) shall include the 
     following:
       (A) A detailed description of activities under the pilot 
     programs during the one-year period ending on the date of the 
     report.
       (B) An evaluation of the data collected under subsection 
     (g) during that period.

[[Page S7331]]

       (C) Any other matters regarding the programs that the 
     Secretary considers appropriate.
       (i) Duration of Programs.--(1) The Secretary shall commence 
     carrying out the pilot programs required by this section not 
     later than 90 days after the date of the enactment of this 
     Act.
       (2) The authority of the Secretary to provide services 
     under the pilot programs shall cease on the date that is 
     three years after the date of the commencement of the pilot 
     programs under paragraph (1).
       (j) Definitions.--In this section:
       (1) The term ``eligible veteran'' means the following:
       (A) Any veteran entitled to hospital care and medical 
     services under section 1710(a)(1) of title 38, United States 
     Code.
       (B) Any veteran (other than a veteran described in 
     subparagraph (A)) if the veteran is enrolled in the system of 
     annual patient enrollment under section 1705 of title 38, 
     United States Code.
       (2) The term ``long-term care needs'' means the need by an 
     individual for any of the following services:
       (A) Personal care.
       (B) Nursing home and home health care services.
       (C) Habilitation and rehabilitation services.
       (D) Adult day care services.
       (E) Case management services.
       (F) Social services.
       (G) Assistive technology services.
       (H) Home and community based services, including assistive 
     living.
                                 ______