[Congressional Record Volume 154, Number 92 (Thursday, June 5, 2008)]
[Senate]
[Pages S5215-S5216]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BAUCUS:
  S. 3095. A bill to amend title XVIII of the Social Security Act to 
expand the Medicare Rural Hospital Flexibility Program to increase the 
delivery of mental health services and other health services to 
veterans of Operation Enduring Freedom and Operation Iraqi Freedom and 
to other residents of rural areas, and for other purposes; to the 
Committee on Finance.
  Mr. BAUCUS. Mr. President, an Iraq veteran named Travis Williams told 
his story at a field hearing in Great Falls, Montana last summer. After 
graduating from Capitol High School in Helena in 2002, Travis quickly 
joined the Marine Corps. Travis was deployed to Iraq in 2005. He served 
in Al Anbar province.
  Like thousands of other American men and women in uniform, Travis 
served nobly and with honor under the most difficult of circumstances. 
He experienced the horrors of combat. He lost numerous friends. And he 
saw unspeakable violence.
  Travis testified that after months of combat, his emotions seemed to 
dull or shutdown. As he later learned, he was experiencing a normal 
reaction to a highly abnormal situation. His reaction was a defense 
mechanism that allowed him to continue to operate in a combat zone. His 
mind was finding a way to keep going. Thousands of marines, soldiers, 
airmen and seamen have experienced this phenomenon.
  Travis testified that when he arrived home it seemed ``surreal.'' He 
felt more out of place in his own home than he did in Iraq. Travis 
isolated himself from his friends. He was frequently drunk and angry. 
Looking back, he understands that he was on what he called the ``path 
to destruction.''
  One day, Travis received a phone call from Deb McBee. Deb is a 
veteran's service officer from the Military Order of the Purple Heart. 
Deb had heard about Travis' experiences in combat. She recommended that 
he visit the VA clinic to seek help. Travis took her advice. The VA 
referred Travis to a veteran's liaison for the Western Montana Mental 
Health Clinic.
  Travis connected immediately with his mental health counselor. The 
counselor was also a veteran who understood the nightmare of combat and 
the loneliness of coming home. Over time, the counselor helped Travis 
to get back on track. Before long, Travis was enrolled in a pre-med 
program and had overcome many of the feelings of anger and loss he had 
felt before.
  I begin with Travis' story because it offers hope. But it offers hope 
amid a very dark picture facing our veterans. A recent study by the 
RAND Corporation revealed that American veterans are facing a crisis of 
epic proportions. RAND estimates that around 300,000 service members 
suffer from post-traumatic stress disorder--also known as PTSD--or 
major depression. And 320,000 individuals reported experiencing 
probable traumatic brain injury during deployment.
  The RAND study found that only 53 percent of service members with 
post-traumatic stress disorder or depression have seen a doctor or 
mental health provider in the past year. Of those who had a mental 
disorder and sought care, about half received only ``minimally 
adequate'' treatment.
  Tragically, on any single day, on average, 18 veterans commit 
suicide. More than one out of five of those vets were patients 
undergoing treatment by the VA. Think of it: Today, 18 veterans are 
liable to commit suicide.
  The VA has responded to this crisis with numerous initiatives that 
offer hope to thousands of veterans. This year, the VA will spend more 
than $3.5 billion for mental health services. Some of these funds will 
be invested in a new mental health inpatient ward in Helena, Montana. 
Over the last several years, the VA has opened up hundreds of new rural 
health clinics. Today, there are more than 700 of these clinics 
providing health care to our Nation's veterans. Montana has recently 
received two new rural health clinics in Lewistown and Cut Bank. The VA 
is making great strides.
  But we need to do more. Thousands of veterans still remain out of 
reach.
  The VA has undertaken an aggressive campaign to make mental health 
care services available to veterans living in rural areas. But 
thousands of Americans returning from Iraq and Afghanistan live 
hundreds of miles away from the health care that they need.
  The Veteran's Affairs Office of Policy Analysis and Forecasting 
counts 118,685 registered highly-rural veterans in America. Of these, 
only 39,158 live within 2 hours of a VA medical center. Thousands of 
veterans returning from Iraq and Afghanistan often have to choose 
between a day-long trip to the VA or no care at all. In my home state 
of Montana 32,404 rural veterans are enrolled in the VA healthcare 
system. Over 10,000 of those veterans must drive more than an hour and 
a half to reach a VA hospital. And thousands of those veterans must 
drive over two hours both ways. In times of crisis, two hours is much 
too far to drive.
  Research conducted by the Department of Veterans Affairs shows that 
veterans residing in rural areas are in poorer health than their urban 
counterparts. Nationwide, one out of every five veterans enrolled in VA 
health care lives in a rural area. Providing quality health care in a 
rural setting has proved to be a daunting challenge. Limited numbers of 
doctors and long highways make inadequate access to care all too 
common.
  But let me return to Travis Williams' story. The key lesson of 
Travis' story is that getting the right care to veterans is all about 
teamwork. It wasn't just the VA that saved Travis. It wasn't just 
professional mental health counselors alone. It wasn't just veterans' 
service organizations. Travis' willpower alone was not sufficient to 
get him through the hard times. It was all of those things. All of 
those factors working together helped Travis to get away from a life of 
anger and despair, and back to a life full of meaning and purpose.
  Teamwork is what the Relief for Rural Veterans Act is all about. The 
bill would enable small rural hospitals, mental health service 
providers, and other rural providers to work together to respond to the 
needs of veterans in crisis. States could apply for funding to increase 
their capacity to deliver mental health services by using state-of-the-
art technology such as tele-health and tele-psychiatry.

[[Page S5216]]

  More specifically, my bill will give the Secretary of Health and 
Human Services authority to award grants under the Medicare Rural 
Hospital Flexibility Program. The Medicare Flex Program has a 
successful 10-year history of strengthening the rural healthcare 
infrastructure. Under this new authority, States can apply for grants 
to increase the capacity of rural providers to provide mental health 
services to veterans and other rural residents. The bill would 
authorize an additional $100 million for this new authority for 2 
years.
  The Medicare Flex Program is a good way to improve health care 
services in rural America. It has provided grants to States to develop 
State rural health care plans. It supports conversion of eligible small 
rural hospital facilities to critical access status. It supports rural 
emergency medical services. And it fosters rural health care network 
development. It makes sense to expand this program to include mental 
health services needed by veterans in crisis.
  Research conducted by the University of Maine found that small rural 
hospitals are playing a major role in providing emergency health care 
services to veterans. They are filling a critical gap in caring for 
veterans in crisis.
  But the Federal Government has not thus far provided funds to help 
rural hospitals to perform this task. The grants authorized in my bill 
could support crisis intervention services and other health care 
services needed by Iraq and Afghanistan veterans. My bill will focus 
upon those veterans who live far from VA facilities. It could provide 
relief for veterans who have to drive hours to receive emergency mental 
health care.
  An additional benefit of these grants is that all rural residents, 
regardless of whether they are veterans or not, would be able to take 
advantage of the increased capacity of their small rural hospitals to 
deliver improved healthcare services.
  Iraq and Afghanistan Veterans of America and the National Alliance on 
Mental Health Care have endorsed this bill.
  The RAND study I mentioned earlier concluded that we need a major 
national effort to improve the capacity of the mental health system to 
care for veterans. The report stated that the effort must include the 
military, veterans, and civilian healthcare systems.
  This bill is one answer to that call. This bill is a way to approach 
the problems facing our veterans from a new perspective. The philosophy 
behind the bill is that all agencies that can lend a hand to our 
veterans should do so. The challenges facing our Nation's veterans are 
too large for the VA to handle on its own.
  Researchers estimate that PTSD and depression among returning service 
members will cost the Nation as much as $6.2 billion in the 2 years 
following deployment. That's an amount that includes both direct 
medical care and costs for lost productivity and suicide. Investing in 
more high-quality treatment could save close to $2 billion within 2 
years by substantially reducing those indirect costs.
  Last month, Chairman Bob Filner said this about the crisis facing our 
veterans: This is not a crisis that only concerns numbers. This is a 
matter of life and death for the veterans for whom we are responsible.
  I urge the VA to continue its efforts to extend its reach into rural 
areas. I applaud the nation's thousands of volunteers who serve our 
Nations' veterans. And I offer this legislation as one way to begin a 
new approach to help those who have sacrificed so much in the name of 
duty, honor, and country.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 3095

       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 ``Relief for Rural Veterans in 
     Crisis Act of 2008''.

     SEC. 2. EXPANSION AND EXTENSION OF THE MEDICARE RURAL 
                   HOSPITAL FLEXIBILITY PROGRAM.

       (a) In General.--Section 1820(g) of the Social Security Act 
     (42 U.S.C. 1395i-4(g)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Providing mental health services and other health 
     services to veterans and other residents of rural areas.--
       ``(A) Grants to states.--The Secretary may award grants to 
     States that have submitted applications in accordance with 
     subparagraph (B) for increasing the delivery of mental health 
     services or other health care services deemed necessary to 
     meet the needs of veterans of Operation Iraqi Freedom and 
     Operation Enduring Freedom living in rural areas (as defined 
     for purposes of section 1886(d) and including areas that are 
     rural census tracks, as defined by the Administrator of the 
     Health Resources and Services Administration), including for 
     the provision of crisis intervention services and the 
     detection of post-traumatic stress disorder, traumatic brain 
     injury, and other signature injuries of veterans of Operation 
     Iraqi Freedom and Operation Enduring Freedom, and for 
     referral of such veterans to medical facilities operated by 
     the Department of Veterans Affairs, and for the delivery of 
     such services to other residents of such rural areas.
       ``(B) Application.--
       ``(i) In general.--An application is in accordance with 
     this subparagraph if the State submits to the Secretary at 
     such time and in such form as the Secretary may require an 
     application containing the assurances described in 
     subparagraphs (A)(ii) and (A)(iii) of subsection (b)(1).
       ``(ii) Consideration of regional approaches, networks, or 
     technology.--The Secretary may, as appropriate in awarding 
     grants to States under subparagraph (A), consider whether the 
     application submitted by a State under this subparagraph 
     includes 1 or more proposals that utilize regional 
     approaches, networks, health information technology, 
     telehealth, or telemedicine to deliver services described in 
     subparagraph (A) to individuals described in that 
     subparagraph. For purposes of this clause, a network may, as 
     the Secretary determines appropriate, include Federally 
     qualified health centers, rural health clinics, home health 
     agencies, community mental health clinics and other providers 
     of mental health services, pharmacists, local government, and 
     other providers deemed necessary to meet the needs of 
     veterans.
       ``(iii) Coordination at local level.--The Secretary shall 
     require, as appropriate, a State to demonstrate consultation 
     with the hospital association of such State, rural hospitals 
     located in such State, providers of mental health services, 
     or other appropriate stakeholders for the provision of 
     services under a grant awarded under this paragraph.
       ``(iv) Special consideration of certain applications.--In 
     awarding grants to States under subparagraph (A), the 
     Secretary shall give special consideration to applications 
     submitted by States in which veterans make up a high 
     percentage (as determined by the Secretary) of the total 
     population of the State. Such consideration shall be given 
     without regard to the number of veterans of Operation Iraqi 
     Freedom and Operation Enduring Freedom living in the areas in 
     which mental health services and other health care services 
     would be delivered under the application.
       ``(C) Coordination with va.--The Secretary shall, as 
     appropriate, consult with the Director of the Office of Rural 
     Health of the Department of Veterans Affairs in awarding 
     grants to States under subparagraph (A).
       ``(D) Use of funds.--A State awarded a grant under this 
     paragraph may, as appropriate, use the funds to reimburse 
     providers of services described in subparagraph (A) to 
     individuals described in that subparagraph.
       ``(E) Limitation on use of grant funds for administrative 
     expenses.--A State awarded a grant under this paragraph may 
     not expend more than 15 percent of the amount of the grant 
     for administrative expenses.
       ``(F) Final report.--Not later than 1 year after the date 
     on which the last grant is awarded to a State under 
     subparagraph (A), the Secretary shall submit a report to 
     Congress on the grants awarded under such subparagraph. Such 
     report shall include an assessment of the impact of such 
     grants on increasing the delivery of mental health services 
     and other health services to veterans of the United States 
     Armed Forces living in rural areas (as so defined and 
     including such areas that are rural census tracks), with 
     particular emphasis on the impact of such grants on the 
     delivery of such services to veterans of Operation Enduring 
     Freedom and Operation Iraqi Freedom, and to other individuals 
     living in such rural areas.''.
       (b) Use of Funds for Federal Administrative Expenses.--
     Section 1820(g)(5) of the Social Security Act (42 U.S.C. 
     1395i-4(g)(5)) is amended--
       (1) by striking ``beginning with fiscal year 2005'' and 
     inserting ``for each of fiscal years 2005 through 2008''; and
       (2) by inserting ``and, of the total amount appropriated 
     for grants under paragraphs (1), (2), and (6) for a fiscal 
     year (beginning with fiscal year 2009)'' after ``2005)''.
       (c) Extension of Authorization for FLEX Grants.--Section 
     1820(j) of the Social Security Act (42 U.S.C. 1395i-4(j)) is 
     amended--
       (1) by striking ``and for'' and inserting ``for''; and
       (2) by inserting ``, for making grants to all States under 
     paragraphs (1) and (2) of subsection (g), $55,000,000 in each 
     of fiscal years 2009 and 2010, and for making grants to all 
     States under paragraph (6) of subsection (g), $50,000,000 in 
     each of fiscal years 2009 and 2010, to remain available until 
     expended'' before the period at the end.




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