[Congressional Record Volume 154, Number 160 (Thursday, October 2, 2008)]
[Senate]
[Pages S10439-S10444]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




        VETERANS' MENTAL HEALTH AND OTHER CARE IMPROVEMENTS ACT

  Mr. AKAKA. Mr. President, I rise today to urge swift Senate passage 
of S. 2162, the proposed Veterans' Mental Health and Other Care 
Improvements Act of 2008, as amended. This is an omnibus health care 
measure, which responds to the burgeoning mental health concerns of 
veterans and their families. The bill, as it comes before the Senate, 
is a compromise agreement developed with our counterparts on the House 
Committee on Veterans' Affairs. I thank Chairman Filner and Ranking 
Member Buyer of the House committee for their cooperation in this 
endeavor. I also thank my good friend, the committee's ranking member, 
Senator Burr, for his great energy and cooperation as we have developed 
this bill.
  This compromise agreement is also focused on addressing homelessness 
among veterans, increasing VA's efforts on pain management, promoting 
excellence in VA's efforts relating to epilepsy, and improving access 
to care in rural areas. It also includes a series of necessary 
programmatic authorization extensions as well as major medical facility 
construction authorizations.
  The framework for this bill is my legislation, S. 2162 as originally 
introduced. This bill represents a bipartisan approach and was 
cosponsored early on by the ranking member, Senator Burr, along with 
Senators Mikulski, Ensign, Rockefeller, Smith, Bingaman, Dole, Clinton, 
Collins, Sessions, and Stevens.
  Mr. President, I want to share how we began this process. The 
legislation did not stem from a lobbyist or an interest group. It came 
about because of one letter--a letter to me from the parents of Justin 
Bailey--Mary Kaye and Tony Bailey.
  Justin Bailey was a war veteran who survived Iraq only to die while 
receiving care from VA for PTSD and substance use disorder. A week 
after his death last year, Justin's parents were naturally heartbroken 
by the death of their only son, but even more than that, they were 
concerned that other veterans might share his fate if VA mental health 
care did not improve.
  In their own words, they asked, ``Everyone talks about the costs of 
sending troops to Iraq--what about the cost of caring for their 
injuries, both physical and psychological, when they return?''
  From this first letter, the Committee on Veterans' Affairs held 
various hearings on the mental health needs of veterans. The media 
carried so many stories of veterans who were suffering, and various 
studies showed how prevalent mental health difficulties are in those 
who return from duty in Iraq and Afghanistan.
  We worked with experts in the mental health field and others who were 
advocating for veterans, including those at the Disabled American 
Veterans, to craft a bill that responded to the problem. This 
legislation responds to the concerns of the Baileys and many others who 
have come to the committee to tell their stories, and does so with the 
clear understanding that veterans care is a cost of war. If we neglect 
to pay these costs when the service members first return from 
deployment, we as a nation will suffer incalculable human costs that 
can never be repaid.
  Provisions included in this compromise agreement are drawn from 
various bills which have all been reported favorably by the Senate 
Committee on Veterans' Affairs, including S. 1233 as ordered reported 
on August 29, 2007; S. 2004, S. 2142, S. 2160, S. 2162, as ordered 
reported on November 14, 2007; and S. 2969, as ordered reported on June 
26, 2008.
  I will briefly outline some of the key provisions in the compromise 
agreement.
  This legislation would make comprehensive changes to VA mental health 
treatment and research. Most notably, it would ensure a minimum level 
of substance use disorder care for veterans who need such care. It 
would also require VA to improve treatment of veterans with PTSD co-
occurring with substance use disorders. Additionally, in order to 
determine if VA's residential mental health facilities are 
appropriately staffed, this bill would mandate a review of such 
facilities. It would also create a vital research program on PTSD and 
substance use disorders, in cooperation with, and building on the work 
of, the National Center for PTSD.
  It is not uncommon for veterans with physical and mental wounds to 
turn to drugs and alcohol to ease their pain. Many experts believe that 
stress is the primary cause of drug abuse and of relapse to drug abuse. 
Sixty to eighty percent of Vietnam veterans who have sought PTSD 
treatment have alcohol use disorders. VA has long dealt with substance 
abuse issues, but there is much more that can be done. This legislation 
would provide a number of solutions to enhance substance use disorder 
treatment, including an innovative approach to substance use treatment 
via Internet-based programs.
  Furthermore, the inclusion of families in mental health and substance 
use disorder treatment is critical. To that end, the compromise 
agreement would fully authorize VA to provide mental health services to 
families of veterans and would set up a program to proactively help 
veterans and their families to transition from deployment to civilian 
life.
  Beneficiary travel reimbursements are essential to improving access 
to VA health care for veterans in rural areas. This legislation would 
increase the beneficiary travel mileage reimbursement rate from 11 
cents per mile to 28.5 cents per mile and permanently set the 
deductible to the 2007 amount of $3 each way. Senator Tester has been a 
leader on this issue, and I thank him for that.
  Too often, veterans suffer from lack of care not only because they 
reside in rural areas but also because they are unaware of the services 
available to them. This legislation would enhance outreach and 
accessibility by creating a pilot program on the use of peers to help 
reach out to veterans. It would also encourage improved accessibility 
for mental health care in rural areas through coordination with 
community-based resources. Mental Health America and Iraq and 
Afghanistan Veterans of America brought to the committee the concept of 
using peers to help veterans, and I think it is a good one.
  It is crucial that all veterans have access to emergency care. This 
bill would make corrections to the procedure used by VA to reimburse 
community hospitals for emergency care provided to eligible veterans to 
ensure that both veterans and community hospitals are not unduly 
burdened by emergency care costs. This provision is based on 
legislation introduced by Senator Brown in response to a situation in 
his own State of Ohio, where community hospitals were not being 
reimbursed timely from VA.
  The compromise agreement also addresses homelessness among veterans, 
a far too prevalent problem. The bill would create targeted programs to 
provide assistance for low-income veteran families. It would also 
increase the total amount that VA is authorized to spend on its 
successful Grant and Per Diem Program, which assists community-based 
entities that serve homeless veterans. Finally, the bill would expand a 
program to help formerly incarcerated veterans reintegrate into life 
and ensure facilities are up to par for women veterans who are 
homeless.
  Epilepsy is often associated with traumatic brain injury. This 
legislation would establish six VA epilepsy centers of excellence, 
focused on research, education, and clinical care activities in the 
diagnosis and treatment of epilepsy. These centers would restore VA to 
the position of leadership it once held in epilepsy research and 
treatment. Senators Murray and Craig worked together to bring this 
critical legislation to the forefront. I also add that the Epilepsy 
Foundation of America and the American Academy of Neurology were very 
helpful to the committee on this issue.

[[Page S10440]]

  The medical community has made impressive advances in pain care and 
management, but VA has lagged behind in implementing a standardized 
policy. S. 2162 would establish a pain care program at all VA inpatient 
facilities, to prevent long-term chronic pain disability. It also 
provides for education for VA's health care workers on pain assessment 
and treatment and would require VA to expand research on pain care. We 
relied on the Pain Care Forum and their many organizations devoted to 
the relief of pain, and I thank them for their efforts on behalf of 
veterans.
  Finally, S. 2162 contains extensions of authorities for VA to provide 
some essential services to veterans, such as both institutional and 
non-institutional long-term care and caregiver assistance. It would 
also authorize a series of major medical facility construction projects 
and clinic leases in California, Texas, Puerto Rico, Florida, 
Louisiana, Colorado, Nevada, Pennsylvania, Wisconsin, South Carolina, 
Ohio, Arizona, Georgia, and Illinois.
  Mr. President, before I close, I recognize and thank the individuals 
involved in putting together this comprehensive measure. Specifically, 
I thank Cathy Wiblemo and Dolores Dunn from the House committee and Jon 
Towers from the minority on the Senate committee. I also thank my own 
staff who assisted me in forging this bill. Kim Lipsky and Alex 
Sardegna heard the needs of veterans, sought creative solutions to some 
very complex problems, and worked tirelessly to make this bill a 
reality.
  In closing, I thank Mary Kaye and Tony Bailey, who set aside their 
own grief about Justin and fought for better mental health care for all 
veterans. We all owe the Baileys a debt of gratitude for so many 
reasons.
  I urge all of my colleagues to support swift passage of S. 2162, as 
amended. It would bring relief, support, and needed services to so many 
veterans and their families across the country.
  I ask unanimous consent to have the Joint Explanatory Statement 
printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

 Joint Explanatory Statement for S. 2162, Veterans' Mental Health and 
                  Other Care Improvements Act of 2008

       The ``Veterans' Mental Health and Other Care Improvements 
     Act of 2008'' reflects a compromise agreement that the Senate 
     and House of Representatives' Committees on Veterans' Affairs 
     reached on certain provisions of a number of bills considered 
     by the House and Senate during the 110th Congress, including: 
     S. 2162, to improve the treatment and services provided by 
     the Department of Veterans Affairs to veterans with post-
     traumatic stress disorder and substance use disorders, and 
     for other purposes, passed by the Senate on June 3, 2008 
     [hereinafter, ``Senate Bill'']; H.R. 5554, to expand and 
     improve health care services available to veterans from the 
     Department of Veterans Affairs for substance use disorders, 
     and for other purposes, passed by the House on May 20, 2008 
     [hereinafter, ``House Bill'']; S. 1233, to provide and 
     enhance intervention, rehabilitative treatment, and services 
     to veterans with traumatic brain injury, and for other 
     purposes, placed on the Senate calendar on August 29, 2007.
       H.R. 1527, to conduct a pilot program to permit certain 
     highly rural veterans enrolled in the health system of the 
     Department of Veterans Affairs to receive covered health 
     services through providers other than those of the 
     Department, passed by the House on September 10, 2008; H.R. 
     2623, to prohibit the collection of copayments for all 
     hospice care furnished by the Department of Veterans Affairs, 
     passed by the House on July 30, 2007; H.R. 2818, to provide 
     for the establishment of epilepsy centers of excellence in 
     the Veterans Health Administration of the Department of 
     Veterans Affairs, passed by the House on June 24, 2008; H.R. 
     2874, to make certain improvements in the provision of health 
     care to veterans, and for other purposes, passed by the House 
     on July 30, 2007; S. 2969, to enhance the capacity of the 
     Department of Veterans Affairs to recruit and retain nurses 
     and other critical health care professionals, and for other 
     purposes, placed on the Senate calendar on September 18, 
     2008.
       H.R. 3819, to reimburse veterans receiving emergency 
     treatment in non-Department of Veterans Affairs facilities 
     for such treatment until such veterans are transferred to 
     Department facilities, and for other purposes, passed by the 
     House on May 21, 2008; H.R. 4264, to name the Department of 
     Veterans Affairs spinal cord injury center in Tampa, Florida, 
     as the ``Michael Bilirakis Department of Veterans Affairs 
     Spinal Cord Injury Center,'' passed by the House on June 26, 
     2008; H.R. 5729, to provide comprehensive health care to 
     children of Vietnam veterans born with Spina Bifida, and for 
     other purposes, passed by the House on May 20, 2008; H.R. 
     6445, to prohibit the Secretary of Veterans Affairs from 
     collecting certain copayments from veterans who are 
     catastrophically disabled, and for other purposes, passed by 
     the House on July 30, 2008; H.R. 6832, to authorize major 
     medical facility projects and major medical facility leases 
     for the Department of Veterans Affairs for fiscal year 2009, 
     to extend certain authorities of the Secretary of Veterans 
     Affairs, and for other purposes, passed by the House on 
     September 11, 2008; S. 2969, to enhance the capacity of the 
     Department of Veterans Affairs to recruit and retain nurses 
     and other critical health care professionals and for other 
     purposes, which was placed on the Senate legislative calendar 
     on September 18, 2008.
       The House and Senate Committees on Veterans' Affairs have 
     prepared the following explanation of the compromise bill, S. 
     2162 (hereinafter referred to as the ``Compromise 
     Agreement''). Differences between the provisions contained in 
     the Compromise Agreement and the related provisions in the 
     bills listed above are noted in this document, except for 
     clerical corrections and conforming changes made necessary by 
     the Compromise Agreement, and minor drafting, technical, and 
     clarifying changes.


        Title I--Substance Use Disorders and Mental Health Care

     Tribute to Justin Bailey (sec. 101)
       The Senate bill contained a provision (sec. 306) to specify 
     that this title is enacted in tribute to Justin Bailey, who, 
     after returning to the United States from service as member 
     of the Armed Forces in Operation Iraqi Freedom, died in a 
     domiciliary facility of the Department of Veterans Affairs 
     while receiving care for post-traumatic stress disorder and a 
     substance use disorder.
       Section 6 of the House bill contained the identical 
     provision.
       The Compromise Agreement contains this provision.
     Findings on substance use disorders and mental health (sec. 
         102)
       The Senate bill contained a provision (sec. 301) that would 
     express the sense of the Congress that:
       (1) More than 1,500,000 members of the Armed Forces have 
     been deployed in Operation Iraqi Freedom and Operation 
     Enduring Freedom. The 2005 Department of Defense Survey of 
     Health Related Behaviors Among Active Duty Personnel reports 
     that 23 percent of members of the Armed Forces on active duty 
     acknowledge a significant problem with alcohol use, with 
     similar rates of acknowledged problems with alcohol use among 
     members of the National Guard.
       (2) The effects of substance abuse are wide ranging, 
     including significantly increased risk of suicide, 
     exacerbation of mental and physical health disorders, 
     breakdown of family support, and increased risk of 
     unemployment and homelessness.
       (3) While veterans suffering from mental health conditions, 
     chronic physical illness, and polytrauma may be at increased 
     risk for development of a substance use disorder, treatment 
     for these veterans is complicated by the need to address 
     adequately the physical and mental symptoms associated with 
     these conditions through appropriate medical intervention.
       (4) While the Veterans Health Administration has 
     dramatically increased health services for veterans from 1996 
     through 2006, the number of veterans receiving specialized 
     substance abuse treatment services decreased 18 percent 
     during that time. No comparable decrease in the national rate 
     of substance abuse has been observed during that time.
       (5) While some facilities of the Veterans Health 
     Administration provide exemplary substance use disorder 
     treatment services, the availability of such treatment 
     services throughout the health care system of the Veterans 
     Health Administration is inconsistent.
       (6) According to the Government Accountability Office, the 
     Department of Veterans Affairs significantly reduced its 
     substance use disorder treatment and rehabilitation services 
     between 1996 and 2006, and has made little progress since in 
     restoring these services to their pre-1996 levels.
       The House bill contained no similar provision.
       The Compromise Agreement contains the Senate provision but 
     modifies finding (6) to include the year of the Government 
     Accountability report and cites the National Mental Health 
     Program Monitoring System report.
     Expansion of substance use disorder treatment services 
         provided by the Department of Veterans Affairs (sec. 103)
       The Senate bill contained a provision (sec. 302) that would 
     require that the Secretary of Veterans Affairs ensure the 
     provision of services and treatment to each veteran enrolled 
     in the health care system of the Department who is in need of 
     services and treatments for a substance use disorder, and the 
     bill included a specific list of services. The Senate bill 
     would also authorize that the services and treatments may be 
     provided to a veteran: (1) at Department of Veterans Affairs 
     medical centers or clinics; (2) by referral to other 
     facilities of the Department that are accessible to such 
     veteran; or (3) by contract or fee-for-service payments with 
     community-based organizations for the provision of such 
     services and treatments.
       The House bill contained a similar provision (sec. 2) that 
     would require the Secretary to provide a full continuum of 
     care for substance use disorders to veterans in need of such 
     care and included a specific list of services, including 
     three services not included in

[[Page S10441]]

     the Senate bill: marital and family counseling, screening for 
     substance use disorders, and coordination with groups 
     providing peer to peer counseling. The House bill (sec. 3) 
     would also require the Secretary to ensure that the amounts 
     made available for care, treatment, and services are 
     allocated evenly throughout the system, including an annual 
     reporting requirement.
       The Compromise Agreement includes the listing of substance 
     use disorder services included in both the Senate and House 
     bills, and follows the Senate bill with respect to the 
     locations of where services would be provided. The Compromise 
     Agreement follows the House bill with respect to ensuring the 
     equitable distribution of resources for substance abuse 
     services but does not include the annual reporting 
     requirement.
     Care for veterans with mental health and substance use 
         disorders (sec. 104)
       The Senate bill contained a provision (sec. 303) that would 
     ensure that if the Secretary of Veterans Affairs provides a 
     veteran inpatient or outpatient care for a substance use 
     disorder and a comorbid mental health disorder, that the 
     treatment for such disorders be provided concurrently: (1) 
     through a service provided by a clinician or health 
     professional who has training and expertise in treatment of 
     substance use disorders and mental health disorders; (2) by 
     separate substance use disorder and mental health disorder 
     treatment services when there is appropriate coordination, 
     collaboration, and care management between such treatment 
     services; or (3) by a team of clinicians with appropriate 
     expertise.
       The House bill contained no similar provision.
       The Compromise Agreement contains the Senate provision.
     Pilot program for Internet-based substance use disorder 
         treatment for veterans of Operation Iraqi Freedom and 
         Operation Enduring Freedom (sec. 105)
       The House bill contained a provision (sec. 4) that would 
     express the sense of the Congress that:
       (1) Stigma associated with seeking treatment for mental 
     health disorders has been demonstrated to prevent some 
     veterans from seeking such treatment at a medical facility 
     operated by the Department of Defense or the Department of 
     Veterans Affairs.
       (2) There is a significant incidence among veterans of 
     post-deployment mental health problems, especially among 
     members of a reserve component who return as veterans to 
     civilian life.
       (3) Computer-based self-guided training has been 
     demonstrated to be an effective strategy for supplementing 
     the care of psychological conditions.
       (4) Younger veterans, especially those who served in 
     Operation Enduring Freedom or Operation Iraqi Freedom, are 
     comfortable with and proficient at computer-based technology.
       (5) Veterans living in rural areas find access to treatment 
     for substance use disorder limited.
       (6) Self-assessment and treatment options for substance use 
     disorders through an Internet website may reduce stigma and 
     provides additional access for individuals seeking care and 
     treatment for such disorders.
       This provision would also require the Secretary of Veterans 
     Affairs to carry out a pilot program to test the feasibility 
     and advisability of providing veterans who seek treatment for 
     substance use disorders access to a computer-based self-
     assessment, education, and specified treatment program 
     through a secure Internet website operated by the Secretary.
       The Senate bill contained no similar provision.
       The Compromise Agreement contains the House provision.
     Report on residential mental health care facilities of the 
         Veterans Health Administration (sec. 106)
       The Senate bill contained a provision (sec. 305) that would 
     require the Secretary of Veterans Affairs, acting through the 
     Office of Mental Health Services of the Department of 
     Veterans Affairs, not later than six months after the date of 
     the enactment of this Act, conduct a review of all 
     residential mental health care facilities, including 
     domiciliary facilities, of the Veterans Health 
     Administration; and not later than two years after the date 
     of the completion of the first review conduct a follow-up 
     review of such facilities to evaluate any improvements made 
     or problems remaining since the first review was completed. 
     Not later than 90 days after the completion of the first 
     review, the Secretary would be required to submit to the 
     Committee on Veterans' Affairs of the Senate and the 
     Committee on Veterans' Affairs of the House of 
     Representatives a report on such review.
       The House bill (sec. 5) contained a similar provision, 
     except there was no provision for a two-year follow-up 
     review, and the six month review would be carried out by the 
     Office of the Medical Inspector.
       The Compromise Agreement includes the Senate provision 
     which specifies the two-year follow-up review, but would have 
     the Inspector General carry out the reviews.
     Pilot program on peer outreach and support for veterans and 
         use of community mental health centers and Indian Health 
         Service facilities (sec. 107)
       The Senate bill contained a provision (sec. 401) that would 
     require the Secretary of Veterans Affairs to carry out a 
     pilot program to assess the feasibility and advisability of 
     providing the following to veterans of OIF/OEF in at least 
     two Veterans Integrated Service Networks: (1) peer outreach 
     services; (2) peer support services provided by licensed 
     providers of peer support services or veterans who have 
     personal experience with mental illness; (3) readjustment 
     counseling services; and other mental health services. 
     Services would be provided through community mental health 
     centers or other entities under contracts or other agreements 
     and through the Indian Health Service pursuant to a 
     memorandum of understanding entered into by the Secretary of 
     Veterans Affairs and the Secretary of Health and Human 
     Services.
       Section 6 of H.R. 2874 required the Secretary to carry out 
     a program to provide peer outreach services, peer support 
     services, and readjustment and mental health services to 
     covered veterans. This provision was not a pilot program and 
     did not provide for the means to collaborate with the Indian 
     Health Service.
       The Compromise Agreement contains the Senate provision with 
     an amendment that would authorize at least three pilot sites.


                    Title II--Mental Health Research

     Research program on comorbid post-traumatic stress disorder 
         and substance use disorders (sec. 201)
       The Senate bill contained a provision (sec. 501) that would 
     require the Secretary of Veterans Affairs to carry out a 
     program of research into comorbid post-traumatic stress 
     disorder (PTSD) and substance use disorder. This research 
     program shall be carried out by the National Center for 
     Posttraumatic Stress Disorder. In carrying out the program, 
     the Center shall: (1) develop protocols and goals with 
     respect to research under the program; and (2) coordinate 
     research, data collection, and data dissemination under the 
     program.
       The House bill contained no similar provision.
       The Compromise Agreement contains the Senate provision.
     Extension of authorization for Special Committee on Post-
         Traumatic Stress Disorder (sec. 202)
       The Senate bill contained a provision (sec. 502) that would 
     modify section 110(e)(2) of the Veterans' Health Care Act of 
     1984, P.L. 98-528, to extend the reporting requirement for 
     the Special Committee on Post-Traumatic Stress Disorder. 
     Currently, the reporting requirement is set to expire in 
     2008; this provision would extend it through 2012.
       Section 209 of H.R. 6832 contained an identical provision.
       The Compromise Agreement contains the provision.


             Title III--Assistance for Families of Veterans

     Clarification of authority of Secretary of Veterans Affairs 
         to provide mental health services to families of veterans 
         (sec. 301)
       The Senate bill contained a provision (sec. 601) that would 
     amend section 1701(5)(B) of title 38, United States Code, to 
     clarify the authority of the Secretary of Veterans Affairs to 
     provide mental health services to families of veterans.
       Section 3 of H.R. 6445 contained a provision that would 
     modify section 1782(b) of title 38 so as to eliminate the 
     requirement that family support services be initiated during 
     the veteran's hospitalization and deemed essential to permit 
     the veteran's discharge.
       The Compromise Agreement follows the House bill with 
     respect to the provision eliminating the need for services to 
     be initiated during a veteran's hospitalization and essential 
     to the veteran's discharge, but follows the Senate bill with 
     respect to the provision to clarify the authority of the 
     Secretary of Veterans Affairs to provide mental health 
     services to families.
     Pilot program on provision of readjustment and transition 
         assistance to veterans and their families in cooperation 
         with Vet Centers (sec. 302)
       The Senate bill contained a provision (sec. 402) that would 
     establish a pilot program to assess the feasibility and 
     advisability of providing additional readjustment and 
     transition assistance to veterans and their families in 
     cooperation with Readjustment Counseling Centers. The pilot 
     would be similar to family assistance programs previously 
     conducted at ten Army facilities around the country.
       The House bill contained no similar provision.
       The Compromise Agreement contains the Senate provision with 
     an amendment to begin the pilot program no later than 180 
     days after the enactment of the Act.


                     Title IV--Health Care Matters

     Veterans beneficiary travel program (sec. 401)
       The Senate bill contained a provision (sec. 101) that would 
     direct the Secretary to reimburse qualifying veterans at the 
     rate authorized for Government employees under section 
     5707(b) of title 5. The Senate provision would also strike a 
     provision that allows the Secretary to raise or lower the 
     deductible for reimbursements in proportion to a change in 
     the mileage rate. Finally, the Senate provision would 
     reinstate the amount of the deductible for the beneficiary 
     travel reimbursement program to the amount in effect prior to 
     the Secretary's February 1, 2008, decision on beneficiary 
     travel.
       The House bill contained no similar provision.
       The Compromise Agreement contains the Senate provision.

[[Page S10442]]

     Mandatory reimbursement of veterans receiving emergency 
         treatment in non-department of veterans affairs 
         facilities until transfer to department facilities (sec. 
         402)
       The Senate bill contained a provision that would amend 
     section 1725 of title 38 in subsections (a)(1) and (f)(1). 
     Subsection (a)(1) would be amended by replacing ``may 
     reimburse'' with ``shall reimburse.'' This change would make 
     reimbursement for emergency care received at non-VA 
     facilities mandatory for eligible veterans, rather than at 
     the discretion of the Secretary. Subsection (f)(1) would be 
     amended to provide greater specificity regarding the 
     termination of VA's obligation to reimburse. The Senate bill 
     would also amend section 1728 of title 38 so as to make that 
     section, which relates to reimbursement for the emergency 
     treatment of service-connected conditions, consistent with 
     section 1725, as amended. Thus, reimbursement would also be 
     made mandatory under Section 1728. The existing criteria, 
     defining veteran eligibility for reimbursement for emergency 
     care services, would be carried over in the revised statutory 
     language. In addition, the Senate bill would further amend 
     section 1728 so as to strike the phrase ``care and services'' 
     in current subsection (b) of section 1728, and replace that 
     phrase with ``emergency treatment.'' This proposed change is 
     designed to promote consistency between sections 1725 and 
     1728.
       H.R. 3819 contained similar provisions.
       The Compromise Agreement contains these provisions.
     Pilot program of enhanced contract care authority for health 
         care needs of veterans in highly rural areas (sec. 403)
       H.R. 1527 (sec. 2) would require the Secretary to conduct a 
     pilot program which permits highly rural veterans who are 
     enrolled in the system of patient enrollment established 
     under section 1705(a) of title 38, and who reside in Veterans 
     Integrated Service Networks (VISNs) 1, 15, 18, and 19, to 
     elect to receive covered health services for which such 
     veterans are eligible, through a non-Department health care 
     provider.
       The Senate bill contained no similar provision.
       The Compromise Agreement follows the House bill, with an 
     amendment that specifies that the pilot program will be 
     carried out in 5 VISNs, four of which shall include at least 
     three highly rural counties (as determined by the Secretary 
     based upon the most recent census data), and one of which 
     shall include one highly rural county. All VISNs selected 
     must include an area within the borders of at least four 
     states, and not be already participating in Project HERO. 
     Eligibility for participation in the pilot program would be 
     limited to those veterans already enrolled in the VA health 
     care system at the time of commencement of the program, as 
     well as OIF/OEF veterans who are eligible for VA health care 
     under section 1710(e)(3)(C) of title 38.
     Epilepsy centers of excellence (sec. 404)
       The Senate bill contained a provision (sec. 103) that would 
     require that the Secretary, upon the recommendation of the 
     Under Secretary for Health, to designate not less than six 
     Department health care facilities as locations for epilepsy 
     centers of excellence.
       H.R. 2818 (sec. 2) would require the Secretary to designate 
     an epilepsy center of excellence at each of the 5 centers 
     designated under section 7327 of title 38 (Centers for 
     research, education, and clinical activities on complex 
     multi-trauma associated with combat injuries).
       The Compromise Agreement specifies that Secretary shall 
     designate at least four but not more than six Department 
     health care facilities as locations for epilepsy centers of 
     excellence. Not less than two of these centers shall be 
     collocated with centers designated under 7327 of title 38.
     Establishment of qualifications for peer specialist 
         appointees (sec. 405)
       The Senate bill contained a provision (sec. 104) that would 
     amend section 7402(b) of title 38 so as to define 
     qualifications for peer specialist positions employed by the 
     Veterans Health Administration. Specifically, in order to be 
     eligible to be appointed to a peer specialist position, a 
     person must be a veteran who has recovered or is recovering 
     from a mental health condition; and be certified by a not-
     for-profit entity engaged in peer specialist training by 
     having met such criteria as the Secretary shall establish for 
     a peer specialist position; or a State by having satisfied 
     relevant State requirements for a peer specialist position. 
     The Senate bill would also amend section 7402 of title 38 so 
     as to add a new subsection providing authority for the 
     Secretary to enter into contracts with not-for-profit 
     entities to provide peer specialist training to veterans and 
     certification for veterans.
       The House bill contained no similar provision.
       The Compromise Agreement contains the Senate provision.
     Establishment of consolidated patient accounting centers 
         (sec. 406)
       Section 5 of H.R. 6445 contained a provision that would 
     amend chapter 17 of title 38 to insert a new section 
     mandating that not later than 5 years after the date of 
     enactment of this bill, the Secretary of Veterans Affairs 
     shall establish not more than seven consolidated patient 
     accounting centers for conducting industry-modeled 
     regionalized billing and collection activities of the 
     Department.
       The Senate bill contained no comparable provision.
       The Compromise Agreement contains the House provision.
     Repeal of limitation on authority to conduct widespread HIV 
         testing program (sec. 407)
       Section 217 of S. 2969 would repeal section 124 of Public 
     Law 100-322, which permits VA to test a patient for HIV 
     infection only if the veteran receives pre-test counseling 
     and provides written informed consent for such testing. 
     Eliminating this section from the law would bring VA's 
     statutory HIV testing requirements in line with current 
     guidelines issued by the Centers of Disease Control and 
     Prevention.
       Section 6 of H.R. 6445 contained an identical provision.
       The Compromise Agreement contains the provision.
     Provision of comprehensive health care by Secretary of 
         Veterans Affairs to children of Vietnam veterans born 
         with spina bifida (sec. 408)
       H.R. 5729 would amend section 1803(a) of title 38 so as to 
     expand the existing VA Spina Bifida Health Care Program and 
     provide a comprehensive health benefit to beneficiaries.
       The Senate bill contained no comparable provision.
       The Compromise Agreement contains the House provision.
     Exemption from copayment requirement for veterans receiving 
         hospice care (sec. 409)
       Section 309 of S. 1233 would amend section 1710 of title 38 
     so as to exempt hospice care provided in all settings from 
     the copayment requirement for VA long-term care. 
     Under current law, only hospice care provided in a VA 
     nursing home is exempted from copayment.
       H.R. 2623 contained a similar provision.
       The Compromise Agreement contains the provision.


                           Title V--Pain Care

     Comprehensive policy on pain management (sec. 501)
       The Senate bill contained a provision (sec. 201) that would 
     require the Secretary of Veterans Affairs to develop and 
     implement a comprehensive policy on the management of pain 
     experienced by veterans enrolled for VA health care services 
     no later than October 1, 2008.
       The policy would be required to cover the following: the 
     Department-wide management of acute and chronic pain 
     experienced by veterans; the standard of care for pain 
     management to be used throughout the Department; the 
     consistent application of pain assessments to be used 
     throughout the Department; the assurance of prompt and 
     appropriate pain care treatment and management by the 
     Department, system-wide, when medically necessary; Department 
     programs of research related to acute and chronic pain 
     suffered by veterans, including pain attributable to central 
     and peripheral nervous system damage characteristic of 
     injuries incurred in modern warfare; Department programs of 
     pain care education and training for health care personnel of 
     the Department; and Department programs of patient education 
     for veterans suffering from acute or chronic pain and their 
     families.
       Section 4 of H.R. 6445 contained identical provisions.
       The Compromise Agreement contains the provisions, but would 
     require the Secretary of Veterans Affairs to develop and 
     implement a comprehensive policy on pain management no later 
     than October 1, 2009.


                  Title VI--Homeless Veterans Matters

     Increase in authorization of appropriations for the Homeless 
         Grant and Per Diem Program (sec. 601)
       Section 506 of S. 2969 would amend section 2013 of title 
     38, to increase the authorization of appropriations for the 
     Homeless Grant and Per Diem Program from $130 million to $200 
     million.
       The House bill contained no comparable provision.
       The Compromise Agreement contains the Senate provision but 
     changes the authorization amount to $150 million.
     Expansion and extension of authority for program of referral 
         and counseling services for at-risk veterans 
         transitioning from certain institutions (sec. 602)
       Section 403 of S. 1233 would amend section 2023 of title 38 
     so as to extend and expand the authority for a program to aid 
     incarcerated veterans in their transition back to civilian 
     life. The program would be extended until September 30, 2011, 
     and would be expanded from six to twelve sites.
       Section 7 of H.R. 2874 contained identical provisions.
       The Compromise Agreement contains the provision, but would 
     extend the program until September 30, 2012.
     Permanent authority for domiciliary services for homeless 
         veterans and enhancement of capacity of domiciliary care 
         programs for female veterans (sec. 603)
       Section 405 of S. 1233 would amend section 2043 of title 38 
     to make permanent an existing authority to expand domiciliary 
     care for homeless women veterans.
       Section 8 of H.R. 2874 contained identical provisions.
       The Compromise Agreement contains the provisions.
     Financial assistance for supportive services for very-low 
         income veteran families in permanent housing (sec. 604)
       Section 406 of S. 1233 would amend title 38 so as to add a 
     new section 2044, relating to

[[Page S10443]]

     supportive services for very low-income veterans and their 
     families occupying permanent housing. Proposed new section 
     2044 would direct VA to provide grants to eligible entities 
     to provide and coordinate the provision of a comprehensive 
     range of supportive services for very low-income veteran 
     families occupying permanent housing, including those 
     transitioning from homelessness to such housing.
       Those families may be occupying permanent housing, moving 
     into permanent housing within 90 days, or moving from one 
     permanent residence to another to better suit their needs. 
     Entities eligible to receive grants under this provision are 
     public or private non-profit organizations which have 
     demonstrated the capacity and experience necessary to deliver 
     the services outlined in the proposed new section. Under the 
     provisions of the proposed new section 2044, grants would be 
     provided for a wide range of services, so as to give families 
     a broad set of tools to maintain a permanent residence. To 
     this end, providers could receive grants to furnish outreach, 
     case management, assistance in obtaining and coordinating VA 
     benefits, and assistance in obtaining and coordinating other 
     public benefits provided by federal, state, or local agencies 
     or organizations.
       Section 9 of H.R. 2874 contained similar provisions but 
     provided a more expansive list of supportive services, and 
     authorized for appropriations a different funding level.
       The Compromise Agreement contains the Senate provision.


Title VII--Authorization of Medical Facility Projects and Major Medical 
                            Facility Leases

     Authorization for fiscal year 2009 major medical facility 
         projects (sec. 701)
       Section 701 of S. 2969 would authorize: $54,000,000 to 
     construct a facility to replace a seismically unsafe acute 
     psychiatric inpatient building in Palo Alto, California; 
     $131,800,000 for an outpatient clinic in Lee County, Florida; 
     $225,900,000 to make seismic corrections at a VA Medical 
     Center in San Juan, Puerto Rico; and $66,000,000 to construct 
     a state-of-the-art polytrauma health care and rehabilitation 
     center in San Antonio, Texas.
       Section 101 of H.R. 6832 contained the same provisions, 
     except for Lee County, Florida. Instead, H.R. 6832 authorizes 
     the Lee County project under a different section.
       The Compromise Agreement contains the House provision.
     Modification of authorization amounts for certain major 
         medical facility construction projects previously 
         authorized (sec. 702)
       Section 702 of S. 2969 would modify previous authorizations 
     by providing $625,000,000 for restoration, new construction, 
     or replacement of the medical care facility for the VA 
     Medical Center at New Orleans, Louisiana.
       Section 102 of H.R. 6832 contained the same provisions and 
     the following additional provisions: $769,200,000 for the 
     replacement of the VA Medical Center at Denver, Colorado; 
     $131,800,000 for an outpatient clinic in Lee County, Florida; 
     $136,700,000 to correct patient privacy deficiencies at the 
     VA Medical Center in Gainesville, Florida; $600,400,000 to 
     build a new VA Medical Center in Las Vegas, Nevada; 
     $656,800,000 to build a new medical center in Orlando, 
     Florida; and $295,600,000 to consolidate the campuses at the 
     University Drive and H. John Heinz III Divisions in 
     Pittsburgh, Pennsylvania.
       The Compromise Agreement contains the House provision with 
     an amendment to provide $568,000,000 for the replacement of 
     the VA Medical Center at Denver, Colorado.
     Authorization of fiscal year 2009 major medical facility 
         leases (sec. 703)
       Section 703 of S. 2969 would authorize fiscal year 2009 
     major medical facility leases as follows: $4,326,000 for an 
     outpatient clinic in Brandon, Florida; $10,300,000 for a 
     community-based outpatient clinic in Colorado Springs, 
     Colorado; $5,826,000 for an outpatient clinic in Eugene, 
     Oregon;. $5,891,000 to expand an outpatient clinic Green Bay, 
     Wisconsin; $3,731,000 for an outpatient clinic in Greenville, 
     South Carolina; $2,212,000 for a community-based outpatient 
     clinic in Mansfield, Ohio; $6,276,000 for a satellite 
     outpatient clinic in Mayaguez, Puerto Rico; $5,106,000 for a 
     community-based outpatient clinic in Southeast Phoenix, Mesa, 
     Arizona; $8,636,000 for interim research space in Palo Alto, 
     California; $3,168,000 to expand a community-based outpatient 
     clinic in Savannah, Georgia; $2,295,000 for a community-based 
     outpatient clinic in Northwest Phoenix, Sun City, Arizona; 
     and $8,652,000 for a primary care annex in Tampa, Florida.
       Section 102 of H.R. 6832 included the same provisions, 
     except that it provided $3,995,000 for Colorado Springs.
       The Compromise Agreement includes the Senate provisions.
     Authorization of appropriations (sec. 704)
       Section 704 of S. 2969 would authorize for appropriations: 
     $477,700,000 for the aforementioned list of major medical 
     facility projects authorized for fiscal year 
     2009. $625,000,000 for the aforementioned list of major 
     medical facility construction projects previously 
     authorized; $66,419,000 for the aforementioned list of 
     major facility leases authorized for fiscal year 2009.
       S. 2969 also identified funding sources which may be used 
     to carry out major medical facility projects authorized for 
     fiscal year 2009 and for those projects previously 
     authorized.
       Section 105 of H.R. 6832 would authorize for 
     appropriations: $345,900,000 for the aforementioned list of 
     major medical facility projects authorized for fiscal year 
     2009; $1,694,295,000 for the aforementioned list of major 
     medical facility construction projects previously authorized; 
     $54,475,000 for the aforementioned list of major facility 
     leases authorized for fiscal year 2009.
       The Compromise Agreement includes the House provision, with 
     amendments to provide $1,493,495,000 for major facility 
     construction projects previously authorized and $70,019,000 
     for major facility leases authorized for fiscal year 2009. 
     The Agreement also includes the provision in S. 2969 on 
     allowable funding sources to carry out major medical facility 
     projects.
     Increase in threshold for major medical facility leases 
         requiring congressional approval (sec. 705)
       Section 705 of S. 2969 would increase the threshold for 
     major medical facility leases requiring Congressional 
     approval from $600,000 to $1,000,000.
       H.R. 6832 contained no comparable provision.
       The Compromise Agreement contains the Senate provision.
     Conveyance of certain non-Federal land by city of Aurora, 
         Colorado, to Secretary of Veterans Affairs for 
         construction of veterans medical facility (sec. 706)
       Section 706 of S. 2969 would allow the city of Aurora to 
     donate non-Federal land for use by the Secretary of Veterans 
     Affairs no later than 60 days after the enactment of this 
     section.
       H.R. 6832 contained no comparable provision.
       The Compromise Agreement contains the Senate provision.
     Report on facilities administration (sec. 707)
       Section 106 of H.R. 6832 would require the Secretary of 
     Veterans Affairs to submit a report on facilities 
     administration no later than 60 days after the date of the 
     enactment of this section.
       S. 2969 contained no comparable provision.
       The Compromise Agreement includes the House provision.
     Annual report on outpatient clinics (sec. 708)
       Section 107 of H.R. 6832 would require an annual report on 
     outpatient report no later than the date on which the budget 
     for the next fiscal year is submitted to the Congress under 
     section 1105 of title 31.
       S. 2969 contained no comparable provision.
       The Compromise Agreement includes the House provision.
     Name of Department of Veterans Affairs spinal cord injury 
         center, Tampa, Florida (sec. 709)
       H.R. 4264 would name the VA spinal cord injury center in 
     Tampa, Florida, ``Michael Bilirakis Department of Veterans 
     Affairs Spinal Cord Injury Center.''
       S. 2969 contained no comparable provision.
       The Compromise Agreement includes the House provision.

              Title VIII--Extension of Certain Authorities

     Repeal of sunset on inclusion of non-institutional extended 
         care services in definition of medical services (sec. 
         801)
       Section 201 of S. 2969 would amend section 1701 of title 38 
     to repeal the December 31, 2008, sunset on the inclusion of 
     non-institutional extended care services in the definition of 
     medical services.
       Sec. 201 of H.R. 6832 contained an identical provision.
       The Compromise Agreement contains the provision.
     Extension of recovery audit authority (sec. 802)
       Section 202 of S. 2969 would amend section 1703(d)(4) of 
     title 38 to extend the recovery audit authority for fee-basis 
     contracts and other medical services contracts in non-VA 
     facilities from September 30, 2008, to September 30, 2013.
       Sec. 202 of H.R. 6832 contained an identical provision.
       The Compromise Agreement contains the provision.
     Permanent authority for provision of hospital care, medical 
         services, and nursing home care to veterans who 
         participated in certain chemical and biological testing 
         conducted by the Department of Defense (sec. 803)
       Section 203 of S. 2969 would amend subsection (e)(3) of 
     section 1710 of title 38 to provide permanent authority for 
     the provision of hospital care, medical services, and nursing 
     home care to veterans who participated in certain chemical 
     and biological testing conducted by the Department of 
     Defense.
       Section 203 of H.R. 6832 contained an identical provision.
       The Compromise Agreement contains the provision.
     Extension of expiring collections authorities (sec. 804)
       S. 2969 contained no comparable provision.
       Section 204 of H.R. 6832 would extend the expiring 
     collections authorities for the following: a) amend section 
     1710(f)(2)(B) of title 38 to extend health care copayments 
     from September 30, 2008, under current law, to September 30, 
     2010; and b) amend section 1729 (a)(2)(E) of title 38 to 
     extend the medical care cost recovery from October 1, 2008, 
     to October 1, 2010.
       The Compromise Agreement contains the House provision.
     Extension of nursing home care (sec. 805)
       Section 202 of S. 2969 would amend 1710A(d) of title 38 to 
     provide nursing home care to

[[Page S10444]]

     veterans with service-connected disability, which expires on 
     December 31, 2008, to December 31, 2013.
       Section 205 of H.R. 6832 contained an identical provision.
       The Compromise Agreement contains the provision.
     Permanent authority to establish research corporations (sec. 
         806)
       Section 607 of S. 2969 would strike section 7368 of title 
     38 to provide permanent authority to establish research 
     corporations.
       Section 207 of H.R. 6832 contained an identical provision.
       The Compromise Agreement contains the provision.
     Extension of requirement to submit annual report on the 
         committee on care of severely chronically mentally ill 
         veterans (sec. 807)
       Section 210 of H.R. 6832 would amend section 7321(d)(2) of 
     title 38 to extend the requirement to submit an annual report 
     on the committee on care of severely chronically mentally ill 
     veterans through 2012.
       S. 2969 contained no comparable provision.
       The Compromise Agreement contains the House provision.
     Permanent requirement for biannual report on women's advisory 
         committee (sec. 808)
       Section 211 of H.R. 6832 would amend section 542(c)(1) of 
     title 38 to provide for a permanent requirement for a 
     biannual report by the women's advisory committee on the 
     needs of women veterans including compensation, health care, 
     rehabilitation, outreach, and other benefits and programs 
     administered by the VA.
       S. 2969 contained no comparable provision.
       The Compromise Agreement contains the House provision.
     Extension of pilot program on improvement of caregiver 
         assistance services (sec. 809)
       Section 222 of S. 2969 would extend the pilot program on 
     improvement of caregiver assistance services for a three-year 
     period through fiscal year 2009.
       H.R. 6832 contained no comparable provision.
       The Compromise Agreement includes the Senate provision.


                        Title IX--Other Matters

     Technical amendments (sec. 901)
       Section 303 of H.R. 6832 would provide for technical 
     amendments for the following sections of title 38: 1712A; 
     2065(b)(3)(C); 4110(c)(1); 7458(b)(2); 8117(a)(1); 1708(d); 
     7314(f); 7320(j)(2); 7325(i)(2); and 7328(i)(2). It also 
     would provide for technical amendments to the table of 
     sections at the beginning of chapter 36 and chapter 51, as 
     well as amend section 807(e) of the Veterans Benefits, Health 
     Care, and Information Technology Act of 2006 (Public Law 109-
     461) to replace the phrase ``Medical Care'' with ``Medical 
     Facilities''.
       S. 2969 contained no comparable provision.
       The Compromise Agreement contains the House provision.

                          ____________________