[House Report 107-242]
[From the U.S. Government Publishing Office]




107th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 1st Session                                                    107-242

======================================================================



 
 DISABLED VETERANS SERVICE DOG AND HEALTH CARE IMPROVEMENT ACT OF 2001

                                _______
                                

October 16, 2001.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

   Mr. Smith of New Jersey, from the Committee on Veterans' Affairs, 
                        submitted the following

                              R E P O R T

                        [To accompany H.R. 2792]

      [Including cost estimate of the Congressional Budget Office]

  The Committee on Veterans' Affairs, to whom was referred the 
bill (H.R. 2792) to amend title 38, United States Code, to 
authorize the Secretary of Veterans Affairs to make service 
dogs available to disabled veterans and to make various other 
improvements in health care benefits provided by the Department 
of Veterans Affairs, and for other purposes, having considered 
the same, reports favorably thereon with an amendment and 
recommends that the bill as amended do pass.

  The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

  (a) Short Title.--This Act may be cited as the ``Disabled Veterans 
Service Dog and Health Care Improvement Act of 2001''.
  (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.

               TITLE I--VETERANS HEALTH CARE IMPROVEMENT

Sec. 101. Authorization for Secretary of Veterans Affairs to provide 
service dogs for disabled veterans.
Sec. 102. Maintenance of capacity for specialized treatment and 
rehabilitative needs of disabled veterans.
Sec. 103. Threshold for veterans health care eligibility means test to 
reflect locality cost-of-living variations.
Sec. 104. Assessment and report on special telephone services for 
veterans.
Sec. 105. Recodification of bereavement counseling authority and 
certain other health-related authorities.
Sec. 106. Extension of expiring collections authorities.

                TITLE II--CHIROPRACTIC SERVICES PROGRAM

Sec. 201. Chiropractic Service established in the Veterans Health 
Administration.
Sec. 202. Availability of chiropractic care to veterans.
Sec. 203. Chiropractic providers.
Sec. 204. Scope of services; enrollment.
Sec. 205. Training and information.
Sec. 206. Advisory committee.
Sec. 207. Implementation report.

              TITLE III--NATIONAL COMMISSION ON VA NURSING

Sec. 301. Establishment of Commission.
Sec. 302. Duties of Commission.
Sec. 303. Reports.
Sec. 304. Powers.
Sec. 305. Personnel matters.
Sec. 306. Termination of the Commission.

               TITLE I--VETERANS HEALTH CARE IMPROVEMENT

SEC. 101. AUTHORIZATION FOR SECRETARY OF VETERANS AFFAIRS TO PROVIDE 
                    SERVICE DOGS FOR DISABLED VETERANS.

  (a) Authority.--Section 1714 of title 38, United States Code, is 
amended--
          (1) in subsection (b)--
                  (A) by striking ``seeing-eye or'' the first place it 
                appears;
                  (B) by striking ``who are entitled to disability 
                compensation'' and inserting ``who are enrolled under 
                section 1705 of this title'';
                  (C) by striking ``, and may pay'' and all that 
                follows through ``such seeing-eye or guide dogs''; and
                  (D) by striking ``handicap'' and inserting 
                ``disability''; and
          (2) by adding at the end the following new subsections:
  ``(c) The Secretary may, in accordance with the priority specified in 
section 1705 of this title, provide--
          ``(1) service dogs trained for the aid of the hearing 
        impaired to veterans who are hearing impaired and are enrolled 
        under section 1705 of this title; and
          ``(2) service dogs trained for the aid of persons with spinal 
        cord injury or dysfunction or other chronic impairment that 
        substantially limits mobility to veterans with such injury, 
        dysfunction, or impairment who are enrolled under section 1705 
        of this title.
  ``(d) In the case of a veteran provided a dog under subsection (b) or 
(c), the Secretary may pay travel and incidental expenses for that 
veteran under the terms and conditions set forth in section 111 of this 
title to and from the veteran's home for expenses incurred in becoming 
adjusted to the dog.''.
  (b) Clerical Amendments.--
          (1) The heading for such section is amended to read as 
        follows:

``Sec. 1714. Fitting and training in use of prosthetic appliances; 
                    guide dogs; service dogs''.

          (2) The item relating to such section in the table of 
        sections at the beginning of chapter 17 of such title is 
        amended to read as follows:

``1714. Fitting and training in use of prosthetic appliances; guide 
dogs; service dogs.''.

SEC. 102. MAINTENANCE OF CAPACITY FOR SPECIALIZED TREATMENT AND 
                    REHABILITATIVE NEEDS OF DISABLED VETERANS.

  (a) Maintenance of Capacity on a Service-Network Basis.--Section 
1706(b) of title 38, United States Code, is amended--
          (2) in paragraph (1)--
                  (A) in the first sentence, by inserting ``(and each 
                geographic service area of the Veterans Health 
                Administration)'' after ``ensure that the Department''; 
                and
                  (B) in clause (B), by inserting ``(and each 
                geographic service area of the Veterans Health 
                Administration)'' after ``overall capacity of the 
                Department''; and
          (2) by redesignating paragraphs (2) and (3) as paragraphs (4) 
        and (5), respectively;
          (3) by inserting after paragraph (1) the following new 
        paragraphs (2) and (3):
  ``(2) For purposes of paragraph (1), the capacity of the Department 
(and each geographic service area of the Veterans Health 
Administration) to provide for the specialized treatment and 
rehabilitative needs of disabled veterans (including veterans with 
spinal cord dysfunction, traumatic brain injury, blindness, prosthetics 
and sensory aids, and mental illness) within distinct programs or 
facilities shall be measured for seriously mentally ill veterans as 
follows (with all such data to be provided by geographic service area 
and totaled nationally):
          ``(A) For mental health intensive community-based care, the 
        number of discrete intensive care teams constituted to provide 
        such intensive services to seriously mentally ill veterans and 
        the number of veterans provided such care.
          ``(B) For opioid substitution programs and for traumatic 
        brain injury, the number of patients treated annually and the 
        amounts expended.
          ``(C) For dual-diagnosis patients, the number treated 
        annually and the amounts expended.
          ``(D) For substance abuse programs--
                  ``(i) the number of substance-use disorder beds 
                (whether hospital, nursing home, or other designated 
                beds) employed and the average bed occupancy of such 
                beds;
                  ``(ii) the percentage of unique patients admitted 
                directly to substance abuse outpatient care during the 
                fiscal year who had two or more additional visits to 
                specialized substance abuse outpatient care within 30 
                days of their first visit, with a comparison from 1996 
                until the date of the report;
                  ``(iii) the percentage of unique inpatients with 
                substance abuse diagnoses treated during the fiscal 
                year who had one or more specialized substance abuse 
                clinic visits within three days of their index 
                discharge, with a comparison from 1996 until the date 
                of the report; and
                  ``(iv) the percentage of unique outpatients seen in a 
                facility or service network during the fiscal year who 
                had one or more specialized substance abuse clinic 
                visits, with a comparison from 1996 until the date of 
                the report.
          ``(E) For mental health programs, the number and type of 
        staff that are available at each facility to provide 
        specialized mental health treatment, including satellite 
        clinics, outpatient programs, and community-based outpatient 
        clinics, with a trend line comparison from 1996 to the date of 
        the report.
          ``(F) The number of such clinics providing mental health 
        care, the number and type of mental health staff at each such 
        clinic, and the type of mental health programs at each such 
        clinic.
  ``(3) For purposes of paragraph (1), the capacity of the Department 
(and each geographic service area of the Veterans Health 
Administration) to provide for the specialized treatment and 
rehabilitative needs of disabled veterans within distinct programs or 
facilities shall be measured for veterans with spinal cord dysfunction, 
traumatic brain injury, blindness, or prosthetics and sensory aids as 
follows (with all such data to be provided by geographic service area 
and totaled nationally):
          ``(A) For spinal cord injury/dysfunction specialized centers 
        and for blind rehabilitation specialized centers, the number of 
        staffed beds and the number of full-time equivalent employees 
        assigned to provide care at such centers.
          ``(B) For prosthetics and sensory aids, the annual amount 
        expended.''.
  (b) Extension of Annual Report Requirement.--Paragraph (3) of such 
section, as so redesignated, is amended--
          (1) by striking ``April 1, 1999, April 1, 2000, and April 1, 
        2001'' and inserting ``April 1 of each year through 2004''; and
          (2) by adding at the end the following new sentence: ``The 
        accuracy of each such report shall be certified by, or 
        otherwise commented upon by, the Inspector General of the 
        Department.''.

SEC. 103. THRESHOLD FOR VETERANS HEALTH CARE ELIGIBILITY MEANS TEST TO 
                    REFLECT LOCALITY COST-OF-LIVING VARIATIONS.

  (a) Revised Threshold.--Subsection (b) of section 1722 of title 38, 
United States Code, is amended to read as follows:
  ``(b)(1) For purposes of subsection (a)(3), the income threshold 
applicable to a veteran is the amount determined under paragraph (2).
  ``(2) The amount determined under this paragraph for a veteran is the 
greater of the following:
          ``(A) For any calendar year after 2000--
                  ``(i) in the case of a veteran with no dependents, 
                $23,688, as adjusted under subsection (c); or
                  ``(ii) in the case of a veteran with one or more 
                dependents, $28,429, as so adjusted, plus $1,586, as so 
                adjusted, for each dependent in excess of one.
          ``(B) The amount in effect under the HUD Low Income Index 
        that is applicable in the area in which the veteran resides.
  ``(3) For purposes of paragraph (2)(B), the term `HUD Low Income 
Index' means the family income ceiling amounts determined by the 
Secretary of Housing and Urban Development under section 3(b)(2) of the 
United States Housing Act of 1937 (42 U.S.C. 1437a(b)(2)) for purposes 
of the determination of `low-income families' under that section.''.
  (c) Conforming Amendment.--(1) Subsection (a)(3) of such section is 
amended by striking ``amount set forth in'' and inserting ``income 
threshold determined under''.
  (2) Subsection (c) of such section is amended by striking 
``subsection (b)'' and inserting ``subsection (b)(2)(A)''.
  (d) Limitation on Resource Reallocations.-- Within the amount 
appropriated to the Department of Veterans Affairs for medical care for 
each of fiscal years 2002 through 2006. the amount that would otherwise 
be allocated by the Secretary to any geographic service region of the 
Veterans Health Administration in accordance with the established 
resource allocation procedures of the Department may not be increased 
or decreased by more than 5 percent by reason of the implementation of 
this section.
  (e) Effective Date.--The amendments made by this section shall take 
effect on April 1, 2002.

SEC. 104. ASSESSMENT AND REPORT ON SPECIAL TELEPHONE SERVICES FOR 
                    VETERANS.

  (a) Assessment of Current Services.--The Secretary of Veterans 
Affairs shall carry out an assessment of all special telephone services 
for veterans (such as helplines and hotlines) provided by the 
Department of Veterans Affairs. The assessment shall include the 
geographical coverage, availability, utilization, effectiveness, 
management, coordination, staffing, and cost of those services. As part 
of such assessment, the Secretary shall conduct a survey of veterans to 
measure their satisfaction with current special telephone services and 
the demand for additional services.
  (b) Report.--Not later than one year after the date of the enactment 
of this Act, the Secretary shall submit to Congress a report on the 
assessment carried out under subsection (a). The Secretary shall 
include in the report recommendations regarding any needed improvement 
to such services and recommendations regarding contracting for the 
performance of such services.

SEC. 105. RECODIFICATION OF BEREAVEMENT COUNSELING AUTHORITY AND 
                    CERTAIN OTHER HEALTH-RELATED AUTHORITIES.

  (a) Statutory Reorganization.--Subchapter I of chapter 17 of title 
38, United States Code, is amended--
          (1) in section 1701(6)--
                  (A) by striking subparagraph (B) and the sentence 
                following that subparagraph;
                  (B) by striking ``services--'' in the matter 
                preceding subparagraph (A) and inserting ``services, 
                the following:''; and
                  (C) by striking subparagraph (A) and inserting the 
                following:
          ``(A) Surgical services.
          ``(B) Dental services and appliances as described in sections 
        1710 and 1712 of this title.
          ``(C) Optometric and podiatric services.
          ``(D) Preventive health services.
          ``(E) In the case of a person otherwise receiving care or 
        services under this chapter--
                  ``(i) wheelchairs, artificial limbs, trusses, and 
                similar appliances;
                  ``(ii) special clothing made necessary by the wearing 
                of prosthetic appliances; and
                  ``(iii) such other supplies or services as the 
                Secretary determines to be reasonable and necessary.
          ``(F) Travel and incidental expenses pursuant to section 111 
        of this title.''; and
          (2) in section 1707--
                  (A) by inserting ``(a)'' at the beginning of the text 
                of the section; and
                  (B) by adding at the end the following:
  ``(b) The Secretary may furnish sensori-neural aids only in 
accordance with guidelines prescribed by the Secretary.''.
  (b) Consolidation of Provisions Relating to Persons Other Than 
Veterans.--Such chapter is further amended by adding at the end the 
following new subchapter:

     ``SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS

``Sec. 1782. Counseling, training, and mental health services for 
                    immediate family members

  ``(a) Counseling for Family Members of Veterans Receiving Service-
Connected Treatment.--In the case of a veteran who is receiving 
treatment for a service-connected disability pursuant to paragraph (1) 
or (2) of section 1710(a) of this title, the Secretary shall provide to 
individuals described in subsection (c) such consultation, professional 
counseling, training, and mental health services as are necessary in 
connection with that treatment.
  ``(b) Counseling for Family Members of Veterans Receiving Non-
Service-Connected Treatment.--In the case of a veteran who is eligible 
to receive treatment for a non-service-connected disability under the 
conditions described in paragraph (1), (2), or (3) of section 1710(a) 
of this title, the Secretary may, in the discretion of the Secretary, 
provide to individuals described in subsection (c) such consultation, 
professional counseling, training, and mental health services as are 
necessary in connection with that treatment if--
          ``(1) those services were initiated during the veteran's 
        hospitalization; and
          ``(2) the continued provision of those services on an 
        outpatient basis is essential to permit the discharge of the 
        veteran from the hospital.
  ``(c) Eligible Individuals.--Individuals who may be provided services 
under this subsection are--
          ``(1) the members of the immediate family or the legal 
        guardian of a veteran; or
          ``(2) the individual in whose household such veteran 
        certifies an intention to live.
  ``(d) Travel and Transportation Authorized.--Services provided under 
subsections (a) and (b) may include, under the terms and conditions set 
forth in section 111 of this title, travel and incidental expenses of 
individuals described in subsection (c) in the case of--
          ``(1) a veteran who is receiving care for a service-connected 
        disability; and
          ``(2) a dependent or survivor receiving care under the last 
        sentence of section 1783(b) of this title.

``Sec. 1783. Bereavement counseling

  ``(a) Deaths of Veterans.--In the case of an individual who was a 
recipient of services under section 1782 of this title at the time of 
the death of the veteran, the Secretary may provide bereavement 
counseling to that individual in the case of a death--
          ``(1) that was unexpected; or
          ``(2) that occurred while the veteran was participating in a 
        hospice program (or a similar program) conducted by the 
        Secretary.
  ``(b) Deaths In Active Service.--The Secretary may provide 
bereavement counseling to an individual who is a member of the 
immediate family of a member of the Armed Forces who dies in the active 
military, naval, or air service in the line of duty and under 
circumstances not due to the person's own misconduct.
  ``(c) Bereavement Counseling Defined.--For purposes of this section, 
the term `bereavement counseling' means such counseling services, for a 
limited period, as the Secretary determines to be reasonable and 
necessary to assist an individual with the emotional and psychological 
stress accompanying the death of another individual.

``Sec. 1784. Humanitarian care

  ``The Secretary may furnish hospital care or medical services as a 
humanitarian service in emergency cases, but the Secretary shall charge 
for such care and services at rates prescribed by the Secretary.''.
  (c) Transfer of CHAMPVA Section.--Section 1713 of such title is--
          (1) transferred to subchapter VIII of chapter 17 of such 
        title, as added by subsection (b), and inserted after the 
        subchapter heading;
          (2) redesignated as section 1781; and
          (3) amended by adding at the end of subsection (b) the 
        following new sentence: ``A dependent or survivor receiving 
        care under the preceding sentence shall be eligible for the 
        same medical services as a veteran, including services under 
        sections 1782 and 1783 of this title.''.
  (d) Repeal of Recodified Authority.--Section 1711 of such title is 
amended by striking subsection (b).
  (e) Cross Reference Amendments.--Such title is further amended as 
follows:
          (1) Section 103(d)(5)(B) is amended by striking ``1713'' and 
        inserting ``1781''.
          (2) Sections 1701(5) is amended by striking ``1713(b)'' in 
        subparagraphs (B) and (C)(i) and inserting ``1781(b)''.
          (3) Section 1712A(b) is amended--
                  (A) in the last sentence of paragraph (1), by 
                striking ``section 1711(b)'' and inserting ``section 
                1784''; and
                  (A) in paragraph (2), by striking ``section 
                1701(6)(B)'' and inserting ``sections 1782 and 1783''.
          (4) Section 1729(f) is amended by striking ``section 
        1711(b)'' and inserting ``section 1784''.
          (5) Section 1729A(b) is amended--
                  (A) by redesignating paragraph (7) as paragraph (8); 
                and
                  (B) by inserting after paragraph (6) the following 
                new paragraph (7):
          ``(7) Section 1784 of this title.''.
          (6) Section 8111(g) is amended--
                  (A) in paragraph (4), by inserting ``services under 
                sections 1782 and 1783 of this title'' after ``of this 
                title,''; and
                  (B) in paragraph (5), by striking ``section 1711(b) 
                or 1713'' and inserting ``section 1782, 1783, or 
                1784''.
          (7) Section 8111A(a)(2) is amended by inserting ``, and the 
        term `medical services' includes services under sections 1782 
        and 1783 of this title'' before the period at the end.
          (8) Section 8152(1) is amended by inserting ``services under 
        sections 1782 and 1783 of this title,'' after ``of this 
        title),''.
          (9) Sections 8502(b), 8520(a), and 8521 are amended by 
        striking ``the last sentence of section 1713(b)'' and inserting 
        ``the penultimate sentence of section 1781(b)''.
  (f) Clerical Amendments.--
          (1) The table of sections at the beginning of such chapter is 
        amended--
                  (A) by striking the item relating to section 1707 and 
                inserting the following:

``1707. Limitations.'';

                  (B) by striking the item relating to section 1713; 
                and
                  (C) by adding at the end the following:

     ``subchapter viii--health care of persons other than veterans

``1781. Medical care for survivors and dependents of certain veterans.
``1782. Counseling, training, and mental health services for immediate 
family members.
``1783. Bereavement counseling.
``1784. Humanitarian care.''.

          (2) The heading for section 1707 is amended to read as 
        follows:

``Sec. 1707. Limitations''.

SEC. 106. EXTENSION OF EXPIRING COLLECTIONS AUTHORITIES.

  (a) Health Care Copayments.--Section 1710(f)(2)(B) of title 38, 
United States Code, is amended by striking ``September 30, 2002'' and 
inserting ``September 30, 2007''.
  (b) Medical Care Cost Recovery.--Section 1729(a)(2)(E) of such title 
is amended by striking ``October 1, 2002'' and inserting ``October 1, 
2007''.

                    TITLE II--CHIROPRACTIC SERVICES

SEC. 201. CHIROPRACTIC SERVICE ESTABLISHED IN THE VETERANS HEALTH 
                    ADMINISTRATION.

  (a) New Service in Veterans Health Administration.--Section 7305 of 
title 38, United States Code, is amended--
          (1) by redesignating paragraph (7) as paragraph (8); and
          (2) by inserting after paragraph (6) the following new 
        paragraph (7):
          ``(7) A Chiropractic Service.''.
  (b) Director.--Section 7306(a) of such title--
          (1) by redesignating paragraphs (7) through (10) as 
        paragraphs (8) through (11), respectively; and
          (2) by inserting after paragraph (6) the following new 
        paragraph (7):
          ``(7) A Director of Chiropractic Service, who shall be a 
        qualified doctor of chiropractic and who shall be responsible 
        to the Secretary for the operation of the Chiropractic 
        Service.''.

SEC. 202. AVAILABILITY OF CHIROPRACTIC CARE TO VETERANS.

  (a) Establishment.--The Secretary of Veterans Affairs shall establish 
a program to provide chiropractic care to veterans through all 
Department of Veterans Affairs medical centers.
  (b) Implementation.--The program under this section shall be 
implemented at Department of Veterans Affairs medical centers as 
follows:
          (1) At not less than 30 medical centers by the end of fiscal 
        year 2002.
          (2) At not less than 60 medical centers by the end of fiscal 
        year 2003,
          (3) At not less than 90 medical centers by the end of fiscal 
        year 2004.
          (4) At not less than 120 medical centers by the end of fiscal 
        year 2005.
          (5) At all of the Department of Veterans Affairs medical 
        centers by the end of fiscal year 2006.
  (c) Initial Participating Medical Centers.--The initial 30 medical 
centers at which the program is to be carried out shall be designated 
by the Secretary not later than 60 days after the date of the enactment 
of this Act. In designating those medical centers, the Secretary shall 
select medical centers to reflect geographic diversity, facilities of 
various size and capabilities, and the range of services in the 
Department health care system.

SEC. 203. CHIROPRACTIC PROVIDERS.

  The program under section 202 shall be carried out through personal 
service contracts and with appointments of licensed chiropractors for 
delivery of chiropractic services at Department of Veterans Affairs 
medical centers.

SEC. 204. SCOPE OF SERVICES; ENROLLMENT.

  (a) Scope of Services.--The chiropractic services provided under 
section 202 shall include, at a minimum, care for neuro-musculoskeletal 
conditions.
  (b) Enrollment.--A veteran enrolled under section 1705 of title 38, 
United States Code, may, as part of such enrollment, choose a 
chiropractor as the veteran's primary care provider. A veteran with a 
primary care provider other than a chiropractor may be referred to 
chiropractic services for neuro-musculoskeletal conditions by a medical 
provider.

SEC. 205. TRAINING AND INFORMATION.

  (a) Primary Care Teams.--The Secretary shall provide training and 
materials relating to chiropractic services to members of Department 
health care providers assigned to primary care teams for the purposes 
of familiarizing those providers with the benefits of appropriate use 
of chiropractic services.
  (b) Future Program Sites.--During the period covered by section 
202(b), the Secretary shall provide materials relating to chiropractic 
services to medical centers and other health care facilities of the 
Department not yet participating in the program in order to ensure that 
health care providers at those facilities are aware of chiropractic 
care as a future referral source.
  (c) Approval of Materials.--The Secretary may approve materials to be 
furnished under subsections (a) and (b) only after consulting with, and 
receiving the views of, the advisory committee established under 
section 206.

SEC. 206. ADVISORY COMMITTEE.

  (a) Establishment.--The Secretary shall establish an advisory 
committee to review implementation of the program under this title.
  (b) Members.--In appointing the members of the advisory committee, 
the Secretary shall include on the advisory committee--
          (1) members of the chiropractic profession;
          (2) persons who are experts in human resources appointments 
        in the Federal service;
          (3) persons with expertise in academic matters;
          (4) persons with knowledge of credentialing and the granting 
        of professional privileging to health care practitioners; and
          (5) other persons as determined necessary by the Secretary 
        and the functional needs of the advisory committee in 
        establishing the chiropractic health program.
  (c) Functions.--The advisory committee shall provide advice to the 
Secretary on--
          (1) the granting of professional privileges for chiropractors 
        at Department medical centers;
          (2) the scope of practice of chiropractors at Department 
        medical centers;
          (3) training materials; and
          (4) such other matters as are determined appropriate by the 
        Secretary.

SEC. 207. IMPLEMENTATION REPORT.

  Not later than 18 months after the date of the enactment of this Act, 
the Secretary shall submit to the Committees on Veterans Affairs of the 
Senate and House of Representatives a report on the implementation of 
this title.

              TITLE III--NATIONAL COMMISSION ON VA NURSING

SEC. 301. ESTABLISHMENT OF COMMISSION.

  (a) Establishment.--There is hereby established in the Department of 
Veterans Affairs a commission to be known as the ``National Commission 
on VA Nursing'' (hereinafter in this title referred to as the 
``Commission'').
  (b) Composition.--(1) The Commission shall be composed of 12 members.
  (2) Eleven members shall be appointed by the Secretary of Veterans 
Affairs, as follows:
          (A) Three shall be recognized representatives of employees, 
        including nurses, of the Department of Veterans Affairs.
          (B) Three shall be representatives of professional 
        associations of nurses of the Department or similar 
        organizations affiliated with the Department's health care 
        practitioners.
          (C) Two shall be representatives of trade associations 
        representing the nursing profession.
          (D) Two shall be nurses from nursing schools affiliated with 
        the Department of Veterans Affairs.
          (E) One shall be a representative of veterans.
  (3) The Nurse Executive of the Department of Veterans Affairs shall 
be an ex officio member of the Commission.
  (d) Chairman of Commission.--The Secretary of Veterans Affairs shall 
designate one of the members of the Commission to serve as chairman of 
the Commission.
  (e) Period of Appointment; Vacancies.--Members shall be appointed for 
the life of the Commission. Any vacancy in the Commission shall be 
filled in the same manner as the original appointment.
  (f) Initial Organization Requirements.--All appointments to the 
Commission shall be made not later than 60 days after the date of the 
enactment of this Act. The Commission shall convene its first meeting 
not later than 60 days after the date as of which all members of the 
Commission have been appointed.

SEC. 302. DUTIES OF COMMISSION.

  (a) Assessment.--The Commission shall--
          (1) consider legislative and organizational policy changes to 
        enhance the recruitment and retention of nurses by the 
        Department of Veterans Affairs; and
          (2) assess the future of the nursing profession within the 
        Department.
  (b) Recommendation.--The Commission shall recommend legislative and 
organizational policy changes to enhance the recruitment and retention 
of nurses in the Department.

SEC. 303. REPORTS.

  (a) Commission Report.--The Commission shall, not later than two 
years after the date of its first meeting, submit to Congress and the 
Secretary of Veterans Affairs a report on the Commission's findings and 
conclusions.
  (b) Secretary of Veterans Affairs Report.--Not later than 60 after 
the date of the Commission's report under subsection (a), the Secretary 
shall submit to Congress a report--
          (1) providing the Secretary's views on the Commission's 
        findings and conclusions; and
          (2) explaining what actions, if any, the Secretary intends to 
        take to implement the recommendations of the Commission and the 
        Secretary's reasons for doing so.

SEC. 304. POWERS.

  (a) Hearings.--The Commission or, at its direction, any panel or 
member of the Commission, may, for the purpose of carrying out the 
provisions of this title, hold hearings and take testimony to the 
extent that the Commission or any member considers advisable.
  (b) Information.--The Commission may secure directly from any Federal 
department or agency information that the Commission considers 
necessary to enable the Commission to carry out its responsibilities 
under this title.

SEC. 305. PERSONNEL MATTERS.

  (a) Pay of Members.--Members of the Commission shall serve without 
pay by reason of their work on the Commission.
  (b) Travel Expenses.--The members of the Commission shall be allowed 
travel expenses, including per diem in lieu of subsistence, at rates 
authorized for employees of agencies under subchapter I of chapter 57 
of title 5, United States Code, while away from their homes or regular 
places of business in the performance of services for the Commission.
  (c) Staff.--(1) The Secretary may, without regard to the provisions 
of title 5, United States Code, governing appointments in the 
competitive service, appoint a staff director and such additional 
personnel as may be necessary to enable the Commission to perform its 
duties.
  (2) The Secretary may fix the pay of the staff director and other 
personnel appointed under paragraph (1) without regard to the 
provisions of chapter 51 and subchapter III of chapter 53 of title 5, 
United States Code, relating to classification of positions and General 
Schedule pay rates, except that the rate of pay fixed under this 
paragraph for the staff director may not exceed the rate payable for 
level V of the Executive Schedule under section 5316 of such title and 
the rate of pay for other personnel may not exceed the maximum rate 
payable for grade GS-15 of the General Schedule.
  (d) Detail of Government Employees.--Upon request of the Secretary, 
the head of any Federal department or agency may detail, on a 
nonreimbursable basis, any personnel of that department or agency to 
the Commission to assist it in carrying out its duties.

SEC. 306. TERMINATION OF THE COMMISSION.

  The Commission shall terminate 90 days after the date of the 
submission of its report under section 303(a).

                              Introduction

    The reported bill, in the nature of a substitute to H.R. 
2792, the Disabled Veterans Service Dog and Health Care 
Improvement Act of 2001, reflects the Committee's consideration 
of matters necessary to make a number of improvements in the 
Department of Veterans Affairs health care programs.
    On April 3, 2001, the Subcommittee on Health held a hearing 
concerning the current state of the VA health care system. 
Those testifying at the hearing included: the Honorable Thomas 
L. Garthwaite, Under Secretary for Health, Department of 
Veterans Affairs; Dr. Frances M. Murphy, Deputy Undersecretary 
for Health, Department of Veterans Affairs; Dr. John G. 
Clarkson, Senior Vice President Medical Affairs and Dean, 
University of Miami School of Medicine, Miami, FL; Dr. George 
Thibault, Chairman, Special Medical Advisory Group, Department 
of Veterans Affairs, Vice President and Chairman of Clinical 
Affairs, Partners Health Care, Inc.; Mr. James R. Fischl, 
Director, National Veterans Affairs and Rehabilitation 
Commission, The American Legion; Mr. Paul A. Hayden, Associate 
Director, National Legislative Service, Veterans of Foreign 
Wars; Ms. Joy J. Ilem, Assistant National Legislative Director, 
Disabled American Veterans; Mr. John Bollinger, Deputy 
Executive Director, Paralyzed Veterans of America; Mr. Richard 
Jones, National Legislative Director, AMVETS; Mr. Bobby J. 
Harnage, Sr., National President, American Federation of 
Government Employees; Ms. Ellen M Pitts, R.N., President, VA 
Medical Center, Brockton, MA, Local R1-187, National 
Association of Government Employees; and Ms. Elaine Gerace, 
R.N., Divisional President, VA Medical Center, Syracuse, NY, 
Local 200B, Service Employees International Union.
    On June 20, 2001, the Subcommittee on Health held a hearing 
on mental health, substance use disorders, and homelessness in 
the veteran population, and the Department's policies in 
dealing with these difficult challenges. Those testifying at 
the hearing included: the Honorable Thomas Garthwaite, Under 
Secretary for Health, Department of Veterans Affairs; Mr. Peter 
H. Dougherty, Director, Homeless Veterans Programs, Office of 
Public and Intergovernmental Affairs, Department of Veterans 
Affairs; Dr. Paul Errera, Connecticut VA Health System, Former 
Director, VHA Mental Health and Behavioral Sciences; Dr. 
Laurent S. Lehmann, Chief Consultant, Mental Health and 
Behavioral Sciences Services, Department of Veterans Affairs; 
Dr. Miklos Losonczy, New Jersey VA Health System Co-chair, VA 
Advisory Committee on Serious Mental Illness; Dr. Richard 
McCormick, Ohio VA Health System, Co-chair, VA Advisory 
Committee on Serious Mental Illness; Dr. Bruce Rounsaville, 
Connecticut VA Health System, Professor of Psychiatry, Yale 
University; Ms. Linda Boone, Executive Director, National 
Coalition for Homeless Veterans; Dennis Culhane, Ph.D., 
Associate Professor, University of Pennsylvania, Fred Frese, 
Ph.D., Chair, Veterans Committee, National Alliance for the 
Mentally Ill; Mr. Ralph Ibson, Vice President for Government 
Affairs, National Mental Health Association; Mr. Richard 
Fuller, National Legislative Director, Paralyzed Veterans of 
America; Ms. Joy Ilem, Assistant National Legislative Director, 
Disabled American Veterans; Ms. Linda Spoonster-Schwartz, 
Associate Research Scientist, Yale University School of 
Nursing; and Mr. Richard Weidman, Executive Director, 
Government Relations, Vietnam Veterans of America.
    On September 6, 2001, the Subcommittee on Health, Committee 
on Veterans' Affairs held a legislative hearing on H.R. 2792, 
the Disabled Veterans Service Dog and Health Care Improvement 
Act of 2001. Those testifying at the hearing included: the 
Honorable Lois Capps, U.S. House of Representatives; the 
Honorable Dave Weldon, U.S. House of Representatives; the 
Honorable Roger Wicker, U.S. House of Representatives; Ms. Beth 
Barkley, Vice President, A Rinty for Kids, Inc., (with service 
dogs ``Rin Tin Tin #8'', ``Fearghas'', and ``Gustav''); the 
Honorable Anthony J. Principi, Secretary of Veterans Affairs, 
Department of Veterans Affairs; Dr. Frances Murphy, Deputy 
Under Secretary for Health, Department of Veterans Affairs; Mr. 
Richard Fuller, National Legislative Director, Paralyzed 
Veterans of America; Ms. Joy Ilem, Assistant National 
Legislative Director, Disabled American Veterans; Mr. Thomas H. 
Miller, Executive Director, Blinded Veterans Association; and 
Ms. Jacqueline Garrick, Deputy Director, American Legion; and 
Mr. Richard Jones, National Legislative Director, AMVETS.
    On September 24, 2001, the Subcommittee on Health held a 
hearing in Wichita, Kansas, on health systems and health care 
related issues and concerns. Those testifying at the hearing 
included: Mr. James R. Franklin, Vietnam Veteran, Liberal, 
Kansas; Mr. Olen Mitchell, World War II Veteran, Hutchinson, 
Kansas; Mr. Scott Ratzlaff, Desert Storm Veteran, Colby, 
Kansas; Ms. Tamina Fromme, Vietnam Veteran, Dodge City, Kansas; 
Mr. Kent Hill, Director, VA Medical and Regional Office Center, 
Wichita, Kansas; Dr. L.S. Raju, VA Community Based Outpatient 
Clinic, Liberal, Kansas; Ms. Leann Zimmerman, Nurse 
Practitioner, VA Community Based Outpatient Clinic, Hays, 
Kansas; Dr. Peter Almenoff, VISN 15 Network Medical Director, 
VA Heartland Network, Kansas City, Missouri.
    Through these hearings, meetings and through other 
mechanisms of oversight, the Subcommittee and full Committee on 
Veterans Affairs considered the following bills: H.R. 2792; 
H.R. 1136; H.R. 1435; and H.R. 936, dealing with a variety of 
matters pertaining to health care, specialized resources and 
human services offered to the Nation's veterans by the 
Department of Veterans Affairs and other agencies of the 
federal government.
    On October 4, 2001, the Subcommittee on Health met and 
unanimously ordered H.R. 2792 reported favorably to the full 
Committee with an amendment in the nature of a substitute.

    On October 10, 2001, the full Committee met and ordered 
H.R. 2792 reported favorably to the House with an amendment in 
the nature of a substitute by voice vote.

                      Summary of the Reported Bill

    H.R. 2792, as amended, would:

    1. LAuthorize service dogs be provided by VA to a veteran 
suffering from spinal cord injuries or dysfunction, other 
diseases causing physical immobility, hearing loss or other 
types of disabilities susceptible to improvement or enhanced 
functioning in activities of daily living through employment of 
a service dog. A veteran would be required to be enrolled in VA 
care as a prerequisite to eligibility for a service dog. 
Service dogs would be provided in accordance with existing 
priorities for all VA health care enrollment.

    2. LStrengthen the mandate for VA to maintain capacity in 
specialized medical programs for veterans by requiring each 
Veterans Integrated Service Network to maintain a proportional 
share of national capacity in certain specialized health care 
programs for veterans (those with serious mental illness, 
including substance use disorders, spinal cord, brain injured 
and blinded veterans; veterans who need prosthetics and sensory 
aids); and extend capacity reporting requirement for 3 years.

    3. LModify VA's system of determining nonservice-connected 
veterans' ``ability to pay'' for VA health care services by 
introducing (generally as an upper income bound compared to 
current income limits) the ``Low Income Housing Index'' 
employed by the Department of Housing and Urban Development 
(HUD). This index is used to determine family income thresholds 
for HUD housing assistance eligibility. This index is adjusted 
for all Standard Metropolitan Statistical Areas (SMSA), and is 
updated periodically by HUD to reflect economic changes within 
the SMSAs. This change in law would be phased in with no VISN 
experiencing greater than 5 percent change in funding 
allocation than would otherwise occur.

    4. LRequire the Secretary of Veterans Affairs to assess all 
special telephone services made available to veterans, such as 
``help lines'' and ``hotlines.'' The assessment would include 
geographical coverage, availability, utilization, 
effectiveness, management, coordination, staffing, cost, and a 
survey of veterans to measure effectiveness of these telephone 
services and future needs. A report to Congress would be 
required within 1 year of enactment.

    5. LExtend expiring authority for VA to collect proceeds 
from veterans' health insurance policies for care provided for 
non-service connected care.

    6. LEstablish a VA chiropractic services program, to be 
implemented in a 5-year period; authorize VA to employ 
chiropractors as federal employees and obtain chiropractic 
services through contracts; create a VA advisory committee on 
chiropractic health care; authorize chiropractors to function 
as VA primary care providers; authorize appointment of a 
director of chiropractic service reporting to the Secretary, 
with the same authority as other service directors in the VA 
health care system.

    7. LEstablish a National Commission on VA nursing, 
consisting of 12 members appointed by the Secretary; their 
review would include legislative and organizational policy 
changes to enhance recruitment and retention of nurses and 
assess future of the nursing profession in the VA; a report to 
Congress would be required within 2 years of establishment.

                       Background and Discussion

    Authorization for Service Dogs for Disabled Veterans.--The 
Department of Veterans Affairs (VA) is authorized to provide 
blinded veterans with guide dogs to aid them in adjusting to 
blindness and severe vision impairments. Many veterans who are 
enrolled in VA health care are suffering from mobility or 
hearing impairments would benefit greatly from use of service 
dogs, but VA is not authorized to furnish assistive animals 
under current law. A service dog would not only provide a 
companion to the disabled veteran, but could also reduce the 
amount of time and resources needed from an aide for activities 
of daily living.
    With proper training, service dogs can perform tasks such 
as opening and closing doors, turning switches on and off, 
assisting a person from a sitting or lying position, providing 
help in and out of bathtubs or showers, picking up and 
retrieving objects, pulling wheelchairs, or helping a person 
with clothing, including helping to dress and undress. The 
benefits service dogs provide are well known and documented in 
medical journals, studies, and personal testimony. The 
testimony received at the Subcommittee's hearing on September 
6, 2001, supported extending this special benefit to enrolled 
veterans.
    The reported bill expands the authority of the Department 
of Veterans Affairs to provide service dogs to veterans, but in 
accordance with current enrollment priorities. In the 
Committee's view, section 101 would strengthen VA benefits to 
hearing impaired and mobility-impaired veterans to improve the 
quality of life.

    Maintenance of Capacity in Specialized Programs.--Congress 
provided a mandate in legislation (Public Law 104-262) that 
requires VA to maintain nationwide capacity to provide for 
specialized treatment and rehabilitative needs for veterans, 
including those with amputations, spinal cord injury or 
dysfunction, traumatic brain injury, and severe, chronic, 
disabling mental illnesses, including schizophrenia, PTSD and 
substance-use disorders. To validate VA's compliance with 
capacity maintenance, the legislation requires an annual report 
to Congress. The emphasis in the law is clearly on VA 
maintaining specialized capacity, including appropriate VA 
inpatient care and VA intensive-case management--approaches 
that a number of studies have shown to be more effective than 
primary care in the treatment of persons with mental illnesses. 
There is little question that primary care costs less, but its 
effectiveness as a substitute for these traditional VA programs 
for its most vulnerable patients is still uncertain.
    The Committee has been made well aware that there have been 
recurring problems with VA's observance of the capacity law, 
and the most recent report submitted to the Congress by VA 
confirms their continued existence. According to the report, 
the three largest problems center on: 1) lack of confidence in 
VA's own data; 2) inability to identify VA patients receiving 
care in specialized programs, and 3) lack of outcome measures 
to assess program effectiveness. Several years of these 
reports, all claiming the same kinds of continuing data and 
definitional difficulties, causes the Committee to question 
whether VA is in full compliance with the law. The report 
requirement was designed to ensure that Congress has a fair and 
frank depiction of resource investment in VA's mental health, 
drug abuse, blind rehabilitation, and other specialized care 
programs. The Congress recognizes that optimal treatment 
modalities may change over time, but has directed the Secretary 
to ensure that overall capacity for service delivery is not 
lost.
    The Committee's bill would strengthen the requirement for 
VA to maintain capacity by applying the requirement both 
nationally and to the 22 Veterans Health Administration patient 
care networks. The Committee bill would also add new reporting 
requirements to better elucidate for Congress VA's changing 
capacity to provide and maintain care systems for the most 
seriously mentally ill and substance-addicted patients; 
veterans who need prosthetics and sensory aids services; and 
programs in spinal cord injury and blind rehabilitation, among 
others.

    Threshold for Means Test to Reflect Cost of Living.--
Section 103 of the Committee bill would modify the ``means 
test'' employed by the Department of Veterans Affairs to 
determine eligible veterans' enrollment priority, as set forth 
in section 1722 of title 38, United States Code. Enrollment 
priority is important because veterans in lower categories 
(i.e., VA priority levels 6 and 7) whose incomes are above 
current means test levels (in 2001, $23,688 per year for a 
single veteran) are required to make co-payments for their 
care. These copayments must be made for hospitalization (the 
current Medicare first-day deductible of $792 plus $10.00 per 
day); nursing home care (one-half the Medicare hospitalization 
first-day deductible for each 90 days plus $5.00 per day); 
outpatient services ($50.80 per day); and pharmaceutical 
services ($2.00 for each 30-day supply of medication). The 
Secretary of Veterans Affairs is authorized to limit veterans' 
enrollment and access to VA health services because of 
budgetary limitations.
    VA's national income threshold is insensitive to regional 
variations in cost of living, cost of health care, cost of 
housing, employment factors, rural or urban influences and 
other matters that determine or heavily affect an individual 
veterans' ability to pay. One method of ensuring equity for 
veterans in access to VA health care would be adjustment of the 
national means test by locality, to more accurately reflect 
well-recognized differences in geographic cost-of-living.
    The HUD low-income limits are established under Section 3 
of the U.S. Housing Act of 1937, as amended. HUD income limits 
are currently used to determine eligibility in 22 separate 
federal programs, including a number of tax incentive programs. 
Although HUD acknowledges that its income estimates are not 
completely reliable for every metropolitan area, it regularly 
corrects estimating errors and assesses data sources for the 
most reliable and up-to-date information. The limits are a 
viable method to aid VA in establishing a proxy for a veteran's 
ability to pay on a regional basis. HUD defines ``low income'' 
families as those with incomes that do not exceed 80 percent of 
the median family incomes for the areas in which they reside. 
Limits are established for 2,680 geographic areas, including 
Metropolitan Statistical Areas (MSAs), Primary Metropolitan 
Statistical Areas (PMSAs) and counties.
    Using the HUD low-income limits in place of VA's current 
means test threshold would mean that all veterans residing in a 
defined locality would have a means test threshold adjusted to 
reflect the cost-of-living determined for that particular 
defined area. This new threshold would be more indicative of 
the veteran's ability to defray the cost of care. Furthermore, 
to ensure that no veterans would be dislodged from Category 5 
into Category 7 and thus compelled to make copayments, when 
these new thresholds were implemented, the bill would maintain 
the existing national income threshold as the lowest figure for 
any means test variation, even if the HUD formula were to 
determine in a given instance that the low-income rate for a 
particular area is actually below the VA's national income 
threshold. This would provide assurance that existing category 
5 veterans would not be affected by the application of the HUD 
limits, but some current ``higher income'' veterans whose 
incomes now place them above the margin would move to category 
5 as a consequence of the new means test system.
    Use of the HUD low-income rates to augment VA's current, 
single means test standard would create a more realistic, 
equitable system to reflect cost-of-living variations from one 
locality to another. This new methodology would affirm 
Congressional intent that VA provide care for poor veterans on 
a high-priority basis.
    To address concerns about the potential effect of using the 
alternative HUD low-income limits on VA's internal allocation 
system, the bill includes a provision that no VHA geographic 
service area's allocation could be increased or decreased by 
more than 5 percent in any year due to the application of the 
HUD limits in determination of a veterans' priority of 
enrollment in VA care.

    Assessment and Report on Special Telephone Services.--The 
Committee is concerned about the status of the variety of 
telephone services VA may be making available to veterans in 
both its health care and benefits programs, and in particular, 
any telephone ``hotlines'' or ``help lines'' focused on 
providing information to veterans who may be in crisis or who 
are homeless and in need of urgent services or information. 
Section 104 directs the Secretary to study the availability, 
utilization, effectiveness, and cost of these VA services. The 
study would include a survey of veterans who have used such 
services in the past as to whether they are satisfied with the 
current availability of services and the demand for additional 
services. The study should assess VA capabilities to offer 
local referrals for the provision of emergency shelter and food 
for homeless veterans, VA substance use disorder rehabilitation 
sources, opportunities for employment and training, and small 
business assistance programs, if appropriate.

    The report of the Secretary would be required within 180 
days of enactment of the Committee's bill.

    Extension of Collections Authorities.--VA is authorized to 
retain third-party recoveries and other co-payments from the 
provision of health-care services to certain non-service 
connected veterans and to use those resources to provide 
additional care to veterans. This authority allows VA necessary 
flexibility to enhance funding through user fees that Congress 
would otherwise have to provide through appropriations.
    Since this fund was restructured in the Balanced Budget Act 
of 1997, enabling VA to retain and expend funds thus collected, 
the Department has in fact retained $139.5 million in fiscal 
year 1997, $560.1 million in fiscal year 1998, $573.6 million 
in fiscal year 1999, and $563.8 million in fiscal year 2000. 
The Department estimates that it will retain $675 million in 
fiscal year 2001. Extending the authority to collect third-
party insurance proceeds for care provided to service-connected 
veterans for non-service connected conditions to September 30, 
2007, will allow VA to continue providing health care to many 
enrolled veterans.

    Chiropractic Services in the Department of Veterans' 
Affairs.--Title II of the bill establishes a new chiropractic 
health benefit within the Department of Veterans Affairs. The 
Committee believes the Department is long overdue in 
establishing a firm, comprehensive policy to provide a full 
scope of chiropractic service to veterans. Over the last 106 
years, chiropractic health science has become the third-largest 
physician-level health care profession in the world. Doctors of 
chiropractic are licensed in all 50 states as health care 
service providers.
    The Committee bill would establish chiropractic services 
immediately in the Department, but would provide a 5-year 
phase-in period to enable the health care facilities of the 
Department to fully implement the national program. A minimum 
of 30 VA medical centers would be required to make chiropractic 
services available to veterans annually, beginning in 2002, so 
that all VA medical centers will be providing chiropractic 
services within 5 years of enactment of the Committee bill. The 
Committee bill specifically directs VA to activate a 
chiropractic service for veterans through both direct 
employment of doctors of chiropractic and by obtaining their 
services for veterans through available contracting mechanisms.
    The Committee bill also requires the establishment of a 
national office of chiropractic, headed by an appointed 
Director, who shall be appointed within 90 days of enactment, 
and who reports to the Secretary of Veterans Affairs. The 
establishment of a chiropractic service in the Department will 
be guided by an advisory committee on chiropractic, whose 
members shall included chiropractors, human resources 
specialists and others whose expertise will facilitate optimal 
establishment of chiropractic within the health benefits 
available to veterans.

    National Commission on VA Nursing.--Title III of H.R. 2792 
would establish a national VA commission on nursing. The 
Committee, through meetings and other interactions with VA 
officials, reports from associations representing the nursing 
and allied nursing professions, reports and hearings from other 
committees of the House and Senate, and from reports and 
testimony of the General Accounting Office, is aware of a 
conundrum concerning the present state of nursing in the 
Department of Veterans Affairs, as well as the future of 
nursing in the United States. To better assist the Committee 
and Congress in dealing with necessary actions to sustain a 
dependable source of nursing staff for the VA health care 
system, the bill authorizes the establishment of an independent 
national nursing commission. This body is to include 
representatives of trade associations, professional 
associations representing VA nurses, unions and academic 
nursing. It should reflect the full spectrum of nursing 
professionals within the Department.
    The commission will be required to assemble and meet as an 
independent activity, assess the current and projected supply 
and demand of nursing professionals, review any relevant 
reports or assessments from available literature, consult as 
necessary with academic institutions, the Secretary, elements 
of the Veterans Health Administration and other health care 
providers, and report to Congress within 2 years its findings, 
conclusions and recommendations. The report would be required 
to be reviewed by the Secretary of Veterans Affairs, and the 
Secretary would be required to report VA's views and 
recommendations on the national commission's report within 60 
days of its receipt.

                      Section-By-Section Analysis

Section 1. Short Title
    Section 1(a) declares the title of this Act to be the 
``Disabled Veterans Service Dog and Health Care Improvement Act 
of 2001.'' Section 1(b) sets forth the table of contents, 
including Title I, Veterans Health Care Improvement; Title II, 
Chiropractic Services Program; and Title III, National 
Commission on VA Nursing.

               TITLE I - VETERANS HEALTH CARE IMPROVEMENT

Section 101. Authorization for Secretary of Veterans Affairs to provide 
        Service Dogs for Disabled Veterans
    Section 101 would amend the existing law to expand the 
Department's authority to provide guide dogs to blind veterans. 
Current law limits the provision of guide dogs to blind 
veterans who are entitled to disability compensation. The bill 
removes that language, and provides the benefit to all enrolled 
veterans. This provision would also authorize the Department to 
provide service dogs to veterans who are hearing impaired or 
who have spinal cord injury or dysfunction or other chronic 
impairment that substantially limits mobility. The provision 
states that these services are to be provided in accordance 
with the priority specified in section 1705.

    Existing statutory authority allows the Department to pay 
for certain travel and incidental expenses incurred by veterans 
while adjusting to guide dogs. Section 101 would amend the 
language to allow these expenses for all guide dogs or service 
dogs covered by this legislation.
Section 102. Maintaining Capacity
    Section 102 addresses the Department's statutory obligation 
to maintain the capacity to provide for the specialized 
treatment and rehabilitative needs of disabled veterans, 
including veterans with spinal cord dysfunction, blindness, 
amputations, and mental illness. Congress imposed this 
requirement with the enactment of the Veterans' Health Care 
Eligibility Reform Act of 1996, Public Law 104-262. The law 
requires that capacity be maintained at its 1996 level. The 
bill would amend the statute to require that the Department 
maintain this capacity not only in the Department as a whole, 
but within each geographic service area, or VISN, of the 
Veterans Health Administration.

    Section 102 would amend 38 U.S.C. Sec. 1706(b) to provide 
detail on how VA is to measure the capacity to provide 
specialized treatment and rehabilitative needs of disabled 
veterans within distinct programs or facilities. It states that 
the distinct programs or facilities must be measured for 
seriously ill veterans in different ways for different types of 
services provided. All of the data must be provided by 
geographic service area and totaled nationally.

    For mental health intensive community-based care, capacity 
is to be measured by the number of discrete intensive care 
teams constituted to provide such intensive services to 
seriously mentally ill veterans and the number of veterans 
provided such care. For opioid substitution programs and for 
traumatic brain injury, capacity is to be measured by the 
number of patients treated annually and the amounts expended. 
For dual-diagnosis patients, capacity is to be measured by the 
number treated annually and the amounts expended. For substance 
abuse programs, capacity is to be measured by four different 
measures. First, it is measured by the number of substance-use 
disorder beds employed (hospital, nursing home or other 
designated beds) and the average bed occupancy of such beds. 
The second measure is the percentage of unique patients 
admitted directly to substance abuse outpatient care during the 
fiscal year who had two or more additional visits to 
specialized substance abuse outpatient care within 30 days of 
their first visit, with a comparison from 1996 until the date 
of the report. The third measure is the percentage of unique 
inpatients with substance abuse diagnoses treated during the 
fiscal year who had one or more specialized substance abuse 
clinic visits within three days of their index discharge, with 
a comparison from 1996 until the date of the report. Finally, 
the fourth measure of capacity for substance abuse programs is 
the percentage of unique outpatients seen in a facility or 
service network during the fiscal year who had one or more 
specialized substance abuse clinic visits, with a comparison 
from 1996 until the date of the report. For mental health 
programs, capacity is to be measured by the number and type of 
staff that are available at each facility to provide 
specialized mental health treatment, including satellite 
clinics, outpatient programs, and community-based clinics, with 
a trend line comparison from 1996 to the date of the report. 
The measurement should indicate the number of clinics providing 
mental health care, the number and type of mental health staff 
at each such clinic, and the type of mental health programs at 
each such clinic. For spinal cord injury specialized centers 
and for blind rehabilitation specialized centers, capacity is 
to be measured by the number of beds in the centers, and by the 
number of staff assigned on a full-time basis to provide care 
in such centers. For prosthetics and sensory aids, capacity is 
to be measured by the annual amount expended.

    The Department's obligation to report on compliance with 
this requirement is extended through 2004. Section 102 adds a 
new requirement that the Inspector General of the Department 
certify or comment on the accuracy of each such capacity 
report.
Section 103.--Means Test Threshold
    Section 103 would amend 38 U.S.C. Sec. 1722 to establish 
new geographically based income thresholds for determining a 
non-service-connected veteran's priority for receiving VA care 
and whether the veteran must agree to pay copayments in order 
to receive that care. It would utilize low-income limits 
developed by the Department of Housing and Urban Development 
(HUD) to establish these alternative income thresholds. The 
income threshold for the veteran would be either the specific 
income threshold set forth on a national basis, or the low-
income limits set by HUD--whichever is greater.

    Section 103 also includes a limitation on resource 
allocation by capping the amount of money that can be 
reallocated because of this provision. Within the amount 
appropriated to the Department for medical care for each of 
fiscal years 2002 through 2006, the amount that would otherwise 
be allocated by the Secretary to any geographic service region 
of the Veterans Health Administration in accordance with the 
established resource allocation procedures of the Department 
may not be increased or decreased by more than 5 percent 
because of this new provision.
Section 104.--Assessment and Report on Special Telephone Services for 
        Veterans
    Section 104 is a provision that requires the Secretary to 
assess all special telephone services for veterans (such as 
help lines and hotlines) provided by the Department. The 
assessment will include the geographic coverage, availability, 
utilization, effectiveness, management, coordination, staffing, 
and cost of those services. The assessment must also include a 
survey of veterans to measure satisfaction with the current 
special telephone services, as well as the demand for 
additional services. The Secretary shall submit a report to 
Congress on the assessment no later than one year after the 
enactment of this bill. The report must include recommendations 
regarding any needed improvement to the services, and 
recommendations regarding contracting for such services.
Section 105.--Recodification of Bereavement Counseling and other 
        Authorities
    Section 105 would amend chapter 17 of title 38, United 
States Code to consolidate and reorganize without substantive 
change, in a new subchapter, all of the various legal 
authorities under which VA provides services to non-veterans. 
It would reorganize 38 U.S.C. Sec. 1701 by transferring one 
provision (pertaining to sensori-neural aids) to section 1707.

    Section 105 would create a new Subchapter VIII in Chapter 
17 to incorporate provisions concerning counseling and 
bereavement counseling services for family members. The new 
subchapter would include a section on VA's provision of 
counseling, training and mental health services for family 
members of veterans who are receiving certain service-connected 
and non-service-connected treatment.

    A new section 1782 provides counseling, training, and 
mental health services for immediate family members. Subsection 
(a) of section 1782 states that in the case of a veteran who is 
receiving treatment for a service-connected disability pursuant 
to paragraph (1) or (2) of section 1710(a), the Secretary shall 
provide to individuals described in subsection (c) such 
consultation, professional counseling, training, and mental 
health services as are necessary in connection with that 
treatment. Subsection (b) of section 1782 states that in the 
case of a veteran who is eligible to receive treatment for a 
non-service-connected disability under certain conditions, the 
Secretary may, in the discretion of the Secretary, provide to 
individuals described in subsection (c) such consultation, 
professional counseling, training, and mental health services 
as are necessary in connection with that treatment if those 
services were initiated during the veteran's hospitalization; 
and if the continued provision of those services on an 
outpatient basis is essential to permit the discharge of the 
veteran from the hospital. Subsection (c) of section 1782 
identifies eligible individuals who may be provided services as 
members of the immediate family or the legal guardian of a 
veteran; or the individual in whose household such veteran 
certifies an intention to live. Subsection (d) allows certain 
travel and transportation expenses of eligible individuals.

    Section 105 would also recodify the Secretary's authority 
to provide bereavement counseling following the death of 
certain veterans. Subsection (a) of the new Section 1783 states 
that in the case of an individual who was a recipient of 
services under section 1782 of this title at the time of the 
death of the veteran, the Secretary may provide bereavement 
counseling to that individual in the case of a death that was 
unexpected; or that occurred while the veteran was 
participating in a hospice program (or a similar program) 
conducted by the Secretary. Subsection (b) states that the 
Secretary may provide bereavement counseling to an individual 
who is a member of the immediate family of a member of the 
Armed Forces who dies in the active military, naval, or air 
service in the line of duty and under circumstances not due to 
the person's own misconduct. Subsection (c) states that the 
term 'bereavement counseling' means such counseling services, 
for a limited period, as the Secretary determines to be 
reasonable and necessary to assist an individual with the 
emotional and psychological stress accompanying the death of 
another individual. The counseling described in section 1782 
and 1783 are currently authorized in the definition of 
outpatient medical services.

    Section 105 would place in the new subchapter the current 
dependent health care authorities (transferred from current 
section 1713 to the new section 1781). A new provision in the 
bill provides that a dependent or survivor receiving VA-
sponsored care would also be eligible for the bereavement 
counseling and the other counseling, training and mental health 
services provided to family members under this new subchapter.

    The existing authority to provide hospital care or medical 
services as a humanitarian service in emergency cases would be 
moved to this new subchapter from the current location in 
section 1711(b).

    Section 105 also makes various technical changes to 
accommodate the reorganization. These changes would recodify 
the currently existing provisions, and consolidate and clarify 
the existing statutory authority to provide care to non-
veterans.
Section 106.--Extension of Expiring Collections Authorities
    Section 106 would amend sections 1710(f)(2)(B) and 
1729(a)(2)(E) of title 38, United States Code, to extend VA's 
authority to collect per diem nursing home and hospital co-
payments from certain veterans, and to collect third-party 
payments for the treatment of the nonservice-connected 
disabilities of veterans with service-connected disabilities.

                    TITLE II - CHIROPRACTIC SERVICES

Section 201.--Chiropractic Service Established in the Veterans Health 
        Administration
    Section 201 amends 38 U.S.C. section 7305 to create a new 
position of Director of Chiropractic Service. The Director of 
the service is to be a qualified doctor of chiropractic and is 
responsible to the Secretary for the operation of the 
Chiropractic Service.
Section 202.--Availability of Chiropractic Care to Veterans
    Section 202 requires the Secretary to establish a program 
to provide chiropractic care in all Veterans Affairs medical 
centers. The provision phases in the program by requiring a 
chiropractic service at not less than 30 medical centers by the 
end of fiscal year 2002; at not less than 60 medical centers by 
the end of fiscal year 2003; at not less than 90 medical 
centers by the end of fiscal year 2004; and not less than 120 
medical centers by the end of fiscal year 2005; and at all 
medical centers by the end of fiscal year 2006. The Secretary 
shall designate the initial 30 medical centers not later that 
60 days after the date of enactment of this provision. The 
Secretary must select medical centers to reflect geographic 
diversity, facilities of various size and capabilities, and the 
range of services within medical centers in the Department 
health care system.
Section 203.--Chiropractic Providers
    Section 203 states that the program under section 202 shall 
be carried out through personal service contracts and with 
appointments of licensed chiropractors for delivery of 
chiropractic services at Department of Veterans Affairs medical 
centers.
Section 204--Scope of Services; Enrollment
    Section 204 stipulates that the chiropractic services 
provided under section 202 shall include, at a minimum, care 
for neuro-musculoskeletal conditions. Veterans enrolled for 
care under section 1705 of title 38, United States Code, may 
choose a chiropractor as the veteran's primary care provider. 
Veterans with a primary care provider other than a chiropractor 
may be referred to chiropractic services for neuro-
musculoskeletal conditions by another primary care provider.
Section 205.--Training and Information
    Section 205 requires the Secretary to provide training and 
materials relating to chiropractic services to members of 
Department health care providers assigned to primary care teams 
in order to familiarize those providers with the benefits of 
appropriate use of chiropractic services. During the phase-in 
period described in section 202, the Secretary is required to 
provide materials relating to chiropractic services to medical 
centers and other health care facilities of the Department that 
are not participating in the program in order to ensure that 
health care providers at non-participating facilities are aware 
of chiropractic care as a future referral source.
Section 206.--Advisory Committee
    Section 206 directs the Secretary to establish an advisory 
committee to review the implementation of the chiropractic 
program in Department medical facilities. In appointing members 
to the advisory committee, that Secretary shall include members 
of the chiropractic profession; persons who are experts in 
human resources appointments in the Federal service; persons 
with expertise in academic matters; persons with knowledge of 
credentialing and the granting of professional privileging to 
health care practitioners; and other persons determined 
necessary by the Secretary and the functional needs of the 
advisory committee in establishing the chiropractic health 
program. The advisory committee shall provide advice to the 
Secretary on the granting of professional privileges for 
chiropractors at Department medical centers; the scope of 
practice of chiropractors at Department medical centers; 
training materials; and such other matters as are determined 
appropriate by the Secretary.
Section 207.--Implementation Report
    No later than 18 months after the date of the enactment of 
this bill, the Secretary shall submit to the Committees on 
Veterans Affairs of the Senate and House of Representatives a 
report on the implementation of this title.

             TITLE III - NATIONAL COMMISSION ON VA NURSING

Section 301.--Establishment of Commission
    Section 301 establishes a commission known as the 
``National Commission on VA Nursing.'' The commission is to be 
composed of 12 members. Eleven members shall be appointed by 
the Secretary. They include three recognized representatives of 
employees, including nurses, of the Department; three 
representatives of professional associations of nurses of the 
Department or similar organizations affiliated with the 
Department's health care practitioners; two representatives of 
trade associations representing the nursing profession; two 
nurses from nursing schools affiliated with the Department; and 
one representative of veterans. The twelfth member, the Nurse 
Executive of the Department, is be an ex officio member of the 
commission. The Secretary shall designate one of the members to 
serve as chairman of the Commission. Members shall be appointed 
for the life of the Commission. Any vacancy will be filled in 
the same manner as the original appointment. The appointments 
are to be made no later that 60 days after enactment of this 
Act. The Commission shall convene its first meeting not later 
than 60 days after the date as of which all members of the 
Commission have been appointed.
Section 302.--Duties of the Commission
    Section 302 describes the duties of the Commission. The 
Commission is to assess legislative and organizational policy 
changes to enhance the recruitment and retention of nurses by 
the Department, and the future of the nursing profession within 
the Department, and recommend legislative and organization 
policy changes to enhance the recruitment and retention of 
nurses in the Department.
Section 303.--Reports
    Section 303 states that the Commission shall submit to 
Congress and the Secretary a report on its findings and 
conclusions. The report is due no later than two years after 
the date of the first meeting of the Commission. Not later than 
60 days after the date of the Commission's report, the 
Secretary shall submit a report to Congress. The Secretary's 
report to Congress shall provide the Secretary's views on the 
Commission's findings and conclusions. It shall explain what 
actions, if any, the Secretary intends to take to implement the 
recommendations of the Commission, and the Secretary's reasons 
for doing so.
Section 304.--Powers
    Section 304 states that the Commission or, at its 
direction, any panel or member of the Commission, may hold 
hearings and take testimony to the extent that the Commission 
or any member considers it advisable to do so. The Commission 
may secure directly from any agency or department information 
that the Commission considers necessary to enable it to carry 
out its responsibilities under this title.
Section 305.--Personnel Matters
    Section 305 states that the members of the Commission shall 
serve on the Commission without pay. While performing services 
for the Commission away from their homes or regular places of 
business, Commission members shall be allowed travel expenses, 
including per diem in lieu of subsistence, at rates authorized 
for employees of agencies.

    The Secretary may appoint a staff director and such 
additional personnel as may be necessary to enable the 
Commission to perform its duties. The appointment may be made 
without regard to the provisions of title 5, United States 
Code, governing appointments in the competitive service. The 
Secretary may fix the pay of the staff director and the 
personnel without regard to the provisions of chapter 51 and 
subchapter III of chapter 53 of title 5, United States Code, 
relating to the classification of positions and General 
Schedule pay rates. The pay fixed for the staff director may 
not exceed the rate payable for level V of the Executive 
Schedule under section 5316 of title 5, United States Code, and 
the rate of pay for other personnel may note exceed the maximum 
rate payable for grade GS-15 of the General Schedule.

    Upon the request of the Secretary, the head of any Federal 
department or agency may detail, on a nonreimbursable basis, 
any personnel of that department or agency to the commission.
Section 306.--Termination of the Commission
    The Commission shall terminate 90 days after the date of 
the submission of its report.

                    Performance Goals and Objectives

    The reported bill would authorize health care benefits 
enhancements for veterans and VA program improvements, and 
require certain assessments and reports to Congress. It would 
extend VA's specialized medical care capacity reporting for 
three years and specify detailed reporting requirements. It 
would require a VA assessment and report within one year of 
enactment on VA's specialized telephone services for veterans. 
It would establish a VA chiropractic services program over a 
five year period and require a report on implementation within 
18 months after enactment. It also would establish a National 
Commission on VA Nursing that would be required to assess 
recruitment and retention of nurses, and assess the future of 
the nursing profession in the VA, with a report required within 
two years of establishment. These programs, assessments and 
reports are subject to the Committee's regular oversight.

              STATEMENT OF THE VIEWS OF THE ADMINISTRATION

  Statement of Anthony J. Principi, Secretary, Department of Veterans 
 Affairs, On Proposed Legislation, before the Subcommittee on Health, 
Committee on Veterans' Affairs, United States House of Representatives, 
                           September 6, 2001

    Mr. Chairman and Members of the Subcommittee:

    I am pleased to be here this morning to comment on H. R. 2792, the 
``Disabled Veterans Service Dog and Health Care Improvement Act of 
2001.'' If enacted, this bill would authorize the Secretary of Veterans 
Affairs to make service dogs available to disabled veterans and to make 
various other changes in health care benefits provided by the 
Department of Veterans Affairs. This morning I would like to briefly 
summarize the various sections of the bill, and provide VA's views of 
these sections.

Section 2--Service Dogs

    The bill would amend the existing law to expand VA's authority to 
provide guide dogs to blind veterans. Current law limits the provision 
of guide dogs to blind veterans who are entitled to disability 
compensation. The bill removes that limitation and would authorize VA 
to provide service dogs to veterans who are hearing impaired or who 
have spinal cord injury or dysfunction or other chronic impairment that 
substantially limits mobility. Service dogs can assist a disabled 
person in his or her daily life and can assist that person during 
medical emergencies. They can be trained in many tasks, including, but 
not limited to, pulling a wheelchair, carrying a back-pack, opening and 
closing doors, helping with dressing and undressing, retrieving dropped 
items, picking up the telephone, and hitting a distress button on the 
telephone. Some service dogs can perceive when the disabled individual 
is in distress and can find help. Dogs can also assist the hearing 
impaired by alerting them to doorbells, ringing phones, smoke 
detectors, crying babies, and emergency sirens on vehicles.
    The existing statutory authority allows VA to pay for certain 
travel and incidental expenses incurred by veterans while adjusting to 
seeing-eye or guide dogs. The bill would amend the language to allow VA 
to pay these expenses for all guide dogs or service dogs covered by 
this legislation.
    Mr. Chairman, the benefit of guide dogs for the blind is well 
known, and we support having authority to also provide service dogs for 
veterans who are hearing impaired and who have spinal cord injuries or 
other chronic impairments, and to pay for certain costs associated with 
adjusting to the dogs. However, we believe the provision of guide dogs 
and service dogs should continue to be limited to veterans who are 
entitled to service-connected compensation. If this provision becomes 
law, we would promulgate prescription criteria and guidelines to insure 
that we provide dogs only to those veterans who can most benefit from 
them.

    Section 3--Maintaining Capacity

    Section 3 of the bill addresses VA's statutory obligation to 
maintain the capacity to provide for the specialized treatment and 
rehabilitative needs of disabled veterans, including veterans with 
spinal cord dysfunction, blindness, amputations, and mental illness. As 
you know, Mr. Chairman, Congress imposed this requirement with the 
enactment of the Veterans' Health Care Eligibility Reform Act of 1996, 
Public Law 104-262. The law requires that capacity be maintained at its 
1996 level. The bill would amend the statute to require that VA 
maintain this capacity not only in the Department as a whole, but 
within each geographic service area, or VISN, of the Veterans Health 
Administration. Additionally, the bill adds new language stating that 
the capacity to provide specialized treatment and rehabilitative needs 
of disabled veterans within distinct programs or facilities must be 
measured by the annual amount spent for the care of such veterans in 
dedicated programs that provide these services through specialized 
staff. VA's obligation to report on compliance with this requirement is 
extended through 2004.
    Mr. Chairman, we do not object to the provision which would require 
maintenance of capacity within each geographic service area. This 
provision is consistent with our desire to ensure that there is 
equality of access to quality specialized services. However, in order 
to accomplish this, we propose that the capacity be based on the 
enrolled veteran population in each geographic service area. In 
addition, we oppose the provision that would measure capacity by 
dollars expended. The cost of care is not an adequate measure, by 
itself, to demonstrate whether VA is maintaining the quality of and 
access to specialized care. Cost alone is not a valid and reliable 
measure of capacity. Limiting the capacity report to measurement of 
dollars expended will neither indicate nor ensure that VA is upholding 
its commitment to these high priority patients. Capacity must be 
measured by the actual number of patients receiving care in the 
specialized programs, the quality of the care provided, patients' 
health outcomes, and patients' access to that care, including waiting 
times for appointments.
    Furthermore, Mr. Chairman, it is currently not possible to know 
whether the amount of care and the dollars expended in 1996 were 
optimal for measuring capacity in the targeted special programs. The 
care provided in 1996 provides only a snapshot of what was then a 
rapidly changing VA health care delivery system. It is not clear that 
1996 can or should serve as a baseline out to 2004, as proposed by this 
bill.
    We understand that the staff of the Senate Veterans Affairs' 
Committee is developing a different position with regard to VA's 
obligation to maintain capacity. We would be happy to work with both 
the Senate and House staff on this issue to develop amendments that 
would allow us to provide the best possible information on VA's 
capacity for treating veterans with specialized treatment and 
rehabilitative needs.

Section 4--Means Test Threshold

    Mr. Chairman, section 4 would establish new geographically based 
income thresholds for VA to use in determining a non-service-connected 
veteran's priority for receiving VA care and whether the veteran must 
agree to pay copayments in order to receive that care. This would be an 
alternative to the threshold presently set by statute. As you know, Mr. 
Chairman, the law now requires that most veterans enroll in our health 
care system in order to receive care. Enrollees are placed in an 
enrollment priority group that is based, in many instances, on their 
level of income and net worth. Although we currently provide care to 
veterans in all enrollment priority groups, if there were medical care 
funding shortages in the future, it might be necessary to determine 
that those non-service connected veterans with relatively higher 
incomes must be disenrolled, meaning they could no longer receive VA 
care. Current law establishes, on a National basis, the specific income 
thresholds that we must use to determine the priority group of any 
given enrollee with no service-connected disability or other special 
status. We place higher income veterans in priority group 7 and lower 
income veterans in priority group 5.
    This provision would establish a new, geographically based income 
threshold that VA could use for placing veterans in priority groups. It 
would utilize a poverty index developed by the Department of Housing 
and Urban Development (HUD) to establish this alternative income 
threshold. The income threshold for the veteran would be either the 
specific income thresholds set forth on a National basis, or the amount 
set forth by the HUD index--whichever is greater. In most instances, 
this new income threshold would be greater than the current statutory 
income threshold used for determining whether a veteran should be 
placed in priority group 5.
    We are very interested in examining the use of geographically based 
income thresholds for placing nonservice-connected veterans in 
different enrollment priority groups. We recognize that the cost of 
living in large urban areas is much greater than in many more rural 
parts of the country. What might be considered a reasonably high income 
in some locations may be totally inadequate in other higher cost 
locations. However, at this time we cannot support the specific 
methodology proposed in this bill. There are many poverty indices that 
are established in various ways, and there are serious issues about 
what these indexes really measure. We believe further study is needed 
to determine the most appropriate method for tackling this problem.
    We are currently reviewing the various poverty indices in order to 
identify the best way to proceed. We expect to have this work completed 
in September. We would be happy to work with staff members from the 
Congressional Committees to consider the alternative indices and other 
changes to ensure that the means test for VA health care is equitable 
and affords reasonable access to VA health care services.

Section 5--Pilot Program for Coordination of Ambulatory Community 
Hospital Care

    Section 5 is a provision that is essentially the same as a measure 
passed by the House of Representatives last year despite the strong 
opposition of VA. The provision would establish a pilot program 
entitled ``Coordination of Hospital Benefits Program.'' The program 
would authorize special benefits for some veterans receiving care in a 
VA outpatient clinic who need hospital care. Under the program, 
veterans with third-party health plan coverage (including Medicare and 
Medicaid) may receive different hospital care benefits from those 
without third-party coverage. Veterans with no third-party coverage of 
any sort would be offered hospital care in the nearest VA hospital with 
the ability to provide care. That facility may not be particularly 
close to where the veteran resides. On the other hand, veterans with 
third-party coverage would be offered a choice. First, they could 
choose to use the nearest VA hospital. Alternatively, they could choose 
to use a private facility, with VA paying for certain costs, such as 
the health plan deductible, coinsurance, or the cost of inpatient care 
or medical services that are not covered by the health plan.
    The pilot program would be open only to veterans to whom VA 
``shall'' furnish care, essentially all enrollees except those in 
enrollment priority group 7. To be eligible, the veterans must also 
meet certain additional conditions. Specifically, participants must be 
enrolled to receive medical services from a VA outpatient clinic, 
require hospital care for a non service-connected condition that could 
not be provided by a clinic operated by VA and elect to receive such 
care under the non-VA health care plan. The program would be limited to 
veterans who have received VA care during the 24-month period preceding 
the veteran's application to enroll in the pilot program. In 
designating the geographic areas in which to establish the program, VA 
must ensure that at least 70 percent of the veterans who reside in a 
designated area reside at least two hours' driving distance from the 
closest VA medical center.
    The provision also limits expenditures for the pilot program to $50 
million in any fiscal year. Moreover, funds from the proposal must come 
from the Medical Care Collections Fund and no funds may be used that 
are otherwise available for treating veterans requiring specialized 
care.
    We strongly oppose this proposed pilot program. The proposal would 
create a disparate eligibility status based on a veteran's third-party 
coverage and priority group. We are also concerned that the program 
would undermine our ability to maintain existing services, especially 
specialized medical services and programs for veterans. Limiting care 
to general medical and surgical services would mean that veterans 
needing specialty health services would still need to come to VA for 
care. The health care covered by this proposal would be inpatient care 
for non-service-connected conditions. A veteran currently receiving 
care for a service-connected condition, for which VA does not or cannot 
contract locally, would also be forced to receive care in multiple 
locations. These types of disparities are not consistent with our goals 
and strategies of improving access, convenience, and timeliness of VA 
health care to all eligible veterans.
    Funding for the program would be drawn from the Medical Care 
Collections Fund (MCCF). The Fund's collections, which are available to 
VA facilities to support current VA-provided medical care, would be 
reduced by this provision. MCCF collections supplement the dollars 
appropriated for medical care and are a necessary component of VHA's 
budget. Use of MCCF funds for this pilot would negatively impact care 
for veterans not enrolled in the pilot. In addition, this provision may 
affect the Medicare Trust Fund.
    The bill would also require that not less that 15 percent of the 
veterans participating in the pilot program are veterans who do not 
have a health-care plan. This requirement is confusing, as the purpose 
of the pilot program is to allow VA to pay for the out of pocket costs 
that veterans incur through non-VA health plans. It is not clear how VA 
would achieve this goal for veterans who have no other health care 
plan. The 15 percent limit might be a false floor or ceiling, depending 
on the actual number of veterans at a particular pilot site that have 
no insurance. This could affect the potential outcomes of the pilot. If 
there are a large number of insured veterans, the out-of-pocket expense 
covered by VA would be less that the expense of covering the full care 
provided to an uninsured veteran. This could make the pilot look 
financially successful. On the other hand, if the number of non-insured 
veterans is high, the expenses could make the pilot program less 
financially viable.
    The bill also defines the term ``health-care plan'' by cross-
reference to section 1725(f). The bill states that the term ``health-
care plan'' has the meaning given that term in section 1725(f)(3). 
However, the referenced section does not define the term health plan or 
health-care plan, but rather defines the term ``third party'' for 
purposes of reimbursement for emergency treatment. We believe that this 
reference might be an error, and that the intended reference was to 
section 1725(f)(2). Section 1725(f)(2) defines the term ``health-plan 
contract'' which includes, among other things, Medicare and Medicaid 
plans.

Section 6-- Pilot Program for Contract Hospitalization and Fee Basis 
Ambulatory Care

    This section of the bill would require the Secretary to conduct a 
three-year pilot program in which veterans receiving fee basis and 
contract hospitalization would be provided such care through a 
contractor who acts as a managed care coordinator. The provision states 
that the program shall be conducted in four selected geographical areas 
that have mature managed care markets. To the extent practicable all 
fee basis and contract hospitalization provided by VA in the selected 
geographical service areas would be provided through the contractor. 
The contractor must be an experienced managed care coordinator with an 
in-place network of credentialed providers. All enrolled veterans in a 
selected geographical service area who are authorized to use non-VA 
care services through fee basis programs of the Department, or who are 
eligible for contract hospitalization, would be automatically enrolled 
for participation in the pilot program. Once approved to receive non-VA 
fee basis care, or when they seek care for a health emergency, 
participants would be given a directory of health care providers from 
which to choose.
    In conducting the pilot program, VA would be required to use 
standards (commercial-industry or, in their absence, Department 
standards) for measuring access, timeliness, patient satisfaction, and 
utilization management. The contractor must establish a toll-free 
telephone system staffed by registered nurses to provide advice and 
health care referral information to veterans enrolled in the pilot 
program on a 24-hour a day, seven-day a week basis, and a veterans 
service telephone line for the provision of information on eligibility, 
enrollment, and provider locations. The program also must provide 
concurrent review, demand management, disease management and health and 
wellness programs.
    Each medical center participating in the program must have a 
primary care manager. The primary care manager at each VA facility 
would be responsible for the coordination and case management of each 
enrolled veteran who is participating in the pilot program to ensure 
that such veterans receive the appropriate care, and that veterans are 
brought back into the VA system for follow-up whenever possible and 
appropriate. The pilot program includes extensive reporting 
requirements by VA, and a mandatory review by the Comptroller General.

          We are interested in a pilot program to examine the costs and 
        benefits of operating our fee basis program in a new manner; 
        however, we are concerned about some of the restrictive 
        requirements in this specific provision. For example, we would 
        like ensure that VA retains clinical control with respect to 
        the type of care that the patient receives, as well as the 
        amount of care authorized. We would also want to ensure that 
        the costs of any contract would be no more than the current 
        cost for the fee basis program in the selected locations. 
        Finally, we believe that it would be appropriate for VA to 
        continue to provide the toll-free telephone system providing 
        information on eligibility, enrollment and provider locations. 
        We would be pleased to work with staff members of the Committee 
        to consider alternative language that would allow VA the 
        flexibility to evaluate alternative delivery systems without 
        some of the limitations and requirements mandated by this 
        provision.

Section 7--Recodification of Bereavement Counseling and other 
Authorities

    Mr. Chairman, section 7 of the bill would consolidate, in a new 
subchapter of title 38, United States Code, all of the various legal 
authorities under which VA provides services to non-veterans. The new 
subchapter would include a section on VA's provision of counseling, 
training and mental health services for family members of veterans who 
are receiving treatment. It would also include a section on bereavement 
counseling following the death of certain veterans. Both types of 
counseling are currently authorized in the definition of outpatient 
medical services. This change will make the authority much clearer.
    The authority under which we provide CHAMPVA benefits, presently 
section 1713 of title 38, would be transferred to this new subchapter. 
A new provision in the bill provides that a dependent or survivor 
receiving CHAMPVA care would also be eligible for the bereavement 
counseling and the other counseling, training and mental health 
services provided to family members under this new subchapter. Finally, 
the existing authority to provide hospital care or medical services as 
a humanitarian service in emergency cases would be moved to this new 
subchapter.
    The proposed changes would recodify the currently existing 
provisions. We support this change, as it would consolidate and clarify 
the existing statutory authority to provide care to non-veterans.

Section 8--Extension of Expiring Collections Authorities

    Mr. Chairman, this final provision would amend title 38 to extend 
VA's authority to collect per diem nursing home and hospital co-
payments from certain veterans, and to collect third-party payments for 
the treatment of the nonservice-connected disabilities of veterans with 
service-connected disabilities. We strongly support and welcome the 
extensions proposed in this section. These collections constitute an 
important and necessary supplement to our annual appropriations.
    Mr. Chairman, this ends my statement. I will be pleased to answer 
any questions you may have.

               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, October 12, 2001.
Hon. Christopher H. Smith
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. 2792, the Disabled 
Veterans Service Dog and Health Care Improvement Act of 2001.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sam 
Papenfuss, who can be reached at 226-2840.

    Sincerely,
                                            Dan L. Crippen,
                                                          Director.

    Enclosure.

               Congressional Budget Office Cost Estimate

 H.R. 2792, Disabled Veterans Service Dog and Health Care Improvement 
 Act of 2001, as ordered reported by the House Committee on Veterans' 
                      Affairs on October 10, 2001

    SUMMARY. H.R. 2792 would provide expanded benefits for some 
veterans and would consolidate several existing provisions of 
law that authorize health care for nonveterans into one chapter 
of Title 38 of the U.S. Code. The bill would direct the 
Department of Veterans Affairs (VA) to calculate the income 
thresholds for determining whether a veteran qualifies for free 
health care on a regional basis rather than using a single 
national level. The bill also would require the VA to provide 
chiropractic care at all VA medical centers by 2006. Finally, 
H.R. 2792 would extend the authority for VA to collect certain 
payments from both veterans and insurance companies.
    H.R. 2792 would authorize funding or modify provisions 
governing discretionary spending for veterans' programs, which 
CBO estimates would result in additional outlays of about $390 
million in 2002 and more than $3 billion over the 2002-2006 
period, assuming appropriation of the necessary amounts. 
Because the bill would not affect direct spending or receipts, 
pay-as-you-go procedures would not apply.
    H.R. 2792 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would impose no costs on state, local, or tribal 
governments.

    ESTIMATED COST TO THE FEDERAL GOVERNMENT. The estimated 
budgetary impact of H.R. 2792 is shown in the following table. 
This estimate assumes the legislation will be enacted near the 
start of calendar year 2002, that the necessary funds for 
implementing the bill will be provided for each year, and that 
outlays will follow historical spending patterns for existing 
or similar programs. The costs of this legislation fall within 
budget function 700 (veterans benefits and services).



                                Table 1. Estimated Budgetary Impact of H.R. 2792
----------------------------------------------------------------------------------------------------------------
                                                                 By Fiscal Year, in Millions of Dollars
                                                     -----------------------------------------------------------
                                                        2001      2002      2003      2004      2005      2006
----------------------------------------------------------------------------------------------------------------
Spending Under Current Law
for Veterans' Medical Care
  EstimatedAuthorization Level \1\..................    20,863    21,866    22,110    22,839    23,547    24,285
  Estimated Outlays.................................    20,418    21,501    22,020    22,613    23,298    24,028

Proposed Changes
  Income Threshold
    EstimatedAuthorization Level....................         0       420       550       680       700       710
    Estimated Outlays...............................         0       380       530       660       690       700

  Chiropractic Care
    EstimatedAuthorization Level....................         0        15        34        61        89       133
    Estimated Outlays...............................         0        13        32        57        86       128

  Offsetting Collections
    EstimatedAuthorization Level....................         0         0         0         0         0         0
    Estimated Outlays...............................         0         0       -85       -25       -15       -16

  Total Changes
    EstimatedAuthorization Level....................         0       435       584       741       789       843
    Estimated Outlays...............................         0       393       477       692       761       812

Spending Under S. 1188
  Estimated Authorization Level.....................    20,863    22,301    22,694    23,580    24,336    25,128
  Estimated Outlays.................................    20,418    21,894    22,497    23,305    24,059    24,840
----------------------------------------------------------------------------------------------------------------
\1\ The 2001 level is the estimated net amount appropriated for that year. The current-law amounts for the 2002-
  2006 period assume that appropriations remain at the 2001 level, with adjustments for inflation.


    Income Threshold. Under current law, VA furnishes free 
medical care to veterans who meet certain eligibility 
requirements-one of which is an income threshold. Any veteran 
who is eligible for Medicaid, who receives a VA pension, or who 
has an income below a statutory level (currently $23,688 for a 
veteran without a dependent) can receive free health care. 
Under the bill, veterans eligible for low-income housing also 
would qualify for free medical care. In general, the Department 
of Housing and Urban Development sets eligibility for low-
income housing at 80 percent of each county's median income 
with adjustments for cost-of-living.
    This provision would affect both veterans who currently 
receive medical care from VA and those who do not currently use 
VA health care services. CBO estimates that the total cost 
associated with expanding eligibility for free VA medical care 
would be $380 million in 2002 and about $3 billion over the 
2002-2006 period, assuming appropriation of the estimated 
amounts.

    Current VA Health Care Users.--Using data from VA and the 
Current Population Survey, CBO estimates that under this 
provision about 1.4 million veterans would become eligible for 
free health care. CBO estimates that this number includes more 
than 250,000 veterans who currently use VA medical facilities 
but are not presently eligible for free health care. Under the 
bill, these veterans would no longer need to make copayments 
when receiving health care benefits. Because individuals use 
more health care services when they do not face any out-of-
pocket costs, the cost of providing medical care would increase 
for those users who become eligible for free health care. Using 
data from VA and from published research, CBO estimates that 
those veterans receiving free health care would cost VA about 
$700 more per person in 2002. Using that information and 
adjusting for inflation, CBO estimates that providing free 
health care to veterans currently using VA would cost about 
$170 million in 2002 and almost $1 billion over the 2002-2006 
period, assuming appropriation of the estimated amounts.
    Because the veterans discussed above would be eligible for 
free health care, VA also would lose the copayments that these 
veterans make when receiving care. CBO estimates that the lost 
copayments would total about $40 million over the 2002-2006 
period.

    New VA Health Care Users.--CBO also estimates that some 
veterans who do not currently use VA medical facilities because 
of the requirement to make copayments would do so once they 
became eligible for free health care. Currently, only about 20 
percent of veterans eligible for free health care based on 
income actually use VA medical facilities. CBO expects that an 
even lower percentage of those who would become eligible for 
free health care would end up using VA medical facilities, 
because some of those veterans have access to health care from 
other sources. CBO estimates that eventually about 100,000 
newly eligible veterans would begin using VA medical care at a 
cost of more than $4,000 per person. CBO estimates that 
providing free health care to these veterans would cost $210 
million in 2002 and about $2 billion over the 2002-2006 period, 
assuming appropriation of the estimated amounts.

    Chiropractic Care. Under current policy, VA does not employ 
chiropractors and VA spends less than $500,000 a year for 
veterans who see chiropractors outside of a VA hospital. Title 
II of H.R. 2792 would require that VA provide chiropractic care 
to veterans at all of its medical centers. Under the bill, VA 
would have to provide chiropractic services in at least 30 
medical centers by the end of fiscal year 2002 and in all 172 
medical centers by the end of fiscal year 2006. In addition to 
seeking chiropractic care for specific problems, veterans also 
would be able to choose a chiropractor as their primary health 
care provider, instead of a medical doctor.
    In order to provide chiropractic care at its medical 
centers, VA would need to physically modify each medical center 
and purchase basic chiropractic equipment. Extrapolating from a 
Department of Defense (DoD) report that analyzed the costs of a 
pilot program that provided chiropractic care at military 
hospitals, CBO estimates that the start-up costs for providing 
chiropractic care at VA medical centers would average a little 
more than $100,000 per center. Additionally, based on the DoD 
experience and given the scope of potential chiropractic usage, 
CBO estimates that each medical center would need to provide a 
minimum of four chiropractors along with the necessary support 
personnel. CBO estimates that it would cost almost $800,000 in 
2002 to staff and operate a chiropractic center. Accounting for 
both the gradual implementation under the bill and a two-year 
adjustment period for each medical center, CBO estimates that 
implementing title II would cost $13 million in 2002 and $316 
million over the 2002-2006 period, assuming appropriation of 
the estimated amounts.

    Offsetting Collections. Under current law VA has the 
authority to bill third-party insurance for veterans with a 
service-connected disability who receive care that is not 
related to the service-connected disability. VA also has the 
authority to collect a $10 daily payment for hospital stays and 
a $5 daily payment for nursing home stays from all veterans who 
do not qualify for free healthcare. Both of these authorities 
expire on September 30, 2002. These collections are currently 
deposited into the Medical Care Collections Fund (MCCF). Under 
current law, amounts deposited to the MCCF are considered to be 
offsets to discretionary appropriations and spending from the 
MCCF is subject to annual appropriations. Section 107 would 
extend these authorities through September 30, 2007.
    Based on information from VA, CBO estimates that in 2001 VA 
will collect more than $190 million from third-party insurance 
companies and about $3 million from the daily payments. 
Accounting for inflation and increased usage, CBO estimates 
that implementing this provision would increase offsetting 
collections deposited to the MCCF by $213 million in 2003 and 
$907 million over the 2003-2006 period.
    Subject to annual appropriations, VA can spend the money in 
the MCCF to provide medical care for veterans. CBO estimates 
that implementing section 107 would increase discretionary 
spending on medical care for veterans by $128 million in 2003 
and $766 million over the 2003-2006 period, assuming 
appropriation of the collected amounts. Because CBO assumes 
that VA will spend the collections, the estimated budget 
authority for collections and spending offset each other 
exactly, while the outlays lag behind spending.

    Service Dogs. H.R. 2792 would authorize VA to provide 
service dogs to veterans with certain disabilities. According 
to information from VA, the department does not actually 
provide the service dogs but serves as an intermediary between 
eligible veterans and the nonprofit organizations that train 
the service dogs. Because these organizations typically pay for 
the travel and training costs associated with a veteran 
receiving a guide dog, CBO estimates that this provision would 
have no budgetary impact.

    PAY-AS-YOU-GO CONSIDERATIONS: None

    INTERGOVERNMENTAL AND PRIVATE-SECTOR IMPACT .H.R. 2792 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would impose no costs on state, local, or 
tribal governments.

    PREVIOUS CBO ESTIMATES. On September 10, 2001, CBO prepared 
an estimate for S. 1188, the Department of Veterans Affairs 
Medical Programs Enhancement Act of 2001, as ordered reported 
by the Senate Committee on Veterans' Affairs on August 2, 2001. 
The provision relating to determining income thresholds for 
free medical care is the same in both bills. H.R. 2792 also 
includes a requirement for chiropractic care and extends the 
authority for VA to collect certain payments from veterans and 
insurance companies, while S. 1188 does not. S. 1188, in turn, 
provides increased benefits to VA employees which H.R. 2792 
does not.

    ESTIMATE PREPARED BY:

        Federal Costs: Sam Papenfuss.
        Impact on State, Local, and Tribal Governments: Elyse 
        Goldman.
        Impact on the Private Sector: Allison Percy.

    ESTIMATE APPROVED BY:

        Robert A. Sunshine, Assistant Director for Budget 
        Analysis

                     Statement of Federal Mandates

    The preceding Congressional Budget Office cost estimate 
states that the bill contains no intergovernmental or private 
sector mandates as defined in the Unfunded Mandates Reform Act.

                  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 the bill would only affect certain 
Department of Veterans Affairs programs and benefits 
recipients.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, the reported bill is authorized by Congress' 
power to ``provide for the common Defense and general Welfare 
of the United States.''

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) 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 I--GENERAL PROVISIONS

           *       *       *       *       *       *       *


CHAPTER 1--GENERAL

           *       *       *       *       *       *       *


Sec. 103. Special provisions relating to marriages

  (a)  * * *

           *       *       *       *       *       *       *

  (d)(1)  * * *

           *       *       *       *       *       *       *

  (5) Paragraphs (2) and (3) apply with respect to benefits 
under the following provisions of this title:
          (A)  * * *
          (B) Section [1713] 1781, relating to medical care for 
        survivors and dependents of certain veterans.

           *       *       *       *       *       *       *


PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


                          subchapter i--general

Sec.
1701.    Definitions.
     * * * * * * *
[1707.    Restriction on use of funds for assisted suicide, euthanasia, 
          or mercy killing.]
1707.    Limitations.
     * * * * * * *

 subchapter ii--hospital, nursing home or domiciliary care and medical 
                                treatment

     * * * * * * *
[1713.    Medical care for survivors and dependents of certain veterans.
[1714.    Fitting and training in use of prosthetic appliances; seeing-
          eye dogs.]
1714.    Fitting and training in use of prosthetic appliances; guide 
          dogs; service dogs.
     * * * * * * *

       subchapter viii--health care of persons other than veterans

1781.    Medical care for survivors and dependents of certain veterans.
1782.    Counseling, training, and mental health services for immediate 
          family members.
1783.    Bereavement counseling.
1784.    Humanitarian care.

                         SUBCHAPTER I--GENERAL

Sec. 1701. Definitions

  For the purposes of this chapter--
  (1)  * * *

           *       *       *       *       *       *       *

  (5) The term ``hospital care'' includes--
          (A)  * * *
          (B) such mental health services, consultation, 
        professional counseling, and training for the members 
        of the immediate family or legal guardian of a veteran, 
        or the individual in whose household such veteran 
        certifies an intention to live, as may be essential to 
        the effective treatment and rehabilitation of a veteran 
        or dependent or survivor of a veteran receiving care 
        under the last sentence of section [1713(b)] 1781(b) of 
        this title; and
          (C)(i) medical services rendered in the course of the 
        hospitalization of a dependent or survivor of a veteran 
        receiving care under the last sentence of section 
        [1713(b)] 1781(b) of this title, and (ii) travel and 
        incidental expenses for such dependent or survivor 
        under the terms and conditions set forth in section 111 
        of this title.
  (6) The term ``medical services'' includes, in addition to 
medical examination, treatment, and rehabilitative [services--] 
services, the following:
          [(A)(i) surgical services, dental services and 
        appliances as described in sections 1710 and 1712 of 
        this title, optometric and podiatric services, 
        preventive health services, and (in the case of a 
        person otherwise receiving care or services under this 
        chapter) wheelchairs, artificial limbs, trusses, and 
        similar appliances, special clothing made necessary by 
        the wearing of prosthetic appliances, and such other 
        supplies or services as the Secretary determines to be 
        reasonable and necessary, except that the Secretary may 
        not furnish sensori-neural aids other than in 
        accordance with guidelines which the Secretary shall 
        prescribe, and (ii) travel and incidental expenses 
        pursuant to the provisions of section 111 of this 
        title; and
          [(B)(i) such consultation, professional counseling, 
        training, and mental health services as are necessary 
        in connection with the treatment--
                  [(I) of the service-connected disability of a 
                veteran pursuant to paragraph (1) or (2) of 
                section 1710(a) of this title, and
                  [(II) in the discretion of the Secretary, of 
                the non-service-connected disability of a 
                veteran eligible for treatment under paragraph 
                (1), (2) or (3) of section 1710(a) of this 
                title where such services were initiated during 
                the veteran's hospitalization and the provision 
                of such services on an outpatient basis is 
                essential to permit the discharge of the 
                veteran from the hospital,

        [for the members of the immediate family or legal 
        guardian of a veteran, or the individual in whose 
        household such veteran certifies an intention to live, 
        as may be essential to the effective treatment and 
        rehabilitation of the veteran (including, under the 
        terms and conditions set forth in section 111 of this 
        title, travel and incidental expenses of such family 
        member or individual in the case of a veteran who is 
        receiving care for a service-connected disability, or 
        in the case of a dependent or survivor of a veteran 
        receiving care under the last sentence of section 
        1713(b) of this title); and
          [(ii) in the case of an individual who was a 
        recipient of services under subclause (i) of this 
        clause at the time of--
                  [(I) the unexpected death of the veteran; or
                  [(II) the death of the veteran while the 
                veteran was participating in a hospice program 
                (or a similar program) conducted by the 
                Secretary,

        [such counseling services, for a limited period, as the 
        Secretary determines to be reasonable and necessary to 
        assist such individual with the emotional and 
        psychological stress accompanying the veteran's death.]
          (A) Surgical services.
          (B) Dental services and appliances as described in 
        sections 1710 and 1712 of this title.
          (C) Optometric and podiatric services.
          (D) Preventive health services.
          (E) In the case of a person otherwise receiving care 
        or services under this chapter--
                  (i) wheelchairs, artificial limbs, trusses, 
                and similar appliances;
                  (ii) special clothing made necessary by the 
                wearing of prosthetic appliances; and
                  (iii) such other supplies or services as the 
                Secretary determines to be reasonable and 
                necessary.
          (F) Travel and incidental expenses pursuant to 
        section 111 of this title.

           *       *       *       *       *       *       *


Sec. 1706. Management of health care: other requirements

  (a)  * * *
  (b)(1) In managing the provision of hospital care and medical 
services under such section, the Secretary shall ensure that 
the Department (and each geographic service area of the 
Veterans Health Administration) maintains its capacity to 
provide for the specialized treatment and rehabilitative needs 
of disabled veterans (including veterans with spinal cord 
dysfunction, blindness, amputations, and mental illness) within 
distinct programs or facilities of the Department that are 
dedicated to the specialized needs of those veterans in a 
manner that (A) affords those veterans reasonable access to 
care and services for those specialized needs, and (B) ensures 
that overall capacity of the Department (and each geographic 
service area of the Veterans Health Administration) to provide 
such services is not reduced below the capacity of the 
Department, nationwide, to provide those services, as of 
October 9, 1996. The Secretary shall carry out this paragraph 
in consultation with the Advisory Committee on Prosthetics and 
Special Disabilities Programs and the Committee on Care of 
Severely Chronically Mentally Ill Veterans.
  (2) For purposes of paragraph (1), the capacity of the 
Department (and each geographic service area of the Veterans 
Health Administration) to provide for the specialized treatment 
and rehabilitative needs of disabled veterans (including 
veterans with spinal cord dysfunction, traumatic brain injury, 
blindness, prosthetics and sensory aids, and mental illness) 
within distinct programs or facilities shall be measured for 
seriously mentally ill veterans as follows (with all such data 
to be provided by geographic service area and totaled 
nationally):
          (A) For mental health intensive community-based care, 
        the number of discrete intensive care teams constituted 
        to provide such intensive services to seriously 
        mentally ill veterans and the number of veterans 
        provided such care.
          (B) For opioid substitution programs and for 
        traumatic brain injury, the number of patients treated 
        annually and the amounts expended.
          (C) For dual-diagnosis patients, the number treated 
        annually and the amounts expended.
          (D) For substance abuse programs--
                  (i) the number of substance-use disorder beds 
                (whether hospital, nursing home, or other 
                designated beds) employed and the average bed 
                occupancy of such beds;
                  (ii) the percentage of unique patients 
                admitted directly to substance abuse outpatient 
                care during the fiscal year who had two or more 
                additional visits to specialized substance 
                abuse outpatient care within 30 days of their 
                first visit, with a comparison from 1996 until 
                the date of the report;
                  (iii) the percentage of unique inpatients 
                with substance abuse diagnoses treated during 
                the fiscal year who had one or more specialized 
                substance abuse clinic visits within three days 
                of their index discharge, with a comparison 
                from 1996 until the date of the report; and
                  (iv) the percentage of unique outpatients 
                seen in a facility or service network during 
                the fiscal year who had one or more specialized 
                substance abuse clinic visits, with a 
                comparison from 1996 until the date of the 
                report.
          (E) For mental health programs, the number and type 
        of staff that are available at each facility to provide 
        specialized mental health treatment, including 
        satellite clinics, outpatient programs, and community-
        based outpatient clinics, with a trend line comparison 
        from 1996 to the date of the report.
          (F) The number of such clinics providing mental 
        health care, the number and type of mental health staff 
        at each such clinic, and the type of mental health 
        programs at each such clinic.
  (3) For purposes of paragraph (1), the capacity of the 
Department (and each geographic service area of the Veterans 
Health Administration) to provide for the specialized treatment 
and rehabilitative needs of disabled veterans within distinct 
programs or facilities shall be measured for veterans with 
spinal cord dysfunction, traumatic brain injury, blindness, or 
prosthetics and sensory aids as follows (with all such data to 
be provided by geographic service area and totaled nationally):
          (A) For spinal cord injury/dysfunction specialized 
        centers and for blind rehabilitation specialized 
        centers, the number of staffed beds and the number of 
        full-time equivalent employees assigned to provide care 
        at such centers.
          (B) For prosthetics and sensory aids, the annual 
        amount expended.
  [(2)] (4) Not later than [April 1, 1999, April 1, 2000, and 
April 1, 2001] April 1 of each year through 2004, the Secretary 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report on the Secretary's 
compliance, by facility and by service-network, with the 
requirements of this subsection. The accuracy of each such 
report shall be certified by, or otherwise commented upon by, 
the Inspector General of the Department.
  [(3)] (5)(A) To ensure compliance with paragraph (1), the 
Under Secretary for Health shall prescribe objective standards 
of job performance for employees in positions described in 
subparagraph (B) with respect to the job performance of those 
employees in carrying out the requirements of paragraph (1). 
Those job performance standards shall include measures of 
workload, allocation of resources, and quality-of-care 
indicators.

           *       *       *       *       *       *       *


[Sec. 1707. Restriction on use of funds for assisted suicide, 
                    euthanasia, or mercy killing]

Sec. 1707. Limitations

  (a) Funds appropriated to carry out this chapter may not be 
used for purposes that are inconsistent with the Assisted 
Suicide Funding Restriction Act of 1997.
  (b) The Secretary may furnish sensori-neural aids only in 
accordance with guidelines prescribed by the Secretary.

           *       *       *       *       *       *       *


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

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

  (a)  * * *

           *       *       *       *       *       *       *

  (f)(1)  * * *
  (2) A veteran who is furnished hospital care or nursing home 
care under this section and who is required under paragraph (1) 
of this subsection to agree to pay an amount to the United 
States in order to be furnished such care shall be liable to 
the United States for an amount equal to--
          (A)  * * *
          (B) before September 30, [2002] 2007, an amount equal 
        to $10 for every day the veteran receives hospital care 
        and $5 for every day the veteran receives nursing home 
        care.

           *       *       *       *       *       *       *


Sec. 1711. Care during examinations and in emergencies

  (a) The Secretary may furnish hospital care incident to 
physical examinations where such examinations are necessary in 
carrying out the provisions of other laws administered by the 
Secretary.
  [(b) The Secretary may furnish hospital care or medical 
services as a humanitarian service in emergency cases, but the 
Secretary shall charge for such care at rates prescribed by the 
Secretary.]

           *       *       *       *       *       *       *


Sec. 1712A. Eligibility for readjustment counseling and related mental 
                    health services

  (a)  * * *
  (b)(1) If, on the basis of the assessment furnished under 
subsection (a) of this section, a physician or psychologist 
employed by the Department (or, in areas where no such 
physician or psychologist is available, a physician or 
psychologist carrying out such function under a contract or fee 
arrangement with the Secretary) determines that the provision 
of mental health services to such veteran is necessary to 
facilitate the successful readjustment of the veteran to 
civilian life, such veteran shall, within the limits of 
Department facilities, be furnished such services on an 
outpatient basis. For the purposes of furnishing such mental 
health services, the counseling furnished under subsection (a) 
of this section shall be considered to have been furnished by 
the Department as a part of hospital care. Any hospital care 
and other medical services considered necessary on the basis of 
the assessment furnished under subsection (a) of this section 
shall be furnished only in accordance with the eligibility 
criteria otherwise set forth in this chapter (including the 
eligibility criteria set forth in section [1711(b)] 1784 of 
this title).
  (2) Mental health services furnished under paragraph (1) of 
this subsection may, if determined to be essential to the 
effective treatment and readjustment of the veteran, include 
such consultation, counseling, training, services, and expenses 
as are described in [section 1701(6)(B)] sections 1782 and 1783 
of this title.

           *       *       *       *       *       *       *


[Sec. 1714. Fitting and training in use of prosthetic appliances; 
                    seeing-eye dogs]

Sec. 1714. Fitting and training in use of prosthetic appliances; guide 
                    dogs; service dogs

  (a)  * * *
  (b) The Secretary may provide [seeing-eye or] guide dogs 
trained for the aid of the blind to veterans [who are entitled 
to disability compensation, and may pay travel and incidental 
expenses (under the terms and conditions set forth in section 
111 of this title) to and from their homes and incurred in 
becoming adjusted to such seeing-eye or guide dogs] who are 
enrolled under section 1705 of this title. The Secretary may 
also provide such veterans with mechanical or electronic 
equipment for aiding them in overcoming the [handicap] 
disability of blindness.
  (c) The Secretary may, in accordance with the priority 
specified in section 1705 of this title, provide--
          (1) service dogs trained for the aid of the hearing 
        impaired to veterans who are hearing impaired and are 
        enrolled under section 1705 of this title; and
          (2) service dogs trained for the aid of persons with 
        spinal cord injury or dysfunction or other chronic 
        impairment that substantially limits mobility to 
        veterans with such injury, dysfunction, or impairment 
        who are enrolled under section 1705 of this title.
  (d) In the case of a veteran provided a dog under subsection 
(b) or (c), the Secretary may pay travel and incidental 
expenses for that veteran under the terms and conditions set 
forth in section 111 of this title to and from the veteran's 
home for expenses incurred in becoming adjusted to the dog.

           *       *       *       *       *       *       *


   SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND 
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS

           *       *       *       *       *       *       *


Sec. 1722. Determination of inability to defray necessary expenses; 
                    income thresholds

  (a) For the purposes of section 1710(a)(2)(G) of this title, 
a veteran shall be considered to be unable to defray the 
expenses of necessary care if--
          (1)  * * *

           *       *       *       *       *       *       *

          (3) the veteran's attributable income is not greater 
        than the [amount set forth in] income threshold 
        determined under subsection (b).
  [(b)(1) For purposes of subsection (a)(3), the income 
threshold for the calendar year beginning on January 1, 1990, 
is--
          [(A) $17,240 in the case of a veteran with no 
        dependents; and
          [(B) $20,688 in the case of a veteran with one 
        dependent, plus $1,150 for each additional dependent.
  [(2) For a calendar year beginning after December 31, 1990, 
the amounts in effect for purposes of this subsection shall be 
the amounts in effect for the preceding calendar year as 
adjusted under subsection (c) of this section.]
  (b)(1) For purposes of subsection (a)(3), the income 
threshold applicable to a veteran is the amount determined 
under paragraph (2).
  (2) The amount determined under this paragraph for a veteran 
is the greater of the following:
          (A) For any calendar year after 2000--
                  (i) in the case of a veteran with no 
                dependents, $23,688, as adjusted under 
                subsection (c); or
                  (ii) in the case of a veteran with one or 
                more dependents, $28,429, as so adjusted, plus 
                $1,586, as so adjusted, for each dependent in 
                excess of one.
          (B) The amount in effect under the HUD Low Income 
        Index that is applicable in the area in which the 
        veteran resides.
  (3) For purposes of paragraph (2)(B), the term ``HUD Low 
Income Index'' means the family income ceiling amounts 
determined by the Secretary of Housing and Urban Development 
under section 3(b)(2) of the United States Housing Act of 1937 
(42 U.S.C. 1437a(b)(2)) for purposes of the determination of 
``low-income families'' under that section.
  (c) Effective on January 1 of each year, the amounts in 
effect under subsection (b)(2)(A) of this section shall be 
increased by the percentage by which the maximum rates of 
pension were increased under section 5312(a) of this title 
during the preceding calendar year.

           *       *       *       *       *       *       *


Sec. 1729. Recovery by the United States of the cost of certain care 
                    and services

  (a)(1)  * * *
  (2) Paragraph (1) of this subsection applies to a non-
service-connected disability--
          (A)  * * *

           *       *       *       *       *       *       *

          (E) for which care and services are furnished before 
        October 1, [2002] 2007, under this chapter to a veteran 
        who--
                  (i) has a service-connected disability; and
                  (ii) is entitled to care (or payment of the 
                expenses of care) under a health-plan contract.

           *       *       *       *       *       *       *

  (f) No law of any State or of any political subdivision of a 
State and no provision of any contract or other agreement, 
shall operate to prevent recovery or collection by the United 
States under this section or with respect to care or services 
furnished under section [1711(b)] 1784 of this title.

           *       *       *       *       *       *       *


Sec. 1729A. Department of Veterans Affairs Medical Care Collections 
                    Fund

  (a)  * * *
  (b) Amounts recovered or collected after June 30, 1997, under 
any of the following provisions of law shall be deposited in 
the fund:
          (1)  * * *

           *       *       *       *       *       *       *

          (7) Section 1784 of this title.
          [(7)] (8) Public Law 87-693, popularly known as the 
        ``Federal Medical Care Recovery Act'' (42 U.S.C. 2651 
        et seq.), to the extent that a recovery or collection 
        under that law is based on medical care or services 
        furnished under this chapter.

           *       *       *       *       *       *       *


      SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS

[Sec. 1713.] Sec. 1781. Medical  care  for  survivors  and  dependents  
                    of  certain veterans

  (a)  * * *
  (b) In order to accomplish the purposes of subsection (a) of 
this section, the Secretary shall provide for medical care in 
the same or similar manner and subject to the same or similar 
limitations as medical care is furnished to certain dependents 
and survivors of active duty and retired members of the Armed 
Forces under chapter 55 of title 10 (CHAMPUS), by--
          (1)  * * *

           *       *       *       *       *       *       *

In cases in which Department medical facilities are equipped to 
provide the care and treatment, the Secretary is also 
authorized to carry out such purposes through the use of such 
facilities not being utilized for the care of eligible 
veterans. A dependent or survivor receiving care under the 
preceding sentence shall be eligible for the same medical 
services as a veteran, including services under sections 1782 
and 1783 of this title.

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Sec. 1782. Counseling, training, and mental health services for 
                    immediate family members

  (a) Counseling for Family Members of Veterans Receiving 
Service-Connected Treatment.--In the case of a veteran who is 
receiving treatment for a service-connected disability pursuant 
to paragraph (1) or (2) of section 1710(a) of this title, the 
Secretary shall provide to individuals described in subsection 
(c) such consultation, professional counseling, training, and 
mental health services as are necessary in connection with that 
treatment.
  (b) Counseling for Family Members of Veterans Receiving Non-
Service-Connected Treatment.--In the case of a veteran who is 
eligible to receive treatment for a non-service-connected 
disability under the conditions described in paragraph (1), 
(2), or (3) of section 1710(a) of this title, the Secretary 
may, in the discretion of the Secretary, provide to individuals 
described in subsection (c) such consultation, professional 
counseling, training, and mental health services as are 
necessary in connection with that treatment if--
          (1) those services were initiated during the 
        veteran's hospitalization; and
          (2) the continued provision of those services on an 
        outpatient basis is essential to permit the discharge 
        of the veteran from the hospital.
  (c) Eligible Individuals.--Individuals who may be provided 
services under this subsection are--
          (1) the members of the immediate family or the legal 
        guardian of a veteran; or
          (2) the individual in whose household such veteran 
        certifies an intention to live.
  (d) Travel and Transportation Authorized.--Services provided 
under subsections (a) and (b) may include, under the terms and 
conditions set forth in section 111 of this title, travel and 
incidental expenses of individuals described in subsection (c) 
in the case of--
          (1) a veteran who is receiving care for a service-
        connected disability; and
          (2) a dependent or survivor receiving care under the 
        last sentence of section 1783(b) of this title.

Sec. 1783. Bereavement counseling

  (a) Deaths of Veterans.--In the case of an individual who was 
a recipient of services under section 1782 of this title at the 
time of the death of the veteran, the Secretary may provide 
bereavement counseling to that individual in the case of a 
death--
          (1) that was unexpected; or
          (2) that occurred while the veteran was participating 
        in a hospice program (or a similar program) conducted 
        by the Secretary.
  (b) Deaths In Active Service.--The Secretary may provide 
bereavement counseling to an individual who is a member of the 
immediate family of a member of the Armed Forces who dies in 
the active military, naval, or air service in the line of duty 
and under circumstances not due to the person's own misconduct.
  (c) Bereavement Counseling Defined.--For purposes of this 
section, the term ``bereavement counseling'' means such 
counseling services, for a limited period, as the Secretary 
determines to be reasonable and necessary to assist an 
individual with the emotional and psychological stress 
accompanying the death of another individual.

Sec. 1784. Humanitarian care

  The Secretary may furnish hospital care or medical services 
as a humanitarian service in emergency cases, but the Secretary 
shall charge for such care and services at rates prescribed by 
the Secretary.

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PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


Sec. 7305. Divisions of Veterans Health Administration

  The Veterans Health Administration shall include the 
following:
          (1)  * * *

           *       *       *       *       *       *       *

          (7) A Chiropractic Service.
          [(7)] (8) Such other professional and auxiliary 
        services as the Secretary may find to be necessary to 
        carry out the functions of the Administration.

Sec. 7306. Office of the Under Secretary for Health

  (a) The Office of the Under Secretary for Health shall 
consist of the following:
          (1)  * * *

           *       *       *       *       *       *       *

          (7) A Director of Chiropractic Service, who shall be 
        a qualified doctor of chiropractic and who shall be 
        responsible to the Secretary for the operation of the 
        Chiropractic Service.
          [(7)] (8) Such directors of such other professional 
        or auxiliary services as may be appointed to suit the 
        needs of the Department, who shall be responsible to 
        the Under Secretary for Health for the operation of 
        their respective services.
          [(8)] (9) The Director of the National Center for 
        Preventive Health, who shall be responsible to the 
        Under Secretary for Health for the operation of the 
        Center.
          [(9)] (10) The Advisor on Physician Assistants, who 
        shall be a physician assistant with appropriate 
        experience and who shall advise the Under Secretary for 
        Health on all matters relating to the utilization and 
        employment of physician assistants in the 
        Administration.
          [(10)] (11) Such other personnel as may be authorized 
        by this chapter.

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PART VI--ACQUISITION AND DISPOSITION OF PROPERTY

           *       *       *       *       *       *       *


   CHAPTER 81--ACQUISITION AND OPERATION OF HOSPITAL AND DOMICILIARY 
    FACILITIES; PROCUREMENT AND SUPPLY; ENHANCED-USE LEASES OF REAL 
PROPERTY

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SUBCHAPTER I--ACQUISITION AND OPERATION OF MEDICAL FACILITIES

           *       *       *       *       *       *       *


Sec. 8111. Sharing of Department and Department of Defense health-care 
                    resources

  (a)  * * *

           *       *       *       *       *       *       *

  (g) For the purposes of this section:
          (1)  * * *

           *       *       *       *       *       *       *

          (4) The term ``health-care resource'' includes 
        hospital care, medical services, and rehabilitative 
        services, as those terms are defined in paragraphs (5), 
        (6), and (8), respectively, of section 1701 of this 
        title, services under sections 1782 and 1783 of this 
        title any other health-care service, and any health-
        care support or administrative resource.
          (5) The term ``primary beneficiary'' (A) with respect 
        to the Department means a person who is eligible under 
        this title (other than under [section 1711(b) or 1713] 
        section 1782, 1783, or 1784 or subsection (d) of this 
        section) or any other provision of law for care or 
        services in Department medical facilities, and (B) with 
        respect to the Department of Defense, means a member or 
        former member of the Armed Forces who is eligible for 
        care under section 1074 of title 10.

           *       *       *       *       *       *       *


Sec. 8111A. Furnishing of health-care services to members of the Armed 
                    Forces during a war or national emergency

  (a)(1)  * * *
  (2) For the purposes of this section, the terms ``hospital 
care'', ``nursing home care'', and ``medical services'' have 
the meanings given such terms by sections 1701(5), 101(28), and 
1701(6) of this title, respectively, and the term ``medical 
services'' includes services under sections 1782 and 1783 of 
this title.

           *       *       *       *       *       *       *


     SUBCHAPTER IV--SHARING OF MEDICAL FACILITIES, EQUIPMENT, AND 
INFORMATION

           *       *       *       *       *       *       *


Sec. 8152. Definitions

  For the purposes of this subchapter--
          (1) The term ``health-care resource'' includes 
        hospital care and medical services (as those terms are 
        defined in section 1701 of this title), services under 
        sections 1782 and 1783 of this title, any other health-
        care service, and any health-care support or 
        administrative resource.

           *       *       *       *       *       *       *


CHAPTER 85--DISPOSITION OF DECEASED VETERANS' PERSONAL PROPERTY

           *       *       *       *       *       *       *


SUBCHAPTER I--PROPERTY LEFT ON DEPARTMENT FACILITY

           *       *       *       *       *       *       *


Sec. 8502. Disposition of unclaimed personal property

  (a)  * * *
  (b) If any veteran (admitted as a veteran), or a dependent or 
survivor of a veteran receiving care under [the last sentence 
of section 1713(b)] the penultimate sentence of section 1781(b) 
of this title, upon such person's last admission to, or during 
such person's last period of maintenance in, a Department 
facility, has personal property situated on such facility and 
shall have designated in writing a person (natural or 
corporate) to receive such property when such veteran, 
dependent or survivor dies, the Secretary or employee of the 
Department authorized by the Secretary so to act, may transfer 
possession of such personal property to the person so 
designated. If there exists no person so designated by such 
veteran, dependent, or survivor or if the one so designated 
declines to receive such property, or failed to request such 
property within ninety days after the Department mails to such 
designate a notice of death and of the fact of such 
designation, a description of the property, and an estimate of 
transportation cost, which shall be paid by such designate if 
required under the regulations hereinafter mentioned, or if the 
Secretary declines to transfer possession to such designate, 
possession of such property may in the discretion of the 
Secretary or the Secretary's designated subordinate, be 
transferred to the following persons in the order and manner 
herein specified unless the parties otherwise agree in writing 
delivered to the Department, namely, executor or administrator, 
or if no notice of appointment received, to the spouse, 
children, grandchildren, parents, grandparents, siblings of the 
veteran. If claim is made by two or more such relatives having 
equal priorities, as hereinabove prescribed, or if there are 
conflicting claims the Secretary or the Secretary's designee 
may in such case deliver the property either jointly or 
separately in equal values, to those equally entitled thereto 
or may make delivery as may be agreed upon by those entitled, 
or may in the discretion of the Secretary or the Secretary's 
designee withhold delivery from them and require the 
qualification of an administrator or executor of the veterans' 
estate and thereupon make delivery to such.

           *       *       *       *       *       *       *


        SUBCHAPTER II--DEATH WHILE INMATE OF DEPARTMENT FACILITY

Sec. 8520. Vesting of property left by decedents

  (a) Whenever any veteran (admitted as a veteran), or a 
dependent or survivor of a veteran receiving care under [the 
last sentence of section 1713(b)] the penultimate sentence of 
section 1781(b) of this title, shall die while a member or 
patient in any facility, or any hospital while being furnished 
care or treatment therein by the Department, and shall not 
leave any surviving spouse, next of kin, or heirs entitled, 
under the laws of the decedent's domicile, to the decedent's 
personal property as to which such person dies intestate, all 
such property, including money and chooses in action, owned by 
such person at the time of death and not disposed of by will or 
otherwise, shall immediately vest in and become the property of 
the United States as trustee for the sole use and benefit of 
the General Post Fund (hereinafter in this subchapter referred 
to as the ``Fund''), a trust fund prescribed by section 
1321(a)(45) of title 31.

           *       *       *       *       *       *       *


Sec. 8521. Presumption of contract for disposition of personalty

  The fact of death of a veteran (admitted as such), or a 
dependent or survivor of a veteran receiving care under [the 
last sentence of section 1713(b)] the penultimate sentence of 
section 1781(b) of this title, in a facility or hospital, while 
being furnished care or treatment therein by the Department, 
leaving no spouse, next of kin, or heirs, shall give rise to a 
conclusive presumption of a valid contract for the disposition 
in accordance with this subchapter, but subject to its 
conditions, of all property described in section 8520 of this 
title owned by said decedent at death and as to which such 
person dies intestate.

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