Congressional Record, Volume 149 Issue 164 (Wednesday, November 12, 2003)

[Congressional Record Volume 149, Number 164 (Wednesday, November 12, 2003)]
[Senate]
[Pages S14496-S14504]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

DEPARTMENTS OF VETERANS AFFAIRS AND HOUSING AND URBAN DEVELOPMENT AND
INDEPENDENT AGENCIES APPROPRIATIONS ACT, 2004--Continued

Mr. BOND. Madam President, is the pending business now the VA-HUD
appropriations bill?
The PRESIDING OFFICER. Yes.
Mr. BOND. Madam President, there are about 45 seconds worth of things
that we need to clear up, pending amendments. Then I intend to turn to
the distinguished minority whip for the offering of an amendment, on
which we will have a very short time limit.
I see my colleague, Senator Mikulski, is in the Chamber.

Amendment No. 2156

Madam President, I believe we have had a full debate on the Bond
amendment. I call up the Bond amendment and ask for its adoption.
The PRESIDING OFFICER. There are two Bond amendments pending.
Mr. BOND. This is the Bond amendment on small engines.
The PRESIDING OFFICER. Amendment No. 2156 is now pending.
Mr. BOND. Madam President, I ask for its adoption.
The PRESIDING OFFICER. Is there objection?
Without objection, it is so ordered. The amendment is agreed to.
The amendment (No. 2156) was agreed to.
Mr. BOND. Madam President, I ask unanimous consent to add, as
cosponsors, Senators McConnell, Talent, and Chambliss.
The PRESIDING OFFICER. Without objection, it is so ordered.

Amendment No. 2158

Mr. BOND. Next, Madam President, I call up the Craig amendment on
pesticides.
The PRESIDING OFFICER. Amendment No. 2158 is now pending.
Is there further debate?
Mr. BOND. Madam President, I think we have had a full debate on that
amendment. I know of no other debate.
The PRESIDING OFFICER. If not, without objection, the amendment is
agreed to.
The amendment (No. 2158) was agreed to.
Mr. HARKIN. Madam President, I am pleased to have joined Mr. Craig in
offering this amendment to add the Pesticide Maintenance Fees
Reauthorization Act of 2003 to the VA-HUD appropriations bill.
The authority for the Environmental Protection Agency to collect
these maintenance fees for the reregistration of pesticides expired 2
years ago. Since that time, authority has been extended through riders
on the VA-HUD appropriations bill. This amendment would provide a long-
term authorization that has been agreed to by the Senate and House
Agriculture Committees and a broad array of stakeholders, including
environmental and agricultural groups.
This proposal ensures that EPA continues to collect fees from the
industry of an estimated $20 million per year. This will cover the
costs of reevaluating chemicals first registered prior to 1984,
including the cost of 200 EPA employees engaged in this important work.
The EPA has no alternative but to collect these fees or sharply reduce
their commitment to oversight of these chemicals. A slowdown in
consideration of these applications is neither in the interest of the
environment, nor of the farmers or chemical manufacturers.
This is a bill that has broad support, and it is important to get
this done this year, so that it is in place for next year's budget.
Adoption of this amendment will ensure that EPA has resources to
evaluate and approve safer, more effective chemicals, and that older
pesticides are reviewed for safety in accordance with the Food Quality
Protection Act of 1996. I urge my colleagues to support this amendment.

Amendment No. 2167

Mr. BOND. Madam President, I am going to send a very brief amendment
to the desk that removes the emergency designation. The committee has
reallocated funds to us so that our bill now comes within the
allocation offered by our committee.
Madam President, the amendment was with us in the cloakroom. I
apologize to my colleague in the chair. Here it is. This is it.
Madam President, I send this amendment to the desk and ask for its
immediate consideration.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:

The Senator from Missouri [Mr. Bond] proposes an amendment
numbered 2167.

The amendment is as follows:

(Purpose: To remove the emergency designation on VA Medical Care)

Beginning on page 9, line 20, strike ``: Provided, That''
and all that follows through ``Congress'' on line 5, page 10.

Mr. BOND. Madam President, it simply strikes the emergency clause. I
think there is no debate on that. I ask for its immediate adoption.
The PRESIDING OFFICER. Is there further debate?
The Senator from Maryland.
Ms. MIKULSKI. Madam President, I thank Senator Bond and Senator
Stevens for working very closely with us to ensure that promises made
to veterans are promises kept. This $1.3 billion is a dire need. I am
ready to give my consent to this amendment, and the veterans of America
will be happy because of it.
The PRESIDING OFFICER. Is there further debate on the amendment?
If not, without objection, the amendment is agreed to.
The amendment (No. 2167) was agreed to.
Ms. MIKULSKI. I move to reconsider the vote.
Mr. REID. I move to lay that motion on the table.
The motion to lay on the table was agreed to.
Mr. BOND. Madam President, I thank my colleagues.
Madam President, I also ask unanimous consent to add Senator Miller
of Georgia as a cosponsor to amendment No. 2156.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. REID. Madam President, I have spoken to the two managers of the
bill. The distinguished Senator from New Jersey, Mr. Lautenberg, has
agreed to allow the Senators from New York and Wyoming to go forward.
Senators Clinton and Enzi have an amendment to offer. They have agreed
to 20 minutes equally divided, followed by a vote on or in relation to
that amendment, with no second-degree amendments in order. I ask
unanimous consent that be the case.
The PRESIDING OFFICER. Is there objection?
Without objection, it is so ordered.
The Senator from New York.

Amendment No. 2152

Mrs. CLINTON. Madam President, I thank the minority whip and the
chairman and ranking member of the subcommittee for an opportunity to
discuss this very important amendment.
I call up amendment No. 2152.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:

The Senator from New York [Mrs. Clinton], for herself, Mr.
Enzi, Ms. Cantwell, Mr. Grassley, Mrs. Murray, Mr. Smith, Mr.
Schumer, Mr. Wyden, Mr. Harkin, Ms. Stabenow, Mr. Kerry, Mr.
Dodd, and Mr. Lieberman, proposes an amendment numbered 2152.

Mrs. CLINTON. Madam President, I ask unanimous consent that reading
of the amendment be dispensed with.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendment is as follows:

(Purpose: To permit the use of funds for the Capital Asset Realignment
for Enhanced Services (CARES) initiative of the Department of Veterans
Affairs for purposes of enhanced services while limiting the use of
funds for the initiative for purposes of the closure or reduction of
services pending a modification of the initiative to take into account
long-term care, domiciliary care, and mental health services and other
matters)

At the end of title I, add the following:

[[Page S14497]]

Sec. 116. (a) Limitation on Use of Funds for CARES
Initiative.--No funds appropriated or otherwise made
available for the Department of Veterans Affairs for a fiscal
year before fiscal year 2005 may be obligated or expended to
take any actions proposed under the Capital Asset Realignment
for Enhanced Services (CARES) initiative that would result in
the closure of a Department of Veterans Affairs health care
facility, or reduction in services at such a facility, until
the Secretary of Veterans Affairs--
(1) modifies the Capital Asset Realignment for Enhanced
Services initiative national planning procedures to require
that no changes be made in long-term care, domiciliary care,
or mental health services without a completed and separate
Capital Asset Realignment for Enhanced Services planning
process intended to assess the future demand for such
services;
(2) modifies the Capital Asset Realignment for Enhanced
Services initiative national planning process to take into
account the impact that any transfer of health care services
under the initiative will have on the access of veterans to
primary outpatient care, inpatient hospital care, and
tertiary hospital care in rural and frontier population
areas, as defined by the Census Bureau, taking into
consideration such travel matters as road conditions, numbers
of lanes on roads, and seasonal changes in and other factors
relating to the weather;
(3) modifies the Capital Asset Realignment for Enhanced
Services initiative national planning process to permit
veterans to testify at hearings of the Capital Asset
Realignment for Enhanced Services Commission and reconvenes
the Commission for further hearings on the initiative in
regions where the Commission has held hearings without
permitting veterans to testify;
(4) modifies the Capital Asset Realignment for Enhanced
Services initiative national planning process to hold at
least one hearing regarding the realignment of services under
the initiative within 30 miles of each Department of Veterans
Affairs facility that would experience a realignment of
services under the national plan for the initiative; and
(5) submits to Congress a report on the Capital Asset
Realignment for Enhanced Services initiative national
planning process that sets forth the results of the
modifications under paragraphs (1), (2), (3), and (4).
(b) Availability of CARES Initiative Funds for Enhanced
Services.--Notwithstanding any other provision of law,
neither subsection (a) nor any other provision of law shall
be construed to limit the obligation or expenditure of funds
under the Capital Asset Realignment for Enhanced Services
initiative for the provision of enhanced services as long as
the provision of such services does not involve the closure
of a Department health care facility or a reduction in
services as such a facility.

Mrs. CLINTON. Madam President, my cosponsor and I, Senator Enzi of
Wyoming, are offering this amendment today, which is a bipartisan
amendment. The sponsors include Senators Murray, Grassley, Cantwell,
Smith, Wyden, Schumer, Harkin, Stabenow, Kerry, Dodd, Lieberman, and
Levin.
Our amendment would prevent any spending directed toward closing or
reducing services under the so-called CARES plan until this plan
considers long-term care, domiciliary care, and mental health care, as
well as rural health care issues.
It would also offer veterans, many of whom have not been able to
offer their views, a meaningful opportunity to participate in the CARES
process.
This amendment is supported by the American Legion, the Eastern
Paralyzed Veterans, the Vietnam Veterans of America, and the American
Federation of Government Employees.
I want to be absolutely clear, this amendment does not affect, in any
way, the CARES Commission or the VA moving forward on enhancing or
increasing services for our veterans. It contains explicit language
that allows enhancements under CARES to go forward.
I know the Secretary of the Veterans' Administration, a very
distinguished gentleman, certainly has made the case strongly to
veterans service organizations and to my colleagues that this amendment
would stop enhancements.
It absolutely does not. The clear language makes it absolutely
positive that we are not stopping enhancements. But what we are doing
is saying: Wait a minute. The process that has ended up with
recommending the closure of many of our VA hospitals, three of them in
the State of New York alone, and the fact that in testifying, as my
colleague Senator Schumer and I did before the CARES commission in
Canandaigua, one of the hospitals that is on the target list to be
closed, the commissioners had to admit they did not take into account
mental health services, domiciliary services, and long-term services.
I am hoping this amendment will help us get a handle on some of these
decisions that appear to be ill-advised and not part of a larger plan
aimed at helping our veterans and that, in fact, the Department would
go back to the drawing board to develop a plan through a fair process
that would explicitly take into account mental health, domiciliary, and
long-term care.
There is much to be said about this important amendment.
I ask unanimous consent to print in the Record a letter of support
from the American Legion.
There being no objection, the letter was ordered to be printed in the
Record, as follows:

The American Legion,

Washington, DC, November 10, 2003.
Hon. Hillary Rodham Clinton,
U.S. Senate, Russell Senate Office Building,
Washington, DC.
Dear Senator Clinton: The American Legion supports your
proposed amendment to S. 1584, to limit the use of funds for
the Capital Asset Realignment for Enhanced Services (CARES)
initiative of the Department of Veterans Affairs, pending a
modification to take into account long-term care, domiciliary
care, mental health care and other issues.
As for the CARES initiative in general, The American Legion
supports the program. However, in doing so we continue to
monitor the process, share dialogue with the CARES
Commission, and have several times expressed concern over the
very issues set forth in the amendment.
We appreciate the fact that you and your colleague, Senator
Mike Enzi, share the Legion's concerns on these important
matters.
Sincerely,
John A. Brieden III,
National Commander.

Mrs. CLINTON. The bottom line is that this process, which holds such
promise to make sure we have the right mix of services for our
veterans, is seriously flawed.
On Sunday, I was with a group of veterans served by the Manhattan VA.
Their concerns range from the blinded veteran who suffered a service-
connected loss of hearing and sight in the Vietnam war, who cannot
possibly get to any other VA because of transportation problems, to the
closure of important research that is being done on that campus in
conjunction with the New York University Medical School, to the very
serious problems raised by veterans who are getting superb mental
health services and cannot get them anywhere else if these facilities
are closed or the services reduced.
I wish the VA would hear us on this. I know they are opposed to it. I
know they are concerned about it. But the exclusion of factors
affecting mental health and long-term care is absolutely unacceptable.
In fact, the VA has told us that next year in the strategic plan, they
will get to those important services. How can we be closing facilities
and not having taken into account those services?
I ask unanimous consent to print in the Record a letter of support
from the Vietnam Veterans of America and the American Federation of
Government Employees.
There being no objection, the letters were ordered to be printed in
the Record, as follows:

Vietnam Veterans of America,

Silver Spring, MD, November 12, 2003.
Hon. Hillary Rodham Clinton,
U.S. Senate, Russell Senate Office Building,
Washington, DC.
Dear Senator Clinton: On behalf of Vietnam Veterans of
America (VVA), I wish to thank you and Senator Michael B.
Enzi for your bi-partisan efforts to ensure that vitally
needed veterans health care facilities are not closed in a
precipitous manner. Your amendment to be offered to the FY04
VA-HUD Appropriations bill is a much needed modification of
the Capital Asset Realignment for Enhanced Services (CARES)
process that will provide for a cooling off period and full
public consideration before any Department of Veterans
Affairs (VA) medical facility is closed or services further
reduced. As long as the needed enhancements and new
construction contained in the CARES plan can proceed, VVA
strongly supports this amendment.
The process of devising a mathematical formula for CARES
had been underway for several years before anyone in the
veterans service organization community knew about this
effort. The CARES process is ostensibly designed as a data-
driven system. VVA has objected for more than a year to the
data used, and to the civilian formula that is being
inappropriately applied to veterans health care needs using
that data. The data is not a needs assessment, but rather a
snapshot of what services are left after six to seven years
of reductions in staff in the core

[[Page S14498]]

VA area of specialized services, most particularly in mental
health. The original civilian formula still in use does not
address the special medical needs of the veterans' community.
All who served in the military practiced a very dangerous
occupation. Our wounds, toxic exposures, and even mental
health needs are dramatically different in prevalence and in
kind from those of the general civilian populace. The VA was
created to be a veterans' health care system that addresses
those special needs of veterans, and not just general health
care that happens to be for veterans. The formula that VA is
using estimates one to three presentations (illnesses,
medical conditions, or maladies) per individual, whereas
veterans using the VA system average five to seven
presentations per person. As a result, the current formula
will always underestimate the resources needed to properly
care for veterans. Although there were some adjustments made,
separate from the formula, to increase facilities for Spinal
Cord Injury (SCI) and for Blind and Visually Impaired
Rehabilitation, no such adjustment was made for mental
health.
The formula simply does not properly address mental health
care needs of veterans, nor long-term care, nor the needs of
veterans returning from Iraq and Afghanistan. It is not
surprising that a disproportionate number of the targeted
facilities are psychiatric facilities. VVA believes that what
is needed is development of a veterans health care formula,
and a true needs assessment of the entire veterans' community
by geographic area.
VVA believes in the concept of stewardship, that it is the
task of each of us to leave things better than we found them.
VVA understands and supports the impetus of Senators Bond and
Mikulski to force the VA to plan for future needs before
providing any further construction funds for facilities that
might be abandoned in just a few years. This is what led to
the CARES process.
VVA also is grateful to Secretary of Veterans Affairs
Anthony J. Principi for his response to the concerns of the
veterans' community about CARES. VVA is also grateful to
CARES Commission Chair Everett Alvarez and the other
distinguished members of that body for their work in trying
to ameliorate the results of the inappropriate formula and
bad data. We also recognize that the process is not yet over.
However, even though the CARES process is not yet finished,
the fact that mental health facilities have been so
prominently and inappropriately targeted for closure is ample
cause for alarm. It is important to note that the chair of VA
Advisory Committee on Serious Mental Illness testified before
the CARES Commission hearing held in the Russell Senate
Office Building in September 2003 that 65 percent of the
organizational capacity that VA possessed in 1996 for mental
health care is now gone.
It is also important to note that the dire shortage of
funding of the veterans health care system, which has become
a structural shortfall that is widening with each passing
year, is contributing to the distortions of plans for proper
care for all eligible and much deserving veterans in the
nation, both rural and urban residents. After adding
additional funds to the VA-HUD Appropriations bill for 2004,
currently under consideration, we urge that the Senate work
with the President to move to address this gross and growing
scarcity of resources at VA medical facilities.
In summary, VVA supports the amendment you plan to propose,
along with Senators Enzi, Kerry, Dodd, Lieberman, Cantwell,
Grassley, Murray, Smith, Schumer, Wyden, Harkin, Stabenow,
Kerry, Levin, and others that would have the effect of
preventing any closures until further consideration can be
given as to whether these proposed closures or diminishment
of staff are indeed in the best interest of our nation's
veterans. It is our understanding that this amendment does
not mean that any of the enhancements, remodeling, or
construction in the proposed CARES plan will be delayed or
stopped.
Again, thank you and Senator Enzi for your strong
leadership on this issue.
Sincerely,
Thomas H. Corey,
National President.
____

American Federation of

Government Employees, AFL-CIO,

Washington, DC, November 12, 2003.
Dear Senator: On behalf of the American Federation of
Government Employees, AFL-CIO, which represents 600,000
government employees, including 150,000 employees in the
Department of Veterans' Affairs (VA), I strongly urge you to
support the bipartisan amendments on CARES offered by Senator
Hillary Rodham Clinton (D-NY) and Senator Michael Enzi (R-
WY).
Under VA's planning process--Capital Assets Realignment for
Enhanced Services--known as CARES, the VA is proposing to
close VA nursing homes, domiciliaries, and inpatient mental
health care beds without fully considering how the VA will
meet the surging long-term care needs of elderly veterans or
the needs of homeless veterans. The Clinton-Enzi amendment
would allow the VA to spend funds to improve and repair
facilities but would hold in abeyance the expenditure of
funds to close or reduce services at VA facilities until the
CARES process addresses VA's needs for nursing home care
facilities, domiciliaries and mental health care delivery.
VA's own data projections indicate that in order to meet
the current and future health care needs of elderly veterans
the VA will need roughly 17,000 additional nursing home beds
by 2022. The current CARES proposals target nursing home beds
for closure without considering how the VA will meet the
surging demand for veterans' nursing home and adult day care.
Veterans deserve access to quality care. Congress must make
sure that VA plans for current and future veterans' demand
for nursing home care, mental health services and supportive
environments like domiciliaries.
AFGE strongly urges you to vote yes for the Clinton-Enzi
amendment on CARES. If you have any questions, please contact
Linda Bennett at 202-639-6456.
Sincerely yours,

Beth Moten,

Director,
Legislative and Political Action Department.

Mrs. CLINTON. In summary, I am offering this amendment because I
believe that the Draft National CARES Plan and the process used to
develop it are deeply flawed. The Plan has not adequately taken into
account the impact of these proposals on long term care, domiciliary
care and mental health services. The Development of Veterans Affairs
needs to go back to the drawing board and develop its plan through a
fair process that takes into account all relevant factors and allows
veterans to fully participate in the plan's development.
At this time in our nation's history, with U.S. troops bravely
serving in Iraq, Afghanistan and elsewhere, it sends exactly the wrong
message to propose such drastic changes in veterans' health care
without proper throught and deliberation. Our troops are fighting
overseas to defend our values and way of life. We owe it to our current
and future veterans to make sure that we provide the best health care
possible for them and not rush to implement recommendations that
provide our veterans with less adequate health care.
As a starting point, our bottom-line goal should be the delivery of
high quality health care services to our veterans, delivered as
efficiently as possible. Unfortunately, the hasty procedures that the
Department of Veterans Affairs followed to develop these
recommendations are fundamentally flawed.
Veterans' health care is too important an issue to require an
adherence to artificial deadlines and hasty recommendations. With
literally the lives of veterans at stake, the Commission should not
engage in a rush to judgment over closing VA facilities.

failure to consider long term, domiciliary and mental health needs

As a result of the flawed CARES process, several important factors
that are critical to veterans' health care have been neglected. In this
rushed process, the impact of the proposed changes to long-term care,
domiciliary care and mental health needs were not considered. The
exclusion of these important factors taints the recommendations of the
draft national plan. For example, the Draft National CARES Plan states
that its mental health outpatient psychiatric provisions are
``undergoing revision'' and ``should be available for next year's
strategic planning cycle.'' As you can see from this panel, we found a
speech on the VA web site in which then-Deputy Secretary Mackay
admitted in April that ``As you are also aware, there have been aspects
of care that have been left out of his CARES plan. Long-term care,
domiciliary care, and outpatient mental health care were all determined
to need more work before reliable forecasts could be made.''
Incredibly, despite this admission, the Draft National CARES Plan
proposes reductions in beds in facilities that provide mental health
services. Similarly, there is widely expected to be an increase in the
demand for long term beds for veterans over the next 20 years. However,
the Draft National Plan does not contain any analysis of how many long-
term beds are needed in the coming decades and yet still recommends
closing facilities with long-term beds.

During a meeting between members of the New York delegation and VA
Secretary Anthony Principi a few weeks ago, Secretary Principi
acknowledged that a plan for long-term psychiatric needs has not yet
been developed. With all due respect to Secretary Principi and the
Commission, it

[[Page S14499]]

seems to me that developing a Draft National Plan before developing a
plan for mental health needs is getting it exactly backwards. A plan
for addressing mental health care should have been developed before the
Draft National Plan was released, not after.
The Draft National Plan's failure to consider long-term mental health
care has disastrous implications for veterans around the country,
including thousands in New York. One of the facilities targeted by the
CARES plan is the VA hospital in Canandaigua. I have visited the VA
Hospital at Canandaigua and was greatly impressed by the quality of
care provided at the facility as well as the overwhelming support that
the VA hospital has in the community. And indeed, it is a cruel irony
that Canandaigua has been recommended for closure in the same year that
it received the highest facility rating in patient satisfaction in the
country.
The omission of mental health care needs from the Draft National Plan
is particularly striking because of the effect that the closure of the
Canandaigua VA will have on the veterans with mental health care needs
who are currently receiving care at the facility. Veterans at
Canandaigua receive a specialized level of treatment for mental health
illness that is not readily available at other facilities. Further, if
the Canandaigua VA were to close, many veterans would be forced to
drive long distances for care. As my colleague Senator Enzi has pointed
out, the CARES national plan has not adequately taken into account the
impact of the recommendations on rural health care.
The Draft National CARES Plan for VISN 3 recommends eliminating all
inpatient services at Montrose VA hospital and transferring most of
these services to the Castle Point VA hospital. A decision to follow
through on this recommendation would be a serious blow to veterans who
currently rely on the Montrose VA hospital for their care.
As I mentioned previously, the need for long term beds has not been
properly assessed and current projections forecast that there will be a
significant increase in the need for psychiatry beds through 2012. In
order to ensure adequate capacity to handle the projected case load,
local veterans organizations support retaining all services at Montrose
and Castle Point.
Moving inpatient services from Montrose to Castle Point will require,
by VA's own admission between $85 and $100 million and take at least 5
and maybe as many as 10 years to accomplish. However, the Draft
National CARES plan provides no explanation for what will happen to
services at Montrose in the meantime. Further, there is no analysis of
how veterans will get services if future budgets do not include enough
funds for the transition. The often substantial waiting periods that
veterans living in this region already experience at the Montrose and
Castle Point Campuses and their satellite facilities underline the
strain the system is experiencing.
The Draft National CARES Plan will also have a significant impact on
the Castle Point VA. Wait times at Castle Point are already too long.
With the closure of Montrose and the shifting of veterans to Castle
Point, the wait times are likely to get even worse. In addition, many
area veterans have questioned the adequacy of space available for
expansion at Castle Point.

The CARES Draft National Plan recommends developing ``a plan to
consider the feasibility of consolidating inpatient care [from
Manhattan] at Brooklyn.'' Yet, once again there is no requirement that
the development of this ``plan'' solicit the input of veterans.
Further, the proposal does not properly take into account how the
consolidation of inpatient care in Brooklyn will impact the
relationship between the New York University School of Medicine (NYU)
and the Manhattan VA. The NYU-Manhattan VA relationship, and the high
quality of care for veterans it produces, would be imperiled by the
potential closure of the Manhattan VA.
Finally, the practical matter of transportation deserves an important
role in your deliberations. The high quality tertiary services at the
Manhattan VA attract veterans from New York, and other states including
New Jersey and Pennsylvania. One of the reasons the Manhattan VA is
able to serve these veterans is its amazing accessibility, located, as
it is, in the heart of Manhattan, at the center of a mass transit
system that is unmatched anywhere else in the Nation.
Since the release of the CARES Draft National Plan, a frequent
complaint that I have heard from area veterans has been that the VA has
not been listening to their concerns. Veterans who contributed to the
VISN 2 market plan, which called for no closures in VISN 2, feel
betrayed by the decision to overrule the market plan and call for this
facility's closure.
Further, the VA did not hold hearings near many facilities on the
closure list around the nation. Our amendment would require new
hearings within 30 miles of a facility where a reduction in services is
proposed and require that veterans be allowed to testify.
In meeting with the veterans of New York, I have learned a tremendous
amount about the value of the New York VA facilities and the quality of
health care that is delivered there. And as letters to my office from
veterans who use the facility demonstrate, the veterans' community in
New York is united behind keeping these facilities open.
One veteran who wrote to me explained that he suffered a massive blow
to the head while serving in the Marines and suffers from Organic Brain
Syndrome and Organic Affective Disorder. He currently uses the
Canandaigua VA's day treatment program. He wrote to me that ``I have a
lot of difficulty with my short term memory and the thought of losing
one of the places that I am most familiar with bother me. . . . [I]t
has taken a long time but I have finally reached a little bit of
independence. By losing this hospital, I will be losing that
independence. Also, the place that I live is very rural and there are
no other facilities in my area. The idea of sitting around the house
day after day depresses me.''
Another veteran from Rockland County wrote to me about the potential
closure in Montrose stating that ``I was wounded in 1944 during World
War II by shrapnel in the mouth causing the loss of several teeth. In
early 1945, I was captured by German soldiers and held as a POW until
the end of World War II. . . if [Montrose] were to close, I would have
to travel an additional 45 minutes to one hour depending on weather for
treatment at Castle Point VA Hospital. I am 84 years old and
transportation is getting more difficult for me. As you know there is
no public transportation to this facility.''
Our Nation's veterans have served their country with distinction. Our
nation made a pact with those who serve their country in the Armed
Forces--a commitment that those who served would have access to quality
health care through the VA hospital system. Yet this ill-considered and
rushed Draft National CARES Plan threatens to undermine our commitment
to our nation's veterans. That is we are this offering legislation in
the Senate to halt any spending towards closure or reduction in
services until long-term, domiciliary, mental health care and rural
care are adequately considered and veterans are allowed to fully
participate in the CARES process. If this amendment passes, the
Department of Veterans Affairs and the CARES Commission can begin anew
by taking into account the proper factors and input from veterans. I
urge my colleagues to support the Clinton-Enzi amendment.
I also ask unanimous consent to print the letter from the Eastern
Paralyzed Veterans Association.
There being no objection, the material was ordered to be printed in
the Record, as follows:
Eastern Paralyzed

Veterans Association,

November 10, 2003.
Hon. Hillary Rodham Clinton,
U.S. Senate,
Washington, DC.
Dear Senator Clinton: The Eastern Paralyzed Veterans
Association strongly supports your proposed amendment to S.
1584, the FY 2004 VA-HUD Appropriations Bill to prohibit the
Department of Veterans Affairs (VA) use of appropriated funds
for the implementation of the VA's Capital Asset Realignment
for Enhanced Services (CARES) initiative until CARES
addresses such vitally important issues as mental health
care, long term care, domiciliary care, and other outstanding
issues. We have closely monitored the CARES process since its
inception and, while we agree with VA that infrastructure
analysis is necessary, we cannot support the

[[Page S14500]]

National plan currently being considered for implementation
until these concerns are addressed, as would be required by
your legislation.
From the outset, VA has claimed that CARES would be a data
driven process with sound and justifiable conclusions and
proposals. Unfortunately this has not been the case. VA has
refused to run data on its mental health programs and has
maintained that CARES would not impact on this population.
Despite these claims, 12 of the 14 VA facilities slated for
closure or discontinuation of in-patient services have a
major psychiatric service component. Additionally, the CARES
National plan includes nothing with regard to long term and
domiciliary care; two services that VA is Congressionally
mandated to provide over the next twenty years. Finally, the
data that was used to formulate the National plan completely
excluded veterans in Priority Groups 7 and 8 from the twenty-
year projected usage data. By excluding Priority 7 and 8
veterans from the CARES projections, VA is creating a system
that will be unable to treat these veterans. This cannot be
allowed to occur.
While CARES was well intentioned, the fact that this
process has so many flaws on so many levels forces us to
oppose it until these issues are addressed. Your amendment
would require just that. Eastern Paralyzed Veterans
Association is grateful that you, together with Senator Mike
Enzi, will introduce this amendment to insure that these
issues are dealt with before allowing the process to advance.
Thank you.
Sincerely,
Gerard M. Kelly,
Executive Director.

Mrs. CLINTON. I see my colleague and partner Senator Schumer. I yield
to him such time as he needs.
Mr. SCHUMER. I thank my colleague from New York and all of those who
have worked so hard. I plead to my colleagues, the CARES Commission had
a good idea. Let's study and see how we can make health services better
for veterans. But looking at what they recommended in New York State,
something went amuck; to close the Canandaigua Hospital makes no sense
whatsoever. It is desperately needed by so many veterans. It is a
fountain point of the community, and it does special work in mental
health and psychological services that no hospital within miles and
miles and miles around, tens of miles, hundreds of miles around, can
do.
All we are asking is a chance. Let the CARES Commission go back to
the drawing board and figure out what they did wrong. Let them look at
what they have done wrong in New York in terms particularly of
Canandaigua but also of Montrose and the Manhattan VA hospital where
anyone who looks at it up close sort of scratches their head in
wonderment and says: How did they come up with these recommendations?
This is a bipartisan bill. It does not stop any kind of restructuring
except for the fact that it says: Go back and look at other factors
they seem to have missed.
It is desperately needed in many parts of the country. The veterans
groups of America are totally for this amendment.
This Chamber and the other just voted for $87 billion for Iraq.
Whatever one's opinion of that was, how can we at the same time turn
our backs on so many of those veterans who fought in other wars? I know
the intentions of the commission may have been good, but the effect, at
least in our State, is to do just that. It is to turn its back on tens
of thousands of veterans who served their country, many of whom were
wounded in the course of battle.
This is a pro-veteran amendment, supported by veterans throughout the
country. I urge my colleagues to support it.
I thank my colleague from New York for the great job she has done. We
have worked as a team to try to prevent this from happening. This
amendment gives us a good opportunity to go back and reargue. We hope
our colleagues will support it.
Mrs. CLINTON. Madam President, this is an issue that affects veterans
across our country. My cosponsor, Senator Enzi, is concerned
particularly about the impact on his veterans who live in rural areas
and are not going to be able to travel the long distances that will be
required if services are reduced, if facilities are closed. I know my
colleagues from Iowa, Michigan, Washington, Oregon, Texas, in addition
to Wyoming, have asked for similar relief.
I hope my colleagues who are in States that, under this process, are
in line to get enhancements and increases will vote for this because it
doesn't affect your enhancements. It does not affect your increase, but
it gives those of us who have mental health needs, who have rural
health needs, who have domiciliary and long-term health needs the
opportunity to get this process right and to fix the problems that
would lead to the closure and reduction of services that are so needed
in so many States for so many veterans.
I hope this amendment will find favor with my colleagues and will
give those of us who are particularly on shaky ground because of the
recommendations of this commission a chance to have a more rational
process that really takes into account the needs of our veterans.
I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second?
There appears to be a sufficient second.
The yeas and nays were ordered.
Mr. ENZI. Mr. President, I am pleased to be a cosponsor of this
amendment and I hope to clarify some of the reasons I believe every
Senator should support our efforts.
I think everyone in this Chamber agrees on the importance of our
national veterans community. Just yesterday ceremonies throughout the
Nation and speeches here on the Senate floor paid tribute to those who
have been willing to sacrifice so much. When young men and women
volunteer their lives for the fight for freedom and democracy we, as a
nation, promise to take care of them.
The amendment Senator Clinton introduced today addresses the Capital
Asset Realignment for Enhanced Services or CARES process from the
Department of Veteran's Affairs.
I believe the intent of the CARES process is good. If we can clear up
some of the unused space in the VA health care system and remove
redundancy in services, we can save money and put it towards effective
health care for our veterans. I do not believe, however, that rushing
into changes for the sake of making changes is a good policy. How can
we expect good changes to come from a broken system?
There is no doubt in my mind that the CARES Commissioners have the
best interests of veterans at heart. I believe that given enough time
and proper information, they will be able to make changes in veterans
health care that will fully benefit current and future veterans for
years to come. I must admit, however, that they currently have neither
the time nor the proper information to make good changes.
Now, let's be clear about what this amendment does and does not do.
It does not prevent the CARES process from moving forward. It does not
prevent improvements from being made or new hospitals from being built.
It does not kill the CARES initiative.
It does require the VA to commit to a separate process for long-term
care, domiciliary care, and mental health care needs. It does require
the VA to confirm that they have examined local travel factors such as
road and weather conditions. It does require the CARES Commission to
hold hearings within 30 miles of each facility targeted for a closure
or a reduction of services and it requires veteran participation in
these hearings.
Let me touch on a couple of these requirements. One is that there be
a CARES Commission hearing within 30 miles of every facility facing a
realignment of services under the national plan.
We recently had a CARES hearing in Cheyenne, WY near the Cheyenne VA
Medical Center. I think the hearing went extraordinarily well. The
veterans who attended where given an opportunity to understand more
about the future of their health care. Likewise, the CARES
Commissioners were able to hear the veteran's concerns through the
veterans service organizations. Just holding a hearing in Denver about
reducing services in Cheyenne--a town more than 100 miles away--would
have sent a strong statement to Wyoming veterans that the VA cared
neither for their health nor their opinions.

I believe each facility and community should have the opportunity to
have this same interaction. Each community should be able to understand
what the changes will mean for them and what differences in services
the veterans will face. I now the burden falls to the CARES
Commissioners to attend and consider the testimony at these additional
hearings, but I believe

[[Page S14501]]

they will then be better informed about the decisions they will need to
make.
I also want to point out the travel issue in the amendment. I think
we all realize the difficult nature of taking weather into
consideration nationally. After all, northern Wyoming's winter and
southern Florida's winter are hardly the same. What this part of the
amendment intends to do is ensure that the local factors were
considered when drafting the national plan. Distance cannot be the only
factor considered--we all know that even in Washington, DC, 30 miles
travel distance doesn't mean 30 minutes travel time.
Let me say again, this amendment does not stop the CARES process. It
merely requires the VA to consider a couple of factors that we believe
should have been considered from the very beginning.
I know letters from some veterans service organizations may have
raised concerns for my colleagues about our amendment. these
organizations were able to meet with the Secretary of Veterans Affairs
and had many of their worries addressed. the Secretary told them that
no services would be reduced until replacement services are fully
available. He also stressed that no net changes would be made in long-
term care, domiciliary care, or mental health care.
I think this meeting was a great idea. It is, however, a shame that
it took news of this amendment to get the VA, moving. I am very glad
that the veterans organizations had the opportunity to meet with the
Secretary. Through this amendment we are trying to make sure the VA
addresses the concerns of Congress. We are just trying to make sure
that the promises made are promises kept.
Again, I want to reiterate my support for the CARES Commissioners
themselves. They are doing their best to make good decisions in a
broken system. I appreciate their patience and most of all their
willingness to serve America's veterans. I urge my colleagues to
support the amendment.
Mr. REID. Madam President, I rise to speak against this amendment,
and in support of the CARES process.
As many Senators are aware, Nevada has experienced unprecedented
growth over the last decade. In Clark County alone, the home of Las
Vegas, 14 new schools are constructed each year to keep up with the
approximately 8,000 people that move to the county each month.
The growth in our veterans population has been just as rapid. With
approximately 245,000 veterans, Nevada has the second highest
concentration of veterans in the country. Only Alaska ranks higher.
About 176,000 of Nevada's veterans have served in a war: 18 percent
in the Gulf War, 49 percent in Vietnam, 21 percent in Korea, and 21
percent in World War II. Many of our veterans even served in multiple
wars.
Therefore, Nevada's veterans have been combat-tested. And
regrettably, the average age of our veterans' population is growing
older each year. The rising average age, coupled with the many years of
often very harsh service to defend our Nation's freedom, has placed a
tremendous strain and great demand on the veterans health care system
in Nevada.
More than 70,000 veterans are enrolled in the Reno and southern
Nevada VA health care facilities, with more coming in each day. We have
an excellent VA hospital in Reno, but other parts of northern Nevada
are underserved. And the Las Vegas area continues to be one of the most
densely populated regions of the country for veterans seeking quality
health care and one of the most severely underserved.
In the past several years, the VA has not kept pace with the demand
and growth in our State. Long lines, prolonged waiting times, old and
crowded facilities: this is no way to provide health care to our
courageous veterans, and it is no way to deal with the population
explosion in Nevada.
So when this subcommittee called for a new plan and independent
commission to examine the VA's resources and reallocate resources based
on the greatest demand, I applauded that action. I also welcomed VA
Secretary Tony Principi's active role and interest in supporting
Nevada. He has been an honest advocate for our Nation's veterans, and a
bright spot in the President's cabinet.
It came as no surprise to me that the CARES plan, which is the
subject of this debate, found Nevada to be dramatically underserved by
the VA.
The draft CARES plan contains $130 million in upgrades to improve
health care facilities for the veterans who live in Nevada.
The plan also calls for the construction of a major medical center,
clinic and nursing home in the Las Vegas area. This new hospital is
only one of two hospitals recommended in the entire VA plan. I credit
our hardworking VA staff in Nevada and the thousands of veterans
themselves for making sure that the CARES Commission got the message
about Nevada's desperate needs.
Therefore, I must oppose any effort to delay, derail or diminish the
CARES process and the money and resources that would flow to the
veterans in my State under the draft plan.
I have the greatest respect and admiration for the Senator from New
York. I understand her concerns, and the concerns of other senators,
about certain CARES recommendations that will impact other States. But
these concerns should be addressed directly with the VA, and not by
cutting off appropriations to the VA for the CARES process to continue.
The veterans of Nevada can't wait much longer for the upgrades and
new facilities that they desperately need and deserve.
I therefore will vote against this amendment, and I would urge my
colleagues to do the same.
The PRESIDING OFFICER. The Senator from Missouri.
Mr. BOND. Madam President, how much time remains?
The PRESIDING OFFICER. There are 10 minutes in opposition.
Mr. BOND. Madam President, I yield myself 7 minutes, and I reserve
time for my colleague.
I rise in strong opposition to the Clinton-Enzi amendment. It would
deny up to $1 billion in funds to support our Nation's veterans. I
especially object to the amendment because it would likely extend
waiting lines for veterans already waiting for medical care.
Before I go into further explanation, I ask unanimous consent to
print in the Record letters from the Veterans of Foreign Wars, Amvets,
Disabled American Veterans, and the Paralyzed Veterans of America.
There being no objection, the material was ordered to be printed in
the Record, as follows:

Veterans of Foreign Wars

of the United States,

Washington, DC, November 6, 2003.
To: All Members of the U.S. Senate.
From: Robert E. Wallace, Executive Director, VFW Washington
Office.
Re: Clinton/Enzi amendment to H.R. 2861.

On behalf of the 2.6 million members of the Veterans of
Foreign Wars of the United States (VFW) and our Ladies
Auxiliary, I would like to take this opportunity to urge you
to oppose the Clinton/Enzi Amendment to H.R. 2861, the FY
2004 VA/HUD Appropriations bill.
This amendment would limit the use of funds for the
Capital Asset Realignment for Enhanced Services (CARES)
initiative. The VFW is concerned that if this amendment
passes, the CARES process will essentially be put on
indefinite hold.
We share Senators Clinton's and Enzi's concerns regarding
long-term care, domiciliary care, and mental health services;
however, it is our understanding that the CARES Commission is
currently reviewing the data to include these services.
Therefore, at this stage, we believe it is important to move
ahead as the location and mission of some VA facilities need
to change to improve veterans' access; to allow more
resources to be devoted to medical care, rather than the
upkeep of inefficient buildings; and to adjust to modern
methods of health care service delivery. Our nation's
veterans deserve no less.
Again, I urge you not to support the Clinton/Enzi
Amendment regarding the limiting of funds for the VA CARES
initiative.
____

AMVETS,
Lanham, MD, November 7, 2003.
To: All Members of the U.S. Senate.
From: S. John Sisler, National Commander.
Re: Consideration of CARES amendment in VA/HUD appropriations
bill.

It is our understanding that Sen. Hillary Rodham Clinton
may offer an amendment to S. 1584, the VA/HUD appropriations
bill, that would block the Department of Veterans Affairs
from spending any money to enact the CARES Commission
recommendations.
On behalf of the nationwide membership of AMVETS (American
Veterans), I write to express our strong opposition to Sen.
Clinton's

[[Page S14502]]

proposed amendment aimed to stop progress of the Department
of Veterans Affairs National Capital Asset Realignment for
Enhanced Services (CARES) Plan.
The CARES initiative is clearly needed to assess what
facilities will best meet the healthcare needs of America's
veterans. AMVETS believes that adoption of the amendment
would further delay moving forward with construction projects
that are obviously essential to patient safety and that will
eventually pay for themselves as a result of modernization.
AMVETS agrees with the Department of Veterans Affairs that
many of their facilities need to be upgraded or replaced. We
also agree with the Department that part of the solution for
providing high quality health care to America's veterans is
upgrading some facilities and replacing others with new and
modern medical care treatment facilities.
AMVETS and I ask that you oppose any amendment that would
cause the VA National CARES process to be used as an excuse
to defer vital infrastructure maintenance and construction
projects.
____

Disabled American Veterans,

Washington, DC, November 7, 2003.
Hon. Hillary Rodham Clinton,
U.S. Senate,
Washington, DC.
Dear Senator Clinton: On behalf of the more than one
million members of the Disabled American Veterans (DAV), we
write to express our concern over your proposed amendment to
limit the use of funds for the Department of Veterans Affairs
(VA) Capital Asset Realignment for Enhanced Services (CARES)
initiative, pending modification of the initiative to include
long-term care, domiciliary care, and mental health services
in addition to reconvening the Commission for further
hearings.
Intially, please know that preservation of the integrity of
the VA health care system is of the utmost importance to the
DAV and our members, and we greatly appreciate your efforts
and insistence that long-term care, domiciliary care, and
mental health services are included in the CARES initiative.
These specialized programs are an integral part of providing
sick and disabled veterans comprehensive health care.
However, we are concerned your amendment may completely stall
the CARES process and prohibit VA from making the necessary
changes to improve its health care system and enhance access
and services for veteran patients.
As you are aware, over the past seven years, following
national trends, VA's Veterans Health Administration
converted from a primarily hospital-based system to an
outpatient focused health care delivery model. With these
sweeping changes, there clearly came a need to reassess VA's
physical structures and the need to realign, renovate, and
modernize VA facilities to meet the changing health care
needs of veterans today and well into the future. Many VA
medical facilities have an average age of 54 years and are in
critical need of repair. Unfortunately, VA's construction
budget has decreased sharply over the last several years with
political resistance to fund any major projects before a
formal plan was developed. VA responded with the CARES
initiative. However, many desperately needed construction and
maintenance projects, including seismic repairs that could
potentially compromise patient safety, have been
unnecessarily delayed. DAV strongly believes that CARES
should not distract VA or Congress from its obligation to
protect its physical assets whether they are to be used for
current capacity or realigned.
On a national level, DAV firmly believes that realignment
of capital assets is critical to the long-term health and
viability of the entire VA health care system. We do not
believe that restructuring is inherently detrimental to the
VA health care system. However, we will remain vigilant and
press VA to focus on the most important element in the
process, enhancement of services and timely delivery of high
quality health care services to our nation's sick and
disabled veterans.
VA Secretary Anthony J. Principi met with DAV and other
veterans service organizations this morning and gave us his
personal commitment that there would be no realignment or
reduction in services as a result of CARES for mental health
or long-term care until a definitive plan is developed and in
place to absorb the workload for these specialized services.
His promise to us satisfies our over-arching concern about
the inclusion of these essential programs. Therefore, we
believe the CARES process should be allowed to proceed at
this critical juncture.
Again, we want to thank you for your efforts on CARES and
for your strong leadership and support of veterans' issues.
We very much look forward to continuing a positive and
meaningful working relationship with you regarding matters of
great importance to veterans. We hope that you will
reconsider your position on this issue based on these new
developments.
Sincerely,

David W. Gorman,

Executive Director,
Washington Headquarters.
____

Paralyzed Veterans of America,

Washington, DC, November 7, 2003.
Members,
U.S. Senate,
Washington, DC.
Dear Senators: On behalf of the Paralyzed Veterans of
America (PVA) I am writing to express our concerns regarding
an amendment we understand will be offered by Senator Hillary
Rodham Clinton to the VA, HUD, Independent Agencies
Appropriation bill. As we understand, this amendment
addresses the Department of Veterans Affairs' Capital Asset
Realignment for Enhanced Services (CARES) process and, if
passed, will limit the expenditure of funds for the process
greatly delaying necessary improvements to the VA's medical
care system.
While PVA concurs with Senator Clinton that the CARES
process inadequately addresses issues of long-term care,
mental health services and rural health care we believe that
the amendment will so severely restrain the process that the
many beneficial aspects of CARES will be seriously harmed.
Delay of CARES projects that will benefit veterans, and in
particular veterans with spinal cord injury or dysfunction,
can only serve to weaken the VA health care system upon which
our members and millions of other veterans rely.
Veterans' service organizations have received assurances
from Secretary of Veterans Affairs Anthony Principi that no
VA beds will be closed or capacity reduced until appropriate
alternative health care resources have been identified and
put in place. Additionally, the Secretary has assured us that
long term care and mental health services will be included in
the planning process with specificity to be provided as to
who will be involved, how the process will operate and what
timelines will be put in place. Finally the Secretary has
indicated that the issue of inter-VISN (Veterans Integrated
Service Network) planning and cooperation will be addressed.
In light of these assurances and the need to proceed with
the positive findings, to date, of the CARES process, PVA
believes any restrictions on funding for the CARES process
can only serve to delay improvements in capacity and access
of VA health care. We request that no limitation be placed on
appropriated dollars for the Department of Veterans Affairs
and that the CARES process be allowed to expeditiously move
forward.
Sincerely,
Delatorro L. McNeal,
Executive Director.

Mr. BOND. These organizations all oppose the Clinton-Enzi amendment
because they understand the problem the VA has.
In 1999, the General Accounting Office found that VA could spend
billions of dollars operating hundreds of unneeded buildings over the
next 5 years. The GAO reported that the VA wastes more than $1 million
per day on medical care funds for unneeded infrastructure instead of
direct patient care. This money could be used to provide medical care
to over 100,000 veterans.
Our committee, the VA-HUD committee, after the GAO report, directed
the VA to do something about it, to develop a comprehensive strategy.
Thus, in 1999, under the Clinton administration, the VA created the
CARES Commission to address this concern.
I have traveled around the State of Missouri. I have seen firsthand
the need for construction funds to update surgical and intensive care
units. By the way, I gave at the office. One of the first closures the
VA instituted was of a surgery center in the State of Missouri because
they weren't doing enough surgeries to be proficient. I believed our
veterans needed the best care. So now we have a primary care facility
and we send them to a surgical hospital where they do enough surgeries
to be proficient and safe.
We know we have different needs from veterans than when the VA was
set up many years ago. The Clinton-Enzi amendment would deny over $600
million in construction funds to build new hospitals in States such as
Nevada, Florida, and Colorado. It would deny funds to address safety,
seismic and other deficiencies for facilities in Kentucky, California,
Colorado, Ohio, Pennsylvania, and others. It would deny construction of
48 new community-based outpatient clinics.
It would deny funding for 37 nursing home investments, such as
construction of new nursing homes in West Virginia and Pennsylvania.
This is not a fatally flawed process. I cannot agree with the assertion
of the Senator from New York. In an October 27 letter to all Senators,
this year Secretary Principi outlines the great extent to which he has
gone to ensure that the process and review be thorough at every stage.
Local veterans groups, union officials, as well as affiliate
representatives participated directly in the development of these
plans.
The CARES Commission received more than 169,000 public comments. I
take exception to the characterization of the plan as a ``cost
cutting'' plan. The draft proposes to spend $4.6 billion in
construction funds to expand services. It preserves more than 97
percent of the current bed capacity. Further,

[[Page S14503]]

the draft plan provides for no reduction in VA capacity to provide
domiciliary or long-term care, including long-term mental health care.
Let me repeat that. The draft plan provides for no reduction in VA
capacity to provide domiciliary or long-term care, including long-term
mental health care.
In some areas, the draft plan would increase overall bed capacity. In
New York State, the realignment would increase overall bed capacity by
about 10 percent. The CARES Commission has held field hearings, and the
Senator from New York has attended two of them. The CARES Commission
held 38 field hearings with over 700 witnesses and made 68 site visits.
Clearly, Secretary Principi and the CARES Commission have been
thorough, responsive, fair, and open.
This is a process that still is in its development stage. The Senate
authorizing committee, chaired by Senator Specter, is working on
legislation to establish funding for CARES, which will provide Congress
an opportunity to review the final CARES plan before it can be
implemented. The VA Committee held a hearing with Secretary Principi
and the CARES Commission chair, Everett Alvarez, to provide oversight
on the process.
I am committed to and fully supportive of CARES because we need to
support veterans' medical care over unneeded buildings. To keep
unneeded or excess buildings in operation deprives veterans of the care
they need. There has been much opposition to this.
Mr. President, to reiterate, I oppose vigorously the Clinton-Enzi
amendment to stop the VA's Capital Asset Realignment for Enhanced
Services or CARES process. The amendment would deny up to $1 billion in
funds to support our Nation's veterans. I object to this amendment
because I believe in putting the needs of veterans ahead of the costs
of keeping open unneeded buildings. I especially object to this
amendment because it would likely extend the waiting lines for veterans
already waiting for medical care. It is imperative that the CARES
process moves forward so that the VA can move its outdated medical care
infrastructure into the 21st Century.
Before I explain my reasons for opposing this amendment, I ask that
letters from the Veterans of Foreign Wars, AMVETS, Disabled American
Veterans, and the Paralyzed Veterans of America be added to the Record.
As the largest veterans' service organizations in the Nation, they all
oppose the Clinton-Enzi amendment because of its negative impact on
veterans.
Why does the amendment hurt veterans? In 1999, the General Accounting
Office (GAO) performed a study of the VA's medical care infrastructure
and found that the VA ``could spend billions of dollars operating
hundreds of unneeded buildings over the next five years.'' The GAO
reported that the VA wastes $1 million per day in medical care funds on
unneeded infrastructure, instead of direct patient care. Therefore,
instead of wasting some $400 million annually on unneeded buildings,
the VA could use these funds to provide medical care to over 100,000
needy veterans.
In response to the GAO's report, our committee directed VA to develop
a comprehensive strategy to realign its medical care facilities so that
it can deliver health care in a more accessible and effective manner.
Thus, in 1999, the VA created the CARES initiative during the Clinton
Administration to address this concern.
The amendment also hurts veterans by denying much-needed construction
funds to areas that need modernized facilities to serve its veteran
population. In my travels around my own home State of Missouri, I have
seen first-hand the need for construction funds to update surgical
suites and intensive care units, among other things. For those Senators
who have veterans in rural areas, they know that there is a critical
need for outpatient clinics so veterans do not have to travel hundreds
of miles to the nearest hospital. With an aging veteran population,
there is a significant need to build nursing homes and long-term care
facilities. The Clinton-Enzi amendment will deny over $600 million in
construction funds to these places. It will deny funds to build new
hospitals in States such as Nevada, Florida, and Colorado. It will deny
funds to address safety, seismic, and other deficiencies for facilities
in States such as Kentucky, California, Colorado, Ohio, and
Pennsylvania. It will deny the construction of 48 new community based
outpatient clinics throughout the country. It will deny funding for 37
nursing home investments, such as the construction of new nursing homes
in States such as West Virginia and Pennsylvania.
Another reason why I oppose the Clinton-Enzi amendment is that the
CARES process is still in its developmental stage and it is premature
to pull the plug. Yet, Senator Clinton has already concluded that the
CARES process is ``fundamentally flawed'' and the CARES Commission has
``neglected'' the important health care issues facing our veterans.
Further, she characterizes CARES as a ``cost-cutting'' plan.
I do not agree with the Senator's assertions and I think it is
unfortunate that she has been so critical of Secretary Principi who has
been extremely responsive to the Congress's concerns. To Secretary
Principi's credit, he has made the CARES process open and fair for all
affected parties, including veterans to participate.
In an October 27, 2003 letter sent to all Senators, Secretary
Principi outlines the great extent he has gone through to ensure that
``the process and review be thorough at every stage.'' Local veterans
groups, local officials, union officials as well as affiliate
representatives participated directly in the development of
local plans. Since the announcement of the Draft National CARES Plan,
the CARES Commission has received more than 169,000 public comments.
According to the VA, all comments will be made a part of the official
record and will be considered by the CARES Commission during its
deliberations.

I take great exception to Senator Clinton's characterization of CARES
as a ``cost-cutting plan.'' The Draft plan proposes to spend $4.6
billion in construction funds to expand services. It preserves more
than 97 percent of VA's current bed capacity. Ninety-seven percent. It
increases outpatient capacity by more than 12 million visits a year. It
creates 48 new community-based outpatient clinics and at least 2 new
hospitals. Further, the Draft plan provides for no reduction in VA
capacity to provide domiciliary or long-term care, including long-term
mental health care. Let me repeat that last sentence. The Draft plan
provides for no reduction in VA capacity to provide domiciliary or
long-term care, including long-term mental health care. Moreover, in
some areas, the Draft plan's realignment would increase overall bed
capacity. For example, in New York State, the realignment would
increase overall bed capacity by about 10 percent. The Draft plan
provides for all of these enhanced services and additional facilities
despite the VA's projections that the veteran population is expected to
decline by more than 25 percent over the next 20 years. I ask my Senate
colleagues, does this sound like a cost-cutting plan?
Further, the CARES Commission has held a number of field hearings and
site visits across the Nation to listen first-hand to the concerns of
interested parties. In fact, Senator Clinton participated in two CARES
hearings. In total, the CARES Commission held 38 field hearings that
included over 700 witnesses and made 68 site visits. In some instances,
the Commission altered its schedule to respond to local interests such
as in New York.
Clearly, Secretary Principi and the CARES Commission have been
thorough, responsive, fair, and open in moving the process. For
example, at Senator Schumer's request, Secretary Principi agreed to
visit the Canandaigua VA hospital before making any final decision.
I also stress again that the CARES process is still in its
developmental stage. The Commission has not completed its work. No
final decisions have been made. The current plan is only a draft and is
an interim step to the overall process. Delaying or stopping this
process is premature and ends up hurting more than helping our
veterans. The CARES Commission must complete the plan and the Secretary
and the Congress must approve it.
The Senate authorizing committee, chaired by Senator Specter, is
working on legislation that establishes criteria for funding CARES
projects,

[[Page S14504]]

which will provide the Congress an opportunity to review the final
CARES plans before it can be implemented. In fact, the Veterans Affairs
Committee held a hearing with Secretary Principi and the CARES
Commission Chair Everett Alvarez to provide oversight on the process
and to ensure that the process was moving in a public and deliberative
manner. The Committee also recently passed legislation that was
originally sponsored by Senator Bob Graham and co-sponsored by nine
other senators, including Senator Clinton that would give the Congress
60 days to approve before any VA facility could be closed. If enacted,
this legislation ensures that the Congress is involved in the
implementation of the CARES plan.
I am committed and fully supportive of CARES because I believe in
supporting veterans medical care needs over unneeded buildings. I
believe that CARES is the most important initiative in the VA and it
must be done. We cannot afford any more delays. For too long, the VA
was unable to rationalize its infrastructure and millions of medical
care dollars were wasted on empty, obsolete, or redundant buildings
instead of focusing those dollars on medical care for our veterans.
Now, after nearly 4 years of work on CARES, the VA is developing a
national plan that will ensure that the medical care needs of our
Nation's veterans come first and they will receive the best care in
modernized 21st Century facilities. We owe it to our veterans to move
away from the old medical model of hospital-centered medicine to the
contemporary, modern patient-centered medicine model.
The veterans also agree with my view and oppose this amendment. The
VFW's November 6, 2003 letter states, ``we believe it is important to
move ahead as the location and mission of some VA facilities need to
change to improve veterans' access; to allow more resources to be
devoted to medical care, rather than the upkeep of inefficient
buildings and to adjust to modern methods of health care service
delivery. Our Nation's veterans deserve no less.''
The sponsors of this amendment have tried to assuage the concerns of
Senators who expect to receive new medical facilities in their State by
limiting the amendment to facilities where closures may occur. However,
I tell my colleagues, do not be fooled. This amendment would still
prevent new hospitals, clinics, and nursing homes to be constructed
because the VA cannot break up its CARES plan into separate pieces.
There is only one plan for the Nation. It is a National Plan and it
cannot be separated into pieces. In addition, many new construction
projects under CARES cannot be financed unless some obsolete facilities
are closed. In some areas, such as Chicago and Pennsylvania,
construction for new facilities will be financed by the proceeds of
leases of the closed facilities. Finally, this amendment continues the
wasteful practice of spending medical care funds on unnecessary and
empty buildings. Under CARES, these funds would be re-focused on direct
patient care, the construction of new outpatient clinics, and operating
costs for new hospitals, such as the proposed facilities in Las Vegas
and Orlando. Implementing CARES will allow the VA to serve more
veterans and especially ensure that our most vulnerable veterans will
not be forced to wait for several months or years to obtain medical
care.
I urge my colleagues to place the needs of veterans ahead of unneeded
facilities. Efforts to delay the CARES process will cause significant
harm to our veterans. Outside of funding for VA medical care, CARES is
my highest priority for VA. I have supported CARES from its inception
in 1999, including the implementation of the pilot program in VISN 12.
I strongly urge my colleagues to oppose the Clinton-Enzi amendment and
allow the VA to move the CARES process forward.
The PRESIDING OFFICER (Mr. Cornyn). Who yields time?
Ms. MIKULSKI. Mr. President, first, I compliment our two colleagues
from New York on their advocacy for veterans and the attempt to work to
form a bipartisan coalition and for being concerned about mental health
services and long-term care, as well as the rural needs.
I say to my two colleagues, we on the VA Committee have to be
concerned that we are in the veterans health care business and not in
the veterans health real estate business. So we want to advocate for
services, not for buildings.
I think the Senator is also aware that we just had to work very hard
to forage to come up with the $1.3 billion to meet the compelling needs
for our veterans. I ask the Senator from New York, with her very strong
advocacy and the support of a bipartisan list of cosponsors, would she
consider a different approach--that, perhaps, report language be in the
bill acknowledging the validity of the concerns raised by her, Senator
Enzi, and others, talking about the need for long-term care, and pay
attention to this as well as the rural health care?
I say to my dear and esteemed colleague, the CARES project or process
is due December 3. To make these recommendations, some of which are
quite excellent--inclusion, participation, et cetera--would derail
CARES. It could affect our spinal injury programs or more outpatient
clinics. I know it could have unintended consequences.
Would the Senator consider an alternative other than having the vote
on the amendment?
Mrs. CLINTON. Mr. President, I appreciate greatly the understanding
of my friend and colleague. I am somewhat concerned, however. We have
many charts, but I will not go into them, under the circumstances. They
are very clear that there has not been adequate conversation on mental
health and the other needs. I respect what the Senator from Missouri
said. If you look overall, there may not be a loss of services defined
in a certain way, but that is not necessarily tied to where the
veterans need the services, or where the high-quality services have
historically been given.
I also add that Senator Enzi, my esteemed cosponsor, is at this
moment chairing a hearing. We were, obviously, unprepared to get this
up and get it out. But he told us to go ahead. I would like the
opportunity to discuss this with my cosponsor. I don't want to make a
decision without his awareness of what the Senator's idea is.
Ms. MIKULSKI. Mr. President, I ask unanimous consent that this
colloquy be extended for another 5 minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mrs. CLINTON. Mr. President, I suggest that we at least have an
opportunity to discuss this with not only the prime cosponsor, but all
the other cosponsors because many of us feel very strongly about the
way this CARES process proceeds.
Could the managers of the bill tell us what the plan is, and whether
we are going to have votes on this bill when we finish the 30 hours?
Where do we stand in the process? That would give me a better idea as
to how to respond to the offer of the Senator from Maryland.
Mr. BOND. Mr. President, in order to get this bill completed, we are
going to have to wrap it up one way or the other by 6 o'clock tonight.
It can either walk out or go out feet first. I will join my colleague
from Maryland in saying if she wants to withdraw the amendment, I
understand her concerns. I am sympathetic to the concerns. We would be
delighted to put it in report language and work with the Secretary of
the VA to make sure her concerns are fully addressed.
But in the meantime, unless the Senator is ready to acquiesce, I ask
unanimous consent that this amendment and the yeas and nays be set
aside temporarily until we can have further discussions with the
Senator from New York and the other sponsors.
The PRESIDING OFFICER. Without objection, it is so ordered.

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