[Senate Report 109-177]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 284
109th Congress                                                   Report
                                 SENATE
 1st Session                                                    109-177

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



 
                   VETERANS' HEALTH CARE ACT OF 2005

                                _______
                                

               November 10, 2005.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                             together with

                             MINORITY VIEWS

                         [To accompany S. 1182]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (S. 1182) to amend 
title 38, United States Code, to improve and enhance the health 
care for veterans, and for other purposes, having considered 
the same, reports favorably thereon with an amendment in the 
nature of a substitute, and recommends that the bill, as 
amended, do pass.

                              Introduction

    On June 9, 2005, Committee Chairman Larry E. Craig 
introduced S. 1182, the Veterans Health Care Act of 2005. The 
bill, as introduced, would have: eliminated copayments for 
hospice care provided to veterans; repealed the requirement 
that the Department of Veterans Affairs (hereinafter ``VA'') 
maintain long-term care bed capacity at 1998 levels; exempted 
former POWs from certain long-term care copayments; authorized 
VA to reimburse insured veterans for emergency care provided at 
non-VA facilities; authorized VA to provide, or pay for, up to 
14 days of care for a newborn child of a female VA patient; 
allowed providers of care to Spina Bifida-afflicted children of 
Vietnam Veterans to balance bill private insurers; permanently 
authorized grant and per diem payments to homeless assistance 
providers; authorized Senior Executive Service compensation to 
VA's national Director, Nursing Services; repealed the ban on 
the use of appropriated funds to conduct cost-comparison 
studies; and required the expansion and improvement of mental 
health services and care for veterans suffering from Post-
traumatic Stress Disorder (hereinafter ``PTSD''). The bill was 
referred to the Committee on Veterans' Affairs.
    On June 7, 2005, Committee Ranking Member, Daniel K. Akaka, 
introduced S. 1177. The bill, as introduced, would have: 
required the VA to adjust funding for mental health services by 
adding inflation to the amount appropriated for such services 
each year starting in 1996; required VA's Under Secretary for 
Health to ensure that 90 percent of VA's community-based 
outpatient clinics (hereinafter ``CBOCs'') have the capacity to 
provide mental health services onsite, via contract referral, 
or through tele-health services; required that each VA primary 
medical facility have the capacity to provide not less than 
five days of inpatient detoxification services; required VA and 
the Department of Defense (hereinafter ``DoD'') to develop a 
standardized pre-separation mental health and sexual trauma 
examination; required VA national guidelines for screening 
primary care patients for mental illness; and required a joint 
working group between VA and DoD to develop methods for 
combating the stigma of mental illness, improving the 
availability of treatment for mental illnesses, and advance 
family education for transition. Committee Members John D. 
Rockefeller, Patty Murray, and Ken Salazar along with Senator 
Richard Durbin were added as cosponsors. The bill was referred 
to the Committee on Veterans' Affairs.
    On June 7, 2005, Senator Barack Obama introduced S. 1180. 
The bill as introduced would have: specified that per diem 
payments to providers of services to homeless veterans should 
be paid at the same as per diem payments to state veterans 
homes; expanded VA's homeless reintegration program; extended 
to 2011 VA's authorization to treat seriously mentally ill 
homeless veterans; made permanent VA's program to transfer 
acquired properties to homelessness service providers; extended 
VA's special needs homeless grant program through 2011; removed 
the 60 day limitation on homeless veterans' dental care 
eligibility; authorized appropriations for VA's technical 
assistance program for applicants for grants to assist homeless 
veterans; extended through 2011 VA's Advisory Committee on 
Homeless Veterans; and required a study by VA on relationships 
between military sexual trauma and homelessness. Committee 
Member Patty Murray along with Senators Richard Durbin, Tim 
Johnson, and Byron Dorgan were added as cosponsors. The bill 
was referred to the Committee on Veterans' Affairs.
    On June 7, 2005, Senator Ken Salazar introduced S. 1189, a 
bill to require the Secretary to develop a strategic plan for 
the provision of long-term care services to veterans and submit 
that plan to Congress. The bill was referred to the Committee 
on Veterans' Affairs.
    On June 7, 2005, Senator Ken Salazar introduced S. 1190, a 
bill that would have: required the Secretary to establish the 
position of Blind Rehabilitation Outpatient Specialist 
(hereinafter ``BROS'') at each VA facility that treats more 
than 150 blind veterans; and authorized $5 million per year 
through 2010 to hire such specialists. Senators Rick Santorum 
and Tim Johnson were added as cosponsors. The bill was referred 
to the Committee on Veterans' Affairs.

                           Committee Hearings

    On June 9, 2005, the Committee held hearings on, among 
other bills: S. 716, S. 1177, S. 1180, S. 1189, and S. 1190. 
Testimony was heard from: The Honorable R. James Nicholson, 
Secretary of Veterans Affairs; The Honorable Jonathan B. 
Perlin, VA's Under Secretary for Health; The Honorable Tim 
McClain, VA's General Counsel; Mr. Donald Mooney, Assistant 
Director, The American Legion; Mr. Dennis Cullinan, Director of 
National Legislative Service, Disabled American Veterans; Mr. 
Adrian Atizado, Assistant National Legislative Director, 
Disabled American Veterans; Mr. Carl Blake, Associate National 
Legislative Director, Paralyzed Veterans of America; and Mr. 
Richard Jones, AMVETS.

                           Committee Meeting

    After carefully reviewing the testimony from the foregoing 
hearing, the Committee met in open session on September 15, 
2005 to consider, among other legislation, S. 1182. The 
Committee voted by voice vote to report favorably S. 1182, as 
amended to incorporate provisions derived from S. 1177, S. 
1180, S. 1189, and S. 1190 as well as an amendment offered by 
Committee Ranking Member Daniel K. Akaka and an amendment from 
Committee Ranking Member Daniel K. Akaka as amended by 
Committee Chairman Larry E. Craig.

               Summary of the Committee Bill as Reported

    S. 1182, as reported (hereinafter the ``Committee bill''), 
consists of changes to current law that would:
          1. Authorize VA to provide up to 14 days of care for 
        newborn children of female veterans who are receiving 
        maternity care furnished by VA (section 2);
          2. Permit private sector providers of care to certain 
        disabled children of Vietnam Veterans to balance bill 
        private insurers for costs of that care not paid by the 
        Secretary (section 3);
          3. Permanently authorize VA's Homeless Grant and Per 
        Diem Program, provide an authorization for $130,000,000 
        in funding for Fiscal Year 2006 and each year 
        thereafter for the program, and re-authorize $1,000,000 
        for each of Fiscal Years 2006--2011 for the Homeless 
        Service Provider Technical Assistance Program (section 
        4);
          4. Authorize VA to employ licensed and credentialed 
        Marriage and Family Therapists and Licensed 
        Professional Mental Health Counselors (section 5);
          5. Authorize VA to pay the Chief Nursing Officer of 
        the department at the Senior Executive Schedule rate of 
        pay (section 6);
          6. Repeal the statutory prohibition on VA spending 
        any funds comparing the costs and efficiency of 
        services provided by government employees with similar 
        services provided in the private sector (section 7);
          7. Authorize $95,000,000 to: expand the number of 
        clinical treatment teams principally dedicated to the 
        treatment ofPTSD in VA facilities; expand and improve 
services available to diagnose and treat substance abuse; expand and 
improve tele-health initiatives to provide better access to mental 
health services in areas of the country that are determined to be 
underserved; improve educational programs for primary care clinicians 
to allow them to better recognize and treat mental illness in veterans; 
expand the number of VA CBOCs capable of providing on-site mental 
health services; and expand the number of Mental Health Intensive Case 
Management Teams to provide services to veterans with Serious Chronic 
Mental Illness (section 8(b));
          8. Require the Under Secretary for Health to take 
        appropriate steps and provide incentives to encourage 
        Regional Directors of the Veterans Health 
        Administration (hereinafter ``VHA'') to: prioritize the 
        provision of mental health services; foster 
        collaborative working environments among clinicians for 
        the provision of mental health services; and conduct 
        mental health consultations during primary care 
        appointments (section 8(c));
          9. Require the Secretary to ensure that VA CBOCs have 
        the capacity to provide, or monitor the provision of, 
        mental health services to veterans through: a contract-
        provider, referral to another facility of the 
        department, or an employee of the department (section 
        8(c));
          10. Require the Secretaries of Defense and VA to 
        enter into a Memorandum of Understanding to ensure that 
        separating service-members receive standardized mental 
        health and sexual trauma assessments and that the two 
        Secretaries share guidelines on how to conduct such 
        assessments (section 8(d));
          11. Establish a Joint Working Group within DoD and VA 
        to analyze the feasibility of initiatives related to: 
        combating stigma associated with service-members who 
        suffer from mental illness; VA making its expertise in 
        the treatment of mental illness more readily available 
        to DoD providers; the education of family members of 
        veterans to assist them in recognizing and coping with 
        readjustment issues; and the seamless transition of 
        service-members who have been diagnosed with mental 
        illness. The Joint Working Group would report on its 
        findings and recommendations not later than June 30, 
        2007 (section 8(d));
          12. Require the Under Secretary for Health to 
        establish system-wide guidelines for screening primary 
        care patients for mental illness and ensure that VA 
        clinicians are trained in the use of such guidelines 
        (section 8(e));
          13. Require the National Center on Post Traumatic 
        Stress Disorder to collaborate with the Secretary of 
        Defense to enhance the clinical skills of military 
        clinicians and promote pre-deployment resilience and 
        post-deployment re-adjustment for veterans of 
        Operations Iraqi Freedom and Enduring Freedom (section 
        8(f));
          14. Permit the exchange of certain health information 
        between VA and DoD (section 9);
          15. Require the expansion of VA's Global War on 
        Terrorism Outreach Program (hereinafter ``GWOT'') and 
        ensure the coordination with appropriate State 
        officials to ensure members of the National Guard 
        receive accurate and timely information about VA's 
        benefits and services (section 10);
          16. Require the Secretary to expand the number of 
        Veterans Readjustment Counseling Service facilities 
        capable of providing services to veterans through tele-
        health linkages and to submit a report on accomplishing 
        this expansion in Fiscal Years 2006 and 2007 (section 
        11);
          17. Require the Secretary to submit a report to the 
        Committees on Veterans' Affairs of the Senate and House 
        of Representatives containing: a description of the 
        mental health data maintained by VA; an analysis as to 
        whether the current method of collecting and storing 
        the data is efficient and effective, and any 
        recommendations for improving the collection, storage, 
        and use of mental health data (section 12);
          18. Require the Secretary to publish a strategic plan 
        for the provision of long-term care services to 
        veterans (section 13);
          19. Require the establishment of Blind Rehabilitation 
        Outpatient Specialist positions at not fewer than fifty 
        facilities of VA that do not currently have such a 
        position (section 14);
          20. Extend through 2006 the requirement that the 
        Secretary submit a report to the Committees on 
        Veterans' Affairs of the Senate and House of 
        Representatives detailing VA's compliance with the 
        specialized services capacity requirement (section 15);
          21. Authorize the Secretary to provide health care 
        services to any veteran who lived in the catchments 
        region of VA's medical center in Gulfport or Biloxi, 
        Mississippi or New Orleans, Louisiana and prohibit the 
        Secretary from collecting any out-of-pocket fees 
        associated with that care until January 31, 2006 
        (section 16);
          22. Allow the Secretary to cover out-of-pockets costs 
        for certain insured veterans when such costs are 
        related to care or treatment provided for an emergency 
        health condition in a non-VA medical facility (section 
        17).

                       Background and Discussion


Section 2. Care for Newborn Children of Women Receiving Maternity Care

    Under current law, VA provides what it believes to be a 
``comprehensive package of health benefits for eligible 
veterans''. Unfortunately, while a veteran's care extends to 
maternity, prenatal, and postnatal care for female veterans, it 
does not permit the provision of, or payment for, any care for 
the newborn child of a female veteran-patient. In other words, 
for the increasing number of female veterans enrolling for VA 
care, the word ``comprehensive'' is not exactly accurate.
    VA has advised the Committee that newborn care is not 
provided because VA is only authorized to provide medical care 
and treatment to veterans. While that is true, it is also a 
disservice to our growing female veteran population and an 
inequity that must be addressed.
    As such, Section 2 of the Committee bill would authorize VA 
to provide, or pay for, up to the first 14 days of care for a 
newborn child of an enrolled, female veteran who delivers her 
baby under VA provided, or VA financed, care. The Committee 
hopes that this limited but important step will help equalize 
the health care benefits package and ensure that it addresses 
the health needs of all veterans.

Section 3. Enhancement of Payer Provisions for Health Care Furnished To 
        Certain Children of Vietnam Veterans

    Under current law, VA provides, or pays for, care for 
certain children of Vietnam veterans. Generally, the payment 
provided by VA is considered payment in full for all services 
provided to the patient. However, it has come to the 
Committee's attention that in rare circumstances it may be 
perfectly appropriate for a care provider to seek reimbursement 
for certain services not otherwise covered by VA. Yet, that 
action is not permitted.
    Section 3 of the Committee bill would designate VA as the 
primary payer for care or services furnished to certain 
children of Vietnam veterans under Title 38 U.S.C. Sec. 1803. 
In so designating VA, the language expressly permits a provider 
(or his agent) who furnishes care to children under this 
program to seek payment for the difference between the amount 
billed and the amount paid by the Secretary from a third party 
payer if the beneficiary has a health care plan that would 
otherwise be responsible for payment.
    The Committee is concerned that express authority for so-
called ``balance billing'' would permit providers to send such 
bills to veterans and their family members. In an effort to 
ensure that does not occur, Section 3 would prohibit the health 
care provider (or the provider's agent) from imposing any 
additional charges on the beneficiary who received the care, or 
the beneficiary's family, for any service or item for which the 
Secretary has made payment under this section.
    In addition, it would limit the total amount a provider 
could receive for furnishing care or services under this 
section from all payer sources to the amount billed to VA. 
Finally, under this section, VA would be required, upon 
request, to provide a third party with information concerning 
claims under this section.
    The Committee intends for this provision to encourage 
providers to work with VA to provide care to this very 
deserving and limited beneficiary population.

Section 4. Improvements to Homeless Veterans Service Providers Programs

    VA operates a Homeless Providers Grant and Per Diem Program 
to fund community agencies providing services to homeless 
veterans. The program aims to help homeless veterans achieve 
residential stability, improve skill levels, and increase 
personal income. Only programs that offer supportive housing or 
service centers for case management, education, crisis 
intervention, and counseling are eligible for funds. In 
addition, VA maintains a small program to assist grant 
applicants in their efforts to submit in a timely fashion all 
of the complex paperwork associated with grants under this 
program.
    Since 1992, when this program was established, VA has been 
able to spur development of increased levels of assistance at 
the local level for homeless veterans living throughout the 
country. Indeed, grantees' programs often fill existing gaps in 
the continuum of VA care and services, thus serving as an 
effective complement to VA's own efforts.
    VA has been successful at leveraging new resources to 
increase the overall supply of transitional housing and other 
effective assistance for homeless veterans throughout the 
country. In fact, the only programmatic shortcoming the 
Committee can identify is that there is more interest on the 
part of participating providers than there is grant money to 
support those efforts.
    As such, Section 4 of the Committee bill would permanently 
authorize the Homeless Grant and Per Diem Program and would 
increase the amount of money authorized for these efforts to 
$130,000,000 in each fiscal year. Further, the grantee 
assistance program would be authorized though 2011 with an 
authorized funding level of $1,000,000 for each fiscal year.

Section 5. Additional Mental Health Providers

    Chapter 74 of Title 38, United States Code authorizes VA to 
hire a wide range of clinical care personnel to provide 
treatment to veterans who seek health services from the 
department. These include, but are not limited to: physicians, 
nurses, psychologists, and, social workers. Because the hiring 
authority is specific to listed medical professionals, VA is 
not permitted to employ any professional not mentioned in 
statute.
    Section 5 would add the professions of ``Marriage and 
Family Therapist'' and ``Licensed Mental Health Counselor'' to 
the list of clinical care providers VA is authorized to hire. 
This section does not require VA to hire any of the new 
clinicians. That decision is best left to the medical 
administrative professionals who operate VA's medical centers 
and CBOCs across the United States.
    Still, the Committee believes that VA officials should have 
as much latitude as possible to hire the clinical professionals 
needed to ensure that the Nation's veterans are provided with 
the right clinical care in the most cost-effective manner. The 
military is already offering Marriage and Family Therapy and 
Licensed Mental Health Counseling to those who are returning 
from overseas. And their programs are receiving good reviews 
from those in the mental health and counseling professions. It 
seems only logical that we extend successful ideas from the 
military experience to our veterans.

Section 6. Pay Comparability for Chief Nursing Officer, Office of 
        Nursing Services

    Section 6 would correct a long-time pay inequity for the 
VA's Chief Nursing Officer. Under current law, this official is 
compensated at an annual salary far below that of all other VA 
service chiefs.
    Section 6 would ensure that any future holder of this 
important position is compensated as a salary level equal to 
the executive responsibilities of the job and equal to his or 
her other service chief counterparts.

Section 7. Repeal of Cost Comparison Studies Prohibition

    Under current law, VA is prohibited from using any 
appropriated funds to carry out a study comparing the costs of 
a service provided by VHA with the same service provided under 
contract through a private sector company. The Committee finds 
continuation of this strict prohibition to be unreasonable.
    America's taxpayers have a right to expect that services 
offered by the Federal Government will be provided in the most 
cost efficient and effective manner possible. In order to 
provide that assurance to taxpayers, VA must be permitted to 
compare its performance with the experience of those conducting 
a similar business in the private sector. Section 7 would allow 
those comparison studies to be undertaken.
    It is important to note that the Committee does not believe 
that comparison studies will inevitably result in the reduction 
of government employment. Nor does the Committee believe that 
an increase in outside contracts is the only outcome possible. 
Rather, the Committee expects that such studies will, in many 
cases, verify the good work being done by VA's employees. In 
cases where positive results are not shown, the Committee 
expects that appropriate changes, both inside and outside of 
VHA, will be implemented.

Section 8. Improvement and Expansion of Mental Health Services

    The Committee has followed closely the studies which 
suggest that a number of men and women serving in Operations 
Enduring Freedom and Iraqi Freedom (hereinafter ``OIF/OEF'') 
will need assistance coping with the mental and physical scars 
war leaves. The Committee held a hearing on March 17, 2005 on 
this topic specifically as it relates to the transition from 
active duty to civilian life.
    In order to ensure that VA can adequately address the 
mental health needs of returning servicemen and women, Section 
8 directs VA to expand and improve programs and services in a 
number of settings.
    Specifically, VA is directed to: expand the number of 
clinical treatment teams principally dedicated to the treatment 
of PTSD; expand treatment and diagnosis services for substance 
abuse; expand tele-health initiatives principally dedicated to 
mental health care in communities located great distances from 
current VA facilities; improve programs that provide education 
in mental health treatment to primary care clinicians; and 
expand the number of community based outpatient clinics capable 
of providing treatment for mental illness.
    The Committee bill would authorize $95 million to be 
dedicated to the implementation of this section. It is the 
Committee's expectation that VA will take this opportunity to 
ensure that the treatment teams and the tools to provide care 
are in place before returning OIF/OEF veterans present 
themselves at VHA facilities.
    Section 8 also requires VA to ensure that it has the 
capacity to provide mental health services at every Community-
Based Outpatient Clinic (CBOC) in the system. As part of this, 
VA is directed to establish performance standards and working 
environments that give appropriate recognition to the 
importance of mental health care. Based on the recommendations 
of VA's Mental Health Strategic Plan, the Committee seeks to 
encourage greater collaboration among primary and mental health 
care providers.
    Additionally, the Committee is concerned that a provision 
of P.L. 107-95 has yet to be properly implemented. The 
provision required VA to have a plan to meet the needs of any 
veteran who entered a VA health care facility seeking mental 
health or substance abuse treatment. As such, Section 8 
reiterates and expands on these requirements, by giving the 
option of using tele-mental health services or contracting.
    Another provision in this section seeks to address the 
transition of returning servicemembers from active duty to 
civilian life. The Committee found that there is currently no 
real collaborative body examining or developing ways for VA and 
the Department of Defense (DOD) to work together to provide for 
a smoother transition out of the military for those that may 
require mental health services. Section 8 establishes a joint 
VA-DODworkgroup that will consist of 7 experts in the fields of 
mental health and readjustment counseling from each Department. The 
workgroup will look at ways to combat stigmas associated with mental 
health, to better educate families of servicemembers on how to deal 
with such issues, and will report to Congress on their findings.
    Section 8 also requires the two Departments to enter into a 
Memorandum of Understanding to ensure that all separating 
servicemembers receive mental health and sexual trauma 
screening. The Committee believes that this will ensure that no 
servicemember who may require treatment or counseling leaves 
their military service without that being discovered, and 
ultimately going untreated.
    As part of the effort to encourage improved coordination of 
mental and primary health care, Section 8 directs the Secretary 
to establish systemwide guidelines for screening primary care 
patients for potential mental health issues or disorders, as 
well as properly training physicians to conduct the screening.
    Finally, Section 8 requires VA's National Center on Post-
Traumatic Stress Disorder (PTSD) to collaborate with the 
Secretary of Defense for the purposes of enabling DOD mental 
health care providers and clinicians to benefit from the unique 
and comprehensive expertise that VA has in the area of PTSD 
diagnosis and treatment. It also directs the two entities to 
develop joint training and protocols to ensure consistency. 
This is yet another facet of this Committee's encouragement of 
the two Departments to collaborate on the mental health 
treatment of servicemembers. The Committee has authorized $2 
million for the purpose of carrying out these requirements.

Section 9. Data Sharing Improvements

    Each year, approximately 200,000 active duty personnel 
leave the Armed Forces and become veterans. A good portion of 
those men and women, approximately 20% by historical standards, 
will seek care or services from the Department of Veterans 
Affairs at some point during their lifetime.
    Unfortunately, due to requirements under the Health 
Insurance Portability and Accountability Act (hereinafter 
``HIPAA''), VA must wait until the veteran actually enrolls for 
care at a VA facility before requesting that DoD send the 
veteran's medical records from active duty service. This small 
delay in records processing seriously hinders the seamless 
transition from active duty to civilian life that many 
servicemembers have come to expect and this Committee demands.
    Section 9 of the Committee bill would ensure that DoD would 
not violate HIPAA regulation by providing VA with access to 
certain medical records of servicemembers while the future VA 
beneficiary is still on active duty. The Committee does not 
intend this action to be a license for VA to request access to 
all active duty records maintained by DoD. Records transfer 
costs, privacy expectations, and basic fairness should guide 
the use of this authority.

Section 10. Expansion of Global War on Terrorism Outreach Program

    On February 3, 2004, then-Secretary of Veterans Affairs, 
Anthony Principi, authorized the Veterans Readjustment 
Counseling Service to hire 50 veterans of OIF/OEF to conduct 
outreach to returning servicemembers and help ensure a smooth 
transition back to civilian life. Since that time, it is 
estimated that the Global War on Terrorism Outreach Program 
(hereinafter ``GWOT'') has served 20,000 combat veterans from 
OIF/OEF.
    On March 17, 2005, the Committee held a hearing on the 
activities of this program and learned of its importance to 
ensuring that our new veterans obtain the benefits to which 
they are entitled and the help and services they and their 
families need. Especially noteworthy is the outreach done to 
our returning Guardsmen and Reservists at reserve and state 
guard facilities.
    Unlike active duty personnel, most members of the Guard and 
Reserves quickly begin rebuilding a private, civilian life 
after returning stateside. GWOT Outreach employees are taking 
their important message directly to Guardsmen and Reservists by 
speaking during weekend drilling periods and at special 
gatherings of Guard and Reserve troops.
    The Committee was truly impressed by the dedication of the 
GWOT staff and the passion with which each of them approached 
this important mission.
    As such, Section 10 directs the Secretary to expand the 
total number of persons employed by the GWOT program and to 
ensure that VA is collaborating to the maximum extent 
practicable with appropriate State officials in their outreach 
efforts.

Section 11. Expansion of Tele-health Services

    As has been noted, the Veterans Readjustment Counseling 
Service has made great efforts to improve its outreach and 
services to combat veterans and their families to ensure a 
smooth and seamless transition from active duty to civilian 
life. However, Readjustment Counseling Centers (hereinafter 
``VET Centers'') are often located only in the most urban 
settings around the country. As such, critically important 
transition assistance can be unavailable to veterans who reside 
in rural communities.
    Section 11 of the Committee bill would direct VA to expand 
the number of VET Center facilities capable of providing health 
services and counseling through tele-health linkages. It is the 
Committee's belief that this important step will allow VA to 
reach more veterans in rural areas and provide more services in 
a setting closer to the veterans' homes.

Section 12. Mental Health Data Sources Report

    VA is one of the largest integrated providers of mental 
health care services in the United States. As a consequence, VA 
collects and maintains extraordinary amounts of data and 
statistics on veterans who seek mental health treatment.
    Unfortunately, the Committee has little information on how 
much data is maintained by VA, where it is held, and at what 
cost. Therefore, Section 12 of the Committee bill requires VA 
to submit a report, not later than 180 days after the date of 
enactment of the Committee bill detailing the information 
needed by the Committee to better monitor VA's data collection 
in this sensitive area.

Section 13. Strategic Plan for Long-Term Care

    In 1999, Congress passed and the President signed Public 
Law 106-117, the Veterans Millennium Health Care and Benefits 
Act of 1999 (hereinafter the ``Millennium Act''). The 
Millennium Act, among other things, required VA to develop a 
program of non-institutional long-term care services and 
mandated that VA maintain the institutional staffing and level 
of extended care services at, or above, the level of staffing 
and services during Fiscal Year 1998. These two actions were 
taken simultaneously because, at the time, some felt that the 
development of a non-institutional care program would cause VA 
to discontinue a large portion of its institutional care 
capacity.
    Since that time, VA has increased the number of veterans it 
treats by nearly two million. Yet, VA reports that it does not 
have a need to maintain the number of nursing home beds it is 
required to maintain under the current law. VA asserts that 
this is because they have paralleled the progress of medicine 
and offered tens-of-thousands of veterans the non-institutional 
care services that will keep them at home rather than in a VA 
long-term care bed.
    S. 1182, as introduced, contained a provision that would 
have struck the institutional capacity requirement from current 
law. However, discussion at the Committee's hearing of June 9, 
2005, coupled with legislation introduced by Senator Ken 
Salazar and testimony from the Veterans Service Organizations 
convinced the Committee that a more measured approach would 
serve the interests of the veterans VA serves as well as VA 
itself.
    As such, Section 13 requires the Under Secretary for Health 
to publish a strategic plan for long-term care. The plan should 
address policies and strategies for: care delivery in 
institutional, non-institutional, and domiciliary settings; 
maximizing the use of the State Home Program; identification of 
free-standing nursing homes for care; data collection on 
catastrophically disabled veterans and their geographic 
location; and providing a full spectrum of non-institutional 
care services.
    It is the Committee's hope that this strategic plan will 
provide a clearer focus for the future of VA long-term care as 
well as a roadmap for veterans who rely on VA's services.

Section 14. Blind Rehabilitation Outpatient Specialists

    VA operates a robust program to provide medical and social 
assistance to visually impaired veterans. Typically, care is 
provided at one of VA's ten residential Blind Rehabilitation 
facilities. These facilities provide intensive inpatient care 
services designed to allow blinded veterans to live, work, and 
socialize independently of outside assistance.
    Often, following a stay at a residential program, follow-up 
care will occur through care coordination provided by a Visual 
Impairment Service Team (hereinafter ``VIST'') coordinator at a 
local VA medical facility. Care coordinators ensure that 
veterans' prosthetics are properly maintained, benefits are 
explained, and specialized health care services are provided to 
visually impaired veterans. In FY 2006, VA will employ over 150 
part-time and full-time VIST coordinators. Total VA 
expenditures on blind rehabilitation services will exceed $62 
million.
    Recently, a new model of care has been developed known as 
BROS. BROS are well-trained, blind rehabilitation specialists 
who can provide many of the services on an outpatient basis 
that are normally reserved for the inpatient treatment program. 
This allows VA to treat a greater number of visually impaired 
veterans, closer to home, at a lower cost.
    Further, because travel to one of the ten inpatient 
facilities is often a limitation to participation in 
rehabilitation, many advocates suggest that more veterans will 
become self-sufficient and enjoy greater opportunities for 
independent living through the BROS program.
    Unfortunately, VA has not focused as much as the Committee 
would like on the expansion of the BROS program. As such, 
Section 14 directs VA to employ 35 new BROS at facilities of 
the department over the next three years. It is the Committee's 
belief that by expanding the total number of BROS to over 50 VA 
can make a true, meaningful improvement in the lives of blinded 
veterans and do so closer to their homes.

Section 15. Extension of Compliance Reporting Requirement

    Under current law, 38 U.S.C. Sec. 1706(b)(5), VA is 
required to submit to the Committees on Veterans' Affairs of 
the House and Senate a report on its compliance with the so-
called ``specialized services capacity requirement''. The 
capacity requirement dictates that VA must maintain within each 
Veterans Integrated Service Network (hereinafter ``VISN'') the 
capacity to provide specialized services to veterans. VA's 
specialized services include: spinal cord injury programs; 
blind rehabilitation programs; traumatic brain injury programs, 
and amputation rehabilitation programs.
    Clearly, the Committee believes that VA must continue to 
devote significant resources to these important efforts. 
Renewing the reporting requirement will ensure that the 
Committee can appropriately monitor VA's efforts in this area 
and hold officials accountable.

Section 16. Health Care and Services for Veterans Affected by Hurricane 
        Katrina

    Hurricane Katrina had devastating effects on the citizens 
and infrastructure in the States of Mississippi, Louisiana, 
Alabama, and Texas. Facilities of the Department of Veterans 
Affairs and the veterans served by these facilities were not 
immune to the results of this destruction.
    Over one million veterans reside in Louisiana, Mississippi, 
and Alabama. Hundreds-of-thousands of them were significantly 
affected by Katrina. They were forced to relocate (in many 
cases to Texas and Florida), lost their homes, jobs, and 
unfortunately health insurance coverage. To address some of 
these concerns, Section 16 of the Committee bill seeks to 
ensure that those veterans who lost health insurance and 
primary income can be assured of health coverage in any 
facility of the department as they attempt to put their lives 
back together and recover from this historical storm.
    The bill would authorize VA to treat any veteran from one 
of the affected states in any facility of the department 
regardless of whether the veteran is enrolled in the VA health 
care system, or even eligible to enroll. This authority, which 
also waives any applicable copayments or fees, extends through 
the end of January 2006.
    There were views expressed in Committee about extending the 
cost-free access to all veterans for a longer period of time 
than January 31, 2006. The Committee is prepared to consider an 
extension of the timeline if VA officials believe that a longer 
access period is needed. However, the Committee believes that 
the bill contains a reasonable period of time for recovery of 
the affected veterans. Any efforts to extend the time must be 
mindful of the fact that special geographically-based 
eligibility cannot continue in perpetuity without being unfair 
to similarly situated veterans who reside in states not 
affected by Hurricane Katrina.

Section 17. Reimbursement for Certain Veterans' Outstanding Emergency 
        Treatment Expenses

    Under current law, VA is authorized to pay for emergency 
care services provided to veterans in non-VA facilities if the 
veteran seeking the services is an enrolled patient and has 
seen a VA care provider in the past two years. However, the 
payment is also contingent on the veteran not having any other 
health insurance coverage for the service.
    As a result of the ``payor of last resort'' contingency, 
privately insured veterans are often paying more out-of-pocket 
costs than those with no insurance. VA has some evidence to 
suggest that the out-of-pocket expenditures are causing some 
veterans to attempt to ``make it'' to a VA facility where only 
VA copayments would apply.
    A recent study undertaken for VA showed that the additional 
travel time to a VA facility for emergency care was having 
deleterious health affects on VA patients. Clearly, that is not 
the kind of behavior the Committee seeks to encourage in our 
veterans. Nor is it good medicine.
    The Committee bill clarifies that veterans will be treated 
equally regardless of where emergency care treatment is sought.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the CBO, estimates that enactment of 
the Committee bill would, relative to current law, increase 
spending by $193 million in 2006 and by $1.2 billion over the 
2006-2010 period. Enactment of the Committee bill would not 
affect direct spending or receipts, and would not affect the 
budget of state, local or tribal governments.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                                                  October 14, 2005.
Hon. Larry E. Craig,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman. The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 1182, the Veterans 
Health Care Act of 2005.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Michelle S. 
Patterson.
            Sincerely,
                               Douglas Holtz-Eakin,
                                                          Director.
    Enclosure.

               Congressional Budget Office Cost Estimate


S. 1182--Veterans Health Care Act of 2005

    S. 1182 would expand or establish a number of health care 
benefits for veterans. In particular, the bill would authorize 
the Secretary of the Department of Veterans Affairs (VA) to 
provide medical care to infants born in VA hospitals, to 
reimburse certain veterans who seek emergency care from non-VA 
medical facilities, and to hire additional specialists who 
provide care for blind veterans. The bill also would allow 
veterans in areas affected by Hurricane Katrina who otherwise 
would not be eligible for such care to obtain medical care from 
VA and would prohibit the collection of co-payments and third-
party reimbursements for medical care given to veterans from 
these areas.
    CBO estimates that implementing this bill would cost $193 
million in 2006 and about $1.2 billion over the 2006-2010 
period, assuming appropriation of the authorized and estimated 
amounts. Enacting this bill would not affect direct spending or 
receipts.
    S. 1182 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.
    The estimated budgetary impact of S. 1182 is shown in Table 
1. The costs of this legislation fall within budget function 
700 (veterans benefits and services).

                                 TABLE 1.--ESTIMATED BUDGETARY IMPACT OF S. 1182
----------------------------------------------------------------------------------------------------------------
                                                                       By fiscal year, in millions of dollars--
                                                                    --------------------------------------------
                                                                       2006     2007     2008     2009     2010
----------------------------------------------------------------------------------------------------------------
                                CHANGES IN SPENDING SUBJECT TO APPROPRIATION \1\

Estimated authorization level......................................      297      319      228      234      238
Estimated outlays..................................................      193      303      236      236      237
----------------------------------------------------------------------------------------------------------------
\1\ These amounts do not include the costs of implementing section 7 because CBO cannot estimate such costs at
  this time.

    S. 1182 would affect discretionary spending for veterans' 
medical care and would decrease the amount of offsetting 
collections deposited to the Medical Care Collections Fund 
(MCCF). CBO estimates that implementing S. 1182 would cost $193 
million in 2006 and about $1.2 billion over the 2006-2010 
period (see Table 2), assuming appropriation of the authorized 
and estimated amounts. These amounts do not include the costs 
of implementing section 7, which would allow VA to conduct 
cost-comparison studies, because CBO cannot estimate the costs 
at this time. For this estimate, CBO assumes the bill will be 
enacted before the end of calendar year 2005.
    Section 4 would reinstate and make permanent VA's authority 
to provide grants to organizations that furnish services to 
homeless veterans. That authority expired on October 1, 2005. 
The provision also would authorize the appropriation of $130 
million in fiscal year 2006 and each subsequent year for these 
grants. Finally, the provision would authorize the 
appropriation of $1 million a year over the 2006-2011 period 
for grants to organizations that give technical assistance to 
entities or organizations that assist nonprofit, community-
based groups in applying for grants to furnish services to 
homeless veterans.
    In 2005, the Congress appropriated $75 million for grants 
to organizations that furnish services to homeless veterans and 
$750,000 for grants to provide technical assistance. Based on 
information from VA, CBO assumes that it would take the 
department about three years to expand the grant programs to 
the levels authorized for 2006. Thus, CBO estimates that 
implementing section 4 would cost $67 million in 2006 and $565 
million over the 2006-2010 period, assuming appropriations of 
the authorized amounts.

               TABLE 1.--ESTIMATED CHANGES IN SPENDING SUBJECT TO APPROPRIATION UNDER S. 1182 \1\
----------------------------------------------------------------------------------------------------------------
                                                                       By fiscal year, in millions of dollars--
                             Provision                              --------------------------------------------
                                                                       2006     2007     2008     2009     2010
----------------------------------------------------------------------------------------------------------------
Grants for Helping Homeless Veterans:
    Authorization level............................................      131      131      131      131      131
    Estimated outlays..............................................       67      105      131      131      131
Expansion of Mental Health Services
    Authorization level............................................       97       95        0        0        0
    Estimated outlays..............................................       65      112        9        4        0
Reimbursement for Emergency Treatment at Non-VA Medical Facilities:
    Estimated authorization level..................................       52       73       76       80       83
    Estimated outlays..............................................       47       69       75       79       82
Medical Care for Veterans Affected by Hurricane Katrina:
    Estimated authorization level..................................        6        9        9       10       10
    Estimated outlays..............................................        6        8        9        9       10
Forgone Offsetting Collections:
    Estimated authorization level..................................        3        0        0        0        0
    Estimated outlays..............................................        2        *        *        0        0
Care for Newborns:
    Estimated authorization level..................................        4        7        8        9       10
    Estimated outlays..............................................        4        6        8        9       10
Outpatient Specialists for Blind Rehabilitation:
    Authorization level............................................        4        4        4        4        4
    Estimated outlays..............................................        2        3        4        4        4
    Total Changes: \2\
        Estimated authorization level..............................      297      319      228      234      238
        Estimated outlays..........................................      193      303      236      236     237
----------------------------------------------------------------------------------------------------------------
\1\ Five-year costs in the text differ slightly from a summation of the annual costs shown here because of
  rounding.
\2\ These amounts do not include the costs of implementing section 7 because CBO cannot estimate such costs at
  this time.
Note: * = less than $500,000.


    Section 8 would direct VA to improve and expand mental 
health services offered by the department and would authorize 
the appropriation of $95 million in 2006 and 2007 for these 
purposes. The provision would direct VA to increase the number 
of clinical treatment teams dedicated to the treatment of post-
traumatic stress disorder (PTSD), to expand the services 
available to diagnose and treat substance abuse, and to improve 
tele-health initiatives in areas of the country that are far 
from VA facilities. The provision also would require the 
Department of Defense (DoD) to work with the National Center on 
Post Traumatic Stress Disorder to provide training medical care 
providers within DoD on PTSD and would authorize the 
appropriation of $2 million in 2006 to carry out this 
authority. Assuming outlays follow historical patterns, CBO 
estimates that implementing section 8 would cost $65 million in 
2006 and about $190 million over the 2006-2009 period, assuming 
appropriation of the authorized amounts.
    Section 17 would allow VA to reimburse certain veterans who 
seek emergency treatment from a non-VA medical facility. Under 
current law, a veteran who receives emergency care in the 
private sector for a nonservice-connected condition can only be 
reimbursed if he or she has no other insurance coverage. This 
provision would authorize VA to reimburse veterans who receive 
emergency treatment from a non-VA medical facility for costs 
that the veteran remains personally liable for if the veteran 
is enrolled in VA's health care system, received medical care 
from VA during the 24-month period precedingemergency 
treatment, has health insurance that partially reimburses the cost of 
emergency treatment, is financially liable for the cost of treatment 
that is not reimbursed by his or her health insurance, and is not 
eligible for reimbursement under current law.
    According to VA, it expects about 250,000 veterans would 
qualify each year for reimbursement under this provision and 
that, on average, such veterans would be paid about $280 in 
2006 to cover nonreimbursed treatment costs including net co-
pays and deductibles. (VA indicates that it would deduct the 
co-payment a veteran would have paid if the treatment had been 
provided at a VA facility from any request for reimbursement.) 
Based on this information and adjusting for inflation, CBO 
estimates that implementing section 17 would cost $47 million 
in 2006 (accounting for a partial-year effect) and about $350 
million over the 2006-2010 period, assuming appropriation of 
the necessary amounts.
    Section 16 would require VA to treat certain veterans 
affected by Hurricane Katrina who would otherwise not be 
allowed to receive care from the agency's medical system. Since 
January 2003, VA has not accepted new enrollments from priority 
8 veterans, who are veterans without a service-connected 
disability and with income above certain thresholds. This 
provision would allow those priority 8 veterans in the New 
Orleans, Louisiana, and Gulfport or Biloxi, Mississippi, 
regions who were previously excluded to receive care at VA 
medical facilities through January 31, 2006.
    Based on data from VA about the number of veterans in these 
regions and the projected population of potential priority 8 
enrollees in each state, CBO estimates that there are about 
5,700 veterans from the affected areas who would seek care from 
VA at an average annual cost of about $1,500 in 2006. Although 
the provision would limit such care to the period before 
January 31, 2006, CBO expects that VA would allow these 
veterans to continue to receive medical care beyond that date 
since it has grandfathered such priority 8 veterans in the 
past. Thus, after adjusting for expected inflation, CBO 
estimates that implementing this provision would cost $6 
million in 2006 and almost $45 million over the 2006-2010 
period, assuming appropriation of the necessary amounts.
    Section 16 also would prohibit VA from collecting co-
payments and third-party co-payments and third-party 
reimbursements for medical care given to veterans from these 
areas until January 31, 2006. Under current law, certain 
veterans must make co-payments when receiving health care from 
VA. In addition, VA can bill a veteran's third-party insurance 
when the veteran is treated for nonservice-connected 
conditions. These payments are deposited into the MCCF and, 
under current law, are treated as offsets to discretionary 
spending. Spending from the MCCF is subject to appropriation.
    VA estimates that it will collect nationwide more than $2.1 
billion in co-payments and reimbursements in 2006. Because the 
population for the affected area comprises less than 1 percent 
of all veterans using VA's medical system and CBO expects that 
VA would waive co-payments and third-party reimbursements for 
only one month, CBO estimates that implementing this provision 
would reduce collections by about $3 million in 2006.
    Section 2 would allow VA to provide medical care for up to 
14 days to newborns of female veterans who are delivered in a 
VA facility. Under current law, VA may only provide medical 
benefits to the mother. VA estimates that about 1,000 newborns 
would receive medical care in the first year and that this 
number would grow to about 2,000 infants by 2011. Based on data 
from VA, CBO estimates that the cost of providing neonatal care 
to those infants would be about $5,900 per infant in 2006. 
(Providing neonatal care for most infants would cost much less; 
the high average cost is driven by those infants who require 
extensive care for longer periods of time.) After adjusting for 
expected inflation, CBO estimates that implementing this 
provision would cost $4 million in 2006 and $36 million over 
the 2006-2010 period, assuming appropriation of the necessary 
amounts.
    Section 14 would require VA to employ outpatient 
specialists for blind rehabilitation at no fewer than 35 of its 
facilities and would authorize the appropriation of $3.5 
million a year over the 2006-2011 period to carry out this 
provision. CBO estimates that implementing this provision would 
cost $2 million in 2006 and just over $16 million over the 
2006-2010 period, assuming appropriation of the necessary 
amounts.
    Section 7 would repeal a provision in law that prohibits VA 
from using appropriated funds to conduct studies comparing the 
costs of allowing certain functions to be performed by private 
contractors instead of using VA personnel. CBO cannot estimate 
the budgetary impact of implementing this provision since VA 
has not provided information on the number of studies it would 
conduct or the potential cost per study. It is likely, however, 
that the costs of implementing section 7 would be small 
compared to the total cost of this bill.
    The following provisions would have an insignificant 
budgetary impact on spending subject to appropriation:
           Section 6 would exempt the Chief Nursing 
        Officer with the Office of Nursing Services from 
        current-law restrictions to nurse pay and allow that 
        officer to be paid at a rate up to the maximum rate 
        established by the Senior Executive Service. Based on 
        information provided by VA, CBO estimates that 
        implementing this provision would cost less than 
        $50,000 a year.
           Section 3 would allow medical care providers 
        to collect payment for services from a third-party 
        insurance company when they provide care to certain 
        children of Vietnam veterans. Under current law, 
        medical care providers who treat children of Vietnam 
        veterans with spina bifida or birth defects can only 
        receive payment from VA. This provision would allow 
        providers to seek payment from a responsible third-
        party for the difference between the amount billed and 
        the amount paid by VA. CBO estimates that implementing 
        this provision would not affect VA payments to these 
        providers.
           Section 10 would direct VA to increase the 
        number of personnel employed by VA as part of its 
        Readjustment Counseling Service outreach program. 
        Section 11 would direct VA to increase the number of 
        Veterans Readjustment Counseling Service facilities 
        that can provide tele-health linkages with other VA 
        facilities. VA indicates that it is already 
        implementing such increases. As such, CBO estimates 
        that implementing these provisions would result in no 
        additional costs.
    S. 1182 contains no intergovernmental or private-sector 
mandates as defined in UMRA and would impose no costs on state, 
local, or tribal governments.
    The CBO staff contacts are Michelle Patterson, Melissa 
Merrell, and Allison Percy. This estimate was approved by Peter 
H. Fontaine, Deputy Assistant Director for Budget Analysis.

                      Regulatory Impact Statement

    In compliance with paragraph 11(b) of rule XXVI of the 
Standing Rules of the Senate, the Committee on Veterans' 
Affairs has made an evaluation of the regulatory impact that 
would be incurred in carrying out the Committee bill. The 
Committee finds that the Committee bill would not entail any 
regulation of individuals or businesses or result in any impact 
on the personal privacy of any individuals and that the 
paperwork resulting from enactment would be minimal.

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7 of rule XXVI of the Standing 
Rules of the Senate, the following is a tabulation of votes 
cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its September 15, 2005 meeting.
    On that date, the Committee, by voice vote, ordered S. 1182 
reported favorably to the Senate, with related measures 
included from the following: provisions of S. 1177, a bill by 
Committee Ranking Member Daniel K. Akaka; provisions of S. 
1189, a bill by Committee Member Senator Ken Salazar; and 
provisions of S. 1190, a bill by Committee Member Senator 
Salazar.
    In addition, the Committee adopted two amendments to S. 
1182. One amendment by Committee Ranking Member Akaka 
concerning the provision of emergency care services to veterans 
was adopted by unanimous consent. A second amendment offered by 
Committee Ranking Member Akaka concerning health care 
servicesfor veterans affected by Hurricane Katrina was adopted by voice 
vote after a second degree amendment to the Akaka amendment, offered by 
Chairman Larry E. Craig, was adopted by a vote of 8 yeas and 6 nays.

                             Agency Report

    On June 9, 2005, Secretary of Veterans' Affairs, the 
Honorable R. James Nicholson, appeared before the Committee on 
Veterans' Affairs and submitted testimony on, among other 
things, a draft version of the Veterans Health Care 
Improvements Act of 2005. Excerpts from this statement are 
reprinted below:

              STATEMENT OF THE VIEWS OF THE ADMINISTRATION

             Statement of the Honorable R. James Nicholson

                     Secretary of Veterans' Affairs

    Good Afternoon Mr. Chairman and Members of the Committee:
    I am pleased to be here this morning to present the 
Department's views on several different bills being considered 
by the Committee. They cover a wide range of subjects related 
to VA's provision of health care services to veterans.


             veterans health care improvements act of 2005


    Mr. Chairman, I will begin by commenting on your draft bill 
that includes an array of provisions, many of which would carry 
out proposals that were included in the President's budget 
submitted to Congress earlier this year. We strongly support 
enactment of this measure and we appreciate your inclusion of 
provisions to carry out the President's plans for assisting 
veterans and for assisting the Department to carry out its 
mission.
    One major provision in the bill would expand VA's authority 
to assist with payment for emergency-care costs that veterans 
incur in private hospitals. As you may know, a major study 
found that veterans with cardiac emergencies, despite having 
health insurance, often deliberately forgo emergency treatment 
at the closest community hospital (where they might incur out-
of-pocket expenses) in favor of receiving care from the nearest 
VA facility at no or minimal cost. Delaying needed emergency 
medical treatment can jeopardize their health status and hinder 
the Department's ability to timely and successfully manage 
their emergent medical conditions. Under current law, a veteran 
who obtains emergency care in the private sector for a 
nonservice-connected condition is not eligible for VA 
reimbursement for the related expenses if the veteran has any 
insurance or other coverage for the cost of the care, in whole 
or in part. Your proposal would amend the law to enable the 
Department to reimburse a veteran for out-of-pocket expenses 
not covered by insurance or other coverage, thereby ensuring 
that veterans, whether insured or not, have consistent access 
to optimal care for emergency health conditions.
    Unfortunately, the stress of combat leaves scars on many 
veterans. Your bill contains several new authorities that will 
help assist us in caring for those returning from overseas who 
are suffering from PTSD and other mental health disorders. The 
bill also contains a provision to exempt former POWs from 
having to pay copayments in connection with the receipt of 
extended-care services, and a second provision to exempt 
veterans from copayments for hospice care in a hospital or at 
home. These provisions will be extremely beneficial to the 
affected veterans. The bill would also authorize time-limited 
care for newborn children when veterans deliver the children 
under VA auspices.
    Finally, Mr. Chairman, your bill contains two provisions 
that would repeal laws that have seriously hindered our efforts 
at VA to provide veterans with high-quality care by the best 
and most cost-effective means. The bill would repeal a law that 
requires VA to maintain at least the same staffing and level of 
extended-care services in Department facilities as was provided 
in fiscal year 1998. That law has seriously limited our ability 
to provide or pay for extended care services for veterans in a 
variety of institutional and non-institutional settings outside 
VA, including private nursing homes in the community and State 
nursing home facilities. As you know, many veterans prefer to 
remain in their homes and communities, and it is often cost-
effective to provide care in those settings. Your bill would 
also repeal an old law that generally bars the Department from 
using appropriated funds to compare the costs of providing 
services directly, or by contract, which impedes our ability to 
obtain the best possible value for veterans. On a government-
wide basis, public-private competitions completed in FYs 2003 
and 2004 are estimated to generate savings, or cost avoidances, 
for the taxpayer of more than $2.5 billion over the next three 
to five years. The tailored and responsible use of competitive 
sourcing at VA will help the Department free up resources that 
can be dedicated to our veterans.

                 MINORITY VIEWS OF RANKING MEMBER AKAKA

    The underlying legislation is a step forward in improving 
care for veterans. I am especially pleased that the bill now 
includes my legislation to provide a measure of financial 
relief for those veterans affected by Hurricane Katrina.
    Where this legislation falls short, however, is that it 
does not do enough to improve care for veterans living in rural 
areas. In addition, the legislation would eliminate the long-
standing prohibition against the Veterans Health Administration 
conducting costly private-public cost comparison studies 
without a separate appropriation.
    Let me present my concerns.

                      RURAL CARE IS NOT ADDRESSED

    While the underlying legislation contains varying 
provisions on such subjects as mental health care, emergency 
care, and homeless veterans, none are specifically designed to 
help veterans living in rural areas.
    The Committee rejected an amendment I offered that would 
have provided VA with a viable set of tools with which to 
address the unique needs of veterans living in rural areas. The 
amendment was partially based on legislation I introduced in 
June to improve things for rural veterans in Hawaii. In 
addition, provisions from worthy legislation introduced by 
Senators Thune and Salazar on rural health initiatives were 
also included in the amendment. This amendment received 
bipartisan support but failed on a tie vote.
    Specific to Hawaii, we know that the level of care provided 
to those living on what we call the ``Neighbor Islands''--
Kauai, Molokai, Lanai, Maui, and the Big Island is not at the 
optimal level. My amendment called for a pilot program to test 
the operation of two satellite clinics, as well as expanding 
services at those already in existence.
    This pilot would focus on the islands of Molokai and Lanai, 
which currently lack VA facilities altogether. A veteran living 
on either of these remote islands must either wait for a VA 
provider to visit--which is only nine to ten times a year for 
Molokai and four times a year for Lanai--or take it upon 
himself to get to Maui for clinical care or to Oahu for 
treatment for a more serious condition.
    Filling up the car with a tank of gas and driving across 
the State is obviously not even an option. Inter-island airfare 
is more than $200. VA does not reimburse for this. Add in 
various other travel costs, such as rental car and lodging 
expenses, and a veteran may choose to forgo care rather than 
pay these sizeable out-of-pocket costs. Even when a VA provider 
finally comes to one of these remote islands, they have no 
computer or telemedicine equipment--this from a Department 
which touts their computerized medical records and 
technologies.
    At the Committee's legislative hearing in early June, VA 
couldn't comment on these Hawaii-specific rural access 
components. However, VA now has had four months to comment. And 
they have still not done so. One could assume that the needs of 
Hawaii's veterans do not rank high on the list of Department 
priorities.
    Let us not be under the illusion that State-specific 
projects are not important and have not been moved upon by this 
Committee. For those who would argue that this amendment is too 
prescriptive, I would argue that it absolutely needs to be.
    For example, clinic personnel have asked for home care 
nurses to fulfill the long-term mandate this Committee passed 
six years ago. Veterans on Molokai are literally rallying for 
better care. Even when the Network and the local VA sends up 
proposals to Headquarters they are not acted upon. In the 
meantime, veterans are suffering.
    With respect to this bill including benefits for veterans 
in rural areas in my state, let me state that these are 
legitimate needs of Hawaii veterans and, if these demonstration 
projects are successful, could be used as models for other 
rural areas in our nation.
    At times, Members need to write prescriptive legislation, 
when it is clear that an agency or Department is not doing what 
is required. Because of the distance to the mainland, and 
because of the view that Hawaii is a paradise--which it is--it 
is difficult for us to get policymakers to travel to Hawaii to 
actually witness firsthand the challenges faced by veterans 
living on these geographically remote islands. As a result, the 
needs of neighbor island veterans are being ignored.
    This amendment seeks to fix some of the access problems, 
while giving VA another opportunity to work with veterans to 
see which approach is best for all.
    Also included in this amendment was Senator Thune's rural 
pilot program which would give us more data about how best to 
treat veterans living in highly rural areas. In addition, again 
based on Senator Thune's bill, VA needs to revamp its 
beneficiary travel program. This benefit is one that is highly 
valued by many veterans, especially those on fixed incomes. 
Unfortunately, there has not been an increase in the benefit 
for some time. In 2001, VA found that the current allowances 
under this program were not sufficient to begin to deal with 
high gas prices. Yet, four years later, the increase was never 
put forward.
    This beneficiary travel increase would go hand in hand with 
another provision--an innovative grant program to provide 
options for transportation that Senator Salazar originally 
introduced. Although some ad hoc veterans travel programs have 
community support, many suffer from underfunding. Relatively 
small investments in transportation services can result in 
significantly better care for our Nation's most vulnerable 
veterans.
    While this legislation still does not contain any 
provisions aimed at rural health, I will be working to ensure 
that these provisions come to fruition. For example, the 
Committee will be holding field hearings in my State. The main 
focus of these hearings will be on the unique access issues.

  BLANKET APPROVAL FOR COST COMPARISON STUDIES: UNPROVEN AND EXPENSIVE

    The Committee Bill would eliminate the longstanding 
prohibition against the Veterans Health Administration (VHA) 
conducting private-public cost comparison studies without a 
separate appropriation. This is the wrong course for VA at this 
time.
    VHA has experienced serious shortfalls this year in the 
funding account for veterans' health care. As the cost of 
health care continues to rise to adjust for medical inflation 
and burgeoning demand, VHA resources are stretched thin. Yet, 
the Committee would give VHA this authority without any idea of 
the costs of the studies and the expenses associated with 
implementing the findings.
    VA has yet to provide detailed estimates on how much will 
be spent doing these studies. The annual report on President 
Bush's ``competitive sourcing'' initiative says that the 
government spent $110 million in 2004 on private-public cost 
comparison studies. These studies reviewed, in total, more than 
12,000 positions throughout the Federal government. In the end, 
about 1,000 jobs were contracted out, at a cost to the taxpayer 
of close to $100,000 per position. VA has identified 36,000 
positions which could be affected by cost-comparison studies. 
Given the results from the ``competitive sourcing'' initiative, 
it is unrealistic to expect that VA would spend hundreds of 
millions to conduct its own cost comparison studies. In 
reality, VA would likely spend much, much more.
    At the Committee markup, the Chairman argued that this bill 
would generate, ``$1.3 billion over five years, that this would 
be the opportunity for this Committee to reinvest that money in 
care services.'' Unfortunately, to date, VA has been unable to 
document any substantial savings through its previous 
outsourcing initiatives or the creation of any significant new 
hires of full-time employees (FTE) as a result.
    The Committee Report above states, ``It is important to 
note that the Committee does not believe that comparison 
studies will inevitably result in the reduction of government 
employment.'' In reality, VA's own estimates for FTE 
reinvestment are based upon the potential elimination or 
outsourcing of some or all of 36,000 jobs currently being 
performed by government workers.
    The provision would likely have a disastrous effect on VA 
workers, many of whom are also veterans. VA's own plan calls 
for the first 12,000 VHA employees affected by these cost-
comparison studies to be laundry, canteen, nutrition, and food 
service workers. According to VA's own figures, 75 percent of 
the laundry workers and 57 percent of the food service workers 
are veterans. In addition, there are 3,400 veterans 
participating in VA's compensated work therapy program working 
in these same fields. It makes no sense for the Committee to 
pursue legislation that disregards the unique characteristics 
of VHA's workforce and jeopardizes the employment of veterans 
currently employed in these wage-grade jobs.
    The provision in the legislation also lacks any mechanism 
for effective oversight of these studies. If enacted, there 
would be no transparency, and ergo, no accountability to 
Congress on this issue.
    Before we blindly proceed, we should have a clear idea of 
how and where these savings will occur and what impact they 
will have on VA's existing workforce. A much more prudent 
course of action would allow VA to use its own internal 
management analyses. VA through its own internal program should 
first be given the opportunity to realize its goal for 
management efficiencies without the disruption and uncertainty 
to its workforce created by cost-comparison studies and without 
the unnecessary expenditure of millions of unappropriated 
dollars needed to conduct them.
    In summary, given the current shortfalls in VHA funding, it 
is inappropriate for VHA to spend millions on cost-comparison 
studies without any evidence there are substantial savings to 
be gained from such an endeavor. The legislation would give VA 
blanket approval to spend millions on conducting these studies 
without any provisions for Congressional oversight.

    Changes in Existing Law Made by the Committee Bill, as Reported

    In compliance with rule XXVI paragraph 12 of the Standing 
Rules of the Senate, changes in existing law made by the 
Committee bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

TITLE 38, UNITED STATES CODE

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *



   Subchapter II--Hospital, Nursing Home, or Domiciliary and Medical 
Treatment

           *       *       *       *       *       *       *



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

           *       *       *       *       *       *       *


    (f)(1) The Secretary may not furnish hospital care or 
nursing home care other than hospice care under this section to 
a veteran who is eligible for such care under subsection (a)(3) 
of this section unless the veteran agrees to pay to the United 
States the applicable amount determined under paragraph (2) of 
this subsection.
    (g)(1) The Secretary may not furnish medical services other 
than hospice care under subsection (a) of this section 
(including home health services under section 1717 of this 
title) to a veteran who is eligible for hospital care under 
this chapter by reason of subsection (a)(3) of this section 
unless the veteran agrees to pay to the United States in the 
case of each outpatient visit the applicable amount or amounts 
established by the Secretary by regulation.

           *       *       *       *       *       *       *


Sec. 1710B. Extended care services

           *       *       *       *       *       *       *


    (a) * * *
    [(b) The Secretary shall ensure that the staffing and level 
of extended care services provided by the Secretary nationally 
in facilities of the Department during any fiscal year is not 
less than the staffing and level of such services provided 
nationally in facilities of the Department during fiscal year 
1998.]
    [(c)](b)(1) Except as provided in paragraph (2), the 
Secretary may not furnish extended care services for a non-
service-connected disability other than in the case of a 
veteran who has a compensable service-connected disability 
unless the veteran agrees to pay to the United States a 
copayment (determined in accordance with subsection (d)) for 
any period of such services in a year after the first 21 days 
of such services provided that veteran in that year.
    (2) Paragraph (1) shall not apply--
          (A) to a veteran whose annual income (determined 
        under section 1503 of this title) is less than the 
        amount in effect under section 1521(b) of this title;
          (B) to a veteran who is a former prisoner of war;
          [(B)](C) to a veteran being furnished hospice care 
        under this section; or
          [(C)](D) with respect to an episode of extended care 
        services that a veteran is being furnished by the 
        Department on November 30, 1999.
    [(d)](c)(1) A veteran who is furnished extended care 
services under this chapter and who is required under 
subsection [(c)](b) to pay an amount to the United States in 
order to be furnished such services shall be liable to the 
United States for that amount.
    (2) In implementing subsection [(c)](b), the Secretary 
shall develop a methodology for establishing the amount of the 
copayment for which a veteran described in subsection [(c)](b) 
is liable. That methodology shall provide for--
          (A) establishing a maximum monthly copayment (based 
        on all income and assets of the veteran and the spouse 
        of such veteran);
          (B) protecting the spouse of a veteran from financial 
        hardship by not counting all of the income and assets 
        of the veteran and spouse (in the case of a spouse who 
        resides in the community) as available for determining 
        the copayment obligation; and
          (C) allowing the veteran to retain a monthly personal 
        allowance.
    [(e)](d)(1) There is established in the Treasury of the 
United States a revolving fund known as the Department of 
Veterans Affairs Extended Care Fund (hereinafter in this 
section referred to as the ``fund''). Amounts in the fund shall 
be available, without fiscal year limitation and without 
further appropriation, exclusively for the purpose of providing 
extended care services under subsection (a).
    (2) All amounts received by the Department under this 
section shall be deposited in or credited to the fund.

           *       *       *       *       *       *       *


   Subchapter III--Miscellaneous Provisions Relating to Hospital and 
Nursing Home Care and Medical Treatment of Veterans

           *       *       *       *       *       *       *



Sec. 1725. Reimbursement for Emergency Treatment

           *       *       *       *       *       *       *


    (a) General Authority.--(1) Subject to subsections (c) [and 
(d)], the Secretary may reimburse a veteran described in 
subsection (b) for [the reasonable value of] expenses resulting 
from emergency treatment furnished the veteran in a non-
Department facility for which the veteran remains personally 
liable.
    (2) In any case in which reimbursement is authorized under 
subsection (a)(1), the Secretary, in the Secretary's 
discretion, may, in lieu of reimbursing the veteran, make 
payment [of the reasonable value of the furnished emergency 
treatment directly]--
          (A) to a hospital or other health care provider that 
        furnished the treatment; or
          (B) to the person or organization that paid for such 
        treatment on behalf of the veteran.
    (b) Eligibility.--[(1)] A veteran referred to in subsection 
(a)[(1)] is an individual who--[is an active Department health-
care participant who is personally liable for emergency 
treatment furnished the veteran in a non-Department facility.]
          (1) is enrolled in the health care system established 
        under section 1705(a) of this title;
    [(2) A veteran is an active Department health-care 
participant if--
          (A) the veteran is enrolled in the health care system 
        established under section 1705(a) of this title; and
          (B) the veteran received care under this chapter 
        within the 24-month period preceding the furnishing of 
        such emergency treatment.]
          (2) received care under this chapter during the 24-
        month period preceding the furnishing of such emergency 
        treatment;
      [(3) veteran is personally liable for emergency treatment 
furnished the veteran in a non-Department facility if the 
veteran--
          (A) is financially liable to the provider of 
        emergency treatment for that treatment;
          (B) has no entitlement to care or services under a 
        healthplan contract (determined, in the case of a 
        health-plan contract as defined in subsection (f)(2)(B) 
        or (f)(2)(C), without regard to any requirement or 
        limitation relating to eligibility for care or services 
        from any department or agency of the United States);
          (C) has no other contractual or legal recourse 
        against a third party that would, in whole or in part, 
        extinguish such liability to the provider; and
          (D) is not eligible for reimbursement for medical 
        care of services under section 1728 of this title.]
          (3) is entitled to care or services under a health-
        plan contract that partially reimburses the cost of the 
        veteran's emergency treatment;
          (4) is financially liable to the provider of 
        emergency care treatment for costs not covered by the 
        veteran's health-plan contract, including copayments 
        and deductibles; and
          (5) is not eligible for reimbursement for medical 
        care or services under section 1725 or 1728 of this 
        title.
    (c) Limitations on Reimbursement.--(1) [The Secretary, in 
accordance with regulations prescribed by the Secretary, 
shall--] Any amount paid by the Secretary under subsection (a) 
shall exclude the amount of any payment the veteran would have 
been required to make to the United States under this chapter 
if the veteran had received the emergency treatment from the 
Department.
          [(A) establish the maximum amount payable under 
        subsection (a);
          [(B) delineate the circumstances under which such 
        payments may be made, to include such requirements on 
        requesting reimbursement as the Secretary shall 
        establish; and
          [(C) provide that in no event may a payment under 
        that subsection include any amount for which the 
        veteran is not personally liable.]
    (2) [Subject to paragraph (1)] [t] The Secretary may not 
provide reimbursement under this section with respect to any 
item or service [only after the veteran or the provider of 
emergency treatment has exhausted without success all claims 
and remedies reasonably available to the veteran or provider 
against a third party for payment of such treatment.]--
          (A) provided or for which payment has been made, or 
        can reasonably be expected to be made, under the 
        veteran's health-plan contract; or
          (B) for which payment has been made or can reasonably 
        be expected to be made by a third party.
    (3) (A) Payment by the Secretary under this section on 
behalf of a veteran to a provider of emergency treatment shall, 
unless rejected and refunded by the provider within 30 days of 
receipt, extinguish any liability on the part of the veteran 
for that treatment. [Neither the absence of a contract or 
agreement between the Secretary and the provider nor any 
provision of a contract, agreement, or assignment to the 
contrary shall operate to modify, limit, or negate the 
requirement in the preceding sentence].
    (B) The absence of a contract or agreement between the 
Secretary and the provider, any provision of a contract or 
agreement, or an assignment to the contrary shall not operate 
to modify, limit, or negate the requirement under subparagraph 
(A).
    (4) In accordance with regulations prescribed by the 
Secretary, the Secretary shall (A) establish criteria for 
determining the amount of reimbursement (which may include a 
maximum amount) payable under this section; and
    (B) delineate the circumstances under which such payment 
may be made, including requirements for requesting 
reimbursement.
    (d) Independent Right of Recovery.--(1) In accordance with 
regulations prescribed by the Secretary, the United States 
shall have the independent right to recover any amount paid 
under this section [when] if, and to the extent that, a third 
party subsequently makes a payment for the same emergency 
treatment.
    (2) Any amount paid by the United States to the veteran, 
[(or] the veteran's personal representative, successor, 
dependents, or survivors[)],

or to any other person or organization paying for such 
treatment shall constitute a lien in favor of the United States 
against any recovery the payee subsequently receives from a 
third party forthe same treatment.
    (3) Any amount paid by the United States to the provider 
that furnished the veteran's emergency treatment shall 
constitute a lien against any subsequent amount the provider 
receives from a third party for the same emergency treatment 
for which the United States made payment.
    (4) The veteran [(] or the veteran's personal 
representative, successor, dependents, or survivors [)] shall--
          (A) ensure that the Secretary is promptly notified of 
        any payment received from any third party for emergency 
        treatment furnished to the veteran [.];
          [The veteran (or the veteran's personal 
        representative, successor, dependents, or survivors) 
        shall] (B) immediately forward all documents relating 
        to [such] a payment described in subparagraph (A)
          (C) cooperate with the Secretary in the investigation 
        of [such] a payment described in subparagraph (A); and
          (D) assist the Secretary in enforcing the United 
        States right to recover any payment made under 
        subsection (c)(3).
    (e) Waiver.--The Secretary [, in the Secretary's 
discretion,] may waive recovery of a payment made to a veteran 
under this section that is otherwise required by subsection 
(d)(1) when the Secretary determines that such waiver would be 
in the best interest of the United States, as defined by 
regulations prescribed by the Secretary.
    (f) Definitions.--For purposes of this section [:]--
          [(2)] (1) The term [''] `healthplan contract['']' 
        includes [any of the following:]--
                  (A) An insurance policy or contract, medical 
                or hospital service agreement, membership or 
                subscription contract, or similar arrangement 
                under which health services for individuals are 
                provided or the expenses of such services are 
                paid [.];
                  (B) An insurance program described in section 
                1811 of the Social Security Act (42 U.S.C. 
                1395c) or established by section 1831 of that 
                Act (42 U.S.C. 1395j) [.];
                  (C) A State plan for medical assistance 
                approved under title XIX of such Act (42 U.S.C. 
                1396 et seq.) [.]; and
                  (D) A workers' compensation law or plan 
                described in section 1729(a)(2)(A) of this 
                title [.];
                  [(E) A law of a State or political 
                subdivision described in section 1729(a)(2)(B) 
                of this title.]
        [(3)] (2) The term [''] `third party['']' means [any of 
        the following:];
                  (A) A Federal entity[.];
                  (B) A State or political subdivision of a 
                State [.];
                  (C) An employer or an employer's insurance 
                carrier[.]; and
                  [(D) An automobile accident reparations 
                insurance carrier.]
                  [(E)] (D) A person or entity obligated to 
                provide, or to pay the expenses of, [health 
                services under a healthplan contract.] such 
                emergency treatment; and
          [(1)] (3) The term [''] `emergency treatment['']' 
        [means medical care or services furnished, in the 
        judgment of the Secretary--] has the meaning given such 
        term in section 1725 of this title. 
                  [(A) when Department or other Federal 
                facilities are not feasibly available and an 
                attempt to use them beforehand would not be 
                reasonable;
                  [(B) when such care or services are rendered 
                in a medical emergency of such nature that a 
                prudent layperson reasonably expects that delay 
                in seeking immediate medical attention would be 
                hazardous to life or health; and
                  [(C) until such time as the veteran can be 
                transferred safely to a Department facility or 
                other Federal facility.]
    (b) Clerical Amendment.--The table of sections at the 
beginning of chapter 17 is amended by inserting after the item 
relating to section 1725 the following:

Sec. 1725A. Reimbursement for emergency treatment expenses for which 
          certain veterans remain personally liable
     * * * * * * *

Subchapter VIII--Health Care of Persons Other Than Veterans

           *       *       *       *       *       *       *



Sec. 1785. * * *

           *       *       *       *       *       *       *


Sec. 1786. Care for newborn children of women veterans receiving 
                    maternity care

    (a) The Secretary may furnish care to a newborn child of a 
woman veteran, who is receiving maternity care furnished by the 
Department, for not more than 14 days after the birth of the 
child if the veteran delivered the child in a Department 
contract for the delivery services.
    (b) Clerical Amendment.--The table of sections at the 
beginning of chapter 17 is amended by inserting after the item 
relating to section 1785 the following:

Sec. 1786. Care for newborn children of women veterans receiving 
          maternity care

           *       *       *       *       *       *       *


CHAPTER 18--BENEFITS FOR CHILDREN OF VIETNAM VETERANS

           *       *       *       *       *       *       *



Sec. 1803. Health care

           *       *       *       *       *       *       *


    (b) *  *  *
    (c)(1) If a payment made by the Secretary for health care 
under this section is less than the amount billed for such 
health care, the health care provider or agent of the health 
care provider may, in accordance with paragraphs (2) through 
(4), seek payment for the difference between the amount billed 
and the amount paid by the Secretary from a responsible third 
party to the extent that the provider or agent would be 
eligible to receive payment for such health care from such 
third party.
    (2) The health care provider or agent may not impose any 
additional charge on the beneficiary who received the health 
care, or the family of such beneficiary, for any service or 
item for which the Secretary has made payment under this 
section;
    (3) The total amount of payment a health care provider or 
agent may receive for health care furnished under this section 
may not exceed the amount billed to the Secretary.
    (4) The Secretary, upon request, shall disclose to such 
third party information received for the purposes of carrying 
out this section..
    [c] (d) For the purposes of this section--
          (1) The term ``health care''--
                  (A) means home care, hospital care, nursing 
                home care, outpatient care, preventive care, 
                habilitative and rehabilitative care, case 
                management, and respite care; and
                  (B) includes--
                          (i) the training of appropriate 
                        members of a child's family or 
                        household in the care of the child; and
                          (ii) the provision of such 
                        pharmaceuticals, supplies, equipment, 
                        devices, appliances, assistive 
                        technology, direct transportation costs 
                        to and from approved sources of health 
                        care, and other materials as the 
                        Secretary determines necessary.
          (2) The term ``health care provider'' includes 
        specialized spina bifida clinics, health care plans, 
        insurers, organizations, institutions, and any other 
        entity or individual furnishing health care services 
        that the Secretary determines are authorized under this 
        section.
          (3) The term ``home care'' means outpatient care, 
        habilitative and rehabilitative care, preventive health 
        services, and health-related services furnished to an 
        individual in the individual's home or other place of 
        residence.
          (4) The term ``hospital care'' means care and 
        treatment for a disability furnished to an individual 
        who has been admitted to a hospital as a patient.
          (5) The term ``nursing home care'' means care and 
        treatment for a disability furnished to an individual 
        who has been admitted to a nursing home as a resident.
          (6) The term ``outpatient care'' means care and 
        treatment of a disability, and preventive health 
        services, furnished to an individual other than 
        hospital care or nursing home care.
          (7) The term ``preventive care'' means care and 
        treatment furnished to prevent disability or illness, 
        including periodic examinations, immunizations, patient 
        health education, and such other services as the 
        Secretary determines necessary to provide effective and 
        economical preventive health care.
          (8) The term ``habilitative and rehabilitative care'' 
        means such professional, counseling, and guidance 
        services and treatment programs (other than vocational 
        training under section 1804 of this title) as are 
        necessary to develop, maintain, or restore, to the 
        maximum extent practicable, the functioning of a 
        disabled person.
          (9) The term ``respite care'' means care furnished on 
        an intermittent basis for a limited period to an 
        individual who resides primarily in a private residence 
        when such care will help the individual to continue 
        residing in such private residence.

           *       *       *       *       *       *       *


Sec. 1813. Health care

    (b) *  *  *
    (c)(1) If payment made by the Secretary for health care 
under this section is less than the amount billed for such 
health care, the health care provider or agent of the health 
care provider may, in accordance with paragraphs (2) through 
(4), seek payment for the difference between the amount billed 
and the amount paid by the Secretary from a responsible third 
party to the extent that the provider or agent would be 
eligible to receive payment for such health care from such 
third party.
      (2) The health care provider or agent may not impose any 
additional charge on the beneficiary who received health care, 
or the family of such beneficiary, for any service or item for 
which the Secretary has made payment under this section;
    (3) The total amount of payment a health care provider or 
agent may receive for health care furnished under this section 
may not exceed the amount billed to the Secretary; and
    (4) The Secretary, upon request, shall disclose to such 
third party information received for the purposes of carrying 
out this section.
    [(c)] (d) Definitions.--For purposes of this section, the 
definitions in section 1803(c) of this title shall apply with 
respect to the provision of health care under this section, 
except that for such purposes--
          (1) the reference to ``specialized spina bifida 
        clinic'' in paragraph (2) of that section shall be 
        treated as a reference to a specialized clinic treating 
        the birth defect concerned under this section; and
          (2) the reference to ``vocational training under 
        section 1804 of this title'' in paragraph (8) of that 
        section shall be treated as a reference to vocational 
        training under section 1814 of this title.

           *       *       *       *       *       *       *


CHAPTER 20--BENEFITS FOR HOMELESS VETERANS

           *       *       *       *       *       *       *



Subchapter II--Comprehensive Service Programs

           *       *       *       *       *       *       *



Sec. 2011. Grants

    (a) Authority To Make Grants.--[(1)] Subject to the 
availability of appropriations provided for such purpose, the 
Secretary shall make grants to assist eligible entities in 
establishing programs to furnish, and expanding or modifying 
existing programs for furnishing, the following to homeless 
veterans:
          (A) Outreach.
          (B) Rehabilitative services.
          (C) Vocational counseling and training
          (D) Transitional housing assistance.
    [(2) The authority of the Secretary to make grants under 
this section expires on September 30, 2005.]

           *       *       *       *       *       *       *


Sec. 2013. Authorization of appropriations

    There are authorized to be appropriated $130,000,000 for 
fiscal year 2006 and each subsequent fiscal year to carry out 
this subchapter [amounts as follows:].
          [(1) $60,000,000 for fiscal year 2002.
          [(2) $75,000,000 for fiscal year 2003.
          [(3) $75,000,000 for fiscal year 2004.
          [(4) $75,000,000 for fiscal year 2005.]

           *       *       *       *       *       *       *


CHAPTER 74--VHA--PERSONNEL

           *       *       *       *       *       *       *



Subchapter I--Appointments

           *       *       *       *       *       *       *



Sec. 7402. Qualifications of appointees

    (b)(9) * * *
    (b)(10) Marriage and family therapist--To be eligible to be 
appointed to a marriage and family therapist position, a person 
must--
          (A) hold a master's degree in marriage and family 
        therapy, or a comparable degree in mental health, from 
        a college or university approved by the Secretary; and
          (B) be licensed or certified to independently 
        practice marriage and family therapy in a State, except 
        that the Secretary may waive the requirement of 
        licensure or certification for an individual marriage 
        and family therapist for a reasonable period of time 
        recommended by the Under Secretary for Health.
    (b)[10](11) Chiropractor.--To be eligible to be appointed 
to a chiropractor position, a person must--
          (A) hold the degree of doctor of chiropractic, or its 
        equivalent, from a college of chiropractic approved by 
        the Secretary; and
          (B) be licensed to practice chiropractic in a State.
    (b)[11](12) Other Healthcare Positions.--To be appointed as 
a physician assistant, expanded-function dental auxiliary, 
certified or registered respiratory therapist, licensed 
physical therapist, licensed practical or vocational nurse, 
occupational therapist, dietitian, microbiologist, chemist, 
biostatistician, medical technologist, dental technologist, or 
other position, a person must have such medical, dental, 
scientific, or technical qualifications as the Secretary shall 
prescribe.
    (c) Except as provided in section 7407(a) of this title, a 
person may not be appointed in the Administration to a position 
listed in section 7401(1) of this title unless the person is a 
citizen of the United States.
    (d) A person may not be appointed under section 7401(1) of 
this title to serve in the Administration in any direct 
patient-care capacity unless the Under Secretary for Health 
determines that the person possesses such basic proficiency in 
spoken and written English as will permit such degree of 
communication with patients and other healthcare personnel as 
will enable the person to carry out the person's healthcare 
responsibilities satisfactorily. Any determination by the Under 
Secretary for Health under this subsection shall be in 
accordance with regulations which the Secretary shall 
prescribe.
    (e) A person may not serve as Chief of Staff of a 
Department healthcare facility if the person is not serving on 
a full-time basis.
    (f) A person may not be employed in a position under 
subsection (b) (other than under paragraph (4) of that 
subsection) if--
          (1) the person is or has been licensed, registered, 
        or certified (as applicable to such position) in more 
        than one State; and
          (2) either--
                  (A) any of those States has terminated such 
                license, registration,
                or certification for cause; or
                  (B) the person has voluntarily relinquished 
                such license, registration, or certification in 
                any of those States after being notified in 
                writing by that State of potential termination 
                for cause.

           *       *       *       *       *       *       *


Sec. 7404. Grades and pay scales

    (c) * * *
    (d) Except as provided under [subchapter III] paragraph 
(e), subchapter III and in section 7457 of this title, pay may 
not be paid at a rate in excess of the rate of basic pay for an 
appropriate level authorized by section 5315 or 5316 of title 5 
for positions in the Executive Schedule, as follows:
          (1) Level IV for the Deputy Under Secretary for 
        Health.
          (2) Level V for all other positions for which such 
        basic pay is paid under this section.
    (e) The position of Chief Nursing Officer, Office of 
Nursing Services, shall be exempt from the provisions of 
section 7451 of this title and shall be paid at a rate not to 
exceed the maximum rate established for the Senior Executive 
Service under section 5382 of title 5 United States Code, as 
determined by the Secretary.

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *



Subchapter I--Acquisition and Operation of Medical Facilities

           *       *       *       *       *       *       *



Sec. 8110. Operation of Medical Facilities

    (a)(4) * * *
    [(5) Notwithstanding any other provision of this title or 
of any other law, funds appropriated for the Department under 
the appropriation accounts for medical care, medical and 
prosthetic research, and medical administration and 
miscellaneous operating expenses may not be used for, and no 
employee compensated from such funds may carry out any activity 
in connection with, the conduct of any study comparing the cost 
of the provision by private contractors with the cost of the 
provision by the Department of commercial or industrial 
products and services for the Veterans Health Administration 
unless such funds have been specifically appropriated for that 
purpose.]
    [(6)] (5) (A) Temporary research personnel of the Veterans 
Health Administration shall be excluded from any ceiling on 
full-time equivalent employees of the Department or any other 
personnel ceiling otherwise applicable to employees of the 
Department. (B) For purposes of subparagraph (A) of this 
paragraph, the term ``temporary research personnel'' means 
personnel who are employed in the Veterans Health 
Administration in other than a career appointment for work on a 
research activity and who are not paid by the Department or are 
paid from funds appropriated to the department to support such 
activity.

                                  
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