[House Report 104-648]
[From the U.S. Government Publishing Office]



104th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES

 2d Session                                                     104-648
_______________________________________________________________________

 
  EXTENSION OF AUTHORITY TO PROVIDE PRIORITY HEALTH CARE TO VETERANS 
  EXPOSED TO AGENT ORANGE OR IONIZING RADIATION OR WHO SERVED IN THE 
                PERSIAN GULF WAR, AND FOR OTHER PURPOSES

_______________________________________________________________________


 June 27, 1996.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

   Mr. Stump, from the Committee on Veterans' Affairs, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 3643]

      [Including cost estimate of the Congressional Budget Office]

  The Committee on Veterans' Affairs, to whom was referred the 
bill (H.R. 3643) to amend title 38, United States Code, to 
extend through December 31, 1998, the period during which the 
Secretary of Veterans Affairs is authorized to provide priority 
health care to certain veterans who were exposed to Agent 
Orange or who served in the Persian Gulf War and to make such 
authority permanent in the case of certain veterans exposed to 
ionizing radiation, and for other purposes, having considered 
the same, reports favorably thereon with amendments and 
recommends that the bill as amended do pass.

  The amendments (stated in terms of the page and line numbers 
of the introduced bill) are as follows:

  At the end of section 1 (page 6, after line 15), add the 
following new subsection:

  (d) Priority Health Care for Service in Israel or Turkey 
During Persian Gulf War.--(1) Section 1710(e)(1)(C) of title 
38, United States Code, is amended by inserting after 
``Southwest Asia theater of operations'' the following: ``, or 
who may have been exposed while serving on active duty in 
Israel or Turkey during the period beginning on August 2, 1990, 
and ending on July 31, 1991,''.
  (2) Section 1712(a)(1)(D) of such title is amended by 
inserting after ``during the Persian Gulf War'' the following: 
``, or who served on active duty in Israel or Turkey during the 
period beginning on August 2, 1990, and ending on July 31, 
1991,''.

  Page 7, line 10, insert ``, including the needs of such 
veterans who are women'' after ``Department''.

  At the end of the bill, add the following new sections:

SEC. 6. REPORTING REQUIREMENTS.

  (a) Extension of Annual Report Requirement.--Section 107(a) 
of the Veterans Health Care Act of 1992 (Public Law 102-585; 38 
U.S.C. 1710 note) is amended by striking out ``Not later than 
January 1, 1993, January 1, 1994, and January 1, 1995'' and 
inserting in lieu thereof ``Not later than January 1 of 1993 
and each year thereafter through 1998''.
  (b) Report on Health Care and Research.--Section 107(b) of 
such Act is amended--
          (1) in paragraph (2)(A), by inserting ``(including 
        information on the number of inpatient stays and the 
        number of outpatient visits through which such services 
        were provided)'' after ``facility''; and
          (2) by adding at the end the following new paragraph:
          ``(5) A description of the actions taken by the 
        Secretary to foster and encourage the expansion of such 
        research.''.

SEC. 7. ASSESSMENT OF USE BY WOMEN VETERANS OF DEPARTMENT HEALTH 
                    SERVICES.

  (a) Reports to Under Secretary for Health.--The Center for 
Women Veterans of the Department of Veterans Affairs 
(established under section 509 of Public Law 103-446), in 
consultation with the Advisory Committee on Women Veterans, 
shall assess the use by women veterans of health services 
through the Department of Veterans Affairs, including 
counseling for sexual trauma and mental health services. The 
Center shall submit to the Under Secretary for Health of the 
Department of Veterans Affairs a report not later than April 1, 
1997, and April 1 of each of the two following years, on--
          (1) the extent to which women veterans described in 
        section 1710(a)(1) of title 38, United States Code, 
        fail to seek, or face barriers in seeking, health 
        services through the Department, and the reasons 
        therefore; and
          (2) recommendations, if indicated, for encouraging 
        greater use of such services, including (if 
        appropriate) public service announcements and other 
        outreach efforts.
  (b) Reports to Congressional Committees.--Not later than July 
1, 1997, and July 1 of each of the two following years, the 
Secretary of Veterans Affairs shall submit to the Committees on 
Veterans' Affairs of the Senate and House of Representatives a 
report containing--
          (1) the most recent report of the Center for Women 
        Veterans under subsection (a);
          (2) the views of the Under Secretary for Health on 
        such report's findings and recommendations; and
          (3) a description of the steps being taken by the 
        Secretary to remedy any problems described in the 
        report.

SEC. 8. MAMMOGRAPHY QUALITY STANDARDS.

  (a) In General.--(1) Subchapter II of chapter 73 of title 38, 
United States Code, is amended by adding after section 7320, as 
added by section 3(a), the following new section:

``Sec. 7321. Mammography quality standards

  ``(a) A mammogram may not be performed at a Department 
facility unless that facility is accredited for that purpose by 
a private nonprofit organization designated by the Secretary. 
An organization designated by the Secretary under this 
subsection shall meet the standards for accrediting bodies 
established under section 354(e) of the Public Health Service 
Act (42 U.S.C. 263b(e)).
  ``(b) The Secretary, in consultation with the Secretary of 
Health and Human Services, shall prescribe quality assurance 
and quality control standards relating to the performance and 
interpretation of mammograms and use of mammogram equipment and 
facilities of the Department of Veterans Affairs consistent 
with the requirements of section 354(f)(1) of the Public Health 
Service Act. Such standards shall be no less stringent than the 
standards prescribed by the Secretary of Health and Human 
Services under section 354(f) of the Public Health Service Act.
  ``(c)(1) The Secretary, to ensure compliance with the 
standards prescribed under subsection (b), shall provide for an 
annual inspection of the equipment and facilities used by and 
in Department health care facilities for the performance of 
mammograms. Such inspections shall be carried out in a manner 
consistent with the inspection of certified facilities by the 
Secretary of Health and Human Services under section 354(g) of 
the Public Health Service Act.
  ``(2) The Secretary may not provide for an inspection under 
paragraph (1) to be performed by a State agency.
  ``(d) The Secretary shall ensure that mammograms performed 
for the Department under contract with any non-Department 
facility or provider conform to the quality standards 
prescribed by the Secretary of Health and Human Services under 
section 354 of the Public Health Service Act.
  ``(e) For the purposes of this section, the term `mammogram' 
has the meaning given such term in paragraph (5) of section 
354(a) of the Public Health Service Act (42 U.S.C. 263b(a)).''.
  (2) The table of sections at the beginning of such chapter is 
amended by inserting after the item relating to section 7320, 
as added by section 3(b), the following new item:

``7321. Mammography quality standards.''.

  (b) Deadline for Prescribing Standards.--The Secretary of 
Veterans Affairs shall prescribe standards under subsection (b) 
of section 7321 of title 38, United States Code, as added by 
subsection (a), not later than the end of the 120-day period 
beginning on the date of the enactment of this Act.
  (c) Implementation Report.--The Secretary of Veterans Affairs 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report on the Secretary's 
implementation of section 7321 of title 38, United States Code, 
as added by subsection (a). The report shall be submitted not 
later than 120 days after the later of (1) the date on which 
the Secretary prescribes the quality standards required under 
subsection (b) of that section, or (2) the date of the 
enactment of this Act.

SEC. 9. PATIENT PRIVACY FOR WOMEN PATIENTS.

  (a) Identification of Deficiencies.--The Secretary of 
Veterans Affairs shall conduct a survey of each medical center 
under the jurisdiction of the Secretary to identify 
deficiencies relating to patient privacy afforded to women 
patients in the clinical areas at each such center which may 
interfere with appropriate treatment of such patients.
  (b) Correction of Deficiencies.--The Secretary shall ensure 
that plans and, where appropriate, interim steps, to correct 
the deficiencies identified in the survey conducted under 
subsection (a) are developed and are incorporated into the 
Department's construction planning processes and given a high 
priority.
  (c) Reports to Congress.--The Secretary shall compile an 
annual inventory, by medical center, of deficiencies identified 
under subsection (a) and of plans and, where appropriate, 
interim steps, to correct such deficiencies. The Secretary 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives, not later than October 1, 
1997, and not later than October 1 each year thereafter through 
1999 a report on such deficiencies. The Secretary shall include 
in such report the inventory compiled by the Secretary, the 
proposed corrective plans, and the status of such plans.

                              Introduction

    On March 9, 1995, the Subcommittee on Hospitals and Health 
Care received testimony on the progress of research on 
undiagnosed illnesses of Persian Gulf War Veterans. Those who 
testified were Dr. Kenneth W. Kizer, Under Secretary for Health 
at the Department of Veterans Affairs; Dr. Stephen Joseph, 
Assistant Secretary for Health Affairs at the Department of 
Defense; Dr. Richard Jackson, Director of the National Center 
for Environmental Health at the Centers for Disease Control and 
Prevention, U.S. Public Health Service; Dr. Richard Miller, 
Director of the Medical Follow-up Agency at the Institute of 
Medicine; and Mr. Steve Robertson, Legislative Director of The 
American Legion.
    On April 16, 1996, the Subcommittee heard testimony on 
recent reports dealing with Agent Orange exposure. Testifying 
were Dr. David Tollerud, Associate Professor and Chief, 
Occupational and Environmental Medicine at the University of 
Pittsburgh and the Chair of the Committee to Review the Health 
Effects in Vietnam Veterans of Exposure to Herbicides; Dr. 
Andrew Olshan, Assistant Professor at the Department of 
Epidemiology, School of Public Health, University of North 
Carolina, and a Member of the Committee to Review the Health 
Effects in Vietnam Veterans of Exposure to Herbicides; Dr. 
David Erickson, Chief of the Birth Defects and Genetic Diseases 
Branch at the National Center for Environmental Health, Centers 
for Disease Control; Dr. Joel E. Michalek of the Armstrong 
Laboratory, Epidemiologic Research Division, Population 
Research Branch and a Principal Investigator of the Air Force 
Health Study, accompanied by Colonel Gary Henriksen of the 
Armstrong Laboratory, Human Systems Center and also a Principal 
Investigator of the Air Force Study; and Dr. Kenneth Kizer, 
Under Secretary for Health at the Department of Veterans 
Affairs, accompanied by Dr. Susan Mather, Assistant Medical 
Director for Public Health and Environmental Hazards at the 
Department of Veterans Affairs.
    The Subcommittee met on June 18, 1996, and ordered H.R. 
3643, as amended, reported to the full Committee by unanimous 
voice vote.
    The full Committee met on June 20, 1996, and ordered H.R. 
3643, as amended, reported to the House by unanimous voice 
vote.

                      Summary of the Reported Bill

    H.R. 3643, as amended, would:
    1. Authorize inpatient and outpatient health care for the 
following:

        (a) Lveterans exposed to Agent Orange for diseases 
        which the National Academy of Science has determined 
        that (1) there is sufficient evidence of association 
        between the disease and herbicide exposure, (2) there 
        is some evidence of association between the disease and 
        herbicide exposure, or (3) available studies are 
        insufficient to come to any conclusion on association 
        between the disease and herbicide exposure, or for 
        diseases which the Secretary determines there is 
        credible suggestive evidence of an association, through 
        December 31, 1998;
        (b) LPersian Gulf War veterans for symptoms of diseases 
        relating to service, through December 31, 1998;
        (c) Lveterans who served in Israel or Turkey during the 
        period of the Persian Gulf War (August 2, 1990 to July 
        31, 1991) for symptoms of diseases relating to service, 
        through December 31, 1998, and
        (d) Lveterans exposed to ionizing radiation, 
        permanently.

    2. Establish a Committee on Care of Severely Chronically 
Mentally Ill Veterans.
    3. Authorize the VA to establish up to five centers of 
excellence called Mental Illness Research, Education, and 
Clinical Care Centers (MIRECCs) at VA facilities in order to 
facilitate improved delivery of mental health services.
    4. Authorize VA to enter into disbursement agreements with 
medical schools to administer pay and benefits to residents and 
interns serving in VA outpatient clinics, nursing homes, and 
institutions other than hospitals.
    5. Suspend special pay agreements, and thus, an otherwise 
applicable repayment penalty, for VA physicians and dentists 
who enter residency training programs.
    6. Expand and extend through 1998 reporting requirements 
regarding VA's provision of care to women veterans.
    7. Require the VA to issue a report on women veterans' 
barriers to VA health care.
    8. Require the VA to promulgate mammography quality 
standards.
    9. Require the VA to conduct a survey on deficiencies 
relating to patient privacy for women veteran patients and plan 
corrective action for identified deficiencies.

                       Background and Discussion

    Public Law 102-4, the Agent Orange Act of 1991, required 
the VA to enter into an agreement with the National Academy of 
Sciences (NAS) to conduct a comprehensive review and evaluation 
of the available scientific and medical literature regarding 
the health effects of exposure to Agent Orange and other 
herbicides used during the Vietnam conflict. This Act also 
required not only the review of the scientific literature but 
also that the NAS evaluate the available scientific evidence 
and assess, with respect to each disease suspected of being 
associated with exposure to Agent Orange, the strength of the 
association or associations and their relative strength and 
risk to veterans. In carrying out this task, the NAS reviewed 
6,420 abstracts of scientific or medical articles. From this 
published body of scientific literature, 230 epidemiological 
studies were chosen for detailed review and analysis.
    The findings of the NAS provide a framework based on 
scientific evidence on which determinations of eligibility for 
health care can be based. H.R. 3643, as amended, would 
incorporate those findings in a manner that weds science with a 
spirit of compassion. It would do so by identifying certain 
specific diseases in veterans for which known, limited, and 
even doubtful statistical associations of exposure would be 
considered service-incurred for treatment purposes. The bill 
would authorize VA to provide treatment even for diseases where 
science provides insufficient evidence to determine whether 
there is any relationship between the diseases presented by the 
veteran and exposure to herbicides. It would also 
``grandfather'' those veterans who have been previously treated 
at the VA for conditions which the NAS has now found evidence 
indicating no association to exist between the disease and 
exposure to herbicides for continued VA care of these 
conditions. Included in this category would be skin cancer, 
gastrointestinal tumors, bladder cancer, and brain tumors.
    H.R. 3643, as amended, would also provide a 20-month window 
for the consideration of new peer-reviewed, published research 
not previously considered by the NAS. In the event such a study 
provides credible evidence suggestive of an association between 
a disease and exposure to Agent Orange, the Secretary, based on 
the recommendations of the Under Secretary for Health, could 
authorize VA treatment for that condition.
    The bill would also provide special eligibility in the case 
of radiation-exposed veterans for care of a long list of 
cancers as well as for any diseases for which the VA determines 
there is credible evidence of a positive association between 
disease occurrence and radiation exposure. The bill's 
``grandfather'' clause would also permit VA to continue to care 
for illnesses for which veterans previously or currently 
receive care at the VA even though no positive association 
between the disease occurrence and radiation exposure has been 
found.
    Under this bill, both groups of veterans would receive 
substantially expanded outpatient services for covered 
conditions on a priority basis.
    The provisions of H.R. 3643, as amended, draw on language 
adopted by the House in passing H.R. 1565 in the first session 
of this Congress and in H.R. 3313, which was passed in the 
103rd Congress.
    As part of the legislative requirements of Public Law 102-
4, the National Academy is required to provide subsequent 
reviews of scientific literature regarding the health effects 
of exposure to Agent Orange at least every two years for a 
period of ten years from the date of the first report. The 
first updated review and evaluation of newly published 
scientific evidence regarding associations between diseases and 
exposure to dioxin and other chemical compounds in herbicides 
used in Vietnam was published in March of this year. The 
findings of this review resulted in changes in three of the 
five categories. The changes are reflected in the summary 
provided. For purposes of the bill there is no impact on the 
delivery of health care services for those veterans qualifying 
for care under the Agent Orange provisions.

            Summary of NAS Findings on Agent Orange Exposure

    The following is an updated summary listing from the March 
14, 1996 Veterans and Agent Orange: Update 1996 of the four 
categories established by the National Academy of Sciences and 
the relative strength of each condition in regard to its 
association between the specific condition and exposure to 
herbicides.

                 Sufficient Evidence of an Association

    Evidence is sufficient to conclude that there is a positive 
association.

    Soft tissue sarcoma
    Non-Hodgkin's lymphoma
    Hodgkin's disease
    Chloracne

             Limited /Suggestive Evidence of an Association

    Evidence is suggestive of an association between herbicides 
and the outcome but is limited because chance, bias, and 
confounding could not be ruled out.

    Respiratory cancers (lung, larynx, trachea)
    Prostate cancer
    Multiple myeloma
    Acute and subacute peripheral neuropathy
    Spina bifida
    Porphyia cutanea tarda

       Inadequate/Insufficient Evidence to Determine Whether an 
                           Association Exists

    The available studies are of insufficient quality, 
consistency, or statistical power to permit a conclusion 
regarding the presence or absence of an association.

    Hepatobiliary cancers
    Nasal/nasopharyngeal cancers
    Bone cancer
    Female reproductive cancers (cervical, uterine, ovarian)
    Breast cancer
    Renal cancer
    Testicular cancer
    Leukemia
    Spontaneous abortion
    Birth defects (other than spina bifida)
    Neonatal/infant death and stillbirths
    Low birthweight
    Childhood cancer in offspring
    Abnormal sperm parameters and infertility
    Cognitive and neuropsychiatric disorders
    Motor/coordination dysfunction
    Chronic peripheral nervous system disorders
  Metabolic and digestive disorders (diabetes, changes in liver 
            enzymes, lipid abnormalities, ulcers)
  Immune system disorders (immune suppression and autoimmunity)
    Circulatory disorders
    Respiratory disorders
    Skin cancer

             Limited /Suggestive Evidence of No Association

    Several adequate studies, covering the full range of levels 
of exposure that human beings are known to encounter, are 
mutually consistent in showing no positive association between 
exposure to herbicides and the outcome at any level of 
exposure.

  Gastrointestinal tumors (stomach cancer, pancreatic cancer, 
            colon cancer, rectal cancer)
    Bladder cancer
    Brain tumors

    The bill, as amended, would also extend VA's authority to 
provide health care on a priority basis for Persian Gulf War 
veterans through December 31, 1998. It would also extend 
eligibility for such care to those veterans who were stationed 
in Israel and Turkey during the twelve month time period of 
August 2, 1990 through July 31, 1991. The Department of Defense 
estimates that 140 personnel were stationed in Israel and 8,005 
personnel were stationed in Turkey during that time period.
    During and since the Persian Gulf War, numbers of returning 
American service personnel have reported health problems they 
attribute to their assignment in the Arabian peninsula and the 
surrounding area. Most of the medical problems have been 
diagnosable, but symptoms of several thousand veterans have not 
been readily explained.
    Extensive research is currently underway to attempt to 
answer the perplexing questions of illnesses and diseases which 
some veterans experienced following service in the Persian 
Gulf. The multitude of studies conducted by various government 
agencies are looking into possible physical, chemical, 
biological, and psychological factors in an effort to explain 
these problems.

    Section 2. Department Committee on Care of Severely Chronically 
                         Mentally Ill Veterans

    Following hearings during the 103rd Congress on VA care of 
seriously mentally ill veterans, the VA established a special 
committee, as proposed in legislation passed by the House, to 
monitor, assess, and make recommendations on such care and on 
research.
    The first annual report of the Special Committee for 
Seriously Mentally Ill Veterans estimated that some 326,000 
severely mentally ill (SMI) veterans use VA services each year, 
and that 64 percent of them are service-connected for a 
psychiatric condition. The Special Committee also reported that 
51 percent of SMI veterans served in a war zone, and 43 percent 
served in combat.
    Based on projections regarding the number of severely 
mentally ill veterans in the general population, the Special 
Committee calculated that of all VA-eligible veterans requiring 
psychiatric care for severe mental illness, 52 percent used VA 
services, about five times the proportion of veterans in the 
general population who use VA services. As reflected in 
Committee oversight hearings in June and September 1993, 
however, veterans with severe mental illness have historically 
been an ``underserved'' population within VA (as in the 
community at large), in terms of the relative level of funding 
devoted to VA mental health programs.
    In referring to severe mental illness, the Special 
Committee draws no distinction generally among psychiatric 
diagnoses, but rather to the relative degree of impairment 
associated with a patient's psychiatric condition. The Special 
Committee's report, however, identifies schizophrenia, the most 
prevalent condition among patients suffering from a severe 
mental illness, as exclusively a severe mental illness (along 
with bipolar disorder). The Special Committee reports that the 
care of veterans with severe mental illness is marked by more 
intense service utilization than for veterans with other less 
disabling psychiatric conditions, with both more days per year 
(74 vs. 32 days) of hospitalization and greater numbers of 
outpatient care clinic visits per year (31 vs. 25).
    These considerations highlight the important role to be 
played by a special committee of experts in the care of 
severely mentally ill veterans, and underscore the basis for 
this Committee's having urged VA to make the care of severe 
mentally ill veterans a Department priority. The Department is 
to be commended for its establishment of the Special Committee 
for Seriously Mentally Ill Veterans. Nevertheless, the high 
proportion of veterans with service-connected psychiatric 
conditions and the heavy reliance veterans suffering from 
severe mental illness place on VA mental health care highlight 
the importance of maintaining and codifying the Special 
Committee's role.
    Under the bill, as amended, the Special Committee would be 
charged to evaluate VA mental health care programs, identify 
systemwide problems, and identify specific VA facilities to 
highlight both programs in need of enrichment and model 
programs which should be more widely implemented. The Special 
Committee would also be tasked to provide advice on the 
development of policies for patient care and rehabilitation, 
and to provide recommendations on improving care (both 
systemwide and at specific facilities), establishing special 
programs of education and training for VA employees, research 
needs and priorities, and resource allocation.

Section 3. Centers for Mental Illness Research, Education, and Clinical 
                               Activities

    The concerns which prompted the call for a special 
committee are partly addressed in section 3 of the bill, as 
amended, which authorizes appropriations for VA to establish 
programs of excellence in mental illness research, education, 
and clinical care (MIRECC). The so-called MIRECC concept is 
intended to improve the quality of care, particularly at VA 
psychiatric hospitals, by fostering collaboration between such 
a hospital and a medical center which has a mission of 
providing tertiary medical care. While the MIRECC is modeled in 
part on VA's much lauded geriatric research, education and 
clinical centers (GRECCs), it differs in linking the strengths 
of institutions with very different missions.
    The aim is to channel the interests and expertise of VA 
tertiary medicine to work toward improving mental health care 
at VA's often unaffiliated psychiatric hospitals and developing 
improved models of mental health care delivery. Such 
collaboration in the case of a proposed MIRECC would entail 
establishing a dual-sited (or even multi-sited) ``center'' 
which involves the two (or more) VA institutions forming a 
collaborative program encompassing mental health research, 
education, and clinical care. To ensure adequate incentives for 
participation as well as to achieve an effective partnership 
between the collaborating facilities which operate the center, 
the measure would limit the funding available to any 
participating tertiary-care facility in any such collaborative 
arrangement to 50 percent of the funds appropriated for support 
of care, research, and education, and would require 
establishment of a formal governance structure to ensure that 
the center is operated to improve the quality of mental health 
care at the participating psychiatric facility (or facilities). 
The goal is that a key product of such collaborative 
arrangements would be improved care at those participating 
(non-tertiary) facilities which have a mission centered on care 
of the mentally ill.

 Section 4. Disbursement Agreements Relating to Medical Residents and 
                                Interns

    The VA typically enters into disbursement agreements with 
participating medical institutions for purpose of providing pay 
and other employee benefits to residents and interns who train 
at VAMCs. Current law, however, limits the use of these 
agreements to residents and interns who serve in a VA hospital, 
and not in outpatient clinics, nursing homes or other 
Department medical facilities. This provision would eliminate 
this prohibition and would permit disbursement agreements to be 
arranged for residents and interns who train at any VA health 
care facility. No costs to the federal government are 
associated with this provision.

 Section 5. Authority to Suspend Special Pay Agreements for Physicians 
           and Dentists Who Enter Residency Training Programs

    This provision would authorize the Secretary of Veterans 
Affairs to suspend special pay agreements, and with it an 
otherwise applicable obligation to repay earlier-provided 
special pay, for physicians and dentists who enter into a 
residency training program until its completion and the 
resumption of their VA employment within a time period 
determined by the Secretary.
    Under title 38, United States Code, ``special pay'' is 
authorized in addition to basic pay to assist in physician 
recruitment and retention. To receive special pay, a physician 
must enter into a special pay agreement that carries certain 
service obligations. Failure to complete that obligation 
triggers refund liabilities. Under currently law, employees 
incur a refund liability any time they leave voluntarily. A 
waiver can be granted only when the employee's breach of an 
agreement is for reasons beyond their control, as provided by 
section 7432(b)(2) of title 38, United States Code.
    Under existing law, a physician or dentist who enters a 
residency training program is converted to a special 
appointment category that is excluded from receipt of special 
pay. Entering a residency training position constitutes a 
breach of the agreement and triggers the obligation to repay 
the special pay that the physician or dentist received during 
that year, thereby, imposing adverse financial consequences on 
those individuals entering residency training programs.
    The provision would temporarily suspend the special pay 
agreement during residency training and allows the return of 
the physician or dentist to VA employment without incurring a 
special pay refund obligation. No costs arise from the 
provision, only a deferral of a payment obligation.

               Provision of health care to women veterans

    Women have served as members of the armed forces since 
World War I. But their numbers have expanded substantially 
since then. Today women comprise over 12 percent of the active 
force, 13 percent of the reserves, and over 4 percent of the 
veteran population.
    The increase in the number of women veterans has presented 
distinct challenges to a health care delivery system whose 
patients have historically been overwhelmingly male. As 
recently as 1982, the General Accounting Office (GAO) found 
that women veterans treated in VA medical facilities did not 
receive complete physical examinations or gynecological care.
    Oversight on women's health care conducted during the 103rd 
Congress, which included reviews by the General Accounting 
Office in 1992 and the VA Office of Inspector General (OIG) in 
1993, identified gaps between Departmental policy goals and 
practice at VA medical centers. Both found instances of medical 
centers not consistently monitoring women's care through their 
quality assurance programs, and thus being unable to ensure 
that required physical examinations were being performed. GAO 
also found that VA medical centers were not adequately 
monitoring their in-house mammography programs to ensure 
compliance with quality standards (although GAO also concluded 
that VA mammography service delivery was comparable to that of 
private providers and that its quality assurance exceeded 
private providers). Both GAO and OIG, as well as VA's Advisory 
Committee on Women Veterans also identified patient privacy as 
an issue of concern. The advisory committee, for example, 
pointed out that, although all VA facilities can accommodate 
women veterans, some continued to have patient privacy 
deficiencies, occasionally of such severity that physicians 
could not admit women for certain types of care.
    In March 1996, VA issued a ``Women Veterans Program 
Resource Guide'', which profiles the services provided women 
veterans at individual facilities, as well as listing 
facilities which have developed specific protocols, quality 
monitors, and other instruments relating to the care of women 
veterans. This document reflects that many VA medical centers 
have developed comprehensive programs for the women under their 
care; at the same time, it indicates some lack of consistency 
from center to center, particularly in the extensiveness of 
quality monitoring and the establishment of plans of care for 
women veterans.
    With the expiration of reporting requirements established 
in Public Law 102-585, and the failure of the Advisory 
Committee on Women Veterans to have issued a report (as 
required by section 542 of title 38, United States Code) since 
1994, the Committee has not been furnished current information 
on the extent to which women veterans are applying for and 
receiving VA care, for example, or on the progress VA has made 
in remedying patient privacy deficiencies. It is not clear, for 
example, the extent to which VA is able to provide privacy and 
safety in its own facilities for women veterans who require 
hospitalization for psychiatric conditions.
    Inconsistencies from facility to facility highlight the 
need for additional data on the effectiveness with which 
individual facilities are serving women veterans. Variability 
in whether or not a VA medical center does or does not have a 
comprehensive women's program, a full-time women's coordinator, 
and separate waiting areas for women veterans, for example, 
raise questions regarding patient satisfaction, perceived 
barriers to receipt of care, and differing degrees of 
utilization.
    The bill, as amended, seeks to answer such questions, and 
to remedy problems identified in prior oversight. Thus, the 
bill would extend and expand annual reporting requirements, as 
well as provide for an assessment of women veterans' 
experiences in using VA facilities. The required assessment 
would call for the Department's Center for Women Veterans, 
working in consultation with the Advisory Committee on Women 
Veterans, to assess women veterans' use of health services 
through the Department and to provide annual reports on its 
findings through 1999 to the Under Secretary for Health. The 
reports are to address the extent to which women veterans fail 
to seek health services from the Department, or face barriers 
in such efforts; the reasons for such phenomena; and 
recommendations, as indicated, for remedial action.
    The Committee is aware of an important study on women 
veterans' perceptions and experiences in accessing VA care 
being conducted by researchers with VA's Women's Health 
Sciences Division of the National Center for Post-Traumatic 
Stress Disorder in Boston which should provide valuable survey 
data. Among its objectives, the study aims to determine whether 
perceived and/or actual impediments exist in access to VA 
services for women veterans; to describe such perceived or 
actual barriers; and to examine potential differences in access 
experiences as they relate to such factors as age, service era, 
ethnicity, and health status. While this study, which is 
already underway, is not anticipated to be completed until 
September 1997, the Committee would encourage, to the extent 
feasible, consideration of such preliminary study data as may 
be available in developing the required 1997 report to the 
Under Secretary.
    Under the Mammography Quality Standards Act of 1992, Public 
Law 102-539, Congress exempted VA from requirements imposed on 
all health care facilities to meet quality assurance and 
quality control standards regarding mammography to be 
promulgated by the Secretary of Health and Human Services. Such 
exemption was based on the principle that standards applicable 
to VA should be established by the Secretary of Veterans 
Affairs. The Secretary has voluntarily developed such 
standards. The bill, as amended, would simply codify that 
policy, as reflected in a requirement that VA have quality 
assurance and quality control standards relating to the 
performance and interpretation of mammograms and use of 
mammography equipment and facilities. The measure would require 
that these standards be as stringent as the requirements 
prescribed by the Secretary under Public Law 102-539.
    Finally, the reported bill would require the Secretary 
annually, through 1999, to conduct a survey of all VA medical 
centers to identify patient privacy deficiencies relating to 
the treatment of women veterans, to develop plans for the 
correction of such deficiencies, and to give a high priority to 
such remedial efforts in the Department's construction planning 
and budgeting processes. The provision would require the 
Secretary to report to Congress on such annual inventory of 
deficiencies, as well as on proposed corrective plans and the 
status of those corrective efforts

                      Section-By-Section Analysis

    Section 1(a) would amend section 1710(e) of title 38, 
United States Code, to provide that a herbicide-exposed veteran 
is eligible for hospital and nursing home care under subsection 
(a)(1)(g) through December 31, 1998, for any disease which the 
National Academy of Sciences has found (or subsequently finds) 
either some evidence of, or insufficient evidence to permit a 
conclusion as to, an association between occurrence of the 
diseases in humans and exposure to a herbicide. It would also 
authorize the Secretary of Veterans Affairs, based on the 
recommendation of the Under Secretary for Health, to add to the 
list of covered conditions for which treatment is authorized. A 
disease could be added based on peer-reviewed research 
published within 20 months after the most recent National 
Academy of Sciences report regarding Agent Orange. This section 
would also provide special eligibility for hospital and nursing 
home care in the case of radiation-exposed veterans for care of 
any diseases for which the VA determines there is credible 
evidence of a positive association between disease occurrence 
and radiation exposure or for which Congress has established 
presumptive service-connection. Finally, it would extend 
eligibility for hospital care through December 31, 1998 for 
Persian Gulf War veterans and veterans who served on active 
duty in Israel or Turkey during the period August 2, 1990, 
through July 31, 1991.
    Section 1(b) would amend section 1712 to require, in the 
case of radiation and herbicide-exposed veterans, and veterans 
eligible for care under section 1710(e) by virtue of service 
during the Persian Gulf War, any needed outpatient treatment 
for covered illnesses (under section 1(a)). It would also 
assign the same priority to such treatment as provided for 
treatment of a service-connected condition.
    Section 1(c) would provide that veterans who have received 
care under the expired provisions of sections 1710(e) and 
1712(a) would not lose eligibility for continued care of such 
conditions.
    Section 2 would require that VA establish a Special 
Committee on Care of Severely Chronically Mentally Ill 
Veterans, which shall assess, and carry out a continuing 
assessment of the capability of the Veterans Health 
Administration to effectively meet the treatment and 
rehabilitation needs of severely, chronically mentally ill 
veterans. It would require that the Special Committee advise 
the Under Secretary for Health regarding the development of 
policies on, and improvements in, care for chronically mentally 
ill veterans. It would also require the Secretary to submit to 
the Committees on Veterans Affairs of the House and Senate, not 
later than April 1, 1997, the first of five annual reports on 
improving VA care for the chronically mentally ill.
    Section 3(a) would add a new section 7320 which would 
authorize the establishment of centers of mental illness 
research, education, and clinical activities, and specify the 
manner in which such centers would function, the mechanism for 
selecting the location of such centers, and the means by which 
VA medical centers would collaborate in the establishment and 
operation of such centers.
    Section 3(b) would require annual reporting on the status 
and activities of such centers.
    Section 3(c) would require the designation of at least one 
center under the new section 7320 not later than January 1, 
1998.
    Section 4 would amend section 7406(c) to permit 
disbursement agreements to cover residents and interns serving 
in any VA medical facility.
    Section 5 would amend section 7432(b)(2) to permit the 
suspension, but not termination, of special pay agreements for 
physicians and dentists who enter residency programs.
    Section 6(a) would amend section 107(a) of the Veterans 
Health Care Act of 1992 (Public Law 102-585; 38 U.S.C. 1710 
note) to extend through January 1, 1998 the requirement to 
report to the Committees on Veterans' Affairs of the House and 
Senate on the provision of women's health care services and the 
conduct of research relating to women veterans.
    Section 6(b) would amend section 107(b) of the Veterans 
Health Care Act of 1992 to expand the scope of the information 
to be furnished in the report required in section 6(a).
    Section 7(a) would require the Department's Center for 
Women Veterans, in consultation with the Advisory Committee on 
Women Veterans, to report to the Under Secretary for Health 
annually by April 1, 1997, through April 1, 1999 on real and 
perceived barriers to access to VA health services for women 
veterans.
    Section 7(b) would require the Secretary to report to the 
House and Senate Committees on Veterans' Affairs annually by 
July 1, 1997 through July 1, 1999 on the most recent report of 
the Center for Women Veterans, the Under Secretary for Health's 
views on such report and the remedial actions being taken as a 
result of the report.
    Section 8(a) would amend subchapter II of chapter 73 to add 
``Section 7319. Mammography Quality Standards.'' The new 
section 7319 would require that (1) a VA facility may not 
perform mammograms unless it is accredited to do so by a 
nonprofit organization meeting standards established by law; 
(2) VA prescribe standards relating to VA performance and 
interpretation of mammograms and use of mammogram equipment 
that are consistent with the requirements in the Public Health 
Service Act and that are no less stringent than those 
prescribed by the Secretary of Health and Human Services; (3) 
VA provide for an annual inspection of such equipment and 
facilities; and (4) ensure that contractors meet applicable 
quality standards.
    Section 8(b) would require VA to prescribe standards under 
subsection(a) not later than 120 days after enactment of the 
Act.
    Section 8(c) would require the Secretary to submit to the 
Committees on Veterans Affairs of the House and Senate a report 
on the implementation of section 7319.
    Section 9(a) would require the VA to conduct a survey of 
each medical center to identify deficiencies relating to 
patient privacy afforded to women patients which may interfere 
with appropriate treatment of such patients.
    Section 9(b) would provide that the Secretary ensure that 
plans to correct deficiencies identified in the survey are 
developed and incorporated into VA's construction planning 
processes and given high priority.
    Section 9(c) would require that the VA compile an annual 
inventory of those deficiencies and remedial plans, and inform 
Congress not later than October 1 annually through 1999 
regarding the inventory, proposed corrective plans, and the 
status of such plans.

                           Oversight Findings

    No oversight findings have been submitted to the Committee 
by the Committee on Government Reform and Oversight.

               Congressional Budget Office Cost Estimate

    The following letter was received from the Congressional 
Budget Office concerning the cost of the reported bill:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, June 24, 1996.
Hon. Bob Stump,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 3643, a bill to 
extend the authority of the Department of Veterans Affairs to 
provide priority treatment to certain veterans who were exposed 
to Agent Orange or who served in the Persian Gulf War and to 
make such authority permanent in the case of certain veterans 
exposed to ionizing radiation, and for other purposes, as 
ordered reported by the House Committee on Veterans' Affairs on 
June 20. 1996.
    H.R 3643 would not affect direct spending or receipts and 
thus would not be subject to pay-as-you-go procedures under 
section 252 of the Balanced Budget and Emergency Deficit 
Control Act of 1985.
    The bill contains no intergovernmental or private-sector 
mandates as defined in Public Law 104-4, and would impose no 
direct costs on State, local, or tribal governments.
    If you wish further details on this estimate, we will be 
pleased to provide them.
            Sincerely,
                                           June E. O'Neill,
                                                          Director.

    Attachment

               Congressional Budget Office Cost Estimate

    1. Bill number: H.R. 3643
    2. Bill title: A bill to amend title 38, United States 
Code, to extend through December 31, 1998, the period during 
which the Secretary of Veterans Affairs is authorized to 
provide priority health care to certain veterans who were 
exposed to Agent Orange or who served in the Persian Gulf War 
and to make such authority permanent in the case of certain 
veterans exposed to ionizing radiation, and for other purposes.
    3. Bill status: As ordered reported by the House Committee 
on Veterans' Affairs on June 20, 1996.
    4. Bill purpose: This bill would extend the authority of 
the Department of Veterans Affairs to provide health care to 
certain veterans exposed to toxic substances. It would also 
authorize creation of centers for chronically mentally ill 
veterans. Other sections of the bill would not have significant 
budgetary impacts.
    5. Estimated cost to the Federal Government: The following 
table summarizes the budgetary impact of H.R. 3643, which would 
depend on subsequent appropriations action.

                                                                                                                
                                    [By fiscal year, in millions of dollars]                                    
----------------------------------------------------------------------------------------------------------------
                                                     1996     1997     1998     1999     2000     2001     2002 
----------------------------------------------------------------------------------------------------------------
                                                                                                                
                                    SPENDING SUBJECT TO APPROPRIATIONS ACTION                                   
Spending under current law:                                                                                     
  Budget authority/authorizations 1 2............      200       50        0        0        0        0        0
  Estimated outlays..............................      178       70        0        0        0        0        0
Proposed changes:                                                                                               
  Estimated authorization level..................        0      165      223       70       18       18       12
  Estimated outlays..............................        0      148      218       90       18       18       12
Spending under the bill:                                                                                        
  Estimated authorization level 1................      200      215      223       70       18       18       12
  Estimated outlays..............................      178      218      218       90       18       18       12
----------------------------------------------------------------------------------------------------------------
1 The 1997 figure is the amount authorized but not yet appropriated.                                            
2 The 1996 figure is the amount already appropriated.                                                           


    6. Basis of estimate: The estimate assumes enactment of the 
bill by October 1, 1996, and appropriation of the authorized 
amounts for each fiscal year. CBO used historical spending 
rates for estimating outlays. Only those sections of the bill 
having a significant budgetary impact are discussed.
    Medical treatment for veterans exposed to toxic 
substances.--Under current law, the Department of Veterans 
Affairs (VA) has until December 31, 1996, to provide health 
care to veterans exposed to certain toxic substances. The bill 
would extend through December 31, 1998, VA's authority to treat 
Persian Gulf War veterans and Vietnam veterans exposed to Agent 
Orange and would permanently extend the authority to treat 
veterans exposed to ionizing radiation.
    Data on the number of veterans who have sought treatment in 
the past for disabilities related to exposure to Agent Orange, 
ionizing radiation, or toxic substances while serving in the 
Persian Gulf War, is difficult to obtain. While VA's patient 
treatment files have a count of the number of veterans 
receiving medical treatment and who are suffering from exposure 
to these toxic substances, the files do not have information on 
the number of veterans treated specifically for ailments 
related to exposure to these toxic substances.
    VA estimates the cost of providing health care for veterans 
exposed to ionizing radiation and Agent Orange would be $12 
million and $108 million per year, respectively. The cost of 
treating Persian Gulf War veterans would be $95 million for 
1997, an increase of $15 million over 1996. VA believes that 
the increase is needed both because of the growing number of 
military personnel who served in the Persian Gulf War who have 
been discharged and growing publicity about the availability of 
testing and medical treatment for Gulf War-related ailments.
    Centers for chronically mentally ill veterans.--Section 3 
would authorize the creation of no more than five centers for 
mental illness research, education, and clinical activities. 
This section would authorize appropriations of $3 million in 
1998 and $6 million a year for the three-year period from 1999-
2001 for operation of the centers. Also the bill would allow VA 
to use money appropriated for other purposes to fund programs 
under this section.
    7. Pay-as-you-go considerations: None.
    8. Estimated cost to State, local, and tribal governments: 
H.R 3643 contains no intergovernmental mandates as defined by 
Public Law 104-4 and would not affect the budgets of State, 
local, or tribal governments.
    9. Estimated impact on the private sector: This bill would 
impose no new federal private-sector mandates, as defined in 
Public Law 104-4.
    10. Previous CBO estimate: None
    11. Estimate prepared by:

          Federal cost estimate: Michael Groarke.
          Impact on State, local, and tribal governments: Marc 
        Nicole.
          Impact on private sector: Ellen Breslin Davidson.

    12. Estimate approved by: Paul N. Van de Water, Assistant 
Director for Budget Analysis.

                     Inflationary Impact Statement

    The enactment of the reported bill would have no 
inflationary impact.

                  Applicability to Legislative Branch

    The reported bill would not be applicable to the 
legislative branch under the Congressional Accountability Act, 
Public Law 104-1, because it would apply only to certain 
Department of Veterans Affairs programs and benefits 
recipients.

                     Statement of Federal Mandates

    The reported bill would not establish a federal mandate 
under the Unfunded Mandates Reform Act, Public Law 104-4.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3 of rule XIII of the Rules of the 
House of Representatives, changes in existing law made by the 
bill, as reported, are shown as follows (existing law proposed 
to be omitted is enclosed in black brackets, new matter is 
printed in italics, existing law in which no change is proposed 
is shown in roman):

                      TITLE 38, UNITED STATES CODE

          * * * * * * *

                       PART II--GENERAL BENEFITS

          * * * * * * *

   CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE

          * * * * * * *

 SUBCHAPTER II--HOSPITAL, NURSING HOME OR DOMICILIARY CARE AND MEDICAL 
                               TREATMENT

Sec. 1710. Eligibility for hospital, nursing home, and domiciliary care

  (a) * * *
          * * * * * * *
  [(e)(1)(A) Subject to paragraphs (2) and (3) of this 
subsection, a veteran--
          [(i) who served on active duty in the Republic of 
        Vietnam during the Vietnam era, and
          [(ii) who the Secretary finds may have been exposed 
        during such service to dioxin or was exposed during 
        such service to a toxic substance found in a herbicide 
        or defoliant used in connection with military purposes 
        during such era,
is eligible for hospital care and nursing home care under 
subsection (a)(1)(G) of this section for any disability, 
notwithstanding that there is insufficient medical evidence to 
conclude that such disability may be associated with such 
exposure.
  [(B) Subject to paragraphs (2) and (3) of this subsection, a 
veteran who the Secretary finds was exposed while serving on 
active duty to ionizing radiation from the detonation of a 
nuclear device in connection with such veteran's participation 
in the test of such a device or with the American occupation of 
Hiroshima and Nagasaki, Japan, during the period beginning on 
September 11, 1945, and ending on July 1, 1946, is eligible for 
hospital care and nursing home care under subsection (a)(1)(G) 
of this section for any disability, notwithstanding that there 
is insufficient medical evidence to conclude that such 
disability may be associated with such exposure.]
  (e)(1)(A) A herbicide-exposed veteran is eligible for 
hospital care and nursing home care under subsection (a)(1)(G) 
for any disease suffered by the veteran that is--
          (i) among those diseases for which the National 
        Academy of Sciences, in a report issued in accordance 
        with section 2 of the Agent Orange Act of 1991, has 
        determined--
                  (I) that there is sufficient evidence to 
                conclude that there is a positive association 
                between occurrence of the disease in humans and 
                exposure to a herbicide agent;
                  (II) that there is evidence which is 
                suggestive of an association between occurrence 
                of the disease in humans and exposure to a 
                herbicide agent, but such evidence is limited 
                in nature; or
                  (III) that available studies are insufficient 
                to permit a conclusion about the presence or 
                absence of an association between occurrence of 
                the disease in humans and exposure to a 
                herbicide agent; or
          (ii) a disease for which the Secretary, pursuant to a 
        recommendation of the Under Secretary for Health on the 
        basis of a peer-reviewed research study or studies 
        published within 20 months after the most recent report 
        of the National Academy under section 2 of the Agent 
        Orange Act of 1991, determines there is credible 
        evidence suggestive of an association between 
        occurrence of the disease in humans and exposure to a 
        herbicide agent.
  (B) A radiation-exposed veteran is eligible for hospital care 
and nursing home care under subsection (a)(1)(G) for any 
disease suffered by the veteran that is--
          (i) a disease listed in section 1112(c)(2) of this 
        title; or
          (ii) any other disease for which the Secretary, based 
        on the advice of the Advisory Committee on 
        Environmental Hazards, determines that there is 
        credible evidence of a positive association between 
        occurrence of the disease in humans and exposure to 
        ionizing radiation.
          * * * * * * *
  (2) [Hospital] In the case of a veteran described in 
paragraph (1)(C), hospital and nursing home care may not be 
provided under subsection (a)(1)(G) of this section with 
respect to a disability that is found, in accordance with 
guidelines issued by the Under Secretary for Health, to have 
resulted from a cause other than an exposure described in 
[subparagraph (A), (B), or (C) of paragraph (1) of this 
subsection] paragraph (1)(C).
  (3) Hospital and nursing home care and medical services may 
not be provided under or by virtue of subsection (a)(1)(G) [of 
this section after December 31, 1996] after December 31, 1998, 
in the case of care for a veteran described in paragraph (1)(A) 
or paragraph (1)(C).
  (4) For purposes of this subsection and section 1712 of this 
title:
          (A) The term ``herbicide-exposed veteran'' means a 
        veteran (i) who served on active duty in the Republic 
        of Vietnam during the Vietnam era, and (ii) who the 
        Secretary finds may have been exposed during such 
        service to a herbicide agent.
          (B) The term ``herbicide agent'' has the meaning 
        given that term in section 1116(a)(4) of this title.
          (C) The term `radiation-exposed veteran' has the 
        meaning given that term in section 1112(c)(4) of this 
        title.
          * * * * * * *

Sec. 1712. Eligibility for outpatient services

  (a)(1) Except as provided in subsection (b) of this section, 
the Secretary shall furnish on an ambulatory or outpatient 
basis such medical services as the Secretary determines are 
needed--
          (A) * * *
          * * * * * * *
          (C) to any veteran for a disability for which the 
        veteran is in receipt of compensation under section 
        1151 of this title or for which the veteran would be 
        entitled to compensation under that section but for a 
        suspension pursuant to that section (but in the case of 
        such a suspension, such medical services may be 
        furnished only to the extent that such person's 
        continuing eligibility for medical services is provided 
        for in the judgment or settlement described in that 
        section); [and]
          (D) during the period [before December 31, 1996,] 
        before January 1, 1999, for any disability in the case 
        of a veteran who served on active duty in the Southwest 
        Asia theater of operations during the Persian Gulf War 
        and who the Secretary finds may have been exposed to a 
        toxic substance or environmental hazard during such 
        service, notwithstanding that there is insufficient 
        medical evidence to conclude that the disability may be 
        associated with such exposure[.];
          (E) during the period before January 1, 1999, to any 
        herbicide-exposed veteran (as defined in section 
        1710(e)(4)(A) of this title) for any disease specified 
        in section 1710(e)(1)(A) of this title; and
          (F) to any radiation-exposed veteran (as defined in 
        section 1112(c)(4) of this title) for any disease 
        covered under section 1710(e)(1)(B) of this title.
          * * * * * * *
  (i) The Secretary shall prescribe regulations to ensure that 
special priority in furnishing medical services under this 
section and any other outpatient care with funds appropriated 
for the medical care of veterans shall be accorded in the 
following order, unless compelling medical reasons require that 
such care be provided more expeditiously:
          (1) * * *
          * * * * * * *
          (3) To a veteran [(A)] who is a former prisoner of 
        war[, or (B) who is eligible for hospital care under 
        section 1710(e) of this title].
          * * * * * * *

             PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

          * * * * * * *

 CHAPTER 73--VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS

     * * * * * * *

           subchapter ii--general authority and administration

7311. Quality assurance.
     * * * * * * *
7319. Committee on Care of Severely Chronically Mentally Ill Veterans.
7320. Centers for mental illness research, education, and clinical 
          activities.
7321. Mammography quality standards.
          * * * * * * *

          SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION

          * * * * * * *

Sec. 7319. Committee on Care of Severely Chronically Mentally Ill 
                    Veterans

  (a) Establishment.--The Secretary, acting through the Under 
Secretary for Health, shall establish in the Veterans Health 
Administration a Committee on Care of Severely Chronically 
Mentally Ill Veterans. The Under Secretary shall appoint 
employees of the Department with expertise in the care of the 
chronically mentally ill to serve on the committee.
  (b) Duties.--The committee shall assess, and carry out a 
continuing assessment of, the capability of the Veterans Health 
Administration to meet effectively the treatment and 
rehabilitation needs of mentally ill veterans whose mental 
illness is severe and chronic and who are eligible for health 
care furnished by the Department, including the needs of such 
veterans who are women. In carrying out that responsibility, 
the committee shall--
          (1) evaluate the care provided to such veterans 
        through the Veterans Health Administration;
          (2) identify systemwide problems in caring for such 
        veterans in facilities of the Veterans Health 
        Administration;
          (3) identify specific facilities within the Veterans 
        Health Administration at which program enrichment is 
        needed to improve treatment and rehabilitation of such 
        veterans; and
          (4) identify model programs which the committee 
        considers to have been successful in the treatment and 
        rehabilitation of such veterans and which should be 
        implemented more widely in or through facilities of the 
        Veterans Health Administration.
  (c) Advice and Recommendations.--The committee shall--
          (1) advise the Under Secretary regarding the 
        development of policies for the care and rehabilitation 
        of severely chronically mentally ill veterans; and
          (2) make recommendations to the Under Secretary--
                  (A) for improving programs of care of such 
                veterans at specific facilities and throughout 
                the Veterans Health Administration;
                  (B) for establishing special programs of 
                education and training relevant to the care of 
                such veterans for employees of the Veterans 
                Health Administration;
                  (C) regarding research needs and priorities 
                relevant to the care of such veterans; and
                  (D) regarding the appropriate allocation of 
                resources for all such activities.
  (d) Annual Report.--(1) Not later than April 1, 1997, the 
Secretary shall submit to the Committees on Veterans' Affairs 
of the Senate and House of Representatives a report on the 
implementation of this section. The report shall include the 
following:
          (A) A list of the members of the committee.
          (B) The assessment of the Under Secretary for Health, 
        after review of the initial findings of the committee, 
        regarding the capability of the Veterans Health 
        Administration, on a systemwide and facility-by-
        facility basis, to meet effectively the treatment and 
        rehabilitation needs of severely chronically mentally 
        ill veterans who are eligible for Department care.
          (C) The plans of the committee for further 
        assessments.
          (D) The findings and recommendations made by the 
        committee to the Under Secretary for Health and the 
        views of the Under Secretary on such findings and 
        recommendations.
          (E) A description of the steps taken, plans made (and 
        a timetable for their execution), and resources to be 
        applied toward improving the capability of the Veterans 
        Health Administration to meet effectively the treatment 
        and rehabilitation needs of severely chronically 
        mentally ill veterans who are eligible for Department 
        care.
  (2) Not later than February 1, 1998, and February 1 of each 
of the three following years, the Secretary shall submit to the 
Committees on Veterans' Affairs of the Senate and House of 
Representatives a report containing information updating the 
reports submitted under this subsection before the submission 
of such report.

Sec. 7320. Centers for mental illness research, education, and clinical 
                    activities

  (a) The purpose of this section is to provide for the 
improvement of the provision of health-care services and 
related counseling services to eligible veterans suffering from 
mental illness (especially mental illness related to service-
related conditions) through--
          (1) the conduct of research (including research on 
        improving mental health service facilities of the 
        Department and on improving the delivery of mental 
        health services by the Department);
          (2) the education and training of health care 
        personnel of the Department; and
          (3) the development of improved models and systems 
        for the furnishing of mental health services by the 
        Department.
  (b)(1) The Secretary shall establish and operate centers for 
mental illness research, education, and clinical activities. 
Such centers shall be established and operated by collaborating 
Department facilities as provided in subsection (c)(1). Each 
such center shall function as a center for--
          (A) research on mental health services;
          (B) the use by the Department of specific models for 
        furnishing services to treat serious mental illness;
          (C) education and training of health-care 
        professionals of the Department; and
          (D) the development and implementation of innovative 
        clinical activities and systems of care with respect to 
        the delivery of such services by the Department.
  (2) The Secretary shall, upon the recommendation of the Under 
Secretary for Health, designate the centers under this section. 
In making such designations, the Secretary shall ensure that 
the centers designated are located in various geographic 
regions of the United States. The Secretary may designate a 
center under this section only if--
          (A) the proposal submitted for the designation of the 
        center meets the requirements of subsection (c);
          (B) the Secretary makes the finding described in 
        subsection (d); and
          (C) the peer review panel established under 
        subsection (e) makes the determination specified in 
        subsection (e)(3) with respect to that proposal.
  (3) Not more than five centers may be designated under this 
section.
  (4) The authority of the Secretary to establish and operate 
centers under this section is subject to the appropriation of 
funds for that purpose.
  (c) A proposal submitted for the designation of a center 
under this section shall--
          (1) provide for close collaboration in the 
        establishment and operation of the center, and for the 
        provision of care and the conduct of research and 
        education at the center, by a Department facility or 
        facilities in the same geographic area which have a 
        mission centered on care of the mentally ill and a 
        Department facility in that area which has a mission of 
        providing tertiary medical care;
          (2) provide that no less than 50 percent of the funds 
        appropriated for the center for support of clinical 
        care, research, and education will be provided to the 
        collaborating facility or facilities that have a 
        mission centered on care of the mentally ill; and
          (3) provide for a governance arrangement between the 
        collaborating Department facilities which ensures that 
        the center will be established and operated in a manner 
        aimed at improving the quality of mental health care at 
        the collaborating facility or facilities which have a 
        mission centered on care of the mentally ill.
  (d) The finding referred to in subsection (b)(2)(B) with 
respect to a proposal for designation of a site as a location 
of a center under this section is a finding by the Secretary, 
upon the recommendation of the Under Secretary for Health, that 
the facilities submitting the proposal have developed (or may 
reasonably be anticipated to develop) each of the following:
          (1) An arrangement with an accredited medical school 
        that provides education and training in psychiatry and 
        with which one or more of the participating Department 
        facilities is affiliated under which medical residents 
        receive education and training in psychiatry through 
        regular rotation through the participating Department 
        facilities so as to provide such residents with 
        training in the diagnosis and treatment of mental 
        illness.
          (2) An arrangement with an accredited graduate school 
        of psychology under which students receive education 
        and training in clinical, counseling, or professional 
        psychology through regular rotation through the 
        participating Department facilities so as to provide 
        such students with training in the diagnosis and 
        treatment of mental illness.
          (3) An arrangement under which nursing, social work, 
        or allied health personnel receive training and 
        education in mental health care through regular 
        rotation through the participating Department 
        facilities.
          (4) The ability to attract scientists who have 
        demonstrated achievement in research--
                  (A) into the evaluation of innovative 
                approaches to the design of mental health 
                services; or
                  (B) into the causes, prevention, and 
                treatment of mental illness.
          (5) The capability to evaluate effectively the 
        activities of the center, including activities relating 
        to the evaluation of specific efforts to improve the 
        quality and effectiveness of mental health services 
        provided by the Department at or through individual 
        facilities.
  (e)(1) In order to provide advice to assist the Secretary and 
the Under Secretary for Health to carry out their 
responsibilities under this section, the official within the 
central office of the Veterans Health Administration 
responsible for mental health and behavioral sciences matters 
shall establish a peer review panel to assess the scientific 
and clinical merit of proposals that are submitted to the 
Secretary for the designation of centers under this section.
  (2) The panel shall consist of experts in the fields of 
mental health research, education and training, and clinical 
care. Members of the panel shall serve as consultants to the 
Department.
  (3) The panel shall review each proposal submitted to the 
panel by the official referred to in paragraph (1) and shall 
submit to that official its views on the relative scientific 
and clinical merit of each such proposal. The panel shall 
specifically determine with respect to each such proposal 
whether that proposal is among those proposals which have met 
the highest competitive standards of scientific and clinical 
merit.
  (4) The panel shall not be subject to the Federal Advisory 
Committee Act (5 U.S.C. App.).
  (f) Clinical and scientific investigation activities at each 
center established under this section--
          (1) may compete for the award of funding from amounts 
        appropriated for the Department of Veterans Affairs 
        medical and prosthetics research account; and
          (2) shall receive priority in the award of funding 
        from such account insofar as funds are awarded to 
        projects and activities relating to mental illness.
  (g) The Under Secretary for Health shall ensure that at least 
three centers designated under this section emphasize research 
into means of improving the quality of care for veterans 
suffering from mental illness through the development of 
community-based alternatives to institutional treatment for 
such illness.
  (h) The Under Secretary for Health shall ensure that 
information produced by the research, education and training, 
and clinical activities of centers established under this 
section that may be useful for other activities of the Veterans 
Health Administration is disseminated throughout the Veterans 
Health Administration. Such dissemination shall be made through 
publications, through programs of continuing medical and 
related educationprovided through regional medical education 
centers under subchapter VI of chapter 74 of this title, and through 
other means. Such programs of continuing medical education shall 
receive priority in the award of funding.
  (i) The official within the central office of the Veterans 
Health Administration responsible for mental health and 
behavioral sciences matters shall be responsible for 
supervising the operation of the centers established pursuant 
to this section and shall provide for ongoing evaluation of the 
centers and their compliance with the requirements of this 
section.
  (j)(1) There are authorized to be appropriated to the 
Department of Veterans Affairs for the basic support of the 
research and education and training activities of centers 
established pursuant to this section amounts as follows:
          (A) $3,125,000 for fiscal year 1998.
          (B) $6,250,000 for each of fiscal years 1999 through 
        2001.
  (2) In addition to funds appropriated for a fiscal year 
pursuant to the authorization of appropriations in paragraph 
(1), the Under Secretary for Health shall allocate to such 
centers from other funds appropriated for that fiscal year 
generally for the Department of Veterans Affairs medical care 
account and the Department of Veterans Affairs medical and 
prosthetics research account such amounts as the Under 
Secretary for Health determines appropriate to carry out the 
purposes of this section.

Sec. 7321. Mammography quality standards

  (a) A mammogram may not be performed at a Department facility 
unless that facility is accredited for that purpose by a 
private nonprofit organization designated by the Secretary. An 
organization designated by the Secretary under this subsection 
shall meet the standards for accrediting bodies established 
under section 354(e) of the Public Health Service Act (42 
U.S.C. 263b(e)).
  (b) The Secretary, in consultation with the Secretary of 
Health and Human Services, shall prescribe quality assurance 
and quality control standards relating to the performance and 
interpretation of mammograms and use of mammogram equipment and 
facilities of the Department of Veterans Affairs consistent 
with the requirements of section 354(f)(1) of the Public Health 
Service Act. Such standards shall be no less stringent than the 
standards prescribed by the Secretary of Health and Human 
Services under section 354(f) of the Public Health Service Act.
  (c)(1) The Secretary, to ensure compliance with the standards 
prescribed under subsection (b), shall provide for an annual 
inspection of the equipment and facilities used by and in 
Department health care facilities for the performance of 
mammograms. Such inspections shall be carried out in a manner 
consistent with the inspection of certified facilities by the 
Secretary of Health and Human Services under section 354(g) of 
the Public Health Service Act.
  (2) The Secretary may not provide for an inspection under 
paragraph (1) to be performed by a State agency.
  (d) The Secretary shall ensure that mammograms performed for 
the Department under contract with any non-Department facility 
or provider conform to the quality standards prescribed by the 
Secretary of Health and Human Services under section 354 of the 
Public Health Service Act.
  (e) For the purposes of this section, the term ``mammogram'' 
has the meaning given such term in paragraph (5) of section 
354(a) of the Public Health Service Act (42 U.S.C. 263b(a)).
          * * * * * * *

         CHAPTER 74--VETERANS HEALTH ADMINISTRATION--PERSONNEL

          * * * * * * *

                       SUBCHAPTER I--APPOINTMENTS

          * * * * * * *

Sec. 7406. Residencies and internships

  (a) * * *
          * * * * * * *
  (c)(1) In order to carry out more efficiently the provisions 
of subsection (a)(1), the Secretary may contract with one or 
more hospitals, medical schools, or medical installations 
having hospital facilities and participating with the 
Department in the training of interns or residents to provide, 
by the designation of one such institution to serve as a 
central administrative agency, for the central administration--
          (A) of stipend payments;
          (B) provision of fringe benefits; and
          (C) maintenance of records for such interns and 
        residents.
  (2) The Secretary may pay to such designated agency, without 
regard to any other law or regulation governing the expenditure 
of Government moneys either in advance or in arrears, an amount 
to cover the cost for the period such intern or resident serves 
in a [Department hospital] Department facility furnishing 
hospital care or medical services of--
          (A) stipends fixed by the Secretary pursuant to 
        paragraph (1);
          (B) hospitalization, medical care, and life insurance 
        and any other employee benefits as are agreed upon by 
        the participating institutions for the period that such 
        intern or resident serves in a [Department hospital] 
        Department facility furnishing hospital care or medical 
        services;
          (C) tax on employers pursuant to chapter 21 of the 
        Internal Revenue Code of 1986, where applicable; and
          (D) an amount to cover a pro rata share of the cost 
        of expense of such central administrative agency.
  (3)(A) Any amounts paid by the Secretary to such central 
administrative agency to cover the cost of hospitalization, 
medical care, or life insurance or other employee benefits 
shall be in lieu of any benefits of like nature to which such 
intern or resident may be entitled under the provisions of 
title 5, and the acceptance of stipends and employee benefits 
from the designated central administrative agency shall 
constitute a waiver by the recipient of any claim such 
recipient might have to any payment of stipends or employee 
benefits to which such recipient may be entitled under this 
title or title 5.
  (B) Notwithstanding subparagraph (A), any period of service 
of any such intern or resident in a [Department hospital] 
Department facility furnishing hospital care or medical 
services shall be deemed creditable service for the purposes of 
section 8332 of title 5.
  (4) The agreement with such central administrative agency may 
further provide that the designated central administrative 
agency shall--
          (A) make all appropriate deductions from the stipend 
        of each intern and resident for local, State, and 
        Federal taxes;
          (B) maintain all records pertinent to such deductions 
        and make proper deposits of such deductions; and
          (C) maintain all records pertinent to the leave 
        accrued by such intern and resident for the period 
        during which such recipient serves in a participating 
        [hospital] facility, including a [Department hospital] 
        Department facility furnishing hospital care or medical 
        services.
  (5) Leave described in paragraph (4)(C) may be pooled, and 
the intern or resident may be afforded leave by the [hospital] 
facility in which such person is serving at the time the leave 
is to be used to the extent of such person's total accumulated 
leave, whether or not earned at the [hospital] facility in 
which such person is serving at the time the leave is to be 
afforded.
          * * * * * * *

        SUBCHAPTER III--SPECIAL PAY FOR PHYSICIANS AND DENTISTS

          * * * * * * *

Sec. 7432. Special pay: written agreements

  (a)
          * * * * * * *
  (b)(1) An agreement under this subchapter shall provide that, 
if the physician or dentist entering into the agreement 
voluntarily, or because of misconduct, fails to complete any of 
the years of service covered by the agreement (measured from 
the anniversary date of the agreement), the physician or 
dentist shall refund an amount of special pay received under 
the agreement for that year equal to--
  (2)(A) The Secretary may waive (in whole or in part) the 
requirement for a refund under paragraph (1) in any case if the 
Secretary determines (in accordance with regulations prescribed 
under section 7431(a) of this title) that the failure to 
complete such period of service is the result of circumstances 
beyond the control of the physician or dentist.
  (B) The Secretary may suspend a special pay agreement entered 
into under this section in the case of a physician or dentist 
who, having entered into the special pay agreement, enters a 
residency training program. Any such suspension shall terminate 
when the physician or dentist completes, withdraws from, or is 
no longer a participant in the program. During the period of 
such a suspension, the physician or dentist is not subject to 
the provisions of paragraph (1).
          * * * * * * *
                              ----------                              


          SECTION 107 OF THE VETERANS HEALTH CARE ACT OF 1992

SEC. 107. REPORT ON HEALTH CARE AND RESEARCH.

  (a) In General.--[Not later than January 1, 1993, January 1, 
1994, and January 1, 1995] Not later than January 1 of 1993 and 
each year thereafter through 1998, the Secretary of Veterans 
Affairs shall submit to the Committees on Veterans' Affairs of 
the Senate and House of Representatives a report on the 
provision of health care services and the conduct of research 
carried out by, or under the jurisdiction of, the Secretary 
relating to women veterans.
  (b) Contents.--The report under subsection (a) shall include 
the following information with respect to the most recent 
fiscal year before the date of the report:
          (1) * * *
          (2) A description of (A) the services provided at 
        each such facility (including information on the number 
        of inpatient stays and the number of outpatient visits 
        through which such services were provided), and (B) the 
        extent to which each such facility relies on 
        contractual arrangements under section 1703 or 8153 of 
        title 38, United States Code, to furnish care to women 
        veterans in facilities which are not under the 
        jurisdiction of the Secretary where the provision of 
        such care is not furnished in a medical emergency.
          * * * * * * *
          (5) A description of the actions taken by the 
        Secretary to foster and encourage the expansion of such 
        research.

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