[House Report 110-817]
[From the U.S. Government Publishing Office]





110th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     110-817

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



 
                   RURAL VETERANS ACCESS TO CARE ACT

                                _______
                                

 August 1, 2008.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

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

                              R E P O R T

                        [To accompany H.R. 1527]

      [Including cost estimate of the Congressional Budget Office]

  The Committee on Veterans' Affairs, to whom was referred the 
bill (H.R. 1527) to amend title 38, United States Code, to 
allow highly rural veterans enrolled in the health system of 
the Department of Veterans Affairs to receive covered health 
services through providers other than those of the Department, 
and for other purposes, having considered the same, report 
favorably thereon with amendments and recommend that the bill 
as amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     3
Background and Need for Legislation..............................     3
Hearings.........................................................     4
Subcommittee Consideration.......................................     5
Committee Consideration..........................................     5
Committee Votes..................................................     5
Committee Oversight Findings.....................................     5
Statement of General Performance Goals and Objectives............     5
New Budget Authority, Entitlement Authority, and Tax Expenditures     5
Earmarks and Tax and Tariff Benefits.............................     5
Committee Cost Estimate..........................................     6
Congressional Budget Office Estimate.............................     6
Federal Mandates Statement.......................................     8
Advisory Committee Statement.....................................     8
Constitutional Authority Statement...............................     8
Applicability to Legislative Branch..............................     8
Section-by-Section Analysis of the Legislation...................     9
Changes in Existing Law Made by the Bill as Reported.............     9

                               Amendment

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

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Rural Veterans Access to Care Act''.

SEC. 2. PILOT PROGRAM OF ENHANCED CONTRACT CARE AUTHORITY FOR HEALTH 
                    CARE NEEDS OF VETERANS IN HIGHLY RURAL AREAS.

  (a) In General.--Section 1703 of title 38, United States Code, is 
amended by adding at the end the following new subsection:
  ``(e)(1) The Secretary shall conduct a pilot program which permits 
highly rural veterans--
          ``(A) who are enrolled in the system of patient enrollment 
        established under section 1705(a) of this title, and
          ``(B) who reside within Veterans Integrated Service Network 
        1, 15, 18, and 19,
to elect to receive covered health services for which such veterans are 
eligible through a non-Department health-care provider.
  ``(2) The election under paragraph (1) shall be made by submitting an 
application to the Secretary in accordance with such regulations as the 
Secretary prescribes. The Secretary shall authorize such services to be 
furnished to the veteran pursuant to contracting with such a provider 
to furnish such services to such veteran.
  ``(3) For purposes of this subsection, a highly rural veteran is one 
who--
          ``(A) resides in a location that is--
                  ``(i) more than 60 miles driving distance from the 
                nearest Department health-care facility providing 
                primary care services, if the veteran is seeking such 
                services;
                  ``(ii) more than 120 miles driving distance from the 
                nearest Department health-care facility providing acute 
                hospital care, if the veteran is seeking such care; or
                  ``(iii) more than 240 miles driving distance from the 
                nearest Department health-care facility providing 
                tertiary care, if the veteran is seeking such care; or
          ``(B) in the case of a veteran who resides in a location less 
        than the distance indicated in clause (i), (ii), or (iii) of 
        subparagraph (A), as applicable, experiences such hardship or 
        other difficulties in travel to the nearest appropriate 
        Department health-care facility that such travel is not in the 
        best interest of the veteran, as determined by the Secretary 
        pursuant to regulations prescribed for purposes of this 
        subsection.
  ``(4) For purposes of this subsection, a covered health service is 
any hospital care, medical service, rehabilitative service, or 
preventative health service authorized to be provided by the Secretary 
under this chapter or any other provision of law.
  ``(5) For purposes of this subsection, a health-care provider is any 
qualified entity or individual furnishing a covered health service.
  ``(6) In meeting the requirements of this subsection, the Secretary 
shall develop the functional capability to provide for the exchange of 
medical information between the Department and non-Department health-
care providers.
  ``(7) This subsection shall apply to covered health services provided 
during the 3-year period beginning on the 120th day after the date of 
the enactment of this subsection.
  ``(8) Not later than the 30th day after the close of each year of the 
period described in paragraph (7), the Secretary shall submit a report 
to the Committees of Veterans' Affairs of the House of Representatives 
and the Senate a report which includes--
          ``(A) the Secretary's assessment of the program under this 
        subsection, including its cost, volume, quality, patient 
        satisfaction, benefit to veterans, and any other findings and 
        conclusions of the Secretary with respect to such program, and
          ``(B) any recommendations that the Secretary may have for--
                  ``(i) continuing the program,
                  ``(ii) extending the program to other or all service 
                regions of the Department, and
                  ``(iii) making the program permanent.''.
  (b) Effective Date.--The Secretary of Veterans Affairs shall 
implement the amendment made by subsection (a) not later than the 120th 
day after the date of the enactment of this Act.

  Amend the title so as to read:

    A bill to amend title 38, United States Code, to direct the 
Secretary of Veterans Affairs to conduct a pilot program to 
permit certain highly rural veterans enrolled in the health 
system of the Department of Veterans Affairs to receive covered 
health services through providers other than those of the 
Department.

                          Purpose and Summary

    H.R. 1527 was introduced by Representative Jerry Moran of 
Kansas on March 14, 2007. H.R. 1527, as amended, would require 
the Department of Veterans Affairs (VA) to conduct a three-year 
demonstration project in Veterans Integrated Service Networks 
(VISNs) 1, 15, 18, and 19 to allow highly rural veterans 
enrolled in VA health care to receive covered services through 
non-VA providers.
    The bill would define a highly rural veteran as one who 
resides 60 miles from VA primary care services, 120 miles from 
the nearest VA facility providing acute hospital care, or more 
than 240 miles from the nearest VA facility providing tertiary 
care.
    The bill would require VA to develop the functional 
capability to exchange medical information between VA and non-
VA providers in the pilot.
    The bill would direct the VA to submit a report to Congress 
upon the conclusion of the first year of the pilot, and each 
year thereafter, that includes an assessment of the program 
cost, volume, quality, patient satisfaction, and benefit to 
veterans; and, any recommendations for continuation, extension, 
or for making the program permanent.

                  Background and Need for Legislation

    Approximately 39 percent of enrolled veterans utilizing the 
VA health care system live in rural areas. It is a challenge 
for these veterans to access VA health care services because of 
their geographic distance from VA facilities and limited 
transportation services.
    VA is undertaking a number of initiatives to help veterans 
in rural areas gain better access to health care services. 
Central to this effort is the expansion of community-based 
outpatient care. VA is scheduled to activate 44 new clinics 
over the next 15 months. This would increase VA's network of 
independent and community-based clinics to 782, an addition of 
more than 100 clinics over the past five years. VA is also 
expanding readjustment counseling services through community-
based Vet Centers. Today, VA operates 232 Vet Centers and will 
open an additional 39 centers across the country by the end of 
2009. Additionally, VA is expanding its telehealth and 
telemedicine programs, which are using new technology to bring 
doctors to their patients, rather than patients to their 
doctors.
    In 2007, pursuant to the Veterans Benefits, Health Care, 
and Information Technology Act of 2006 (Public Law 109-461) VA 
established an Office of Rural Health (ORH). The purpose of the 
ORH is to develop policies to provide the best solutions to the 
challenges of providing rural health care and innovative 
practices to support the unique needs of veterans residing in 
rural areas. In June 2008, a Rural Health Advisory Committee 
was created to advise the Secretary on health care issues 
facing enrolled veterans in rural areas.
    The Committee recognizes and commends the steps VA is 
taking to improve care and services for veterans in rural and 
highly rural areas. However, we remain concerned that there are 
still barriers to accessing VA care for veterans in highly 
rural areas and there is a need to expand opportunities for 
veterans living the farthest away from VA facilities to receive 
needed primary care locally in non-VA facilities.
    Current law authorizes VA to provide fee-for-service care 
in a veteran's local community when the treating facility 
cannot provide the required care or because of geographical 
inaccessibility. However, the decision to utilize such care is 
left to the facility providing the care.
    H.R. 1527, as amended, would require VA to conduct a three-
year demonstration project to allow enrolled highly rural 
veterans in four VISNs with large rural populations to receive 
covered services through non-VA providers. To ensure continuity 
of care, the legislation would require VA to develop the 
functional capability to exchange veterans' medical information 
between VA and non-VA providers in the pilot. To effectively 
implement the pilot program, the Committee also expects the 
Secretary to establish regulations for payment that would be 
consistent with the authorized allowable reimbursement rate VA 
currently has established of 70 percent of the applicable 
Medicare rate.
    The Committee believes that this pilot program would 
support VA's efforts to improve care and services for veterans 
who reside in rural areas.

                                Hearings

    On April 26, 2007, the Subcommittee on Health held a 
legislative hearing on a number of bills introduced during the 
110th Congress, including H.R. 1527. The following witnesses 
testified: The Honorable Stevan Pearce of New Mexico; The 
Honorable Ginny Brown-Waite of Florida; The Honorable Solomon 
P. Ortiz of Texas; The Honorable Steven R. Rothman of New 
Jersey; The Honorable Hilda L. Solis of California; The 
Honorable Tom Latham of Iowa; The Honorable Jason Altmire of 
Pennsylvania; The Honorable Jerry Moran of Kansas; The 
Honorable Bob Filner of California; Ms. Shannon Middleton, 
Deputy Director for Health, Veterans Affairs and Rehabilitation 
Commission, The American Legion; Mr. Kimo S. Hollingsworth, 
National Legislative Director, American Veterans (AMVETS); Mr. 
Adrian M. Atizado, Assistant National Legislative Director, 
Disabled American Veterans; Mr. Carl Blake, National 
Legislative Director, Paralyzed Veterans of America; Mr. Dennis 
M. Cullinan, Director, National Legislative Service, Veterans 
of Foreign Wars of the United States; Mr. Richard F. Weidman, 
Executive Director for Policy and Government Affairs, Vietnam 
Veterans of America; Gerald M. Cross, M.D., FAAFP, Acting 
Principal Deputy Under Secretary for Health, Veterans Health 
Administration, U.S. Department of Veterans Affairs, 
accompanied by Mr. Walter A. Hall, Assistant General Counsel, 
U.S. Department of Veterans Affairs. Those submitting 
statements for the record included: the American Academy of 
Neurology, and The Honorable Ruben Hinojosa of Texas.

                       Subcommittee Consideration

    On July 10, 2008, the Subcommittee on Health met in open 
markup session and ordered favorably forwarded to the full 
Committee H.R. 1527, as amended, by voice vote. During 
consideration of the bill the following amendment was 
considered: An amendment in the nature of a substitute by Mr. 
Moran of Kansas to create a pilot program and establish the 
four VISNs where the pilot program will be conducted as VISNs 
1, 15, 18 and 19, was agreed to by voice vote.

                        Committee Consideration

    On July 16, 2008, the full Committee met in an open markup 
session, a quorum being present, and ordered H.R. 1527, as 
amended, reported favorably to the House of Representatives, by 
voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report the legislation and amendments thereto. 
There were no record votes taken on amendments or in connection 
with ordering H.R. 1527 reported to the House. A motion by Mr. 
Buyer of Indiana to order H.R. 1527, as amended, reported 
favorably to the House of Representatives was agreed to by 
voice vote.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
2(b)(1) of rule X of the Rules of the House of Representatives, 
the Committee's oversight findings and recommendations are 
reflected in the descriptive portions of this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are reflected in the descriptive portions 
of this report.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee adopts as its 
own the estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues contained in the 
cost estimate prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

                  Earmarks and Tax and Tariff Benefits

    H.R. 1527 does not contain any congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9(d), 9(e), or 9(f) of rule XXI of the Rules of the 
House of Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
1527 prepared by the Director of the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 1527 provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 31, 2008.
Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 1527, the Rural 
Veterans Access to Care Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                          Peter H. Fontaine
                                   (For Peter R. Orszag, Director).
    Enclosure.

H.R. 1527--Rural Veterans Access to Care Act

    Summary: H.R. 1527 would require the Department of Veterans 
Affairs (VA) to implement a pilot program that would pay for 
certain veterans who are enrolled in the VA health care program 
to receive medical care outside the VA system. The program 
would be carried out over a three-year period in four specific 
Veterans Integrated Services Networks (VISNs), which are 
regional networks of medical facilities. CBO estimates that 
implementing H.R. 1527 would cost about $1.6 billion over the 
2009-2013 period, assuming appropriation of the necessary 
amounts.
    Enacting the bill also could affect direct spending for 
Medicare, but CBO estimates any such effects would not be 
significant. Enacting the bill would not affect revenues.
    H.R. 1527 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would impose no costs on state, local, or tribal 
governments.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of H.R. 1527 is shown in the following table. 
The costs of this legislation fall within budget function 700 
(veterans benefits and services).

----------------------------------------------------------------------------------------------------------------
                                                                   By fiscal year in millions of dollars--
                                                            ----------------------------------------------------
                                                              2009    2010    2011    2012    2013    2009-2013
----------------------------------------------------------------------------------------------------------------
                                 CHANGES IN SPENDING SUBJECT TO APPROPRIATION\1\

Estimated Authorization Level..............................     210     440     685     235       0        1,570
Estimated Outlays..........................................     190     415     660     280      25       1,570
----------------------------------------------------------------------------------------------------------------
\1\In addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
  enacting H.R. 1529 could increase direct spending, but that any such changes would be less than $500,000 a
  year.

    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted near the end of fiscal year 2008, 
that the estimated amounts will be appropriated for each year, 
and that outlays will follow historical spending patterns for 
the VA medical services program.

Spending subject to appropriation

    H.R. 1527 would require VA to implement a pilot program to 
pay for certain enrollees to receive medical care outside the 
VA system. The program would be carried out over a three-year 
period--from February 2009 through January 2012--in VISNs 1, 
15, 18, and 19. Those VISNs include states in various parts of 
the country, including the northeast, central, southwest, and 
northwest. Under the bill, enrollees could elect to receive 
health care through non-VA providers and VA would pay for such 
care if:
           The enrollee requires primary care and lives 
        more than 60 miles driving distance from the nearest VA 
        facility providing such care,
           The enrollee requires acute hospital care 
        and lives more than 120 miles driving distance from the 
        nearest VA facility providing such care,
           The enrollee requires tertiary care and 
        lives more than 240 miles driving distance from the 
        nearest VA facility providing such care, or
           The enrollee does not meet the criteria 
        above but has difficulty traveling to VA facilities, as 
        determined by the Secretary of the VA.
    VA has indicated that the department would implement the 
pilot program required under the bill in the same fashion as 
its current fee-basis program. Under that program, VA has the 
authority to contract with health care providers outside the VA 
system to provide pre-approved services for certain veterans. 
VA negotiates the price of such services and pays the 
providers. Thus, under the pilot program, CBO assumes that VA 
will provide the required services through contracts with 
private health care providers, and that VA will pay the full 
cost of such care.
    Data from VA indicate that about 800,000 veterans in VISNs 
1, 15, 18, and 19 would be eligible for the pilot program. 
(That figure combines both current enrollees in the VA health 
system and veterans that are currently not enrolled.) Of that 
total, about 300,000 are currently using some VA-provided 
health care. Of the remainder, CBO estimates that about 200,000 
might choose to receive care in 2009 through the pilot program.
    CBO expects that, under the bill, eligible veterans would 
receive about 95 percent of their health care through VA. After 
adjusting for inflation and an estimated 10 percent increase in 
health care costs (care provided at non-VA facilities is 
generally more expensive than care provided at VA facilities), 
CBO estimates that in 2009 the department would spend an 
average of roughly $5,000 per new patient under the pilot 
program and less than $3,500, on average, for existing patients 
that participate in this pilot program. Those averages account 
for the different usage patterns of veterans, with some 
enrollees in the new program receiving only primary care, acute 
care, or tertiary care, and others receiving a combination of 
those three types of care.
    Using the above estimates of per-patient costs, and 
assuming appropriation of sufficient amounts to cover all those 
who choose to use the program, implementing it could cost as 
much as $2 billion a year, CBO estimates. However, because the 
proposed pilot program is temporary, CBO expects that not all 
eligible veterans would be able to enroll in the program during 
the three-year period, and that local health care providers 
would hesitate to invest in expanded facilities to accommodate 
veterans. Accounting for a slow, incremental take-up of the 
temporary benefit, CBO estimates that costs would rise from 
almost $200 million in 2009 to $660 million in 2011 (costs fall 
sharply in 2012 because the program would expire that year).

Direct spending

    Enacting H.R. 1527 could affect spending for Medicare, if 
community-based providers of health care would seek to recover 
costs from those programs before billing VA. However, under the 
current fee-basis program, VA pays for the entire cost of care, 
and CBO assumes the same would be true for the pilot program. 
Thus, for this estimate, CBO expects that any direct spending 
effects would be insignificant. (If VA chooses to implement 
this pilot program differently, Medicare could become the 
primary payer for veterans in this program, thus increasing 
direct spending significantly for that program.)
    Intergovernmental and private-sector impact: H.R. 1527 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would impose no costs on state, local, or 
tribal governments.
    Estimate prepared by: Federal Costs: Sunita D'Monte; Impact 
on State, Local, and Tribal Governments: Lisa Ramirez-Branum; 
Impact on the Private Sector: Daniel Frisk.
    Estimate approved by: Peter H. Fontaine, Assistant Director 
for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 1527 prepared by the Director of the 
Congressional Budget Office pursuant to section 423 of the 
Unfunded Mandates Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
1527.

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that the 
Constitutional authority for H.R. 1527 is provided by article 
I, section 8 of the Constitution of the United States.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    This section would provide the short title of H.R. 1527 as 
the ``Rural Veterans Access to Care Act.''

Section 2. Pilot program of enhanced contract care authority for health 
        care needs of veterans in highly rural areas

    This section would amend section 1703 of title 38, United 
States Code, by inserting a requirement that the VA establish a 
3-year pilot program allowing highly rural veterans residing in 
VISNs 1, 15, 18, and 19 to receive covered health services 
through a provider outside of the VA. A ``highly rural'' 
veteran would be defined as a veteran who lives more than 60 
miles driving distance from the nearest VA facility providing 
primary care services; more than 120 miles from the nearest VA 
facility providing acute hospital care; or more than 240 miles 
from the nearest VA facility providing tertiary care.
    Additionally, veterans who fail to meet these distance 
requirements but are subject to hardship or difficulty in 
travel to the nearest appropriate VA facilities may be eligible 
for the program at the determination of the Secretary. The 
Secretary would also be directed to develop the functional 
capability to share medical information with non-departmental 
providers. The 3-year pilot would be effective 120 days 
following enactment and the Secretary would be required to 
submit an annual assessment of the program to the Committee.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (new matter is 
printed in italic and existing law in which no change is 
proposed is shown in roman):

              SECTION 1703 OF TITLE 38, UNITED STATES CODE


Sec. 1703. Contracts for hospital care and medical services in non-
                    Department facilities

  (a) * * *

           *       *       *       *       *       *       *

  (e)(1) The Secretary shall conduct a pilot program which 
permits highly rural veterans--
          (A) who are enrolled in the system of patient 
        enrollment established under section 1705(a) of this 
        title, and
          (B) who reside within Veterans Integrated Service 
        Network 1, 15, 18, and 19,
to elect to receive covered health services for which such 
veterans are eligible through a non-Department health-care 
provider.
  (2) The election under paragraph (1) shall be made by 
submitting an application to the Secretary in accordance with 
such regulations as the Secretary prescribes. The Secretary 
shall authorize such services to be furnished to the veteran 
pursuant to contracting with such a provider to furnish such 
services to such veteran.
  (3) For purposes of this subsection, a highly rural veteran 
is one who--
          (A) resides in a location that is--
                  (i) more than 60 miles driving distance from 
                the nearest Department health-care facility 
                providing primary care services, if the veteran 
                is seeking such services;
                  (ii) more than 120 miles driving distance 
                from the nearest Department health-care 
                facility providing acute hospital care, if the 
                veteran is seeking such care; or
                  (iii) more than 240 miles driving distance 
                from the nearest Department health-care 
                facility providing tertiary care, if the 
                veteran is seeking such care; or
          (B) in the case of a veteran who resides in a 
        location less than the distance indicated in clause 
        (i), (ii), or (iii) of subparagraph (A), as applicable, 
        experiences such hardship or other difficulties in 
        travel to the nearest appropriate Department health-
        care facility that such travel is not in the best 
        interest of the veteran, as determined by the Secretary 
        pursuant to regulations prescribed for purposes of this 
        subsection.
  (4) For purposes of this subsection, a covered health service 
is any hospital care, medical service, rehabilitative service, 
or preventative health service authorized to be provided by the 
Secretary under this chapter or any other provision of law.
  (5) For purposes of this subsection, a health-care provider 
is any qualified entity or individual furnishing a covered 
health service.
  (6) In meeting the requirements of this subsection, the 
Secretary shall develop the functional capability to provide 
for the exchange of medical information between the Department 
and non-Department health-care providers.
  (7) This subsection shall apply to covered health services 
provided during the 3-year period beginning on the 120th day 
after the date of the enactment of this subsection.
  (8) Not later than the 30th day after the close of each year 
of the period described in paragraph (7), the Secretary shall 
submit a report to the Committees of Veterans' Affairs of the 
House of Representatives and the Senate a report which 
includes--
          (A) the Secretary's assessment of the program under 
        this subsection, including its cost, volume, quality, 
        patient satisfaction, benefit to veterans, and any 
        other findings and conclusions of the Secretary with 
        respect to such program, and
          (B) any recommendations that the Secretary may have 
        for--
                  (i) continuing the program,
                  (ii) extending the program to other or all 
                service regions of the Department, and
                  (iii) making the program permanent.

                                  
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