[Congressional Record (Bound Edition), Volume 149 (2003), Part 21]
[Senate]
[Pages 28568-28577]
[From the U.S. 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.

[[Page 28569]]


  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:
       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

[[Page 28570]]

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 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

[[Page 28571]]

     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 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.

[[Page 28572]]

  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 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.


[[Page 28573]]

  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 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

[[Page 28574]]

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 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

[[Page 28575]]

     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, 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.

[[Page 28576]]

  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 28577]]

 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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