[Senate Report 110-473]
[From the U.S. Government Publishing Office]
Calender No. 1034
110th Congress Report
SENATE
2d Session 110-473
======================================================================
VETERANS' HEALTH CARE AUTHORIZATION ACT OF 2008
_______
September 18 (legislative day, September 17, 2008.--Ordered to be
printed
_______
Mr. Akaka, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
together with
SUPPLEMENTAL VIEWS
[To accompany S. 2969]
The Committee on Veterans' Affairs (hereinafter, ``the
Committee''), to which was referred the bill (S. 2969), to
enhance the capacity of the Department of Veterans Affairs to
recruit and retain nurses and other critical health care
professionals, and for other purposes, having considered an
amendment to the bill in the nature of a substitute,
unanimously reports favorably thereon with an amendment, and an
amendment to the title, and recommends that the bill, as
amended, do pass.
Introduction
On May 1, 2008, Chairman Akaka introduced S. 2969, the
proposed ``Veterans' Health Care Authorization Act of 2008.''
S. 2969, as introduced, would enhance the capacity of the
Department of Veterans Affairs (hereinafter, ``VA'') to recruit
and retain nurses and other critical health care professionals.
Earlier, on October 31, 2007, Chairman Akaka introduced, by
request, S. 2273, the proposed ``Enhanced Opportunities for
Formerly Homeless Veterans Residing in Permanent Housing Act of
2007.'' S. 2273 would enhance services for previously homeless
veterans and for veterans at risk of becoming homeless.
On November 16, 2007, Senator Durbin introduced S. 2377,
the proposed ``Veterans Health Care Quality Improvement Act.''
S. 2377 would establish quality assurance mechanisms in VA
medical facilities, and would create additional certification
and licensure requirements for VA physicians. S. 2377 is
cosponsored by Senator Obama.
On April 2, 2008, Chairman Akaka introduced S. 2796. S.
2796 would require VA to conduct a pilot program on the use of
community-based organizations to ensure that transitioning
veterans and their families receive the care and benefits to
which they are entitled.
On April 2, 2008, Chairman Akaka introduced, by request, S.
2797. S. 2797 would authorize major medical facility projects
and major medical facility leases for VA for fiscal year 2009,
among other purposes related to facilities.
On April 2, 2008, Senator Murray introduced S. 2799, the
proposed ``Women Veterans Health Care Improvement Act of
2008.'' S. 2799 would require studies of the health care needs
of women veterans and of the services available to them from
VA, and would require expansion of the services available to
women veterans. S. 2799 is cosponsored by Senators Boxer,
Brown, Casey, Clinton, Hutchison, Johnson, Lincoln, Mikulski,
Murkowski, Rockefeller, Schumer, and Wyden.
On April 17, 2008, Chairman Akaka introduced, by request,
S. 2889, the proposed ``Veterans Health Care Act of 2008.'' S.
2889 would allow VA to contract with community residential care
programs for veterans with serious traumatic brain injuries
(hereinafter, ``TBI''), eliminate copayments for all hospice
care, expand continuing education benefits for physicians and
dentists, and allow the Secretary of Veterans Affairs
(hereinafter, ``Secretary'') to disclose certain personal
information to collect payment from third-party health plans
under certain circumstances.
On April 22, 2008, Senator Harkin introduced S. 2899, the
proposed ``Veterans Suicide Study Act.'' S. 2899 would direct
VA to conduct a study on suicides among veterans. S. 2899 is
cosponsored by Senators Feingold, Grassley, Kerry, Klobuchar,
Mikulski, Murray, Obama, Stabenow, and Tester.
On April 28, 2008, Senator Clinton introduced S. 2921, the
proposed ``Caring for Wounded Warriors Act of 2008.'' S. 2921
would create pilot programs on training, certification, and
compensation for family caregivers of veterans and members of
the Armed Forces withTBI, and on the provision of respite care
to such veterans and servicemembers by graduate students at
affiliated universities. S. 2921 is cosponsored by Senator
Dole.
On April 28, 2008, Chairman Akaka introduced S. 2926, the
proposed ``Veterans Nonprofit Research and Education
Corporations Enhancement Act of 2008.'' S. 2926 would authorize
multi-medical center nonprofit research corporations
(hereinafter, ``NPCs''), clarify existing authorities, and
strengthen VA oversight of NPCs.
On April 29, 2008, Senator Tester introduced S. 2937. S.
2937 would provide VA with permanent authority to provide
health care for participants in certain Department of Defense
(DOD) chemical and biological tests, and would expand the study
of the impact of Project Shipboard Hazard and Defense
(hereinafter, ``Project SHAD'') on veterans' health.
On May 1, 2008, Senator Bond introduced S. 2963. S. 2963
would, among other things, enhance the mental health care
services available to members of the Armed Forces and veterans,
and enhance counseling and other benefits available to
survivors of members of the Armed Forces and veterans. S. 2963
is cosponsored by Senators Boxer, Clinton, Collins, Dole,
Domenici, Grassley, McCaskill, Murkowski, Obama, and Stevens.
On May 6, 2008, Chairman Akaka introduced, by request, S.
2984, the proposed ``Veterans' Benefits Enhancement Act of
2008.'' S. 2984 would extend VA authorities for certain kinds
of long-term care and care for veterans who participated in
certain chemical and biological tests conducted by DOD, extend
VA authority to continue an audit recovery program, eliminate
or modify a number of reporting requirements, modify
authorities relating to collections from third parties for
certain medical care, authorize disclosure of certain personal
information in limited circumstances, increase the threshold
for major medical facility leases requiring Congressional
approval from $600,000 to $1,000,000, and provide authorities
for the operation and upkeep of the VA police force. S. 2984
would also address a number of matters related to veterans'
benefits.
On May 8, 2008, Chairman Akaka introduced S. 3000, the
proposed ``Native American Veterans Access Act of 2008.'' S.
3000 would include Federally recognized tribal organizations in
certain programs for State veterans homes.
On June 19, 2008, Ranking Member Burr introduced S. 3167.
S. 3167 would clarify the conditions under which veterans,
their surviving spouses, and their children may be treated as
adjudicated mentally incompetent for certain purposes.
On June 23, 2008, Ranking Member Burr introduced S. 3178.
S. 3178 would authorize a dental insurance program for
veterans, survivors, and dependents of veterans.
On March 11, 2008, the Committee held a hearing on care for
families of wounded veterans. Testimony was offered by: Col.
Peter Bunce (USAF, Ret.), father of Justin Bunce, a veteran of
Operation Iraqi Freedom; Robert Verbeke, father of Daniel
Verbeke, a veteran of Operation Iraqi Freedom; Jackie
McMichael, wife of Michael McMichael, a veteran of Operation
Iraqi Freedom; Lynda Davis, PhD, Deputy Assistant Secretary of
the Navy for Military Personnel Policy, Department of the Navy;
Kristen Day, LCSW, Chief Consultant, Care Management and Social
Work, Office of Patient Care Services, Veterans Health
Administration, Department of Veterans Affairs; Jane Dulin,
LCSW, Supervisor, Soldier Family Management Branch, U.S. Army
Wounded Warrior Program; and Steven Sayers, PhD, Clinical
Psychologist, Philadelphia VA Medical Center and Assistant
Professor of Psychology in Psychiatry and Medicine, University
of Pennsylvania School of Medicine.
On April 9, 2008, the Committee held an oversight hearing
on personnel issues within VA. Testimony was offered by: Marisa
W. Palkuti, MEd, Director, Healthcare Retention and Recruitment
Office, Veterans Health Administration, Department of Veterans
Affairs; Sheila M. Cullen, Director, San Francisco VA Medical
Center; Steven P. Kleinglass, Director, Minneapolis VA Medical
Center; Marjorie Kanof, MD, Managing Director, Health Care,
Government Accountability Office; John A. McDonald, MD, PhD,
Vice President for Health Sciences and Dean, University of
Nevada School of Medicine, on behalf of the Association of
American Medical Colleges; Valerie O'Meara, NP, VA Puget Sound
Health Care System, Professional Vice President, American
Federation of Government Employees Local 3197; Randy Phelps,
PhD, Deputy Executive Director, American Psychological
Association Practice Directorate; and Jennifer L. Strauss, PhD,
Health Scientist, Center for Health Services Research in
Primary Care, Durham VA Medical Center, and Assistant
Professor, Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center, on behalf of the Friends of VA
Medical Care and Health Research.
On May 21, 2008, the Committee held a hearing on pending
health care legislation. Testimony was offered by: Gerald M.
Cross, MD, Principal Deputy Under Secretary for Health,
Department of Veterans Affairs; accompanied by Walter Hall,
Assistant General Counsel; and Kathryn Enchelmayer, Director,
Quality Standards, Office of Quality and Performance, Veterans
Health Administration; Carl Blake, National Legislative
Director, Paralyzed Veterans of America; Joseph L. Wilson,
Assistant Director for Health Policy, Veterans Affairs and
Rehabilitation Commission, The American Legion; Joy J. Ilem,
Assistant National Legislative Director, Disabled American
Veterans; Chris Needham, Senior Legislative Associate, National
Legislative Service, Veterans of Foreign Wars; Stan Luke, PhD,
Vice President for Programs, Helping Hands Hawaii; J. David
Cox, RN, National Secretary-Treasurer, American Federation of
Government Employees; Cecilia McVey, MHA, RN, Former President,
Nurses Organization of Veterans Affairs; Donna Lee McCartney,
Chair, National Association of Veterans' Research and Education
Foundations; Thomas Berger, PhD, Chair, National PTSD and
Substance Abuse Committee, Vietnam Veterans of America; and
Sally Satel, MD, Resident Scholar, American Enterprise
Institute.
Committee Meeting
After carefully reviewing the testimony from the foregoing
hearings, the Committee met in open session on June 26, 2008,
to consider, among other legislation, an amended version of S.
2969, consisting of provisions from S. 2969 as introduced, from
other legislation noted above, and several freestanding
provisions. The Committee voted unanimously to report favorably
S. 2969, as amended.
Summary of S. 2969 as Reported
S. 2969, as reported, (hereinafter, ``the Committee bill'')
would amend the title of the original bill, and would make
numerous enhancements and expansions to VA health care and
services.
TITLE I--DEPARTMENT PERSONNEL MATTERS
Section 101 would authorize VA to extend title 38, United
States Code (U.S.C.), employment status to certain employees;
amend salary authorities for certain VA positions; amend the
statute governing certain work schedules; amend the statute
governing transparency and conduct of locality pay surveys; and
enhance other authorities to improve recruitment and retention
of medical professionals.
Section 102 would impose limitations on overtime duty and
would amend the statutes governing weekend duty and alternative
work schedules for nurses.
Section 103 would reauthorize and expand certain
educational assistance programs to improve recruitment and
retention.
Section 104 would establish standards for appointment and
practice of physicians in VA medical facilities.
TITLE II--HEALTH CARE MATTERS
Section 201 would repeal the sunset provision on the
inclusion of non-institutional extended care services in the
definition of medical services.
Section 202 would extend the authorities of nursing home
care, research corporations, and recovery audits.
Section 203 would provide permanent authority for the
provision of hospital care, medical services, and nursing home
care to veterans who participated in certain chemical and
biological testing conducted by DOD.
Section 204 would repeal the annual reporting requirements
on nurse pay and long-term planning.
Section 205 would amend the annual Gulf War research report
by changing the report due date.
Section 206 would mandate that payment by VA on behalf of a
covered beneficiary for the Civilian Health and Medical Program
of VA (hereinafter, ``CHAMPVA'') medical care shall constitute
payment and eliminate any liability on the part of the
beneficiary for that care.
Section 207 would modify authorities relating to
collections from third parties for medical care, including care
provided to children of Vietnam veterans born with spina bifida
or birth defects.
Section 208 would authorize VA to make disclosures from
certain medical records under limited circumstances.
Section 209 would require the disclosure to the Secretary
of health plan contract information and social security numbers
of certain veterans receiving care from VA.
Section 210 would require the designation of a National
Quality Assurance Officer, and a Quality Assurance Officer for
each VA facility.
Section 211 would require a report on Department health
care quality assurance.
Section 212 would require VA to establish a pilot program
on training and certification for family caregivers and
personal care attendants for veterans of the Armed Forces with
TBI.
Section 213 would require VA to establish a pilot program
on the provision of respite care to members of the Armed Forces
and veterans with TBI by students in graduate programs of
education related to mental health or rehabilitation.
Section 214 would require VA to establish a pilot program
on the use of community-based organizations to ensure that
transitioning veterans and their families receive the care and
benefits they need.
Section 215 would authorize VA to contract with appropriate
entities for specialized residential care and rehabilitation
for certain Operation Iraqi Freedom or Operation Enduring
Freedom (hereinafter, ``OIF/OEF'') veterans with TBI.
Section 216 would exempt veterans receiving hospice care
from copayment requirements.
Section 217 would repeal the limitation on the authority of
the Secretary to conduct a widespread human immunodeficiency
virus (hereinafter, ``HIV'') testing program.
Section 218 would authorize VA to disclose medical records
to a third party for collection of charges for care or services
provided for a non-service-connected disability.
Section 219 would require VA to establish an expanded study
on the health impact of Project SHAD.
Section 220 would require VA to provide care and services
to certain individuals in non-Department facilities under
limited circumstances.
Section 221 would authorize tribal organizations to access
the construction grants and per diem payments provided under
the State Veterans Home Program in the same manner as other
eligible entities.
Section 222 would authorize the extension of the pilot
program on improvement of caregiver assistance services through
fiscal year 2009.
Section 223 would require VA to establish a pilot program
on the provision of dental insurance plans to veterans,
survivors, and dependents of veterans.
TITLE III--WOMEN VETERANS HEALTH CARE
Section 301 would require VA to report on the barriers to
women veterans' access to VA health care.
Section 302 would require VA to develop a plan to improve
the provision of health care services to women veterans.
Section 303 would require an independent study on the
health consequences of service in OIF/OEF for women veterans.
Section 304 would require VA to implement a program of
training and certification for VA mental health care providers
on care for veterans suffering from military sexual trauma.
Section 305 would require VA to establish a pilot program
on counseling in retreat settings for women veterans newly
separated from service in the Armed Forces.
Section 306 would require a report on full-time women
veterans' program managers at VA medical centers.
Section 307 would require the Advisory Committees on Women
Veterans and Minority Veterans to include women veterans
recently separated from service in the Armed Forces.
Section 308 would require VA to establish a pilot program
on child care for certain veterans receiving health care from
VA.
TITLE IV--MENTAL HEALTH CARE
Section 401 would establish eligibility for members of the
Armed Forces who served in OIF/OEF for readjustment counseling
and related mental health services through the Readjustment
Counseling Service of the Veterans Health Administration.
Section 402 would restore the authority of the Readjustment
Counseling Service to provide referral and other assistance to
former members of the Armed Forces not otherwise authorized for
counseling.
Section 403 would require VA to conduct a study on suicides
among veterans since January 1, 1997, and report to Congress on
the findings.
Section 404 would require VA to transfer $5,000,000 to the
Secretary of Health and Human Services for the Graduate
Psychology Education program.
TITLE V--HOMELESS VETERANS
Section 501 would authorize VA to establish a pilot program
to make grants to public and nonprofit organizations that
coordinate the provision of supportive services to formerly
homeless veterans residing on certain military property.
Section 502 would authorize VA to establish a pilot program
to make grants to public and nonprofit organizations that
coordinate the provision of supportive services to formerly
homeless veterans residing in permanent housing.
Section 503 would authorize VA to establish a pilot program
to make grants to public and nonprofit organizations that
provide outreach to inform low-income and elderly veterans who
reside in rural areas about pension benefits.
Section 504 would authorize VA to establish a pilot program
on financial support of entities that provide transportation
assistance, childcare assistance, and clothing assistance to
veterans entitled to certain rehabilitation services.
Section 505 would require assessments of the pilot programs
authorized by sections 501 through 504.
Section 506 would increase the authorization for the
Homeless Grant and Per Diem (GPD) Program from $130,000,000 to
$200,000,000.
TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS
Section 601 would authorize multi-medical center NPCs,
expand existing corporations to multi-medical center research
corporations, amend authorities on the applicability of state
law, clarify the status of corporations, and reinstate the
requirement of 501(c)(3) status of corporations.
Section 602 would clarify the purpose of NPCs.
Section 603 would amend the requirements for VA and non-VA
Board Members.
Section 604 would amend and clarify the provision on
general powers of corporations.
Section 605 would redesignate section 7364A of title 38,
U.S.C., as section 7365.
Section 606 would amend the provision on reporting by
adding additional information to be reported on; amend the
provision related to the confirmation of application of
conflict of interest regulations to include appropriate
corporation positions; and authorize establishment of an
appropriate payee reporting threshold.
Section 607 would repeal the provision that sunsets the
authority for corporations after December 31, 2008.
TITLE VII--CONSTRUCTION
Section 701 would authorize funds for fiscal year 2009
major medical facility projects.
Section 702 would extend the authorization for major
medical facility construction projects previously authorized.
Section 703 would authorize funds for fiscal year 2009
major medical facility leases.
Section 704 would authorize the appropriation of
$1,902,014,000 for the projects authorized by sections 701
through 703.
Section 705 would increase the threshold for major medical
facility leases requiring congressional approval from $600,000
to $1,000,000.
Section 706 would approve the conveyance of certain non-
federal land by the city of Aurora, CO, to the Secretary for
construction of a VA medical facility.
TITLE VIII--MISCELLANEOUS PROVISIONS
Section 801 would expand the authority for VA police
officers.
Section 802 would provide a uniform allowance for VA police
officers.
Section 803 would clarify the conditions under which
veterans, their surviving spouses, and their children may be
treated as adjudicated mentally incompetent for certain
purposes.
Background and Discussion
TITLE I--DEPARTMENT PERSONNEL MATTERS
Title I of the Committee bill contains a variety of
provisions that are designed to help ensure that VA has the
workforce necessary to serve America's veterans most
effectively.
Health care providers are the backbone of the VA system.
Yet today, it is clear, based on information received by the
Committee during its April 9, 2008, oversight hearing on the
Veterans Health Administration (hereinafter, ``VHA'') personnel
issues, entitled ``Making VA the Work Place of Choice for
Health Care Professionals,'' and from myriad other sources,
that VA faces a looming shortage of health care personnel and
that this situation will only worsen in the coming years
without focused effort to improve VA's ability to attract and
retain needed employees. A recent report by the Partnership for
Public Service, titled Where the Jobs Are: Mission Critical
Opportunities for America (2nd edition, 2007), gave the VHA
poor marks for pay and benefits, and for family support. VHA
also rated poorly among younger employees. To be the health
care employer of choice, VA must be able to offer competitive
salaries, work schedules, and benefits.
In recent years, VA has faced changing demands for health
care and for increasing competition for health care
professionals. The Bureau of Labor Statistics showed an 18.4
percent increase in employment in the health care industry in
2006, and noted that employment rose significantly in
hospitals, ambulatory health care settings, and nursing and
residential care. With an aging veteran population, and a shift
towards non-institutional care, VA has increased hiring of home
health aides and nurses significantly. The return of
servicemembers from the conflicts in Iraq and Afghanistan has
brought new demands for specialized mental health, trauma,
rehabilitation, and other care.
Health care professionals employed by VA are hired under a
variety of authorities--the regular, government-wide, personnel
hiring authorities in title 5, United States Code (U.S.C.); the
VA-specific personnel authority in title 38, U.S.C., and a
hybrid employment system that relies on features of both title
5 and title 38 authorities. The employment of persons in
occupations--physicians, dentists, podiatrists, chiropractors,
optometrists, registered nurses, physician assistants, and
expanded-function dental auxiliaries--listed in section 7401(1)
of title 38, U.S.C., is governed entirely by the title 38
system. Other occupations, listed in section 7401(3), are
referred to as hybrid employees.
The title 38 appointment system, established shortly after
World War II, was designed to be more flexible than the title 5
system. It provides an employment process and compensation
policies and practices that are helpful to VA in effectively
recruiting and retaining health care providers. For example,
under title 38, prospective hires are not required to go
through the competition and ranking process to establish
eligibility for employment, as is required under title 5.
Beginning in 1983, with the passage of the ``Veterans
Health Care Amendments of 1983,'' Public Law 98-160, Congress
authorized VA to hire, advance, and pay certain health care
providers under title 38, while leaving those personnel under
the title 5 personnel system for other purposes. The
appointment of individuals to these so-called ``hybrid''
occupations is governed by title 38, while pay and grievances
are governed by title 5. Hybrid employees are also eligible for
additional premium pay, if the Secretary determines it
necessary for the purposes of recruitment and retention.
Public Law 98-160 authorized VA to appoint and advance
licensed practical/vocational nurses (LPNs/LVNs), physical
therapists, and respiratory therapists under the hybrid system.
Additional occupations were included in 2003, under Public Law
108-170, in 2004, under Public Law 108-422, and in 2006, under
Public Law 109-461.
VA has indicated that this title 38 hybrid employment
system permits the Department to proactively respond to
recruitment and retention issues and reduces the costs
associated with these issues.
Sec. 101. Enhancement of authorities for retention of medical
professionals.
Section 101 of the Committee bill, which is derived from S.
2969, as introduced, contains a number of provisions that would
amend a variety of specific personnel authorities in title 38,
United States Code, so as to give the Secretary additional
tools to retain health care personnel.
Subsec. 101(a)--Secretarial authority to extend title 38 status to
additional positions.
Background. The unique features of the title 5, title 38,
and title 38 hybrid personnel systems have resulted in uneven
conditions of employment for some employees working in the same
occupational series and occupational groups. For example,
corrective therapy Assistants, hired under title 5, provide
services under the same occupational series as occupational
therapy assistants and physical therapy assistants, hired as
title 38 hybrids. All three work in the same organizational
units providing rehabilitation therapy, but are hired and
employed under different conditions.
In addition, testimony submitted by VA for the record of
the May 21, 2008, Committee hearing, stated that nurse
assistants, in particular, are a high priority position that
has proven difficult to fill. Furthermore, turnover of nurse
assistants is fairly high.
Committee Bill. Subsection (a)(1) of section 101 of the
Committee bill would amend section 7401(3) of title 38, so as
to give the Secretary of VA the authority to apply the title 38
hybrid employment system to additional health care occupations
when such action is deemed necessary to meet recruitment or
retention needs. The Secretary would be required to notify the
House and Senate Committees on Veterans' Affairs and the Office
of Management and Budget (OMB) 45 days prior to implementing a
decision to convert an occupation to the hybrid system. Prior
to Congressional and OMB notification, VA would be required to
notify labor organizations representing VHA employees in
occupations being considered for inclusion, in order to seek
their comments.
In testimony submitted for the record of the Committee's
May 21, 2008, hearing, VA indicated that it supports the
provisions of this subsection as this change would give the
Secretary the ability to react quickly, through the title 38
hiring process, to bring on additional employees.
Subsection (a)(2) of section 101 of the Committee bill
would further amend section 7401(3) by adding nurse assistants
to the list of occupations eligible for appointment under title
38. By bringing this position under the title 38 hiring
process, VA will have the ability to expedite hiring to fill
nurse assistant positions.
In accordance with the original purpose for a separate
title 38 hiring system, it is the Committee's intent that VA
continue to have the ability to expedite the hiring of certain
health care personnel. The Committee is aware that, as
presently implemented, the hiring process under title 38 has
not proven as expeditious as intended and that concerns have
been raised that adding additional professions to the list of
hybrid positions could overburden the title 38 hybrid
employment system. It is the Committee's belief, however, that
VA has the capacity, resources, and responsibility to resolve
the obstacles to expedited hiring under title 38.
In testimony submitted for the Committee's May 21, 2008,
hearing, VA indicated that it supports the provisions of
subsection (a)(2) of this section of the Committee bill. VA
cited data showing turnover rates of 10.5 percent for 2006 and
11.1 percent for 2007, which illustrate the great difficulty VA
experiences in retaining nurse assistants.
Subsec. 101(b) and (c)--Probationary periods for registered nurses, and
prohibition on temporary part-time registered nurse
appointments in excess of 4,180 hours.
Subsections (b) and (c) of section 101 of the Committee
bill are addressed below together, as they are dependent upon
each other, and address similar issues.
Subsection (b) would modify the terms of the probationary
period that registered nurses must serve upon employment by VA,
and subsection (c) would limit the extent of a temporary
appointment of part-time registered nurses.
Background. Subsection 7403(b) of title 38, U.S.C.,
provides that appointments of health care providers under that
section shall be for a probationary period of two years. The
probationary period serves to ensure an appropriate time of
observation and vetting before an employee becomes permanent.
Currently, part-time RNs are employed by VA on a temporary
basis under section 7405 of title 38. As temporary employees,
they are not eligible for the same job protection and grievance
rights as employees appointed under section 7403 who have
completed the probationary periods. Further, when an employee
transitions from full to part-time, they are considered
employees under section 7405, with commensurate loss of rights
and protections. Valerie O'Meara, NP, representing the American
Federation of Government Employees, testified before the
Committee on April 9, 2008, about her experience switching from
full- to part-time status to raise a family. She explained that
she lost her grievance and arbitration rights, and was not
permitted to contest Reductions-In-Force decisions. Further,
she described the cases of older nurses who have worked a
decade or more for the VA who switch to part-time because of
the stress of their job or to care for their aging parents. The
Committee believes VA would benefit from retaining the
expertise of these registered nurses, even on a part-time
basis.
VA has been challenged to fill RN positions due to rising
demand for these professionals. In testimony submitted for the
record of the Committee's April 9, 2007, hearing, Ann Converso,
RN, President of United American Nurses, AFL-CIO, stated that
``[t]here exists a health care crisis in our country regarding
the shortage of registered nurses * * *. As nurses leave the VA
system, new nurses are not joining the VA at comparable rates,
and patient load is increasing.'' According to the testimony of
Sheila M. Cullen, Director, San Francisco VA Medical Center, at
that same hearing, more than 29 percent of the employees at the
San Francisco VA Medical Center are eligible to retire.
Committee Bill. Subsections (b) and (c) of section 101 of
the Committee bill would clarify the terms of a probationary
period under section 7403 of title 38, U.S.C., and address the
inequity faced by part-time nurses under section 7405 of title
38.
Subsection (b) would amend section 7403(b) by adding two
new paragraphs. New paragraph (2) would mandate that an
appointment of a registered nurse under the section, whether on
a full- or part-time basis, shall be for a probationary period
of a length considered appropriate by VA but in any event no
more than 4,180 hours. The intent of this provision is to
establish a maximum duration of the probationary period that
can be applied equitably to both full- and part-time
appointments. Further, it provides the Secretary with
additional authority to reduce the duration of the probationary
period.
New paragraph (3) would mandate that an appointment on a
part-time basis under section 7403 of a health care
professional who has previously served on a full-time basis
shall be without a probationary period. This provision would
clarify that no registered nurse (RN), who has already served a
probationary period, would be required to serve a probationary
period upon switching from a full-time to a part-time
appointment. The Committee sees no utility in requiring an RN
who has served a probationary period on a full-time basis to
serve an additional probationary period.
Subsection (c) of section 101 would amend section 7405 of
title 38, to add a new subsection (g). The proposed new
subsection would specify that the appointment of an RN on a
temporary part-time basis under section 7405 would be for a
probationary period, as defined under section 7403(b), as would
be amended by subsection (b) of section 101 of the Committee
bill. Upon completion of the probationary period, the
appointment would no longer be considered temporary, and would
instead be considered an appointment under 7403(a). Pursuant to
this change, and the completion of the probationary period, all
temporary part-time appointments of RNs would be considered
permanent.
It is the Committee's intent that the amendments to
sections 7403 and 7405 will eliminate disincentives to part-
time employment of RNs in VA. Many RNs, after serving a full
career in VA, or in response to family concerns, are faced with
the decision to either retire from VA or transition to part-
time service. Informed by the testimony presented at the
Committee hearings on April 9, 2008, and May 21, 2008, the
Committee believes VA would benefit from the service that these
registered nurses would provide on a part-time basis. Further,
increased use of part-time registered nurses will help VA fully
staff facilities and better meet the rising demand for health
care services.
It is not the intent of the Committee bill to prevent or
limit the hiring of part-time nurses beyond the probationary
period. Rather, the Committee intends that upon completion of
such period, the appointment be considered permanent, with all
accompanying benefits and privileges.
Carl Blake, National Legislative Director, Paralyzed
Veterans of America, in testimony before the Committee on May
21, 2008, voiced support for the provision to eliminate the
probationary period for RNs who transition from full-time to
part-time.
Subsec. 101(d)--Waiver of offset from pay for certain reemployed
annuitants.
Subsection (d) of section 101 of the Committee bill would
authorize VA to waive salary offsets for retirees who are
reemployed in VHA.
Background. Under current law, the salary of a VHA employee
rehired after retirement from the Federal government is reduced
according to the amount of their annuity under a government
retirement system. The reduction is required by sections 8344
and 8468 of title 5, U.S.C., which deal with annuity payments
upon reemployment.
VHA faces a growing wave of retirements at all levels of
administration and health care providers. According to VA, at
the end of 2006, 56 percent of medical center directors were
eligible for retirement, and by 2013 over 90 percent of these
key personnel will be eligible for retirement. Many of the
likely successors for the director positions, current Associate
Directors, are also retirement eligible. VA projects that by
2013, 95,019 VHA employees will be eligible to retire,
including 97 percent of current senior executives, 81 percent
of facility Chiefs of Staff, and 91 percent of nurse
executives. This rate of retirement eligibility is
unprecedented, and the sudden loss of the experience and
expertise of these employees would seriously limit VA's ability
to deliver care.
Because reemployed annuitants receive only that portion of
their salary that is above their annuity payment, there is
little incentive under the current employment system to return
to VA employment. Annuitants who wish to continue working are
able to receive full pay from a non-government employer, in
addition to their annuity, something they can not do at VA.
In testimony before the Committee on May 21, 2008, Cecilia
McVey, MHA, RN, former President of the Nurses Organization of
Veterans Affairs, said that ``During this time of a critical
nursing shortage, it is more important than ever to keep these
valuable resources to provide the best care to veterans.''
Rehiring annuitants addresses issues arising from the high
number of retirements facing VA. Increased employment of
annuitants would potentially limit costs by reducing the use of
expensive contract agreements. Retaining experienced
professionals while younger employees develop their
capabilities would also ensure the transfer of valuable
institutional knowledge from one generation of leaders to
another within VA.
A program which allows the Government Accountability Office
to temporarily hire retirees, without a salary offset, for the
purposes of training, education, and mentoring, has proven
successful.
Committee Bill. Subsection (d) of section 101 of the
Committee bill would amend section 7405 of title 38 so as to
add a new subsection (g) which would authorize the Secretary to
waive sections 8344 and 8468 of title 5, U.S.C., on a case-by-
case basis when reemploying an annuitant on a temporary basis.
This section would further require that an annuitant to whom a
waiver under the proposed new section (g) is granted be subject
to the provisions of chapter 71 of title 5, relating to the
protection of government employees from discrimination and
retaliation.
By authorizing the Secretary to waive these two sections of
title 5, the Committee intends to encourage retirees to return
to work at VHA. At present, many VA employees go on to work
outside of VA after retiring from VA, with some even returning
to work at VA on a contract basis. By eliminating the salary
offset, it is the Committee's hope that there will be a
significant pay incentive that will encourage annuitants to
return to VA, rather than seeking employment elsewhere.
Subsec. 101(e)--Rate of basic pay for appointees to the Office of the
Under Secretary for Health set to rate of basic pay for senior
executive service positions.
Subsection (e) of section 101 of the Committee bill would
amend section 7404(a) of title 38, U.S.C., to set the rate of
basic pay for appointees to the Office of the Under Secretary
for Health.
Background. Under current law, non-physician and non-
dentist appointees under section 7306 of title 38, which
relates to the composition of VA's Office of Under Secretary
for Health, including the Director of Pharmacy Benefits
Management Strategic Health Group, the Director of Dietetics,
the Director of Podiatry, and the Director of Optometry, among
others, serve in executive level positions that are equivalent
in scope and responsibility to positions in the Senior
Executive Service (SES), which includes senior managers and
administrators in the VA Central Office, among others. The pay
level for section 7306 appointees is adjusted each year by
Executive Order, as authorized by chapter 53 of title 5, and is
capped, by subsection 7404(d) of title 38, U.S.C., at the pay
rate for Level V of the Executive Schedule, currently just over
$139,600 including locality pay. VA employees in the SES, on
the other hand, can receive pay up to Level II of the Executive
Schedule, currently $172,200.
According to VA, the disparity between pay levels for SES
and non-SES employees serving in similar capacities has led to
difficulties in recruiting and retaining non-SES executive
level managers. Executives in these positions provide valuable
input to the Under Secretary for Health (USH), and manage
significant elements of VHA.
Committee Bill. Subsection (e) of section 101 of the
Committee bill would amend section 7404(a) of title 38 so as to
add a paragraph that would mandate that pay for certain
appointees to the Office of the Under Secretary for Health be
set according to the SES. This change would be effective on the
first day of the first pay period beginning the day after 180
days after the date of enactment of this legislation.
This change would effectively establish that, for the
purposes of basic pay, all senior executives in the Office of
the Under Secretary for Health would receive pay based on Level
II of the Executive Schedule. By implementing a uniform pay
scale for all senior executives in that office, the Committee
believes VA will be better able to recruit and retain highly
qualified individuals.
This provision was developed in close cooperation with VA,
and VA indicated its support for this subsection in testimony
submitted for the record of the Committee's May 21, 2008,
hearing.
In testimony before the Committee on May 21, 2008, Thomas
Berger, PhD, Chair of the National PTSD and Substance Abuse
Committee, Vietnam Veterans of America (VVA), expressed VVA's
support for additional pay ``to enhance recruitment and
retention of top professionals to run the VA health care
system.''
Subsec. 101(f)--Comparability pay program for appointees to the Office
of the Under Secretary for Health.
Background. VA is challenged match the compensation offered
by non-Federal employers to senior executives. The past decade
has seen significant changes in VA health care. In order to
maintain its position as a premier health care provider, VHA
will require a corps of dedicated, skilled, and experienced
senior executives to carry out the responsibilities involved in
delivering care to veterans. The Committee believes that VA
must deal with pay inequities proactively.
Committee Bill. Subsection (f) of section 101 of the
Committee bill would amend section 7410 of title 38, relating
to additional pay authorities for VHA employees, so as to
authorize VHA to pay ``comparability pay'' of not more than
$100,000 per employee to non-physician/dentist section 7306
employees and VHA SES employees. This pay would be authorized
so that VHA could achieve annual pay levels competitive with
the private sector, and to relieve pay compression over the
complex range of senior executive positions. This special pay
would be in addition to all pay, awards, and performance
bonuses provided under SES or 7306 authorities. Under the
Committee bill, the higher special pay amounts would be
reserved only for the most senior VHA executive positions and,
when added to basic pay and bonus compensation, would be capped
at the annual pay of the President.
Subsec. 101(g)--Special incentive pay for Department pharmacist
executives.
Background. VA is challenged match the compensation offered
by non-Federal employers to senior executives, including
National Pharmacist Executives (NPEs). NPEs include managers of
the VA National Formulary, Directors of the Consolidated Mail
Outpatient Pharmacies, Consultants to the Secretary for
pharmacy issues, Network Pharmacy Benefits Managers, and the
Director of Emergency Pharmacy Services. Under current law,
basic salaries for NPEs are set according to the General
Schedule, which caps salaries for these positions between
$140,000 and $145,000, with up to $5,000 in bonuses. According
to surveys conducted by VA, salary ranges for national and
regional pharmacy executives are between $180,000 and $225,000.
Further inducements commonly available in the private sector
include profit sharing or stock options, yearly bonuses well
above the $5,000 currently available from VA, recruitment and
retention bonuses, and corporate vehicles for individuals in
regional positions.
VA has been challenged to fill NPE positions in recent
years, due largely to the pay disparity between VA and the
private sector, and the lack of financial incentive to take on
responsibilities at the national and regional level. In
addition, applications for Chief of Pharmacy positions at VA
facilities, the primary source of future NPEs, have fallen off
dramatically. The Workforce Succession Strategic Plan for VHA
FY 2006-2010 (October, 2005), listed pharmacists second only to
RNs as national priorities for recruitment and retention.
Committee Bill. Subsection 101(g) of the Committee bill
would further amend section 7410, relating to additional pay
authorities, to authorize recruitment and retention special
incentive pay for pharmacist executives of up to $40,000. The
determination of whether to provide such pay, and its amount,
would be based on: grade, step, scope and complexity of the
position, personal qualifications, characteristics of the labor
market concerned, and such other factors as the Secretary
considers appropriate. As with the comparability pay that would
be authorized by subsection (f) of the Committee bill, this
provision would provide that such pay would be in addition to
other pay, awards, and bonuses.
Subsec. 101(h)--Pay for physicians and dentists.
Subsection 101(h) of section 101 of the Committee bill
would make three separate amendments to section 7431 of title
38, relating to pay for physicians and dentists.
Committee Bill. Paragraph (1) of subsection (h) would
clarify the determination of the non-foreign cost of living
adjustment (COLA), authorized by section 7431(b) of title 38,
U.S.C. The COLA is provided to employees in locations with
substantially higher costs of living than those of Washington,
DC, and or environmental conditions that differ substantially
from those in the continental United States. Similar
provisions, applied to other government employees, exist in
section 5941 of title 5, U.S.C.
Paragraph (1) of subsection 101(h) of the Committee bill
would amend section 7431(b) so as to add a new paragraph that
would provide that the non-foreign cost of living adjustment
allowance authorized under section 5941 of title 5, U.S.C.,
shall, in the case of VA physicians and dentists, be determined
as a percentage of base pay only. Section 7431(b) currently
does not specify the basis for the determination of the
allowance, which has led to inconsistent determinations.
Paragraph (2) of subsection (h) would amend section
7431(c)(4)(B)(i) to exempt physicians and dentists in executive
leadership provisions from the panel process in determining the
amount of market pay and tiers for such physicians and
dentists. Market pay is ``pay intended to reflect the
recruitment and retention needs for the specialty or assignment
* * * of a particular physician or dentist'' in a VA facility.
Under current law, the Secretary is to take into account the
views of ``an appropriate panel or board'' in determining the
amount of market pay for an individual physician or dentist. In
cases where such physicians or dentists in question occupy
executive leadership positions such as chief officers, network
directors, and medical center directors, the consultation of a
panel has some limitations. The small number of providers who
would qualify as peers for the executive leaders results in
their serving on each other's compensation panels. This
amendment will provide the Secretary with discretion to
identify executive physician/dentist positions that do not
require a panel process.
Paragraph (3) of subsection (h) would amend section
7431(c)(7) of title 38, so as to allow an exception to the
prohibition in current law on a reduction in market pay when a
physician or dentist remains in the same position or
assignment. The exception would allow for a reduction in market
pay when there has been a change in board certification or a
reduction of privileges, even when the individual remains in a
position or assignment. By allowing such reduction in market
pay, the Committee bill would prevent a physician or dentist
from receiving additional market compensation for credentials
and or privileges he or she may no longer possess.
In testimony submitted for the record of the Committee
hearing on May 21, 2008, VA indicated support for the
provisions in subsection 101(h) of the Committee bill.
Subsec. 101(i)--Adjustment of pay cap for nurses.
Subsection (i) of section 101 of the Committee bill relates
to pay for RNs.
Background. Under current law, section 7451 of title 38
governs basic pay levels for VA RNs, and certain other VA
employees. Section 7451(c)(2) mandates that the maximum rate of
basic pay for any grade for a covered position, including RNs,
may not exceed the maximum rate of basic pay established for
positions in level V of the Executive Schedule under section
5316 of title 5, U.S.C. Level V is currently set at $139,600.
In testimony submitted for the Committee's April 9, 2008,
hearing, Ms. Converso cited a ``crisis in our country regarding
the shortage of registered nurses.'' At the same hearing,
Marisa W. Palkuti, M.Ed., Director, Healthcare Retention and
Recruitment Office, VHA, cited a growing inadequacy in the
number of health care workers, including RNs, nationwide, and
suggested that ``[t]his shortfall will grow exponentially over
the next 20 years.''
During that hearing, Sheila M. Cullen, the then-Director of
the San Francisco VA Medical Center, testified about her
efforts to retain nurses. To compete with other health care
employers in the region, and to address the high cost of
living, Ms. Cullen has instituted salary increases for RNs
between 5 and 8 percent annually in recent years.
The current level V cap often prevents VA registered nurses
from receiving locality pay. Locality pay, which is in addition
to basic pay, is based on compensation levels in a local labor
market. When a nurse's basic pay is equal to the level V cap,
no additional locality pay can be awarded, regardless of
conditions in local labor market, a result that has a
detrimental effect on recruitment and retention.
Committee Bill. Subsection (i) of section 101 of the
Committee bill would amend section 7451(c)(2) of title 38, so
as to adjust the pay cap for registered nurses and others in
covered positions from Level V to Level IV. Level IV is
currently set at $149,000, according to OMB. By raising the cap
on nurse basic pay by $9,400, the Committee intends to provide
VA with additional flexibility to compete in local labor
markets. Based on testimony presented at Committee hearings,
and on oversight activities, the Committee believes that
additional pay would improve VA's ability to recruit and retain
qualified nurses.
This provision was supported by the American Federation of
Government Employees in testimony before the Committee on April
9 and May 21, 2008. Also, in testimony before the Committee on
May 21, 2008, Cecilia McVey, MHA, RN, Former President of the
Nurses Organization of Veterans Affairs, called for the
increase in the cap on RN pay proposed by the Committee bill.
Subsec. 101(j)--Exemption for certified registered nurse anesthetists
from limitation on authorized competitive pay.
Subsection (j) of section 101 of the Committee bill would
allow pay for certified registered nurse anesthetists (CRNAs)
to exceed the pay caps established for RNs employed by VA.
Background. As discussed above, under subsection 101(i),
current law limits pay for CRNAs at level V of the Executive
Schedule, currently $139,600. Additional compensation may be
provided to CRNAs in the form of recruitment and/or retention
bonuses. As is currently the case with RNs, the level V cap
often prevents CRNAs from receiving locality pay.
In December 2007, the Government Accountability Office
released a report on CRNA retention, titled ``Department of
Veterans Affairs (VA) medical facilities have challenges in
recruiting and retaining VA CRNAs for their workforce'' (GAO-
08-56). GAO found that about three-fourths of all VA medical
facility chief anesthesiologists responding to the survey
reported that they had difficulty recruiting CRNAs. Overall, 54
percent of VA medical facility chief anesthesiologists reported
temporarily closing some operating rooms and 72 percent
reported delaying some elective surgeries due to difficulty
fully staffing CRNAs. GAO projected that 26 percent of VA's
CRNAs will either retire from or leave VA in the next 5 years.
VA medical facility officials reported that the recruitment and
retention challenges are caused primarily by the low level of
VA CRNA salaries when compared with CRNA salaries in local
market areas.
In testimony before the Committee on April 9, 2008, Ms.
Cullen, and Steven P. Kleinglass, Director of the Minneapolis
VA Medical Center, both discussed the challenges created by the
current limit on CRNA pay. Mr. Kleinglass noted that at the
Minneapolis VAMC, the VA pay scale falls behind the local
medical community as a whole, and that ``therefore, in theory,
we should have most of our employees on a retention bonus.''
Ms. Cullen, in San Francisco, is prevented from offering
locality pay due to the statutory limit, even though the local
median salary for CRNAs is $171,334. As a result, she has had
to implement the 25 percent retention incentive extensively. At
the same hearing, Ms. O'Meara echoed these concerns.
``Facilities around the country are finding it increasingly
difficult to recruit CRNAs.''
Committee Bill. Subsection (j) of section 101 of the
Committee bill would further amend section 7451(c)(2) of title
38, as amended by subsection 101(i) of the Committee bill, to
allow pay for CRNAs to exceed the pay caps established for RNs
employed by VA.
This proposed exemption would provide VA with greater
flexibility to offer additional pay to CRNAs, a necessary tool
when CRNA positions prove difficult to fill due to insufficient
compensation.
This proposed amendment was endorsed in testimony before
the Committee on May 21, 2008, by Carl Blake, National
Legislative Director, Paralyzed Veterans of America and J.
David Cox, RN, National Secretary-Treasurer, American
Federation of Government Employees.
Subsec. 101(k)--Locality pay scale computation.
Subsection 101(k) of the Committee bill would amend section
7451(d)(3) of title 38, U.S.C., to improve implementation and
transparency of VA's locality pay system for nurses and others
in covered positions.
Background. Section 7451(d) of title 38 currently
authorizes a locality pay system (LPS) to address
geographically-related pay issues, and to strengthen
recruitment and retention of nurses and others in covered
positions. That section mandates that pay for personnel in
covered positions at each facility be adjusted periodically to
reflect changing pay rates in local labor markets. The director
of each facility is charged with using data from the Bureau of
Labor Statistics (BLS) to determine prevalent pay rates, and to
make necessary adjustments to the pay of nurses and others in
covered positions employed by the facility in question. When
BLS data are not available, the director is required to use
data provided by a third party. If no third party data are
available, the director is required to conduct a locality pay
survey to determine prevalent pay rates. Each locality pay
schedule, of which there are nearly 800, is required to be
reviewed and approved by the USH.
In the report titled ``Many Medical Facilities Have
Challenges Recruiting and Retaining Nurse Anesthetists'' (GAO-
08-56, December, 2007), GAO found that, in 2005 and in 2006,
over half of VA medical facilities used the LPS to determine
whether to adjust VA CRNA salaries. However, in the eight VA
medical facilities visited, GAO found that the majority of the
facilities did not correctly follow VA's LPS policy. Officials
at these facilities did not always know or were not aware of
certain aspects of the LPS policy, and VA has not provided
training on the LPS to VA medical facility officials since the
policy was changed in 2001. As a result, GAO found that VA
medical facility officials cannot ensure that VA CRNA salaries
have been adjusted as needed to be competitive. While the
report dealt only with CRNAs, the conclusions regarding faulty
implementation of the LPS are likely applicable to others in
covered positions, based on Committee oversight activities.
The failure to properly implement the LPS runs the risk of
negatively effecting recruitment and retention, and
inappropriately limits the pay of nurses and others who
continue their employment at VA. Further, due to a lack of
transparency of the LPS process, employees do not have
reasonable access to the surveys that determine locality pay.
Committee Bill. Subsection (k)(1) of section 101 of the
Committee bill would add a new subparagraph (F) to section
7451(d)(3) of title 38. Proposed new subsection (F) would
require the USH to provide appropriate education, training, and
support to directors of Department health care facilities in
the conduct and use of LPS surveys. The Committee intends for
this change to address the inadequate training found by GAO.
In testimony before the Committee on April 9, 2008, Ms.
O'Meara emphasized the need for adequate training in the use
and implementation of the LPS. At the Committee hearing on May
21, 2008, Mr. Cox stated that ``management training on the
nurse locality pay process will increase compliance with the
2000 nurse locality pay law [The Veterans Benefits and Health
Care Improvement Act of 2000, Public Law 106-419] that Congress
enacted to address recruitment and retention.''
In testimony submitted for the record of the Committee
hearing on April 9, 2008, VA stated that development of web-
based training to assist in the conduct of surveys was expected
to be available by late summer 2008, and that additional
training events are planned. The Committee believes these are
important improvements in education on the LPS, but believes
that additional measures may be required.
Subsection (k)(2) of section 101 of the Committee bill
would add a new subparagraph (D) to section 7451(e)(4) of title
38. Under this proposed new subparagraph (D), which is intended
to improve transparency in the LPS, a facility director would
be required to publicize information on the methodology used in
making an adjustment to rates of pay based on the LPS.
Subsection (k)(3) of section 101 of the Committee bill
would further amend section 7451(e) by adding a new paragraph
(6). Under current law, each facility director is required to
report to the Secretary on wage-related staffing issues.
Proposed new paragraph (6) would require such reports to be
made available to any individual in a position included in such
report, or, upon the authorization of such individual, to the
representative of the labor organization representing that
individual. Taken together, the Committee believes that the
changes proposed by subsections (k)(2) and (3) of section 101
of the Committee bill will improve transparency of the LPS.
These amendments address concerns raised in testimony
before the Committee on May 21, 2008, by Mr. Cox, and on April
9, 2008, by Ms. O'Meara. According to Mr. Cox, ``greater
employee access to pay survey data will add accountability to
the locality pay process to ensure that surveys are done
properly and that needed pay adjustments are made.''
The Committee is aware that in some facilities, access to
LPS survey data is unnecessarily challenging for many
employees. As Ms. O'Meara said in her testimony on April 9,
2008, ``[l]ocality pay should be provided based on local labor
market conditions, and be paid according to consistent rules,
not on how hard employees fight for it or whether a particular
manager decides to pay it.''
Concerns have been raised that the Committee bill places
inordinate emphasis on the conduct of LPS surveys, rather than
the use of BLS or third party data, which VA prefers. The
Committee recognizes the value of BLS and third party data and
does not intend that facility directors conduct their own
surveys when such information is available. The Committee
believes that, implemented effectively and according to
statute, the LPS can effectively address geographically-related
pay issues, and can strengthen recruitment and retention.
Subsec. 101(l)--Increased limitation on special pay for nurse
executives.
Subsection 101(l) of the Committee bill would increase the
authorized limit on special pay for nurse executives.
Background. Under current law, the Secretary may provide
between $10,000 and $25,000 in special pay to nurse executives
at each VA health care facility and at VA Central Office. The
amount is determined based on the grade of the nurse executive
position, the scope and complexity of the nurse executive
position, the personal qualifications of the nurse executive,
the characteristics of the health care facility concerned, the
nature and number of specialty care units at the health care
facility concerned, demonstrated difficulties in recruitment
and retention of nurse executives at the health care facility
concerned, and such other factors as the Secretary considers
appropriate.
Given the limits on nurse pay, most nurse executives are
already paid at or near the top of their grade. As such, VA
lacks the ability to provide additional financial incentive to
individuals who take on the increased responsibility of
executive positions. Given the systemic shortage of nurses, as
discussed with respect to sections 101(i) and 101(j) of the
Committee bill, the Committee believes that additional
financial incentives are warranted to attract highly qualified
nurses to executive positions.
Committee Bill. Subsection (l) of section 101 of the
Committee bill would amend section 7452(g)(2) of title 38 so as
to increase the authorized limit on special pay for nurse
executives from $25,000 to $100,000.
In testimony before the Committee on May 21, 2008, Mr.
Blake expressed PVA's support for this provision of the
Committee bill.
Subsec. 101(m)--Eligibility of part-time nurses for additional nurse
pay.
Subsection (m) of section 101 of the Committee bill, which
is derived from S. 2969, would expand eligibility for
additional premium pay to part-time nurses.
Background. Additional pay for nurses is authorized by
section 7453 of title 38. In general, nurses are eligible for
overtime pay when they work over forty hours in a week or eight
hours in a day. Further additional pay is mandated for nurses
who work on weekends, at night, and on holidays. Other than
overtime pay, eligibility for additional pay is limited to
nurses working on specified tours of duty that meet the
requirements of each type of additional pay. Those nurses not
assigned to a specific tour are not eligible for the additional
pay associated with such tour, even if their period of service
includes hours which fall within the eligible time periods.
This limit affects the pay of both full- and part-time nurses,
as well as nurses who are on call and not assigned to tours of
duty.
Based on testimony presented at Committee hearings, and
information gathered during Committee oversight activity, as
discussed with respect to subsections (i) and (j) of section
101 of the Committee bill, the Committee concludes that in many
facilities VA is challenged to fill nurse staff positions and
some nursing tours are difficult to cover. The Committee
believes that the current eligibility criteria for additional
pay are too restrictive to create effective financial
incentives to encourage nurses to work those tours.
Further, the current additional pay statute creates
unacceptable inequities between part-time and full-time nurses.
In testimony before the Committee on April 9, 2008, Ms. O'Meara
cited chronic problems with implementation of additional pay
requirements. She urged ``the Committee to take steps to ensure
that premium pay is available to all RNs who perform services
on weekends or off shifts, work overtime on a voluntary or
mandatory basis, or work during on call duty.'' By not
providing part-time nurses additional pay on the same basis as
full-time nurses, there is a disincentive for part-time and on-
call nurses to serve during times of the day and week that are
harder to staff. This is contrary to the intent of the
additional pay authorities.
In addition, excluding part-time and on-call nurses from
eligibility for additional pay, and denying additional pay for
nurses not assigned to a specific eligible tour, creates
further disparity between VA and non-VA compensation, and
contributes to recruitment and retention challenges.
Committee Bill. Subsection (m) of section101 of the
Committee bill would amend section 7453 of title 38 so as to
expand eligibility for additional premium pay to part-time
nurses.
An amendment to subsection (a) of section 7453 would
provide that part-time nurses would be generally eligible for
additional pay when they meet the criteria in other subsections
of section 7453. Amendments to subsections (b)(concerning
evening pay), (c) (concerning weekend pay), and (d) (concerning
overtime pay), would, in multiple locations, replace ``tour of
duty'' with ``period of service.'' These changes would make any
service performed during evenings or weekends, or as overtime,
eligible for additional pay.
It is the Committee's intent to change the basis for
additional pay from the tour to the nurse's period of service
and the timing of such service. This reflects the original
Congressional intent that additional pay is intended to create
incentives for nurses to work at times that would otherwise be
difficult to staff. The changes proposed by the Committee bill
would not eliminate the utility of established tours nor would
they reduce additional pay for such tours. Rather, the changes
would encourage a greater number of nurses to work during such
times, and would equitably reward all nurses who do so.
In testimony before the Committee on May 21, 2008, Mr.
Blake expressed the support of Paralyzed Veterans of America
for the eligibility of part-time nurses to receive additional
pay.
Subsection (m)(1)(D)(i) of section 101 of the Committee
bill would address an inequity in eligibility for additional
pay for overtime under section 7453(e) of title 38. Under
current law, nurses who perform continuous service in excess of
eight hours but on two different calendar days are not eligible
for additional pay for overtime service. This section of the
Committee bill would amend section 7453(e) to add service
performed in excess of eight consecutive hours to the list of
services eligible for additional overtime pay. In testimony
before the Committee on April 9, 2008, Ms. O'Meara emphasized
the urgency of this legislative change.
Subsec. 101(n)--Exemption of additional nurse positions from limitation
on increase in rates of basic pay.
Subsection (n) of section 101 of the Committee bill, which
is derived from S. 2969, would make additional health care
occupations exempt from limitations on increases in rates of
basic pay.
Background. Under current law, rates of basic pay for
nurses and other health care providers may be increased under
section 7455 of title 38. Under that section, the Secretary may
determine that salary increases are necessary for the purposes
of recruitment and retention, and to compete with pay for
similar positions in non-Federal facilities in the same labor
market.
Under subsection (c)(1) of section 7455, the amount of
increase in the maximum pay rate generally is limited to two
times the amount by which the original maximum exceeds the
minimum, and the maximum rate as so increased may not exceed
the pay rate of the Assistant Under Secretary for Health. Nurse
anesthetists, pharmacists, and licensed physical therapists are
exempted from this limit, based on the challenges VA faces in
recruiting and retaining employees in these occupations, as
discussed earlier in connection with subsections (g), (i), and
(j) of section 101 of the Committee bill.
Committee Bill. Subsection (n) of section 101 of the
Committee bill would amend section 7455(c)(1) of title 38 so as
to make additional occupations exempt from limitations on
increases in rates of basic pay. Specifically, this provision
would add licensed practical nurses, licensed vocational
nurses, and nursing positions otherwise covered by title 5,
U.S.C., to the list of positions exempted from the limits
imposed by section 7455(c)(1) of title 38. This provision,
combined with subsection (i) of section 101 of the Committee
bill, should ensure that VA has the pay flexibility to compete
with other employers for qualified health care providers. In
testimony before the Committee on April 9 and May 21, 2008,
respectively, Ms. O'Meara and Mr. Cox emphasized the need for
additional pay flexibility to strengthen VA's ability to
compete with other employers.
Sec. 102. Limitations on overtime duty, weekend duty, and alternative
work schedules for nurses.
Subsection 102 of the Committee bill, which is derived from
S. 2969, would amend various provisions of title 38 so as to
establish special rules for nurse staff overtime service,
modify rules relating to leave during weekend duty, and change
the underlying authority for alternative work schedules for
nurses.
Subsec. 102(a)--Overtime duty.
Background. Under current law, the Secretary may require
nurses to perform mandatory overtime in emergency situations.
The Committee recognizes that this authority is essential to
ensuring adequate staffing to provide patient care. However,
based on oversight activities, and as discussed at the
Committee hearing on April 9, 2008, it appears that, at some
facilities, the use of emergency mandatory overtime is
excessive and even abusive.
At the Committee hearing on April 9, 2008, Ms. O'Meara
testified that ``facility directors continue to invoke the
emergency exception when staffing shortages are the result of
easily anticipated scheduling and hiring problems.'' At that
same hearing, testimony on this issue was received from two VA
medical center directors, Steven P. Kleinglass, of the
Minneapolis VA Medical Center, and Sheila M. Cullen, of the San
Francisco VA Medical Center. These two facilities illustrate
two different approaches to the use of the emergency mandatory
overtime authority. According to Mr. Kleinglass, in
Minneapolis, mandatory overtime is used to respond to a number
of situations, including unplanned leave, sick leave, emergency
annual leave, absenteeism, and tardiness for duty by nursing
staff. At the San Francisco VA Medical Center, on the other
hand, mandatory overtime has been used only once in the past
three years, an event implemented in cooperation with the local
bargaining unit.
The Committee is concerned that VA lacks a clear definition
of ``emergency'' for the purposes of implementing mandatory
overtime and that VA facility directors appear to have
unbridled discretion on the interpretation and implementation
of this authority. Without a clear definition of what
constitutes allowable situations, the use of emergency
authority can lead to inconsistent implementation and abuse.
Research has highlighted the danger of excessive overtime
service by nurses, as well as other health care providers. In
the report ``Keeping Patients Safe: Transforming the Work
Environment of Nurses'' (2004), the Institute of Medicine
recommended that ``to reduce error-producing fatigue, state
regulatory bodies should prohibit nursing staff from providing
patient care in any combination of scheduled shifts, mandatory
overtime, or voluntary overtime in excess of 12 hours in any
given 24-hour period and in excess of 60 hours per 7-day
period.''
At least nine states have enacted legislation restricting
the use of emergency mandatory overtime. In the interest of
patient and employee safety and appropriate labor standards,
these states limit the number of hours a nurse can be required
to work, except in certain defined emergency situations.
Committee Bill. Subsection (a) of section 102 of the
Committee bill would add a new section 7459 to subchapter IV of
chapter 74 of title 38. This new section would limit nursing
staff, including RNs, licensed practical or vocational nurses,
nurse assistants appointed under title 38 or title 5, U.S.C.,
or any other nurse position designated by the Secretary, to no
more than 40 hours of work per administrative work week (or 24
hours if such staff is covered by section 7456 of title 38),
and not more than eight consecutive hours (or 12 hours if such
staff is covered by sections 7456 or 7456A of title 38).
Nursing staff may exceed these limits voluntarily or in
emergency situations, as defined by the Committee bill.
The definition of ``emergency circumstances'' would be set
out in subsection (c) of the proposed new section 7459. Under
this subsection, the Secretary would be authorized to require
mandatory overtime otherwise prohibited if the following
conditions were met: (1) the work is a consequence of an
emergency that could not have been reasonably anticipated; (2)
the emergency is non-recurring and is not caused by or
aggravated by the inattention of the Secretary or lack of
reasonable contingency planning by the Secretary; (3) the
Secretary has exhausted all good faith, reasonable attempts to
obtain voluntary workers; (4) the nurse staff have critical
skills and expertise that are required for the work; and (5)
the work involves work for which the standard of care for a
patient assignment requires continuity of care through
completion of a case, treatment, or procedure. Nursing staff
would not be required to work hours after the requirement for a
direct role by the staff in responding to medical needs
resulting from the emergency ends.
The concern has been raised by VA that the requirements of
the Committee bill would unduly limit the Secretary's ability
to ensure patient care and safety. The Committee agrees
unequivocally that patient safety is of paramount concern.
However, the Committee is concerned that undue reliance on
mandatory overtime is not desirable and believes that, with
reasonable contingency planning, including consultation with
nurse staff, all VA facilities have the capacity to eliminate
unnecessary use of emergency mandatory overtime. It is clear
that many VA facilities already avoid unnecessary use of
emergency mandatory overtime through effective planning for
adequate nurse staffing.
Subsection (b)(2) of the proposed new section 7459 would
prohibit discrimination or adverse personnel action against
nursing staff if such staff were to refuse to work hours
prohibited by such section. This protection has proven
necessary in the many of the states which have legislatively
limited mandatory overtime, including Connecticut, Maryland,
Minnesota, New Jersey, and Washington.
In testimony before the Committee on May 21, 2008, Mr. Cox
expressed AFGE's support for this provision of the Committee
bill. He stated that these provisions ``will establish a
sensible and safe overtime policy that ensures that all nursing
positions are equally protected.''
Subsec. 102(b)--Weekend duty.
Section 102(b) of the Committee bill, which is derived from
S. 2969, would modify the calculation of leave for nurses
working two 12-hour tours of duty during a weekend.
Background. Section 7456 of title 38 authorizes the
Secretary to provide an alternate work schedule, commonly
referred to as the Baylor Plan, to nurse employees. Under this
plan, an employee who performs two regularly scheduled 12-hour
tours of duty on a weekend is paid for a full forty hours.
Under current law, an employee who is absent on approved sick
leave or annual leave during such a regularly scheduled 12-hour
tour of duty is charged for such leave at a rate of five hours
of leave for three hours of absence.
The Baylor Plan is intended to be used when facilities are
challenged to meet staffing needs on weekends. VA currently has
no nurses employed under this plan.
Committee Bill. Section 102(b) of the Committee bill would
strike section 7456(c) of title 38, to modify the calculation
of leave for nurses working under the Baylor Plan. The change
would specify that leave for such an employee would be charged
at a rate of one to one.
The Committee expects that eliminating the current leave
calculation will facilitate easier implementation of the Baylor
Plan. The provision in the Committee bill was modified from an
earlier version so as to address concerns raised by VA and to
better achieve this goal.
Subsec. 102(c)--Alternative work schedules.
Subsection (c) of section 102 of the Committee bill, which
is derived from S. 2969, would modify an existing alternative
work schedule available to VA nurses.
Background. Section 7456A of title 38, U.S.C., authorizes
the Secretary to provide alternative work schedules to RNs
working for VA. These schedules, known as ``36/40'' schedules,
allow VA nurses to work three regularly scheduled 12-hour tours
of duty within a work week and to have that service considered
for all purposes as a full 40-hour basic work week. These
alternative work schedules are authorized ``in order to obtain
or retain the services of registered nurses.''
Alternative work schedules were authorized in December 2004
by the Department of Veterans Affairs Health Care Personnel
Enhancement Act of 2004, Public Law 108-445. According to the
Senate report accompanying the legislation that resulted in the
new law, S. Rpt. 108-375, this new authority was a response to
an August 2003 request by VA so as to ``enhance its ability to
recruit and retain high quality nurses.'' In that report, the
Committee noted that, based on a survey conducted in 2000 by
the American Organization of Nurse Executives, inflexible
scheduling was a major cause of nurse dissatisfaction. The
original intent of Congress in authorizing alternative work
schedules was that such schedules be widely available so as to
enhance VA's ability to improve employee satisfaction and
therefore be better able to recruit and retain nurses in
competition with other employers.
Since the passage of Public Law 108-445, the implementation
of 36/40 alternative work schedules has varied throughout the
VA health care system. In testimony for the Committee hearing
on April 9, 2008, VA indicated that it ``encourages facility
managers to use alternate work schedules for all eligible
employees whenever feasible,'' and noted that the use of these
schedules ``increases VA's visibility as the employer of
choice.''
Some facilities, such as the San Francisco VA Medical
Center, have made effective use of alternative schedules to
reduce vacancy rates in nursing positions, and to improve nurse
satisfaction. In testimony before the Committee on April 9,
2008, the San Francisco VA Medical Center Director, Ms. Cullen,
stated that ``most new hires are highly interested in an
alternative work schedule. We believe that offering an
alternative work schedule improves recruitment, retention and
employee satisfaction.''
Mr. Kleinglass, the Director of the Minneapolis VAMC, in
testimony before the Committee on April 9, 2008, noted that the
use of alternative schedules at the Minneapolis VA Medical
Center allows staff to ``find balance between their work and
home lives as they feel best suits their individual needs.''
Unfortunately, based on Committee oversight work, many VA
facilities have failed to make 36/40 alternative work schedules
widely available. While facility directors have discretion on
the implementation of these schedules, Congress intended that
their use be throughout the VA health care system. In testimony
before the Committee on April 9, 2008, Ms. O'Meara stated:
As a result of delay and resistance by the VA at the
national and local levels, [alternative work schedules]
have failed to meet their potential for addressing VA
nurse recruitment and retention problems. It seems as
if the law was never passed.
Committee Bill. Subsection (c) of section 102 of the
Committee bill would amend section 7456A of title 38, U.S.C.,
so as to modify the 36/40 alternative work schedule authorized
by that section. Specifically, this section of the Committee
bill would amend section 7456A(b)(1)(A) to modify the
scheduling requirement for the 36/40 alternative work schedule.
Currently, the 36/40 alternative work schedule is defined as
``three regularly scheduled 12-hour tours of duty within a work
week.'' The Committee bill would redefine the schedule as six
regularly scheduled 12-hour periods of service within an 80-
hour pay period.
The intent of this provision is to facilitate easier
implementation of the alternative work schedule. In testimony
for the Committee hearing on May 21, 2008, VA noted that
because a work week is defined as Sunday through Saturday, it
is often difficult schedule three 12-hour tours in their
entirety within one work week. VA expressed support for these
provisions of the Committee bill, as they would provide greater
flexibility to scheduling.
By providing greater flexibility in the scheduling of the
alternative work schedule, the Committee intends to facilitate
and encourage wider use of such schedules. Based on hearing
testimony and oversight activities, the Committee believes that
by unnecessarily limiting the use of the current 36/40
alternative work schedules, VA facilities forego a valuable
recruitment and retention tool, and fail to keep pace with the
health care industry.
Sec. 103. Improvements to certain educational assistance programs.
Section 103 of the Committee bill, which is derived from S.
XXXX, would make amendments to two existing VA Education
Assistance Programs and would provide the Secretary with new
authority to make repayment of educational loans for certain
health professionals.
Background. Chapter 76 of title 38, U.S.C., contains
numerous authorities that are designed to enhance VA's ability
to attract and retain health professions. Among these
authorities are the Health Professional Scholarship Program, in
Subchapter II and the Education Debt Reduction Program, in
Subchapter VII.
The authorization for the programs needs to be extended in
order to continue to give VA this ability, as the private
sector has made recruiting health care professionals
increasingly competitive. Title VII of Public Law 105-368 and
Public Law 107-135 made amendments to these programs. VA
currently awards Employee Incentive Scholarship Program
(hereinafter ``EISP'') scholarships to qualifying and current
employees to help VHA meet the health care staffing
requirements set forth in Section 7401 of title 38, U.S.C., in
which the difficulties surrounding recruitment and retention of
VA health care employees is specifically addressed.
Committee Bill. Subsection (a) of section 103 of the
Committee bill would amend section 7618 of title 38, U.S.C., so
as to reinstate the Health Professionals Educational Assistance
Program (HPEAP) through the end of 2013. The Committee believes
that renewing HPEAP, which expired in 1988, will help reduce
the nursing shortage in VA by enabling VA to provide
scholarships to nursing personnel who, on completion of their
education, will be obligated to work a year for every year of
education, with a minimum obligation of two years, at a VA
health care facility. This subsection would also expand
eligibility for the scholarship program to all VA health
personnel appointed to positions described under paragraphs (1)
and (3) of section 7401 of title 38, which includes all title
38 health care employees as well as all hybrid occupations. The
Committee expects that this expansion of those eligible for the
scholarship program will be helpful in VA's efforts to recruit
and retain employees in a number of difficult-to-fill health
care occupations.
Subsection (b) of section 103 would amend three provisions
in subchapter VII of chapter 76, relating to VA's Education
Debt Reduction Program.
Paragraph (1) of subsection (b) would amend section
7681(a)(2) so as to add retention, along with recruitment, as a
purpose of the debt reduction program.
Paragraph (2) would amend subsection (a)(1) of section 7682
and would strike subsection (c) of that section so as to make
the debt reduction program available to ``an'' employee, not
just to a ``recently appointed'' employee as in current law.
The ``recently appointed'' requirement limits eligibility to
employees who have been appointed within six months. VA's
experience has been that this is not a sufficient period and
that, in some cases, it takes more than six months for
employees to become settled in their new jobs and to even
become aware of this program.
Paragraph (3) would amend subsection (d) of section 7683 to
increase the maximum amounts of education debt that can be
forgiven, both overall and in the fourth and fifth years of
participation in the debt reduction program, so as to raise the
overall amount from $44,000 to $70,000, and the maximum amount
in the fourth and fifth years from $10,000 to $12,000.
Subsection (c) of section 103 would authorize the
Secretary, in consultation with the Secretary of Health and
Human Services, to use the authorities in section 487E of the
Public Health Service Loan Repayment Program for the repayment
of educational loans of health professionals from disadvantaged
backgrounds in order to secure clinical research expertise in
VA from such individuals. This loan repayment program is
currently not available to federal employees other than those
working for the National Institutes of Health. By extending
this authority to VA, clinicians with medical specialization
and research interests may be more likely to join VHA.
Sec. 104. Standards for appointment and practice of physicians in
Department of Veterans Affairs medical facilities.
Section 104, which is derived from S. 2377, would establish
a new section in title 38, U.S.C., which would set out
procedures for appointing new physicians in VA, and the
requisite qualifications of such physicians.
Background. Current section 7402 of title 38, U.S.C., sets
forth the requirements that must be met in order for a person
to be appointed as a physician with VA. Included in these
requirements are that the applicant hold the degree of doctor
of medicine, or doctor of osteopathy, from a university
approved by the Secretary; that the applicant has completed an
internship approved by the Secretary; and that the applicant be
licensed to practice medicine, surgery, or osteopathy in a
State.
Under subsection (f) of section 7402, any applicant who has
or has had multiple licenses or certifications and has had one
or more of them suspended, revoked, or surrendered for cause,
is subject to employment restrictions. All applicants, with
certain exceptions, must possess basic English proficiency.
VA also requires extensive disclosures from applicants,
including the status of their credentials, and is permitted to
deny appointment or terminate employment if that information is
not disclosed. This information must be resubmitted every two
years. A VA policy that took effect on January 1, 2008,
requires applicants to submit an authorization to their State
licensing boards to permit those boards to release records to
VA. According to guidance from the Deputy Under Secretary for
Health for Operations and Management dated October 10, 2007, VA
Service Chiefs are required to review and document any health
care practitioner's record that has been flagged. Additionally,
the guidance requires Veterans Integrated Service Network
(VISN) Chief Medical Officers (CMO) to review any record in the
National Practitioners Data Bank relating to a practitioner
that shows three or more medical malpractice payments, a single
malpractice payment of $550,000 or more, or two malpractice
payments totaling $1,000,000 or more. The VISN CMO is then
required to review the relevant material and determine if the
appointment is appropriate. A similar review occurs for any
search returning negative action regarding an individual's
credentials or licensing.
Current law does not require physicians to be board
certified in the area in which they will practice in order to
be eligible for employment with VA. VA permits facility
directors and chiefs of staff to determine that an applicant is
qualified based on other factors. VA believes its current
requirements are in keeping with medical standards.
Physicians elsewhere in Federal service are not required to
be licensed in the State in which they practice, but simply to
be licensed in any State. VA makes use of telemedicine, and
exchanges physicians or allows physicians to collaborate with
others in the Federal system in different States. This also
occurs during certain emergency situations. Additionally, some
States have licensing procedures that take more than one year
to complete.
Committee Bill. Section 104 of the Committee bill would
establish a new section in title 38, U.S.C.,--Section 7402A.
Appointment and practice of physicians in VA medical
facilities--which would set forth the procedures for appointing
new physicians in VA, and the requisite or desired
qualifications to practice as a VA physician. This provision
would take effect immediately upon enactment, except for
subsection (f) as that section pertains to physicians already
employed by VA, which would go into effect 60 days after
enactment, and subsection (g), relating to performance
contracts with VISN directors, which would go into effect upon
the start of the first cycle, beginning after the date of
enactment, of performance contracts for VISN directors.
Subsection (a) of the proposed new section would require
the Secretary, through the USH, to develop and promulgate
minimum standards a physician must meet in order to be
appointed to that position in the VHA, or to be permitted to
practice in the VA medical facilities. The standards developed
would be required to include the requirements outlined in the
new section 7402A.
Subsection (b) of the proposed new section would require
any individual seeking to be appointed as a physician within
the VHA to provide the following information: a full and
complete explanation of any lawsuit for medical malpractice or
negligence that is pending or was brought against the
applicant; any settlements agreed to as a result of a lawsuit
for malpractice or negligence; and any investigation or
disciplinary action against the applicant that relates to the
applicant's work as a physician. The applicant must also
provide authorization to the licensing board of any state where
the applicant holds or has ever held a license to practice
medicine, to disclose to the Secretary any records pertaining
to: any lawsuit for malpractice or negligence brought against
the applicant, and the details any settlements agreed to as a
result; any court or administrative agency's judgment against
the applicant; any disciplinary action brought against the
applicant by any State body or administrative agency; any
change in the status of the applicant's license to practice
medicine, whether voluntary or involuntary; any open
investigation of, or outstanding allegation against, the
applicant; and any written notification from the State to the
applicant pertaining to the potential termination of the
applicant's license.
Subsection (c) of the proposed new section would require
any physician appointed to practice in the VHA, after the
enactment of the Committee bill, to disclose to the Secretary,
within 30 days of an occurrence: a judgment against the
physician for medical malpractice or negligence; a payment made
as part of a settlement for a lawsuit or action previously
disclosed prior to appointment; or any disposition or change in
status of any issue disclosed prior to appointment.
Additionally, this subsection would require any physician
practicing in VHA at the time of the enactment of the Committee
bill to provide authorization, within 60 days after the date of
enactment, identical to the authorization required for
applicants, to the State licensing board of any State where the
physician has held, or currently holds, a license to practice
medicine. A physician currently practicing in the VHA would be
required, as a condition of employment, to agree to disclose,
within 30 days of occurrence, any future judgment against the
physician or payment as part of a settlement arising from a
lawsuit alleging malpractice or negligence, or the disposition
or change in status of any matter disclosed pursuant to the
authorization for disclosure the physician would be required to
give to a State licensing board.
Subsection (d) of the proposed new section would require
the director of the VISN in which an applicant seeks employment
as a VA physician to conduct an investigation into the
information disclosed by the applicant as required by new
subsection (b). The appropriate VISN director also would be
required to perform a similar investigation of any material
disclosed by a VA physician employed as of the date of
enactment of the Committee bill, or a physician appointed after
that date who discloses information while employed by VA, as
required by new subsection (c). The results of all such
investigations would be required to be fully documented.
Subsection (e) of the proposed new section would require
any applicant seeking to be employed as a VA physician to
receive the approval of the appropriate VISN director. If the
applicant has disclosed information as required by new
subsection (b), the VISN director, if the director chooses to
approve the applicant, would be required to certify in writing
that the investigation of each issue required by new subsection
(d) was completed, and the director would be required to
provide a written explanation as to why any identified issue
did not disqualify the applicant.
Subsection (f) of the proposed new section would require
each VA medical facility that employs physicians who practice
at that facility to enroll each physician in the Proactive
Disclosure Service of the National Practitioners Database.
Subsection (g) of the proposed new section would require
the Secretary to include in each performance contract with a
VISN director, a provision that encourages the director to hire
physicians who are board certified or eligible for such
certification in the field in which they will be practicing
when employed by VA. The Secretary would be authorized to
determine the nature of this provision in the performance
contracts.
The Committee believes that the requirements that would be
put in place by the proposed new section 7402A are necessary to
strengthen qualification standards for hiring physicians at VA
and for monitoring their performance once they are working for
VA. Despite the measures VA has in place regarding review of
qualifications, history, and credentials, there have been
incidents of physicians practicing in VA with suspended
licenses and other problems with their qualifications. One of
the most recent incidents of such a situation occurred at the
Marion, Illinois, VA Medical Center, and that lack of
appropriate review resulted in several patient deaths. The fact
that VA's existing policy failed to prevent this result
illustrates that additional measures to prevent under-qualified
physicians from practicing medicine are needed and that it is
justified to give VA's hiring practices the force of law.
TITLE II--HEALTH CARE MATTERS
Many provisions in this title are taken from S. 2984 which,
as noted earlier, is a bill that was introduced at the request
of the Administration. Chairman Akaka introduced this
legislation, by request. This measure was included on the
agenda for the Committee's May 21, 2008, hearing on pending
health care legislation, and based on testimony at that
hearing, many of the provisions from that bill are included in
the Committee bill, as discussed below.
Sec. 201. Repeal of sunset on inclusion of non-institutional extended
care services in definition of medical services.
Section 201, which is derived from S. 2984, would repeal
the existing, temporary authority for VA to provide non-
institutional extended care services and, instead, include such
services as part of ``medical services'' furnished by VA to
veterans enrolled for VA care.
Background. The initial authority for VA to provide
comprehensive access to alternatives to nursing home care was
included in Public Law 106-117, enacted in 1999. The Congress
anticipated that this authority would be helpful in giving
veterans greater options instead of relying solely on
traditional nursing home care. Since 1999, funding for non-
institutional care for veterans has steadily increased,
evidence that it is meeting the needs of an increasing number
of veterans.
Committee Bill. The Committee bill would permanently
include non-institutional extended care services as part of the
definition of medical services under chapter 17 of title 38,
U.S.C., by repealing section 1701(10), and amending section
1701(6).
The Committee believes making non-institutional care
services a permanent feature of VA's medical benefits package
is necessary. The health care services provided in settings
that are not exclusively nursing homes are now considered to be
appropriate and standard in providing for the long-term care
needs of veterans.
Sec. 202. Extensions of certain authorities.
Section 202, derived from S. 2984, would extend two
expiring authorities: (1) VA's obligation to furnish nursing
home care to certain veterans, and (2) VA's responsibility to
conduct audits of VA payments to outside providers in
connection with care for veterans.
Background. In Public Law 106-117, Congress initially
required that veterans requiring nursing home care for a
service-connected condition, or a veteran rated 70 percent or
greater, have mandatory eligibility for such care. The initial
obligation expired on December 31, 2003. Later, the authority
was extended for an additional five years.
Committee Bill. Subsection (a) of section 202 of the
Committee bill would extend, through December 31, 2013, VA's
obligation to provide nursing home care to veterans who have a
service-connected disability rated at 70 percent or greater,
and to veterans who need nursing home care for their service-
connected disabilities.
This five-year extension would enable VA to continue to
provide nursing home care and will prevent any break in needed
nursing home care services.
Background. The authority for an audit recovery program was
established in Public Law 108-422, enacted in 2004. This
program identifies overpayments resulting from processing or
billing errors as well as fraudulent charges. Recoveries made
under the program are available without fiscal year limitation
and are used to provide medical care to veterans and
beneficiaries in the year in which they are recovered.
Currently, this authority is set to terminate on September 30,
2008.
Committee Bill. Section 202(b) of the Committee bill would
extend VA's mandate in section 1703(d), of title 38, U.S.C., to
conduct, through a contractual arrangement, audits of payments
made by VA for care and services furnished to veterans under
fee basis arrangements and other medical services contracts.
The Committee believes that the operation of a recovery
audit program is consistent with good business practice and,
indeed, it has proven advantageous to VA. Since 2001, VA has
recouped $63,000,000 in all covered program areas, and VA
projects it will recover an additional $24,000,000 if the
authority is extended through 2013. An ancillary benefit of
this program has been the related collection of extensive
quality information on VA's claims processing capabilities. VA
has used this vital information in developing and/or improving
staff training, policies, and requests for and use of new
technology.
Sec. 203. Permanent authority for provision of hospital care, medical
services, and nursing home care to veterans who participated in
certain chemical and biological testing conducted by the
Department of Defense.
Section 203, which is derived from S. 2984, would make
permanent VA's authority to furnish care to veterans who
participated in certain chemical and biological tests conducted
by the Department of Defense (DOD).
Background. According to DOD, Project SHAD was an element
of a project called Project 112, which was a chemical and
biological warfare test program conducted at the Deseret Test
Center. DOD conducted Project 112 tests between 1962 and 1973.
Project SHAD itself was a series of tests apparently designed
to determine potential vulnerabilities of U.S. warships to
attacks with chemical or biological warfare agents. Other
Project 112 tests involved similar experiments conducted on
land rather than aboard ships.
VA first learned of Project SHAD when a veteran filed a
claim for service-connection for disabilities that he felt were
related to his participation in those tests.
Public Law 108-170, enacted in 2003, authorized that
veterans who participated in the tests receive VA care at no
cost for any condition or illness that is not associated with
some cause other than their participation in the testing. While
that care is exempt from any otherwise applicable copayment
requirements, veterans may be subject to copayments for care
provided for conditions that the Secretary determines resulted
from causes other than their participation in these tests. The
initial authority to provide health care services to Project
SHAD participants expired after December 31, 2005. The current
authority expires on December 31, 2008.
Committee Bill. Section 203 of the Committee bill would
remove the sunset date on the existing authority, thereby
making access to VA care for these veterans permanent.
The Committee believes that the veterans who participated
in this testing deserve to receive VA care and treatment at no
cost to the veteran for any condition that can not be
attributed to some cause other than the testing.
Sec. 204. Repeal of certain annual reporting requirements.
Section 204, which is derived from S. 2984, would repeal
the requirement for VA to submit to Congress two annual
reports, one relating to pay adjustments for registered nurses,
and one relating to VA's long-range health planning.
Background. Public Law 101-366, The Department of Veterans
Affairs Nurse Pay Act of 1990, established a reporting
requirement relating to pay adjustments for registered nurses
because, at that time, annual General Schedule (GS)
comparability increases were extended to VA nurses at the
discretion of the facility Director. However, with the
subsequent enactment of Public Law 106-419, the Veterans
Benefits and Health Care Improvement Act of 2000, GS
comparability increases must be given to VA nurses and other
health care personnel described in section 7451.
With respect to VA's long-range health care planning, VA's
annual budget documents contain information on VHA's tactical
and strategic goals, performance measures, and supporting
activities; current and anticipated methods for serving VA's
special populations; and other priorities, resource
requirements and distribution methodologies. With the advent of
VA's 5-Year Strategic Plan in 2004, VA's budget submission also
includes the top 20 priorities for medical construction
projects.
Committee Bill. Subsection (a) of section 204 of the
Committee bill would repeal the requirement to report annually
on any pay adjustments made to the basic pay of VA nurses and
other health care personnel described in section 7451 of title
38, U.S.C. In light of the fact that covered staff receive, at
a minimum, the annual increases in pay provided under the GS
schedule, the Committee views this annual report as
unnecessary.
Subsection (b) of this section of the Committee bill would
repeal the requirement for the Secretary to annually report on
VA's long-range health planning, including operation and
construction plans for medical facilities. The Committee is
satisfied that this report contains information that is already
submitted in other reports and plans, particularly those
prepared annually in connection with VA's budget request.
Sec. 205. Modifications to annual Gulf War research report.
Section 205, which is derived from S. 2984, would make
changes to VA's annual report on Gulf War research.
Background. Under current law, section 707 of the Persian
Gulf War Veterans' Health Status Act, Public Law 102-585, the
Executive Branch, through a designated head of an appropriate
department or agency, is required to report to the Committees
on Veterans' Affairs of the Senate and the House of
Representatives on the status and results of all research
undertaken in the area of Gulf War Illnesses and the research
priorities identified during the previous year. Since the
requirement was enacted in 1992, the Secretary has been the
official responsible for compiling and submitting this report.
This report is due by March 1 of each year. Under current law,
this report is a continuing obligation.
Committee Bill. Section 205 of the Committee bill would
change the due date of this annual report to Congress on the
research on the health effects of service during the Persian
Gulf War from March 1 to July 1 of each year, and also
establish a sunset date for this reporting requirement of July
2013.
VA has testified that it is difficult if not impossible to
submit the report by the current March 1 statutory deadline and
it is the Committee's view that a July 1 deadline is more
attainable. Imposition of a sunset date is intended to afford
Congress sufficient opportunity to assess, in five year's time,
whether there exists a continued need for this formal reporting
requirement.
Sec. 206. Payment for care furnished to CHAMPVA beneficiaries.
Section 206, which is derived from S. 2984, would clarify
the status of payments made by VA to health care providers on
behalf of beneficiaries under the CHAMPVA program.
Background. CHAMPVA is a health care program in which VA
shares the cost of covered health care services and supplies
with eligible beneficiaries. The program is administered by
Health Administration Center. To be eligible for CHAMPVA, a
person must be in one of these categories: (1) the spouse or
child of a veteran who has been rated permanently and totally
disabled for a service-connected disability by VA; or (2) the
surviving spouse or child of a veteran who died from a VA-rated
service connected disability; or (3) the surviving spouse or
child of a veteran who was at the time death rated permanently
and totally disabled from a service connected disability; or
(4) the surviving spouse or child of a service member who died
in the line of duty of a cause other than willful misconduct
(in most of these cases, these family members are eligible for
DOD's health care program known as TRICARE).
While VA's regulations for the CHAMPVA program, located
within 38 CFR (Code of Federal Regulations) section 17.55,
provide for VA payments to providers under the CHAMPVA program
to constitute payment in full, VA's enforcement of this
regulation has been hampered by the lack of statutory
authority. VA has indicated that some providers still attempt
to bill beneficiaries for the difference between the billed
amount and the amount payable under the CHAMPVA program.
Committee Bill. Section 206 of the Committee bill would
provide that payments made by the Secretary to providers who
furnish medical care to a beneficiary covered under CHAMPVA
shall constitute payment in full and thereby extinguish the
beneficiary's liability to the provider for that care.
Sec. 207. Payor provisions for care furnished to certain children of
Vietnam veterans.
Section 207, which is derived from S. 2984, would amend two
sections of title 38, U.S.C., relating to care furnished to
certain children of Vietnam veterans, so as to clarify payment
procedures for such care.
Background. Public Law 104-204, enacted in 1996, authorized
VA to furnish health care--either directly or through
contracts--to certain children of Vietnam veterans. The purpose
was to provide for the special needs of certain children of
Vietnam veterans who were born with the birth defect spina
bifida and, in the case of children of women Vietnam veterans,
other covered birth defects, possibly as the result of the
exposure of one or both parents to herbicides during active
service in the Republic of Vietnam during the Vietnam era. In
order to carry out this health care program, VA developed a fee
for service (indemnity plan) program that provides
reimbursement for medical services and supplies related to
spina bifida and conditions associated with spina bifida.
Currently, providers must accept VA's payment as payment in
full for the services provided, but because VA's payments are
based on the CHAMPVA fee payment schedule, and not actual
charges, many providers no longer agree to participate in these
treatment programs.
Committee Bill. Subsection (a) of section 207 of the
Committee bill would amend section 1803 of title 38, U.S.C., to
add a new subsection which would designate VA as the primary
payer for care or services furnished to children of Vietnam
veterans suffering from spina bifida or other disability
associated with spina bifida. This new subsection would
expressly permit the provider (or his agent) who furnished such
care to seek payment from a third party payer, if the
beneficiary has a health care plan that would otherwise be
responsible for payment for the care and services, for the
difference between the amount billed and the amount paid by the
Secretary. The new subsection 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. 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, the new subsection would require
VA, upon request, to provide a third party with information
concerning claims under this section.
Subsection (b) of section 207 of the Committee bill would
amend section 1813 of title 38, to enact the same provisions as
detailed in subsection (a) above, but, in the case of this
subsection, for children of women Vietnam veterans with other
specified birth defects.
It is the Committee's intention that because providers
would be permitted to bill beneficiaries' health insurance for
amounts not paid by VA, this would lead to potentially higher
reimbursements for providers. The Committee is hopeful that
this would encourage more providers to participate with VA
under these programs.
Sec. 208. Disclosures from certain medical records.
Section 208, which is derived from S. 2984, would permit VA
health care practitioners to disclose the relevant portions of
certain VA records to surrogate decision makers who are
authorized to make decisions on behalf of patients who lack
decision-making capacity.
Background. Section 7332 of title 38, U.S.C., authorizes VA
to disclose treatment information for drug abuse, alcoholism
and alcohol abuse, HIV infection, and sickle cell anemia only
for certain purposes which are set out in the section.
Disclosure to surrogate decision makers for the purpose of
making informed decisions regarding the treatment of patients
who lack decision-making capacity, but to whom the patients had
not specifically authorized release of section 7332-protected
information prior to losing decision-making capacity, is not
one of the specified purposes.
Committee Bill. Section 208 of the Committee bill would
amend section 7332 of title 38, U.S.C., to permit VA health
care practitioners to disclose the relevant portions of VA
records of the treatment of drug abuse, alcoholism and alcohol
abuse, HIV infection, and sickle cell anemia to surrogate
decision makers who are authorized to make decisions on behalf
of patients who lack decision-making capacity, but to whom the
patient has not specifically authorized release of section
7332-protected information prior to losing decision-making
capacity. This change would allow for such disclosure only
under the circumstances where the information is clinically
relevant to decision that the surrogate is being asked to make.
The term ``representative'' means the individual, organization,
or other body authorized under section 7331 of title 38 and the
regulations implementing that provision, to give informed
consent on behalf of a patient who lacks decision-making
capacity.
Sec. 209. Disclosure to Secretary of health plan contract information
and social security number of certain veterans receiving care.
Section 209, which is derived from S. 2984, would add a
section to chapter 17 of title 38, U.S.C., to authorize VA to
require that those seeking or receiving VA health care provide
certain information in connection with such care.
Background. Although VA has authority under section 1729 of
title 38, U.S.C., to recover from health insurance carriers the
reasonable charges for treatment of a veteran's nonservice-
connected disabilities, there is no express statutory authority
that requires an applicant for, or recipient of, VA medical
care to provide information concerning health insurance
coverage.
Under Section 7 of the Privacy Act, VA cannot deny to an
individual any right, benefit, or privilege provided by law
because of such individual's refusal to disclose his or her
social security number. However, this prohibition does not
apply with respect to any disclosure that is required by
Federal statute.
Committee Bill. Section 209 would amend title 38 by adding
section 1709 which would authorize the Secretary to require
that applicant for, and recipients of, VA medical care and
services provide their health plan contract information and
social security numbers to the Secretary upon request.
Subsection (a) would require specific information on any
health plan contract which provides coverage. Information that
may be required regarding health plan coverage would include
the name of the health plan contract, the name of the veteran's
spouse, if coverage is under the spouse's health plan contract,
the plan number, and the plan's group code. This authority will
ensure that VA is able to obtain contract information for a
particular health plan.
Subsection (b) provides that the Secretary may require
applicants for, or recipients of, VA medical care or services
to provide their social security numbers and those of
dependents or VA beneficiaries upon whom the applicant or the
recipient's eligibility is based. This subsection, in
conjunction with subsection (c), discussed below, affords the
Secretary the statutory authority to require applicants for,
and recipients of, VA health care benefits to disclose social
security numbers.
Subsection (c) provides that the Secretary would be
authorized to deny the application of, or terminate the
provision of medical care or services to individuals who fail
to provide information requested pursuant to subsection (b).
The subsection further provides that the Secretary may
reconsider the application for or reinstate the provision of
care or services once the information requested pursuant to
subsection (b) has been provided.
Subsection (d) provides that this section may not be
construed as authority to deny medical care and treatment to an
individual in a medical emergency. If a medical emergency
exists, VA will not be permitted to deny eligibility for
medical care or services should the applicant or recipient fail
to provide health plan contract information or social security
numbers.
Because eligibility for medical care and services is
conditioned on the applicant or recipient's provision of health
plan contract information or social security numbers, VA
believes that the applicant or recipient will have an incentive
to provide the requested information. VHA must match veterans'
income data with the Internal Revenue Services and the Social
Security Administration to carry out its income verification
responsibility under section 5317 of title 38, U.S.C. Such
matching requires the use of verified social security numbers.
According to VHA, officials have obtained verified social
security numbers for approximately 97 percent of its enrolled
veterans and 86 percent of the spouses for whom income is
reported. While this suggests that the voluntary reporting
process is working, VHA estimates that they still have more
than 1,000,000 veterans enrolled for whom no social security
number has been provided. Further, VHA argues that they have
been unable to match income for more than 675,000 spouses
because the social security numbers have not been provided.
The Committee expects VA to provide a high degree of
confidentiality for beneficiaries' health plan information and
social security numbers.
Sec. 210. Enhancement of quality assurance.
Section 210 of the Committee bill, which is derived from S.
2377, would require actions to enhance VA's quality assurance
efforts. Specifically, this section of the Committee bill would
require that: (1) the USH (a) designate a physician to serve as
VHA's principal quality assurance officer and (b) other
physicians to serve as quality assurance officers for each
VISN; (2) the director of each VHA facility appoint a quality
assurance officer for each facility; (3) the USH establish
mechanisms to allow VHA employees to submit confidential
reports on matters related to health care quality; and (4) the
Secretary undertake a comprehensive review of all VA quality
and patient safety policies.
Background. Under current law, section 7311 of title 38,
U.S.C., VA operates a quality assurance system to monitor and
evaluate the quality of VA health care. That system is headed
by the Chief Quality and Performance Management Officer of the
National Quality and Performance Office. While a number of
other entities have a role in VA quality assurance efforts,
including the Office of the Inspector General, the Office of
the Medical Inspector, the National Patient Safety Office, and
the Office of Compliance and Business Integrity, none has a
permanent oversight capacity at every VA medical center. The VA
quality assurance and monitoring program, including the
National Surgical Quality Improvement Program (NSQIP), have
proven effective in certain situations. However, in a report
titled ``Quality of Care Issues, VA Medical Center, Marion,
Illinois'' (January 2008), the VA Office of the Inspector
General (hereinafter, ``OIG'') found that the quality assurance
process was ineffective in many respects. The peer review
process, the tracking of performance data on providers, and
mortality assessments as carried out at the Marion, Illinois,
VA Medical Center were all found to be deficient. The OIG
concluded that:
[T]he oversight reporting structure for quality
management reviews at the Marion VAMC was fragmented
and inconsistent, making it extremely difficult to
determine the extent of oversight of patient quality or
corrective actions taken to improve patient care. This
occurred partially because quality management
responsibilities were split between multiple groups at
the facility with little or no management oversight.
The OIG further concluded that the Marion VAMC Surgery Service
leadership was ineffective, and that communication among the
nurse responsible for NSQIP at the facility, surgical
providers, and the Chief of Surgery was highly ineffective,
allowing multiple quality management processes to fail.
Based on information related to the Marion, IL, experience
and other oversight activity, the Committee believes that VA's
internal processes can ensure quality in some circumstances,
but that significant improvements are necessary. Continuous and
attentive monitoring is not fully in place, and facility
leadership across the VA system must prioritize quality
assurance.
Committee Bill. Section 210 of the Committee bill would add
a new section 7311A to chapter 73 of title 38, U.S.C. This new
section would require the USH to appoint a National Quality
Assurance Officer, reporting directly to the Under Secretary,
who would develop requirements and standards for a national
quality assurance program, and prescribe regulations for its
implementation.
The Committee believes that such a position would be
helpful in order to ensure the thorough and uniform discharge
of quality assurance requirements under such programs and
activities throughout VA facilities. The USH would also be
required to designate quality assurance officers for each VISN.
Such officers would direct the quality assurance effort of each
network and coordinate, monitor, and oversee the quality
assurance programs and activities of the medical facilities in
the Network.
Additionally, section 210 of the Committee bill would
require each VA medical center Director to appoint a physician,
from that facility, to be the quality assurance officer for
that facility. The Director would be required to ensure that
other clinical or administrative duties of the person appointed
as the quality assurance officer are reduced so as to not
interfere with the person's quality assurance duties. The
quality assurance officer would report to the director of the
facility and to the quality assurance officer of the VISN of
which that facility is a part.
Section 210 would also require the USH to put in place a
system through which VHA employees might submit reports, on a
confidential basis, on quality of care matters to the quality
assurance officer at the employee's facility. Such a system
would provide a safe channel through which employees might
report their concerns about care being furnished at the
facility. Such a system should make it possible for any such
reports to receive appropriate attention and review.
This section of the Committee bill also would require the
Secretary to submit a report to Congress on all policies and
protocols of VA that pertain to maintenance of health care
quality and protection of patient safety at VA medical
facilities. This report would be required to include an
assessment of NSQIP, with special emphasis on the effectiveness
of the design and structure of the program's data collection,
evaluation, and assessment structure, and the sufficiency of
resources allocated to that program. In testimony before the
Committee on May 21, 2008, Dr. Gerald Cross, Principal Deputy
Under Secretary for Health, expressed VA's support for the
provisions of this section of the Committee bill that would
require a comprehensive review and report on health care
quality and patient safety policies across the VA health care
system.
Sec. 211. Reports on improvements to Department health care quality
assurance.
Section 211, which is derived from S. 2377, would require
the Secretary to report on VA efforts to implement the
provisions of the Committee bill concerning quality assurance.
Background. There are currently no regular requirements for
VA to report to Congress on VHA quality assurance efforts. This
lack of effective reporting mechanisms can contribute to
ineffective quality oversight. While the Inspector General
performs valuable oversight of individual facilities and
specific events, the Committee believes a comprehensive annual
reporting requirement would more effectively ensure oversight
and accountability by the Committee and the Congress.
Committee Bill. Section 211 would require the Secretary to
submit a report to the Committees on Veterans' Affairs and
Appropriations of the Senate and the Committees on Veterans'
Affairs and Appropriations of the House of Representatives by
December 15, 2009, and annually thereafter, through 2012. This
report would detail VA efforts, over the preceding fiscal year,
to implement the provisions of sections 104 (relating to
standards for appointment and practice of VHA physicians) and
210 (relating to quality assurance officers) of the Committee
bill, along with any recommendations the Secretary may have to
improve the implementation of these sections or to otherwise
improve the quality of VA health care. The Committee expects
that this reporting requirement will lead to increased
oversight of VA's efforts to improve quality assurance efforts
and activities.
Sec. 212. Pilot program on training and certification for family
caregiver personal care attendants for veterans and members of
the Armed Forces with TBI.
Section 212 of the Committee bill, which is derived from S.
2921, would require the Secretary, in collaboration with the
Secretary of Defense, to carry out a pilot program to evaluate,
over a three-year period, the provision of health care
training, certification and compensation to family members of
veterans and members of the Armed Forces with TBI, so as to
allow family members to function as personal care attendants.
Background. Currently, VA operates a Personal Care
Attendant certification program at the San Diego, California,
VA Medical Center for patients with spinal cord injury.
According to the VHA directives, family members can be personal
care providers as long as they are certified by a Spinal Cord
Injury Center. Once certified, VA can compensate these family
members for the services they provide at a rate not to exceed
the hourly rate paid to VA nursing assistants.
There have been two prior attempts to address the issue of
training family caregivers for veterans with TBI. Section 744
of Public Law 109-364, the John Warner National Defense
Authorization Act of 2007 (hereinafter, ``NDAA 2007''),
required the establishment of a panel to develop training
curricula for family members on caregiving techniques for TBI
patients. Section 214 of Public Law 109-461, The Veterans
Benefits, Health Care, and Information Technology Act of 2006,
mandated a VA pilot program to improve caregiver assistance
services, including training and certification.
Committee Bill. Section 212 of the Committee bill would
require the Secretary, in collaboration with the Secretary of
Defense, to carry out a 3-year pilot program in three VA
medical facilities and, if the Secretaries determine it is
appropriate, one DOD medical facility. In selecting locations,
the Secretary would be required to attempt to locate the pilot
program at VA Tier I polytrauma centers. VA currently operates
four such centers at the Minneapolis, Tampa, Richmond, and Palo
Alto VA medical centers. A fifth center is slated to open at
the San Antonio VA Medical Center in the near future.
The Secretary would be required to develop a training
program for those who would serve as personal care attendants
under the pilot program. This training would be required to
incorporate standards of certification programs of national
brain injury care specialist organizations as well as best
practices of caregiving organizations, such as the National
Family Caregivers Association. This training program would be
required to draw on the training curricula that were developed
under NDAA 2007.
The Secretary would be responsible for determining whether
a family member would be eligible for participation in the
pilot program, based upon the needs of the patient, as
determined by the patient's physician. A family caregiver
certified as a personal care attendant under this pilot program
would be eligible to be paid by VA for the care the personal
care attendant provides.
The Secretary or the Secretary of Defense would be required
to pay any costs of training family members of veterans or
members of the armed services, respectively, to be personal
care attendants. Under the pilot program, the Secretary would
be allowed to provide information to a properly certified
personal care attendant, including an assessment of the
attendant's needs and a referral to any services provided in
the attendant's community that are relevant to the attendant's
needs. These services could be provided by community-based
organizations, publicly funded programs, or VA. In making this
assessment, the Secretary would be required, to the greatest
extent practicable, to utilize existing caregiver assessment
tools currently in use by VA.
The Secretary would be required to report to Congress on
the pilot program within two years of the date of enactment of
this Act. The report would include the Secretary's
recommendations regarding the expansion or modification of the
pilot program.
This section of the Committee bill specifies that nothing
within the provision would grant a right to family members to
receive the training and certification under the pilot program,
nor would anything prevent the Secretary from allowing a non-
family member to act as personal care attendant if the patient
prefers such a person to a family member.
The Committee believes that this pilot program has the
potential of allowing for a more efficient and appropriate
program of recovery and long-term care for those with TBIs, for
whom institutional long-term care would be too intensive or
otherwise inappropriate. This program would allow veterans to
stay in their own homes but still receive necessary living
assistance.
This proposed pilot program is supported by The American
Legion, Veterans of Foreign Wars, Disabled American Veterans,
Paralyzed Veterans of America, Vietnam Veterans of America,
Wounded Warrior Project, and the Brain Injury Association of
America.
Sec. 213. Pilot program on provision of respite care to members of the
Armed Forces and veterans with TBI by students n graduate
programs of education related to mental health or
rehabilitation.
Section 213, which is derived from S. 2921, would require
the Secretary of Veterans Affairs, in collaboration with the
Secretary of Defense, to carry out a three-year pilot program
to assess the feasibility and advisability of providing respite
care to veterans and service members through the services of
students in certain graduate education programs.
Background. There has been a marked increase in the number
of family members taking on the role of primary caregiver for
injured and disabled veterans since the start of the wars in
Iraq and Afghanistan. This is consistent with the overall trend
of long-term care moving from institutional to non-
institutional settings. In response to the impact on family
members furnishing care, there has also been an increasing use
of non-institutional care options to relieve and assist family
caregivers.
VA has a long record of entering into affiliations with
academic institutions for the purposes of training clinicians,
as well as for enhancing research opportunities. Academic
affiliations enhance the education and experience of both VA
professionals and the students attending the academic
affiliates.
In testimony submitted for the Committee's May 21, 2008,
hearing, the Brain Injury Association of America (BIAA),
described the need for providing supportive services for family
caregivers:
Particularly in light of the fact that caregivers often
report severe financial strain and frequently must give
up their jobs in order to take care of their loved one
with TBI, increased financial support and access to
respite care for family caregivers of returning
servicemembers with TBI is vital and long overdue.
BIAA cites one study that found that 47 percent of family
caregivers had given up their jobs at one year after the injury
occurred. At two years, that number was still 33 percent. These
demands have been linked to the occurrence of stress reaction
and other physical and emotional problems.
Committee Bill. Section 213 of the Committee bill would
establish a three-year pilot program to test the feasibility
and advisability of using graduate students in certain mental
health and rehabilitation programs to provide respite care to
members of the Armed Forces and veterans with TBI. The students
would provide relief to family caregivers and assist in
developing cognitive and social skills in the patient.
This pilot program would be carried out at no more than ten
separate locations selected by the Secretary, all of which must
be VA medical facilities that are in proximity to or affiliated
in some manner with an educational institution that has a
graduate program in mental health or rehabilitation related
field. The Secretary would be required to give special
consideration to VA facilities that are Tier I polytrauma
centers, and VA facilities that are in proximity to regions
with large concentrations of veterans with TBI.
The Secretary would be required to recruit, train, and
assign graduate students in the designated fields of education
in order to provide respite care to veterans and servicemembers
in the pilot program. The Secretary, in collaboration with the
head of the selected graduate program, would be required to
determine the amount of training required, the number of hours
of care to be provided, and the requirements for successful
participation for the graduate students participating in the
program. The Secretary would be required to incorporate into
the training program any applicable standards and protocols of
national brain injury care specialist organizations, as well as
recognized caregiving best practices.
For purposes of the pilot program, the Committee bill would
define ``respite care'' as the temporary provision of care to
an individual to provide relief to the regular caregiver, and
the term ``family member'' to include friends or partners of
the patient.
The Committee believes that the provision of respite care
as outlined in this pilot program could be vital in further
strengthening the family caregiver model a feasible system of
care.
Sec. 214. Pilot program on the use of community-based organizations and
local and State government entities to ensure that veterans
receive care and benefits for which they are eligible.
Section 214 of the Committee bill, which is derived from S.
2796, would require VA to carry out a pilot program to study
the use of community-based organizations, and local and State
government entities, to help ensure that veterans receive
needed care and benefits.
Background. Dr. Stanley Luke, PhD, Vice President for
Programs of Helping Hands Hawaii, one of Hawaii's largest
social service nonprofits and a provider of direct services to
Hawaii veterans, testified before the Committee on May 21,
2008, expressing support for the pilot program contemplated by
this section of the Committee bill. According to Dr. Luke, as a
consequence of cultural or other factors in certain locations,
VA personnel may sometimes not be most appropriate to reach out
to veterans and that, in such instances, local organizations,
with specific local cultural skills, may be better able to
relate to, and interact with, veterans and their families in
specific locations.
Helping Hands Hawaii has attempted to assist veterans
through outreach, assistance in interacting with VA, explaining
eligibility and available benefits and services, and providing
mental health care. The pilot program provided for under this
section of the Committee bill would have VA focus more intently
on this approach and study whether these efforts can be
effectively replicated.
Committee Bill. Section 214 of the Committee bill would
require the Secretary to establish and implement a pilot
program to study the use of community-based organizations, and
local and State government entities, in the provision of care
and benefits to veterans. This program would specifically seek
to improve coordination between community, State, and Federal
providers of health care and benefits to veterans who are
transitioning from military to civilian life; to make medical
care and mental health care more available to veterans who are
transitioning; to provide assistance to families of
transitioning veterans; and to provide greater outreach to
veterans and their families, and to inform them about their
eligibility for, and availability of, benefits and care.
The pilot program would continue for a period of two years
after enactment of the Committee bill, and be carried out at
five locations that the Secretary would select. In selecting
the program locations, the Secretary would be required to place
special emphasis on rural areas, areas with high proportions of
minority groups, areas with high proportions of individuals who
have limited access to health care, and areas that are not in
close proximity to an active duty military station.
The Secretary would award grants to organizations and
entities for them to use in providing services under the pilot
program. Any organization or entity wishing to participate in
the program would be required to submit an application to the
Secretary containing a description of how the program was
developed in consultation with VA and a plan for the
organization to coordinate activities with local, State, and
Federal government agencies that provide services so as to
avoid duplication of services.
The Secretary would be required to promulgate regulations
governing the appropriate use of grant funds by organizations.
The Secretary would also be required to submit a report on the
pilot program within 180 days after the program's end. The
report would include findings and conclusions, an assessment of
the benefits that were provided, and any recommendations from
the Secretary regarding whether to continue the pilot program.
Sec. 215. Specialized residential care and rehabilitation for certain
veterans.
Section 215, which is derived from S. 2889, would authorize
VA to contract for specialized residential care and
rehabilitation services for certain veterans of OIF/OEF.
Background. Veterans with TBI or other serious disabilities
and conditions have significant long-term care needs. These
veterans may not need nursing home care, but they do not always
have the resources needed to remain at home and live
independently. This presents a challenge both for the veteran
and the health care system.
Committee Bill. Section 215 of the Committee bill would
amend title 38, U.S.C., by adding a new subsection (g) to
section 1720 so as to authorize the Secretary in carrying out
its community residential care program, to contract for
specialized residential care and rehabilitation services for
eligible veterans. Veterans covered by this provision would be
veterans of OEF/OIF who: (1) suffer from TBI; (2) have an
accumulation of deficits in activities of daily living and
instrumental activities of daily living that affects their
ability to care for themselves; and (3) would otherwise receive
their care and rehabilitation in a nursing home care, which
exceeds their needs.
It is the intent of the Committee that VA should have
authority to provide veterans with significant long-term needs
with a much more appropriate treatment setting for long-term
rehabilitation services.
Sec. 216. Exemption from copayment requirement for veterans receiving
hospice care.
Section 216, which is derived from S. 2889, would eliminate
copayment requirements for veterans receiving VA hospice care
in any setting.
Background. In 2004, with the enactment of Public Law 108-
422, Congress eliminated copayment requirements for veterans
receiving hospice care in VA nursing homes, but that change did
not eliminate copayments for hospice care furnished in other
settings. The Medicare program does not impose copayments for
hospice care, regardless of the setting. The Committee does not
believe that VA should require such copayments either.
Committee Bill. Section 216 would amend section 1710 of
title 38, U.S.C., to eliminate copayment requirements for
veterans receiving VA hospice care either in a VA hospital, or
at home on an outpatient basis. The Committee bill would exempt
all hospice care from copayments, thereby providing equitable
treatment for all veterans receiving such care.
Sec. 217. Repeal of limitation on authority to conduct a widespread HIV
testing program.
Section 217, which is derived from S. 2889, would remove a
restriction in current law on VA's ability to conduct
widespread testing for HIV among VA patients.
Background. Currently, section 124 of Public Law 100-322
permits VA to test a patient for HIV infection only if the
veteran receives pre-test counseling and provides written
informed consent for such testing. This differs from other
blood testing that VA conducts routinely, which requires only a
patient's verbal informed consent. VA advises that the
requirements for pre-test counseling and signed consent often
delay testing for HIV infection.
Committee Bill. Section 217 would repeal section 124 of
Public Law 100-322. Eliminating this section from the law would
bring VA's statutory HIV testing requirements in line with
current guidelines issued by the Centers of Disease Control and
Prevention and will not diminish patient rights, as VA would
still be required to obtain the patient's verbal informed
consent. Generally, informed consent requires the responsible
practitioner to discuss and inform the patient about the
procedure/treatment and its risks and benefits, as well as
answer any questions that patient may have about the procedure/
treatment. In addition, a patient may always reject VA
treatment or procedures.
The Committee believes that by eliminating section 124 of
Public Law 100-322, veterans would benefit from earlier medical
intervention, thereby improving the potential health outcomes
of infected patients, while at the same time advancing the
country's broader public health goals.
Sec. 218. Authority to disclose medical records to third party for
collection of charges for provision of certain care.
Section 218, which is derived from S. 2889, would amend two
provisions of title 38, U.S.C., so that VA could disclose
individually-identifiable patient medical information in
connection with the collection of charges for VA care or
services.
Background. Under section 1729 of title 38, U.S.C., VA has
authority to recover from health plans or health insurance
carriers the reasonable charges for treatment of a veteran's
nonservice-connected disabilities. In order to recover charges
and obtain reimbursement for care, VA must submit bills or
claims containing information to the health plan for the
episode of care. If during the episode, the veteran was
diagnosed or treated for certain conditions, this information
is communicated via the bill to the health plan.
Section 5701 of title 38 permits VA to release the names
and home addresses of veterans and their dependents without
consent only for very limited purposes. There is some question
whether disclosures for billing purposes are currently
permitted under subsection (b)(6) of that section in cases in
which the United States has not yet instituted litigation to
collection an amount owed VA under section 1729.
Section 7332 of title 38 similarly permits VA to release
indentifying information and treatment information, without
prior written consent for the medical conditions covered by the
section--drug abuse, alcoholism or alcohol abuse, HIV
infection, or sickle cell anemia--only for certain, limited
purposes specified in subsection (b) of 7332. The authorized
exceptions do not include releasing identifiable patient
information to a third-party health plan for collection
purposes, without the patient's prior written authorization.
Committee Bill. Section 218 would add new subsections to
section 5701 and 7332 of title 38, U.S.C., to authorize the
Secretary to disclose individually-identifiable patient medical
information without the prior written consent of a patient to a
third-party health plan to collect reasonable charges under
section 1729 of this title for care or services provided for a
non-service-connected disability.
The amendment to section 5701 would specifically authorize
disclosure of a patient's name and address information for
collection purposes. Disclosure of the information other than
the patient's name and address is authorized under existing
authority in subsection 5701(e). Similarly, the section 7322
change would authorize disclosure of both individual identifier
information and the medical information for purposes of
carrying out VA's responsibilities under section 1729.
The Committee notes that such disclosures without a
patient's prior written authorization are generally permitted
under regulations promulgated pursuant to section 264 of the
Health Insurance Portability and Accountability Act of 1996
(HIPAA). Since health plans that VA would bill for the
reasonable cost of medical care under this authority are
covered by the HIPAA privacy regulations, they will be able to
use and disclose the patient-identifiable information provider
in accordance with HIPAA.
The Committee anticipates that these changes to current law
will result in higher revenue collections.
Sec. 219. Expanded study on the health impact of Project SHAD.
Section 219 of the Committee bill, which is derived from S.
2937, would require VA to contract with the Institute of
Medicine of the National Academies (IOM) for an expanded study
on the health impact of Project SHAD.
Background. During the period 1962-1974, the Defense
Department conducted a series of tests of chemical and
biological materials in water-borne settings. The tests, known
as Project SHAD exposed hundreds of veterans to VX nerve gas,
E. Coli, and other substances.
The Project SHAD tests were intended to show the
vulnerability of Navy ships to chemical and biological warfare
agents. By learning how those agents would disperse, military
planners hoped to be able to improve procedures to protect
crewmembers and decontaminate ships.
Beginning in 2002, VA contracted with IOM to conduct a
study of the health effects on veterans who participated in
Project SHAD (contract number No. V101(93)P-1637, T/0). While
there are many known medical problems associated with repeated
chemical and biological weapons exposure, the Committee is
concerned that the study, which was released last year, is
incomplete because it omits a number of Project SHAD veterans
who were known to DOD and to VA.
Committee Bill. Section 219 of the Committee bill would
require the Secretary to enter into a contract with IOM, within
90 days after the enactment of this Act, for the purposes of
IOM conducting a study of the health impacts of Project SHAD on
servicemembers participating in the tests. The Committee bill
would require that this study include all servicemembers
involved in the tests, insofar as is practicable and consistent
with the requirements of conducting sound research. The
Committee Bill would authorize the utilization of the results
from the study ``Long-Term Health Effects of Participation in
Project SHAD'' conducted by IOM.
Congress has previously approved unfettered, VA-provided
care for veterans who participated in Project SHAD. While the
Committee believes that these veterans deserve and should
receive care from VA at no cost for any condition that cannot
be attributed to other causes, the Committee believes there is
value in examining the impact of such testing on participants
in order to better understand the potential effects of other
such testing.
The Committee also notes that there is value in continued
research into the areas of chemical and biological weapons
exposure and that VA and DOD should make every effort to
identify and contact all former servicemembers who participated
in Project SHAD as well as testing that occurred during a
similar time period at Edgewood Arsenal, Dugway Proving
Grounds, Ft. McClellan, and Ft. Detrick.
Sec. 220. Use of non-Department facilities for rehabilitation of
individuals with TBI.
Section 220 of the Committee bill would amend a recently
enacted section of title 38, U.S.C., so as to specify the
circumstances in which non-VA facilities would be utilized as
part of the rehabilitation and community reintegration plans
for veterans and members of the Armed Forces who are receiving
care from VA for TBI.
Background. VA has done much in recent years to develop its
capability to treat TBI. However, VA has limited experience in
treating younger veterans with debilitating injuries such as
TBI. As a result, Congress passed a series of VA-related
provisions in NDAA 2007, the bulk of which sought to expand and
enhance TBI care at VA facilities. As part of those provisions,
Congress also gave VA the ability to enter into cooperative
agreements with public or private entities to send certain
veterans suffering with TBI to non-Department facilities for
rehabilitative care. In some circumstances, VA may find the
service of a non-VA facility to be better suited to providing
the care required by some veterans with TBI. In the Senate-
passed version of NDAA 2007, specific criteria for eligibility
and standards of care were laid out, but these provisions were
dropped in reconciliation negotiations with the House.
Committee Bill. Section 220 of the Committee bill would
amend section 1710E of title 38, U.S.C., so as to add two new
subsections that were included in the Senate-passed legislation
from the NDAA 2007. Proposed new subsection (b) would specify
that non-VA facilities would be used when the Secretary cannot
provide treatment or services at the frequency or for the
duration required by the individual plan of veteran or
servicemember suffering from TBI or when the Secretary
determines that it is optimal for the veteran or
servicemember's recovery and rehabilitation. Proposed new
subsection (d) would establish standards for the selection of a
non-Department facility, requiring that the facility itself
maintains care standards that have been established by an
independent, peer-reviewed organization that accredits
specialized rehabilitation programs for adults with TBI.
The Brain Injury Association of America supports section
220, ``as it sets forth a pivotal mechanism for enhancing
cooperation between the private sector and the VA health care
system. Such cooperation is vitally necessary in order to
provide access to, and choice within, the full continuum of
care that returning service members with TBI need and
deserve.''
Sec. 221. Inclusion of tribal organizations in certain programs for
State veterans homes.
Section 221 of the Committee bill, which is derived from S.
3000, would include tribal organizations in certain authorities
relating to State veterans' homes. The health facilities of
tribal organizations would be eligible to be treated as
veterans homes for funding purposes, and tribal organizations
would be eligible to apply for veteran State home construction
grants.
Background. State veterans homes are homes established by
the States for disabled veterans in need of long-term care.
They provide nursing home care, domiciliary care, and adult day
care. VA partners with States in two ways to assist in funding
the homes. Under Sections 1741-1743 of title 38, U.S.C., VA has
the authority to carry out a per diem payment program in which
it provides a portion of the daily cost of care for each
veteran residing in a home. Under Sections 8131-8137 of title
38, VA has the authority to conduct a construction grant
program, in which it can provide up to 65 percent of the total
cost of building a home, with the States required to put up 35
percent. Under current law, tribal organizations are not
considered states for the purposes of being eligible for either
of these programs.
Based on the 2000 U.S. Census, VA projected in a September
2006 report that during the time period from 2005 and 2020, the
number of older veterans overall will decline by 10 percent.
During that same time, VA projected a nearly 60 percent
increase in the number of older American Indian and Alaska
Native veterans. The expected decline in the overall number of
older veterans is attributed largely to the World War II and
Korean War-era veteran populations, which are declining largely
for age-related reasons. In contrast, American Indian veterans
are much less likely to be World War II or Korean War-era, and
more likely to be Vietnam-era than the overall veteran
population.
As early as the 1990s, Native Americans have identified a
pressing need for improved long-term care in Native
communities. In 1995, the National Indian Council on Aging
described long-term care as the most pressing issue facing
American Indian elders. According to a survey reported in the
2002 American Indian and Alaska Native Roundtable on Long-Term
Care, only 17 percent of tribes report having nursing homes
available on the reservation or in the tribal community.
Nineteen percent reported that their tribe was planning to
create or expand long-term care services. Despite recognition
of the need for long-term care, as well as interest among
tribes in developing such care, Native American communities are
constrained by limited federal funding and the abject poverty
that characterizes much of Indian Country.
Committee Bill. Subsection (a) of section 221 of the
Committee bill would amend section 8138 of title 38, U.S.C., so
as to allow for the treatment of health facilities of tribal
organizations, or beds within such facilities, as State
veterans homes. As a result of this amendment, tribal
organization health facilities would be treated in the same
manner as other health facilities (or beds), with the exception
of newly designated subsection (f) of section 8138, which sets
September 30, 2009, as the expiration date for the treatment of
new health facilities as State homes, which would not apply to
the health facilities of tribal organizations.
Subsection (b) of section 221 of the Committee bill would
amend title 38 in a number of ways so as to give the Secretary
the authority to award construction grants to tribal
organizations for the construction of State veterans homes as
set forth in subchapter III of chapter 81 of title 38.
Subsection (b)(1)(A) would provide that, for the purposes
of the subchapter, ``tribal organization'' would have the
meaning given to the term in section 3765 of title 38.
Subsection (b)(1)(B) would amend section 8132 of title 38,
the declaration of purpose for the subchapter, to include
tribal organizations along with the ``several states'' as the
entities to be assisted in creating State veterans homes.
Subsection (b)(1)(C) would amend title 38 by adding a new
section--Section 8133A. Tribal organizations--so as to give the
Secretary the express authority to award construction grants to
tribal organizations. This new section would provide that
grants to tribal organizations shall be awarded in the same
manner as States, with certain exceptions. One such exception
shall be that, for the purpose of assigning priority under
subsection (c)(2) of section 8135 of title 38, if a tribal
organization is located within a State that has previously
applied for a construction grant, the tribal organization shall
be treated as if it previously applied as well. Other
exceptions may be prescribed by the Secretary to take into
account the unique circumstances of tribal organizations.
Recognizing the limited long-term care options in Native
American communities, as well as the sovereign status of
Federally-recognized tribes, section 221 would enable the
Secretary to award State veterans home grants directly to
tribal organizations.
As reported by the Harvard Project on American Indian
Economic Development: ``Where tribes make their own decisions
about what approaches to take and what resources to develop,
they consistently out-perform outside decision makers.'' The
Committee expects that, by including tribal organizations among
those eligible to apply for State veteran homes grants, these
organizations will be able to provide more effective long-term
care for the veterans in their communities.
Sec. 222. Extension of pilot program on caregiver assistance services.
Section 222 of the Committee bill would amend section
214(d) of the Veterans Benefits, Health Care, and Information
Technology Act of 2006 (Public Law 110-461) to extend the pilot
program on caregiver assistance services for an additional
year, to 2009.
Background. In December 2006, Congress passed S. 3421, The
Veterans Benefits, Health Care, and Information Technology Act
of 2006, which became Public Law 109-461. A provision of this
legislation created a two-year pilot program to assist home-
based caregivers of disabled veterans. At the time, spouses and
family members acting as the primary caregivers for wounded
veterans was a growing trend, and the need to provide
supportive services to these caregivers was becomingly
increasingly apparent. The intent behind the pilot was to
incentivize field clinicians to create innovative, localized
programs to assist caregivers in their respective communities.
Along with the authorization for the pilot itself, Congress
authorized $5,000,000 for the administration of the program.
VA is currently providing approximately $4,700,000 for
these pilot programs to expand and improve health care
education and provide needed training and resources for
caregivers who assist disabled and aging veterans in their
homes. This funding enhances the support and training for
family members and other caregivers who work to care for these
veterans.
There are currently eight caregiver projects across the
country. Among the key services provided to caregivers are
transportation, respite care, case management and service
coordination, assistance with personal care (bathing and
grooming), social and emotional support, and home safety
evaluations. Education programs teach caregivers how to obtain
community resources such as legal assistance, financial
support, housing assistance, home delivered meals and spiritual
support.In addition, caregivers are taught skills such as time
management techniques, medication management, communication
skills with the medical staff and the veteran, and ways to take
better care of themselves.
Many of the projects use technology, including computers,
web-based training, video conferencing and teleconferencing to
support the needs of caregivers who often cannot leave their
homes to participate in support activities.
Committee Bill. Section 222 of the Committee bill would
amend section 214(d) of the Veterans Benefits, Health Care, and
Information Technology Act of 2006, Public Law 110-461, so as
to extend the pilot program on caregiver assistance services
for an additional year, through the end of fiscal year 2009.
Families and other caregivers are on the front lines of
efforts to care for veterans who have served this nation.
Because the pilot program was enacted late in 2006, sites were
announced fully one year later and the money has already been
allocated to the various programs, VA needs an additional
year's authorization to fully carry out the pilot program.
Sec. 223. Pilot program on provision of dental insurance plans to
veterans and survivors and dependents of veterans.
Section 223 of the Committee bill, which is derived from S.
3178, would direct the Secretary to carry out a pilot program
to assess the feasibility of providing a dental insurance plan
to eligible veterans, survivors, and dependents of veterans.
Background. VA provides a full range of dental services at
its facilities. However, under current law, section 1712 of
title 38, U.S.C., dental services are only offered to certain
veterans or to veterans under special circumstances. For
example, veterans who have a service-connected compensable
dental condition, are former prisoners of war, or who have 100
percent service-connected disabilities are eligible for any
needed dental care. Other veterans are eligible only for dental
care necessary to resolve problems arising in certain narrowly
defined situations, such as a veteran whose dental condition is
aggravating a service-related condition or who requires dental
care to continue participation in a vocational rehabilitation
program. In addition, CHAMPVA does not provide dental coverage
for survivors and dependents of veterans receiving care under
that program except under very limited circumstances. CHAMPVA,
established by Public Law 93-82, is primarily a fee-for-service
program that provides reimbursement for most medical care for
certain eligible dependents and survivors of veterans rated
permanently and totally disabled from a service-connected
condition. The program reimburses providers and facilities a
fixed amount for treatment given, less any co-pay from
beneficiaries.
DOD administers a health care system for active duty
servicemembers, military retirees, certain Reserve and National
Guard members, and eligible family members under the TRICARE
program. Through TRICARE, dental benefits may be provided to
select beneficiaries at military treatment facilities; for
others, voluntary dental insurance coverage is available
through a DOD contract with private insurers is available.
Section 703 of Public Law 104-201, NDAA 2007, established the
TRICARE Retiree Dental Program (TRDP) through which military
retirees and their eligible family members are given the option
to purchase dental coverage under a contract managed by DOD.
Over 1,000,000 eligible participants have some level of dental
coverage under TRDP. TRDP enrollees have access to a network of
about 112,000 dental plan providers across the nation. Premiums
currently range from $14 to $48 per month for an individual
policy, depending on the region and type of dental plan
selected.
Committee Bill. Section 223 of the Committee bill, in a
freestanding provision, would require the Secretary to carry
out a pilot program on the provision of dental insurance plans
to veterans and survivors, and dependents of veterans.
Subsection (a) of section 223 would require the Secretary
to carry out the pilot program so as to assess the feasibility
and advisability of providing dental insurance.
Subsection (b) of section 223 would define the participants
in the pilot program as veterans enrolled in VA's medical care
system and survivors and dependents of veterans eligible for
medical care under CHAMPVA.
Subsection (c) of section 223 would specify that the pilot
program is to be carried out in not less than two and no more
than four VISNs.
Subsection (d) of section 223 would specify that the
Secretary is to contract with a dental insurer to administer
the dental plan.
Subsection (e) of section 223 would require the dental plan
under the pilot program to provide benefits considered
appropriate by the Secretary, including diagnostic,
preventative, endodontic, surgical, and emergency services.
Subsection (f) of section 223 would provide that enrollment
in the dental insurance plan would be voluntary and would be
for such minimum period of enrollment as the Secretary
prescribes.
Subsection (g) would require the Secretary to set premiums
for dental plan coverage on an annual basis and would specify
that the premiums would be paid entirely by plan enrollees.
Subsection (h) of section 223 would permit the voluntary
disenrollment from a dental plan if the disenrollment occurs
within 30 days of the beginning of the enrollment period or,
under certain allowable circumstances, such as a relocation to
a jurisdiction outside a plan area or a serious medical
condition preventing use of plan benefits, if the disenrollment
does not jeopardize the fiscal integrity of the dental plan.
Subsection (i) of section 223 would specify that nothing
regarding the pilot program will affect VA's responsibility to
provide dental care under section 1712 of title 38 nor would an
individual's participation in an insurance plan under the pilot
program affect the individual's entitlement to dental services
under that section.
Subsection (j) would specify that the dental insurance plan
under the pilot program is to be administered pursuant to
regulations prescribed by VA.
The Committee is interested in testing within the VA health
care system the TRDP concept of supplementing dental benefits
provided at government facilities with more comprehensive,
voluntary dental insurance coverage financed through enrollee
premiums. This concept is not meant to minimize VA's obligation
to provide high quality dental services under existing
requirements of law.
TITLE III--WOMEN VETERANS HEALTH CARE
Sec. 301. Report on barriers to receipt of health care for women
veterans.
Section 301 of the Committee bill, which is derived from S.
2799, would require the Secretary to submit a report to
Congress, no later than June 1, 2009, on the barriers to women
veterans' access to VA health care.
Background. Under current law, VA is authorized to provide
care to all veterans, including women veterans. While there has
been some specific legislative action on certain areas of care
for women veterans, such as for homeless reintegration
services, the Committee believes that much more can be done.
Although this approach has yielded some clear successes, there
are concerns that there may be insufficient attention to
ensuring uniform access to gender-specific services across the
VA health care system. According to DOD, women represent
approximately 17 percent of all deployed service members, and
therefore are a growing portion of the veteran population.
Committee Bill. Section 301 of the Committee Bill would
require VA to submit a report to Congress, not later than June
1, 2009, that would include, among other elements, information
on an identification and assessment of any stigma associated
with women veterans seeking mental health care, access to care
for women veterans described in terms of distance to VA
facilities, availability of child care, the comfort and
personal safety perception of women veteran patients, the
sensitivity of VA health care providers to issues affecting
women veterans, and the effectiveness of outreach to women
veterans.
The Committee seeks to ensure that appropriate attention
and resources are directed to the needs of women veterans. For
that to happen, those needs must be properly identified and
described. That is the goal of this mandated study.
VA testified at the Committee's May 21, 2008, hearing on
pending legislation that it was already in the process of
conducting an assessment of barriers to care for women
veterans. The results of that effort can either be provided to
the Committee as soon as the results are available or can be
made a part of the report mandated by this section of the
Committee bill.
Sec. 302. Plan to improve provision of health care services to women
veterans.
Section 302 of the Committee bill, which is derived from S.
2799, would require VA to develop a plan to improve the
provision of health care services to women veterans, and to
submit this plan to Congress no later than 18 months after
enactment of the Committee bill.
Background. Public Law 102-585, enacted in 1992, authorized
new and expanded services for women veterans, including
counseling for sexual trauma on a priority basis, specific
health services for women, such as Pap smears, mammography, and
general reproductive health care (including birth control and
treatment of menopause) at many VA medical facilities.
Public Law 104-262, enacted in 1996, expanded services
further to include maternity and infertility benefits. In
fiscal year 1997, the USH appointed the first full-time
Director for the Women Veterans Health Program. The program
oversees a system of medical and psychosocial services for
women.
As discussed above, in connection with section 301 of the
Committee bill, the Committee is concerned that these benefits
are not being furnished evenly across the VA system.
The 2008 Report of the Advisory Committee on Women Veterans
found that:
The new and complex needs of today's women veterans,
particularly those who served in Operations Enduring
and Iraqi Freedom, require that VA assess the
effectiveness of its existing gender specific programs
and initiate new ones that strategically address the
many needs of this cohort in a way that is inviting,
compassionate, and demonstrate a driven yield toward
the best outcomes.
The burgeoning demand for care from women veterans requires
that VA be fully prepared to deal with their health care needs.
The estimated population of women veterans as of 2001 was
1,600,000, or about 7.2 percent of the total veteran
population. Currently, women make up 14.8 percent of the active
duty military force and approximately 22.8 percent of the
reserve force. By 2010, they are expected to represent over 14
percent of the total veteran population. Fifty-six percent of
women veterans who use VA are less than 45 years of age.
Committee Bill. Section 302 of the Committee bill would
require VA to develop a plan on the provision of health care
services to women veterans. The plan would include how VA
intends to improve current services to women veterans, as well
as how to appropriately provide for the future needs of women
currently serving in OIF/OEF. As part of this plan, the
Secretary would be required to identify the types of health
care services that will be available to women veterans at each
VA medical center, as well as what personnel would be required
to provide such services. This plan would have to submitted to
the two Veterans' Affairs Committees not later than 18 months
after the date of enactment of the Committee bill.
It is the Committee's view that requiring VA to develop a
plan is a first step to ensuring that the needs of women
veterans are met, now and into the future.
Sec. 303. Independent study on health consequences of women veterans of
military service in OIF/OEF.
Section 303, which is derived from S. 2799, would require
the Secretary to enter into an agreement with a non-Department
entity to conduct an independent study on the health
consequences of service by women veterans in OIF/OEF.
Background. Public Law 98-160, enacted in 1983, established
the Advisory Committee on Women Veterans (hereinafter,
``Advisory Committee''). In addition, Public Law 103-446,
enacted in 1994, created the Center for Women Veterans
(hereinafter, ``Center''). Both entities play invaluable roles
in helping to shape VA's responses to the needs and concerns of
women veterans.
The Advisory Committee evaluates existing VA programs and
makes recommendations for the enhancement of programs and
services for women veterans while the Center oversees all VA
programs for women veterans. However, neither entity is
specifically charged to focus on the possible health
consequences for women veterans who have served on activity
duty in the Armed Forces in deployment in OIF/OEF.
There are more women serving in the U.S. Armed Forces than
in any other period in American history. More than 160,000
female U.S. servicemembers have served in Iraq, Afghanistan,
and the Middle East since 2003. At least 450 women
servicemembers have been wounded in Iraq, more female
casualties than in the Korean, Vietnam, and first Gulf Wars
combined.
Another consequence of the increased number of women
serving in the U.S. military is an increase in the occurrence
of rape and sexual assault by their male comrades. Connie Lee
Best, PhD, a Clinical Psychologist and Professor in the
Department of Psychiatry and Behavioral Sciences at the Medical
University of South Carolina testified before the Committee on
April 25, 2007, noting that:
Numerous research studies have documented rates of rape
ranging from lows of six percent for active duty to
rates that are significantly higher. One study found
that 23% of female users of VA health care reported
experiencing at least one sexual assault while in the
military.
Given the extensive service of women in OIF/OEF, the
Committee is of the view that VA must fully assess the health
consequences of their service. Only then will VA know how best
to meet their specific needs.
Committee Bill. Section 303 of the Committee bill would
require the Secretary to enter into an agreement with a non-
Department entity, such as the IOM, to conduct an independent
study on the health consequences of service in OIF/OEF for
women veterans. The study would include an examination of any
and all possible environmental and occupational exposures and
their effects on the general, mental, and reproductive health
of women veterans who served in OIF/OEF. It would also include
an analysis of all published literature on such exposures, as
well as on combat trauma, including military sexual trauma. The
study would be required to be completed and submitted to
Congress no later than 18 months after the enactment of the
Committee bill, and the Secretary would be required to submit a
response to the report of the study no later than 90 days
following the submission of the findings of the study.
Sec. 304. Training and certification for mental health care providers
on care for veterans suffering from sexual trauma.
Section 304 of the Committee bill, which is derived from S.
2799, would require VA to implement a program for education,
training, and certification for VA mental health care providers
on care and counseling services for veterans suffering from
military sexual trauma.
Background. Public Law 102-585, enacted in 1999, authorized
VA to include outreach and counseling services for women
veterans who experienced incidents of sexual trauma while
serving on active duty in the military. The law was later
amended by Public Law 103-452 so as to authorize VA to provide
counseling related to sexual trauma to men, as well as to
women. Public Law 108-422, enacted in 2004, extended VA's
authority permanently to provide Military Sexual Trauma (MST)
counseling and treatment to active duty service members or
those serving on active duty for training.
VA has a number of strong programs geared toward mental
health needs generally. However, MST is a discrete phenomenon
and must be addressed as such. In addition, given the high
numbers of women subjected to MST, as discussed above in
connection with Section 303 of the Committee bill, the
Committee believes that a more targeted approach is necessary.
Dr. Connie Best testified before the Committee in 2007
that:
* * * the VA is staffed by some of the best mental
health providers and by some with exceptional expertise
in MST. However, I believe the one of the problems
facing the VA in their responsibility to meet the needs
of today's veterans who have experienced MST is one of
sheer numbers * * *. That means more qualified and
appropriately trained providers must be available.
Those providers must be able to provide specialized
sexual assault services and understand the interaction
of sexual trauma with combat-related trauma.
Dr. Best suggested that VA should add specialized training
programs for providers in the treatment of MST.
Committee Bill. Section 304 of the Committee bill would
amend section 1720D of title 38, U.S.C., so as to add two new
subsections.
Proposed new subsection (d) would require VA to implement a
program for education, training, and certification for VA
mental health care providers on care and counseling services
for veterans suffering from MST. The new subsection would
require that the training be carried out in a consistent manner
and that it include principles of evidence-based treatment and
care for sexual trauma. VA would also be required to determine
the minimum qualifications necessary for mental health
professionals certified under the program to provide evidence-
based care and therapy to veterans for MST.
Proposed new subsection (e) would require VA to report to
Congress annually on the care and counseling provided under
section 1720D. Specifically, VA would provide information on
the number of mental health professionals and primary care
providers who have been certified under the program; the amount
and nature of continuing medical education provided under such
program to professionals and providers who have been so
certified; the number of women veterans who received counseling
and care and services from professionals and providers who have
been trained or certified under the program; the number of
training, certification, and continuing medical education
programs operating under subsection (d); and the number of
trained full-time equivalent employees required in each
facility of VA to meet the needs of veterans requiring
treatment and care for sexual trauma.
Finally, subsection (b) of section 304 of the Committee
bill, in a freestanding provision, would require the Secretary
to establish education, training, certification, and staffing
standards for VA health care facilities for full-time employees
who are trained to provide sexual trauma counseling and care.
Sec. 305. Pilot program on counseling in retreat settings for women
veterans newly separated from service in the Armed Forces.
Section 305 of the Committee bill, which is derived from S.
2799, would require VA to carry out a pilot program to evaluate
the feasibility and advisability of providing reintegration and
readjustment services in group retreat settings to certain
women veterans.
Background. VA operates a program of readjustment
counseling which is provided through community-based facilities
known as Vet Centers. Currently, there are 232 Vet Centers,
located in all fifty states, the District of Columbia, Guam,
Puerto Rico and the U.S. Virgin Islands. Each provides
assistance to veterans in need of readjustment counseling. The
Vet Centers are managed by the Readjustment Counseling Service
located in the VHA.
VA appears to appreciate the value of retreats for its
employees, especially those involved in mental health issues.
Recent retreats include one on the implementation of the VA's
Mental Health Strategic Plan and another for those advocating
recovery models of care in VISN 3.
The Committee believes that there is merit to evaluating
the impact of providing reintegration assistance in retreat
settings to woman veterans returning from a prolonged
deployment.
Committee Bill. Section 305 of the Committee bill, in a
freestanding provision, would require VA to establish, not
later than six months after the date of enactment of the
Committee bill, a pilot program designed to evaluate the
feasibility of providing reintegration and readjustment
services in a group retreat setting. Under the pilot program,
which would be carried out through the Readjustment Counseling
Service, these services would be provided to women veterans who
are newly separated from service in the Armed Forces after a
prolonged deployment. This pilot program would be required to
be carried out for two years, beginning on the date the program
begins, in no fewer than five locations selected by the
Secretary.
Participation in the pilot program would be strictly
voluntary. Services provided under the program would include
information and assistance on reintegration into family,
employment, and community; financial and occupational
counseling; information and counseling on stress reduction and
conflict resolution; and any other counseling the Secretary
considers appropriate to assist the participants in
reintegrating into their families and communities.
The Committee bill would authorize the appropriation of
$2,000,000 annually in fiscal years 2009 and 2010 to carry out
the pilot program. VA would be required to report to Congress
on the pilot program no later than 180 days after completion of
the program.
Sec. 306. Report on full-time Women Veterans Program Managers at
medical centers.
Section 306 of the Committee bill, which is derived from S.
2799, would require the Secretary to submit to Congress a
report on the employment of program managers solely for the
management and oversight of women veterans' health care needs.
This report would include whether or not each facility employs
at least one such full-time employee.
Background. Women Veterans Program Managers are generally
available at each VA facility, although not all are full-time
positions.
These coordinators ensure that women veterans are afforded
equal access to all services. They work to ensure that women
veterans receive high quality comprehensive medical care in an
environment that is sensitive to the privacy needs of women.
Women Veterans Program Managers also advocate for gender-
specific issues and needs.
The Committee recognizes the valuable contributions of the
Women Veterans Program Managers and believes that it is
essential that every VA medical center have sufficient
resources to ensure that these positions are full-time.
Committee Bill. Section 306 of the Committee Bill would
require the Secretary, acting through the USH, to submit a one-
time report on Women Veterans Program Managers, so as to
determine how many of these positions are filled on a full-time
basis.
Sec. 307. Service on certain advisory committees of women recently
separated from service in the Armed Forces.
Section 307 of the Committee bill, which is derived from S.
2799, would require the Secretary to appoint women veterans who
are recently separated from the Armed Forces to VA's Advisory
Committee on Women Veterans and to the Advisory Committee on
Minority Veterans.
Background. Public Law 98-160, enacted in 1983, established
the Advisory Committee on Women Veterans and set forth specific
criteria for membership on the Committee, including those with
service-connected disabilities, those who represent women
veterans, and others. There is no specific requirement that any
member of this Advisory Committee be a woman veteran who has
recently separated from service in the Armed Forces.
Public Law 103-446, enacted in 1994, established the
Advisory Committee on Minority Veterans and set forth specific
criteria for membership on the Committee including
representatives of veterans who are minority group members,
individuals who are recognized authorities in fields pertinent
to the needs of veterans who are minority group members,
veterans who are minority group members and who have experience
in a military theater of operations, and others. There is no
specific requirement that any member of this Advisory Committee
be a woman veteran who is also a member of a minority group and
who is recently separated from service in the Armed Forces.
Committee Bill. Subsection (a) of section 307 of the
Committee bill would amend section 542(a)(2)(A) so as to
require the Secretary to appoint women veterans who are
recently separated from the Armed Forces, to the VA Advisory
Committee on Women Veterans.
Subsection (b) of section 307 of the Committee bill would
require the Secretary to appoint women veterans who are also
members of a minority group and recently separated from the
Armed Forces to serve on the Advisory Committee on Minority
Veterans.
Subsection (c) of section 307 of the Committee bill would
provide that the amendments made by this section shall apply
with appointments made to the two advisory committees on or
after the date of enactment of the Committee bill.
Sec. 308. Pilot program on subsidies for child care for certain
veterans receiving health care.
Section 308 of the Committee bill, which is derived from S.
2799, would require the Secretary to implement a pilot program
to assess the feasibility and advisability of providing
subsidies to certain veterans in order to allow them to
purchase child care services to facilitate better access to
health care from VA.
Background. There is no current authority for VA to
reimburse veterans for child care expenses incurred while
receiving VA medical care. The Committee recognizes that some
veterans face significant barriers to receiving health care
from VA and that the absence of adequate child care for those
veterans who are primary caretakers of children is one such
impediment. This problem can be even more daunting for veterans
in that situation who are in need of intensive health care
services, such as care for Post Traumatic Stress Disorder
(PTSD), mental health, and other therapeutic programs.
In order to address the issue of the need for child care
for its own employees, VA created the VA Child Care Subsidy
Program, as authorized by Public Law 107-67, the Treasury and
General Government Appropriations Act for Fiscal Year 2002.
That law authorized the use of appropriated funds by executive
agencies in order to provide child care services for Federal
civilian employees. The VA program is needs based, with the
amount of reimbursement available to an employee depending on
total family income and the amount paid for child care. In
order to qualify for reimbursement, children must be placed in
a licensed day care, home care or before/after school program,
and beneficiaries must complete and submit an application form.
The Committee believes that this existing VA program
provides an excellent model for VA to emulate as it moves
forward with the child care subsidies for veterans which would
be authorized by this section of the Committee bill.
Committee Bill. Section 308 of the Committee bill, in a
freestanding provision, would require VA to carry out a pilot
program to examine what effect subsidies for child care for
certain veterans receiving VA health care would have on
improving access to health care services. The pilot program
would be authorized for two years, beginning on the date the
program begins, and would be required to be carried out in no
fewer than three VISNs.
Subsidies for child care would only be available during the
time period that a veteran is actually receiving specified
health care services at a VA medical facility, and during the
time required by the veteran to travel to and from the site of
treatment. Veterans eligible for subsidies would be those who
are the primary caretaker of a child or children and who are
receiving regular or intensive mental health care, or other
intensive health care services determined by the Secretary as
ones for which access would be improved by payment of a subsidy
for child care.
The pilot program would be required to be modeled, insofar
as practicable, on the VA Child Care Subsidy Program and would
use the same income eligibility and payment structure as used
in that program. The Secretary would be required to report on
the program to Congress within six months of the conclusion of
the program on the Secretary's findings and conclusions about
the program, along with any recommendations the Secretary
considers appropriate. The Committee bill would authorize the
appropriation of $1,500,000 annually for fiscal year 2009 and
2010 for the purposes of the pilot program.
Sec. 309. Care for newborn children of women veterans receiving
maternity care.
Section 309 of the Committee bill, which is derived from S.
2799, would authorize the Secretary to provide health care
services, for not more than seven days after birth, to a
newborn child of a woman veteran who is receiving maternity
care from VA.
Background. Under current law, VA is authorized to provide
maternity and infertility benefits to women veterans who enroll
for VA care. Obstetrical care, excluding care for the newborn,
is provided under contract.
While a veteran's care extends to maternity, prenatal, and
postnatal care for female veterans, there is no authority for
the provision of, or payment for, any care for the newborn
child of a female veteran patient. This results in a
significant gap in care for the increasing number of women
veterans enrolled with VA.
The current women veteran population is predominantly pre-
retirement and of child bearing age. Therefore, it is a
disservice to our growing female veteran population and an
inequity to not provide some newborn care.
According to various studies, the average hospital stay for
low-birth weight infants (a common reason for prolonged
neonatal hospital stays) ranges from 6.2 to 68.1 days, whereas
the average hospital stay for average-sized infants was 2.3
days. Seven days of coverage would assist the mothers of
newborns in need of simple, routine care, as well as many in
need of more complex hospitalization.
Committee Bill. Section 309 of the Committee bill would add
a new section--Section 1786. Care for newborn children of women
veterans receiving maternity care--to Subchapter VIII of
chapter 17 of title 38, U.S.C. This new section would authorize
the Secretary to provide health care services, for not more
than seven days after birth, to a newborn child of a woman
veteran who is receiving maternity care from VA, if the mother
gave birth in a VA medical facility, or in an outside facility
pursuant to a contract between that facility and VA. These
services would include all post-delivery care, including
routine care, required by a newborn.
It is the Committee's belief that this limited but
important step will help to ensure that the needs of women
veterans enrolling for VA care are met in a more complete
manner.
TITLE IV--MENTAL HEALTH CARE
Sec. 401. Eligibility of members of the Armed Forces who serve in
Operation Iraqi Freedom or Operation Enduring Freedom for
counseling and services through Readjustment Counseling
Service.
Section 401, which is derived from S. 2963, would allow
members of the Armed Forces, including members of National
Guard or Reserves, who serve in OIF/OEF to receive services
through VA's Readjustment Counseling Service.
Background. Currently, certain veterans are eligible for
readjustment counseling services under section 1712A of title
38, U.S.C. Those eligible for these services include recently
separated servicemembers from OIF/OEF as well as members of the
National Guard or Reserves who were mobilized for service in
OIF/OEF and served for the period of their mobilization. Under
current law, members of the Armed Forces still on active duty
are not eligible for readjustment counseling services from VA.
Committee Bill. Section 401 of the Committee bill, in a
freestanding provision, would establish eligibility for
readjustment counseling services for any member of the Armed
Forces who serves on active duty in OIF/OEF, including a member
of the National Guard or Reserves.
Subsection (a) of section 401 would set forth the basic
eligibility for this population of servicemembers for
readjustment counseling and related mental health services
under section 1712A of title 38, U.S.C. These services would be
provided through VA's Vet Centers.
Subsection (b) of section 401 would not require that a
servicemember be currently on active duty to be eligible for
these services.
Subsection (c) of section 401 would condition the
eligibility for these services on regulations prescribed
jointly by the Secretaries of Defense and VA.
Subsection (d) of section 401 would limit the availability
of services under this section to the availability of
appropriations for the provision of these services, so as to
ensure that allowing a new population segment into the Vet
Center system will not be a detriment to those the Vet Centers
are currently serving.
The Committee recognizes that, in many parts of the active
duty and reserve Armed Forces, there is stigma associated with
seeking assistance in connection with mental health concerns.
In light of the clear indications that many who serve in combat
may experience psychological impact from such service--as shown
by a 2008 Rand Corporation Study on mental health in OIF/OEF
veterans, (Tanielian and Jaycox [Eds.], ``Invisible Wounds of
War: Psychological and Cognitive Injuries, Their Consequences,
and Services to Assist Recovery,'' Santa Monica, CA: RAND
Corporation, 2008.)--there appears to be significant value in
allowing servicemembers still on active duty to come to VA's
Vet Centers for help in dealing with such concerns.
At the same time, the Committee is concerned about placing
an undue burden upon the Vet Centers, given their current
responsibility to not only provide readjustment counseling to
currently eligible veterans, but also to provide outreach to
returning servicemembers and newly discharged veterans.
Sec. 402. Restoration of authority of Readjustment Counseling Service
to provide referral and other assistance upon request to former
members of the Armed Forces not authorized counseling.
Section 402 of the Committee bill, which is derived from S.
2963, would restore the authority of VA's Readjustment
Counseling Service to provide referral and other assistance,
upon request, to former members of the Armed Forces who have
been discharged or released from active duty but who are not
otherwise eligible for such counseling and services.
Background. VA was first authorized to furnish readjustment
counseling services to Vietnam-era veterans in 1979 in Public
Law 96-22. Included in that original authority was a provision
that required VA to provide referral services and other
assistance to veterans who sought readjustment counseling but
who were not eligible to receive those services because of the
nature of their discharge from the military or for other
reasons.
This authority was repealed in 1996 in Public Law 104-262,
the Veterans Health Care Eligibility Reform Act of 1996.
Committee Bill. Section 402 of the Committee bill would
amend section 1712A of title 38, U.S.C., by adding a subsection
(c) which would restore the provisions which require VA to
provide referral services and other assistance to veterans who
request readjustment counseling but who are not eligible for
such services.
It is the Committee's intent that those who have been
discharged under conditions other than honorable still be
afforded assistance in acquiring mental health services and
also in gaining review of their discharges. The Committee
believes that VA should be available to provide some assistance
to those who have served and are in need of readjustment
assistance, even if they are not eligible for the full array of
VA benefits.
Sec. 403. Study on suicides among veterans.
Section 403 of the Committee bill, derived from S. 2899,
would require VA to conduct a study on suicides among veterans
since January 1, 1997, and report to Congress on the findings.
Background. Numerous reports have been released in the past
six months, illustrating that the rate of suicide among
veterans has been steadily increasing. One such report was the
RAND study (Tanielian and Jaycox [Eds.], ``Invisible Wounds of
War: Psychological and Cognitive Injuries, Their Consequences,
and Services to Assist Recovery,'' Santa Monica, CA: RAND
Corporation, 2008.), which reported that 1 in 5 veterans of the
wars in Iraq and Afghanistan are returning and suffering with
stress or mental health disorders, but that only half of those
veterans are actually receiving treatment for these conditions.
VA's own Office of Mental Health reported that the number
of suicides attempted at VA facilities increased from 492 in
2000 to 790 in 2007. Additionally, according to VA data,
suicide among male veterans between 18 and 29 years of age has
increased from 26.94 suicides per 100,000 to 45.82 suicides per
100,000--nearly a 100 percent increase. This is the highest
rate since at least 2001.
Yet, there remains no centralized database of veteran
suicides and attempts.
Committee Bill. Section 403 of the Committee bill, in a
freestanding provision, would require VA to conduct a study to
determine the number of veterans who died by suicide between
January 1, 1997, and the date of enactment of the Committee
bill.
Subsection (a) of section 403 would set forth the basic
requirements for the study.
Subsection (b) of section 403 would require VA, in carrying
out this study, to coordinate with DOD, Veterans Service
Organizations (VSOs), the Centers for Disease Control and
Prevention (CDC), and state public health offices and veterans
agencies.
Subsection (c) of section 403 would require VA to submit a
report to the Committees on Veterans' Affairs of the Senate and
the House of Representatives on the findings of the study.
Subsection (d) of section 403 would authorize the
appropriation of such sums as may be necessary to carry out the
study.
Because the data show that the incidence of suicide among
veterans is on the rise, the Committee believes a need exists
to have more comprehensive and accurate information so this
issue can be more successfully addressed.
Sec. 404. Transfer of funds to Secretary of Health and Human Services
for Graduate Psychology Education program.
Section 404 would mandate the transfer of $5,000,000 from
VHA accounts to the Secretary of Health and Human Services for
the Graduate Psychology Education program.
Background. The Graduate Psychology Education program was
established under section 755(b)(1)(J) of the Public Health
Services Act. This program is the only federal program solely
dedicated to training post-doctoral psychologists.
Recent studies have projected continuing high demand for
psychological treatment of PTSD, TBI, and other combat-related
stress disorders. Reports issued by GAO, the Department of
Defense Mental Health Task Force, the Presidential Task Force
on Returning Global War on Terror Heroes, IOM, and the
President's Commission on Care For America's Returning Wounded
Warriors, have identified shortages of trained mental health
providers, detailed problems in the training pipeline, and
provided recommendations concerning the workforce needed to
deal with what is projected to be an increased demand for
mental health care among servicemembers and veterans.
VA faces immediate challenges in recruiting mental health
professionals with focused specialty training in combat-related
stress disorders and post deployment readjustment. Establishing
a collaborative VA-HHS training pipeline should help ensure a
steady flow of specially-trained psychologists to serve the
veteran population. Graduates of these training programs will
continue to practice their specialty and will also be
candidates for hire by VA or civilian practices that serve
veteran patient populations. Many of the positions may be in
rural communities where veterans, especially those from
National Guard and Reserve units, often return to find VA
facilities distant or community-based outpatient clinics
lacking mental health professionals.
Committee Bill. Section 404 of the Committee bill would, in
a freestanding provision, mandate the transfer of funds from VA
to the Department of Health and Human Services (HHS) for the
Graduate Psychology Education program and delineate the use of
the funds and the preferences for VA health care facilities.
Subsection (a) of section 404 would require VA, no later
than the September 30, 2009, to transfer $5,000,000 from
accounts of VHA to HHS for the Graduate Psychology Education
program.
Subsection (b) of section 404 would specify that the funds
transferred by VA to HHS be used to make grants that would
support the training of psychologists in the treatment of PTSD,
TBI, and other combat-related psychological disorders.
Subsection (c) of section 404 would establish a preference
in the awarding of grants under this provision to VA health
care facilities and to graduate educational programs affiliated
with VA facilities.
The Committee intends for the grantee training programs
receiving support through this effort to be involved with VA
clinicians and facilities as training sites, thus ensuring that
the substantial services provided in the course of training
will go to veterans. Ensuring an adequate supply of well-
trained psychologists--specializing in combat stress
disorders--is in the strong interest of the Nation, VA, and
individual veterans.
TITLE V--HOMELESS VETERANS
Veterans remain one of the more disproportionately
represented groups among the overall homeless population. It
has been estimated that one in every three homeless persons is
a veteran. Carl Blake, National Legislative Director, Paralyzed
Veterans of America, testified before the Committee on May 21,
2008, that ``[w]hile estimates vary, it is believed that as
many as 250,000 veterans are on the street in any given night.
This fact seems incomprehensible in light of the sacrifices
that these men and women have made.''
VA administers a number of programs aimed at combating and
preventing homelessness among veterans. These programs include
the provision of residential domiciliary-based care (including
mental health care and substance-use disorder treatment), a
grant and per diem program to assist community-based entities
that serve homeless veterans, employment and job training
assistance, and supported permanent housing.
The Committee has been at the forefront of the issue and
has worked cooperatively with VA to expand and enhance its
authority to serve this unique population. Title V of the
Committee bill includes a number of provisions, some from VA,
some suggested by advocates, some from legislation, all of
which are designed to enhance and improve VA efforts to address
the overall problem and to provide assistance to homeless
veterans
Sec. 501. Pilot program on financial support for entities that
coordinate the provision of supportive services to formerly
homeless veterans residing on certain military property.
Section 501 of the Committee bill, which is derived from S.
2273, would authorize the Secretary to create and implement a
pilot program to carry out, and evaluate the impact of,
providing grants to certain organizations that will assist
formerly homeless veterans living on certain government
property.
Background. The National Coalition for Homeless Veterans
(NCHV), in testimony before the Committee on May 21, 2008,
cited VA's 2006 Community Homelessness Assessment and Local
Education Networking Groups report, ``The lack of affordable
permanent housing is cited as the No. 1 unmet need of America's
veterans.'' This need is listed as the second highest unmet
need in the 2007 report.
Currently, veterans can utilize services from organizations
that are sponsored by the Homeless Grant and Per Diem (GPD)
program, but organizations sponsored by this program can only
provide services to a veteran for up to two years. Domiciliary
Care for Homeless Veterans provides treatment and
rehabilitation to homeless veterans, but the average length of
stay is only four months. VA's Compensated Work Therapy/
Transitional Residence program provides both a residence and
employment in conjunction with work-skills training and other
rehabilitation. The average stay in this program is only 174
days. VA's Supported Housing program allows VA staff to assist
in locating permanent housing for veterans, but does not
provide any funding or vouchers to allow VA to provide that
housing.
A new VA pilot program provides loan guarantees for
transitional family housing, but not permanent long-term
housing. All of these programs are beneficial steps, but many
veterans are still not ready for transition to independent
living at the end of these programs. NCHV points out that
despite these programs, ``many formerly homeless veterans still
cannot afford fair market rents, nor will most of them qualify
for mortgages even with the VA home loan guarantee. They are,
essentially, still at risk of homelessness.'' Dr. Gerald M.
Cross, MD, Principal Deputy Under Secretary for Health at VA,
testified at the Committee's May 21, 2008, hearing that
military facilities that have been recently closed or had a
major mission change could potentially be prime locations to
house already homeless veterans or those in danger of becoming
homeless.
Committee Bill. Section 501 of the Committee bill would
authorize the Secretary, subject to the availability of
appropriations, to carry out, and evaluate the impact of, a
pilot program which would provide grants to entities that
coordinate the provision of supportive services for very low
income (as defined in the Resident Characteristics Report of
the Department of Housing and Urban Development), formerly
homeless veterans living on property that had been a military
installation closed as part of the 2005 round of defense base
closure and realignment under the Defense Base Closure and
Realignment Act of 1990, or under subchapter III of chapter 5
of title 40, U.S.C., and which the Secretary of Defense
determines, after reviewing any local authority's redevelopment
plans for the property, that the property can be used to assist
the homeless in accordance with any such redevelopment plan.
The program would be carried out through the provision of
grants from the Secretary to public and nonprofit
organizations, including faith-based organizations. The
Secretary would be authorized to issue grants at not more than
ten properties that had been military installations that were
closed as described above. The Secretary would be required to
determine and publish criteria for awarding the grants. This
pilot program would span a period of five years from the
program's beginning. In order to carry out this program,
$3,000,000 from General Operating Expenses would be authorized
for the program in each fiscal year from 2009 to 2013.
The Committee agrees with VA's position that military
facilities that have been recently closed or have had a major
mission change could serve as excellent locations to house
homeless veterans, or those in danger of becoming homeless. In
developing economic revitalization and community development
plans, local authorities could utilize grants under the program
that would be established by this provision so as to aid in
financing the conversion of such properties. The Committee
believes that veterans with certain applicable skills--
including but not limited to such occupations as carpentry,
plumbing, and landscaping--could be employed in the property
conversion process, or in other aspects of a community's
redevelopment plan, a process that could further aid very low-
income veterans. It is the Committee's belief that this
combination of available housing and employment under local
revitalization plans or in areas of the local economy could
enable participating veterans to become self supporting.
Sec. 502. Pilot program on financial support of entities that
coordinate the provision of supportive services to formerly
homeless veterans residing in permanent housing.
Section 502 of the Committee bill, which is derived from S.
2273, would authorize the Secretary to implement a pilot
program to carry out, and evaluate the impact of, providing
grants to certain organizations for the coordination of efforts
to provide supportive services from the local community to very
low income, formerly homeless veterans.
Background. Currently, there are a number of community-
based and/or non-profit organizations that can and do provide a
variety of services to assist formerly homeless veterans with
their reintegration into society. These groups, coupled with
VA's current efforts to provide supportive services, seek to
prevent homelessness from recurring, which is consistent with
the overall direction of efforts against homelessness. The
focus among both VA providers and community groups is shifting
to prevention rather than reaction to homelessness occurring.
This is done largely through intensive case management and
collaboration with VSOs to find permanent housing for these
veterans.
Committee Bill. Section 502 of the Committee bill would
authorize the Secretary, subject to the availability of
appropriations, to carry out, and evaluate the impact of, a
pilot program which would provide grants to nonprofit and
public organizations, including faith-based organizations, to
coordinate providing supportive services from the local
community to very low income (as defined in the Resident
Characteristics Report from the Department of Housing and Urban
Development), formerly homeless veterans who are residing in
permanent housing. The Secretary would be authorized to award
grants at up to ten locations. Locations that would qualify for
grants would include any property in the United States that
provides permanent housing to formerly homeless veterans.
Criteria for receiving grants would be developed and published
by the Secretary. This program would be conducted over a five
year period, beginning at the start of the pilot program. In
order to carry out this program, $3,000,000 from General
Operating Expenses would be authorized for the program in each
fiscal year from 2009 to 2013.
This effort, in ten communities across the nation, would
further assist veterans in reintegrating into the community and
becoming self sufficient. The Committee expects that the ten
locations selected for the pilot program under section 502 of
the Committee bill will all be different from the locations
selected for the pilot program under section 501, described
above.
Joseph L. Wilson, Deputy Director of the Veterans Affairs
and Rehabilitation Commission of The American Legion, described
the need for the type of pilot program authorize in this
section of the Committee bill and in the prior section, in his
May 21, 2008, testimony before the Committee, saying ``[w]hile
permanent housing provides a stable base for veterans and their
families the need for resources to improve their way of life is
just as important * * *. These funded pilot programs will
extend more opportunities for formerly homeless veterans, which
in turn allow them to achieve and maintain a quality existence,
deserving of their service to our country.''
Sec. 503. Pilot program on financial support of entities that provide
outreach to inform certain veterans about pension benefits.
Section 503 of the Committee bill, which is derived from S.
2273, would authorize the Secretary to implement a pilot
program to carry out, and evaluate the impact of, providing
grants to certain organizations to inform certain veterans and
their spouses about VA pension benefits.
Background. A recent study, (Greg Greenberg, Joyce H. Chen,
Robert A. Rosenheck, Wesley J. Kasprow. ``Receipt of Disability
through an Outreach Program for Homeless Veterans.'' Military
Medicine 172, no. 5 (May 1, 2007): 461-5.), has concluded that
there is an acute need for outreach to low-income and elderly
veterans, and their spouses, to inform them of their potential
eligibility for need-based pension benefits from VA. Some of
these veterans and their spouses live in areas that are far
from VA facilities, and hence are underserved in outreach from
VA.
Pension benefits are given by VA to wartime veterans who
have limited income, and are either 65 years of age, or older,
or who are permanently and totally disabled.
Committee Bill. Section 503 of the Committee bill would
authorize the Secretary to carry out, and evaluate the impact
of, a pilot program which would provide grants to nonprofit or
public organizations, including faith-based organizations, to
provide outreach and information to low-income and elderly
veterans and their spouses, who live in rural areas, of
benefits and services they may qualify for under chapter 15 of
title 38, U.S.C., the chapter relating to VA's needs-based
pension program. The Secretary would develop criteria for
awarding the grants, and publish them in the Federal Register.
This program would span a period of five years from the date of
its inception. In order to carry out this program, $1,275,000
from General Operating Expenses would be authorized for the
program in each fiscal year from 2009 to 2013.
The Committee believes that utilizing local organizations
and their existing networks would be an effective way of
disseminating key information to veterans and their spouses
about the VA pension program.
Sec. 504. Pilot program on financial support of entities that provide
transportation assistance, child care assistance, and clothing
assistance to veterans entitled to a rehabilitation program.
Section 504 of the Committee bill, which is derived from S.
2273, would authorize the Secretary to carry out a pilot
program that would involve providing financial assistance to
certain veterans who are eligible for rehabilitation programs
under chapter 31 of title 38, U.S.C.
Background. VA found that subsistence allowances provided
under chapter 31 of title 38, U.S.C., the chapter which sets
forth VA's Vocational Rehabilitation Program, were insufficient
for veterans to support themselves or their families while
utilizing the vocational rehabilitation services provided
therein. Clothing, transportation, and child care needs were
specifically cited by VA as being major areas of concern for
those participating in the program.
Committee Bill. Section 504 of the Committee bill would
authorize the Secretary, subject to appropriations, to carry
out a pilot program to examine the feasibility and advisable of
providing financial assistance to eligible entities in order
that those entities could establish new, or expand upon
existing, programs to provide assistance to transitioning
individuals who are eligible for rehabilitation programs under
chapter 31 of title 38, U.S.C.
The assistance that would be provided by eligible entities
under the pilot program would include: (1) transportation
assistance, including providing or paying for transportation or
other transportation related expenses (such as orientation to
using the transportation); (2) child care assistance to enable
participation in rehabilitation programs, including providing
or paying for child care; and (3) clothing assistance,
including help in finding suitable work clothing and providing
a clothing purchase allowance.
An eligible individual under this section of the Committee
bill would include a person described in section 3102 of title
38, or someone who was separated or released from active duty
in the Armed Forces on or after October 1, 2006, because of a
service-connected disability. A qualified individual under
section 3102 would be a person who is a veteran: with a 20
percent or greater service-connected disability, incurred or
aggravated after September 16, 1940; receiving medical care,
from a Government facility or at Government direction, for a
service-connected disability, that will likely be rated at or
above 20 percent, while awaiting discharge from active duty;
the Secretary believes is in need of rehabilitation because of
an employment handicap; or a veteran, with a service-connected
disability of 10 percent or greater, incurred or aggravated on
or after September 16, 1940, and who also, in the determination
of the Secretary, suffers from a serious employment handicap.
Grant criteria would be established and published by the
Secretary, but would have to include the kinds of projects for
which grants are available, the number of projects for which
grants are available, and provisions to ensure projects do not
duplicate existing services. Grants would not be permitted for
paying the operating costs of the receiving entities.
Eligible entities under this section of the Committee bill
would include public and nonprofit organizations, including
faith-based organizations which (1) have the capacity to
effectively administer a grant from the Secretary; (2)
demonstrate the availability of sufficient financial resources
for the establishment or expansion of programs; and (3) agree
to and have the capacity to meet the pilot program's criteria
as promulgated by the Secretary. Grant recipients would be
selected by the Secretary based upon an organization's
submission of an application which would be required to
contain: (1) the amount sought; (2) plans, specifications, and
the schedule for implementing the organization's program; and
(3) an agreement to provide the services at accessible
locations, maintain confidentiality of the records of
individuals participating in the program, and establish fiscal
control and accounting procedures to ensure proper disbursement
and accounting.
If a grant or part of a grant under this program were
unused, or if the organization does not establish a program to
provide services, or ceases the program for which they were
awarded a grant, the U.S. would be authorized to recover any
unused amounts of awarded grants and the Secretary would be
authorized to obligate any amount so recovered, without fiscal
year limitation, in order to continue the pilot program. No
amount could be recovered until three years from the date on
which the grant was awarded. Authority for the pilot program
would end three years after the date of the program's
inception. Five million dollars would be allotted in each
fiscal year from 2008-2010 to implement the pilot program.
It is the Committee's hope that, by increasing the benefits
available to veterans under going rehabilitation, and providing
this aid early, it is more likely that the veteran will
successfully complete vocational rehabilitation, which could
have a substantial effect on the unemployment rate among
veterans, specifically disabled veterans.
Sec. 505. Assessment of pilot programs.
Section 505 of the Committee bill, which is derived from S.
2273, would require the Secretary to submit a report to
Congress on each of the pilot programs detailed in sections
501-504 of the Committee bill at least one year before the end
of each program's authorization. Each report would be required
to contain the lessons learned by the Secretary which can be
applied to other similar programs, any recommendations from the
Secretary as to whether to continue the pilot program, the
number of veterans and dependents served by the pilot program,
an assessment of the quality of service provided by the
program, the amount of funds provided to grant recipients under
the program, and the names of all organizations that have
received grants.
Sec. 506. Increased authorization of appropriations for comprehensive
service programs.
Section 506 of the Committee bill, would increase the
amount authorized for comprehensive service programs for
homeless veterans, under subchapter II of chapter 20, title 38,
U.S.C., from $130,000,000 annually to $200,000,000 annually.
The programs referred to in this section are the GPD programs.
Under this program, VA can provide grant funds to assist in the
construction or renovation of a community-based, non-profit
facility for the purposes of housing and providing services to
homeless veterans. These facilities' programs may also be
eligible for per diem funds from VA to offset the cost of care,
for each veteran they serve.
These programs have been largely successful and as such,
the Committee believes that the threshold for total
authorization should be increased to allow more resources to be
directed to this program. The Senate Appropriations Committee
included $200,000,000 for the GPD Program in the Military
Construction-Department of Veterans Affairs Appropriations Bill
for Fiscal Year 2009 that was reported out of Committee on July
XX, 2008, subject to the passage of a corresponding increase in
the authorization level.
TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS
Title VI of the Committee bill includes a number of
provisions that would amend subchapter IV of chapter 73
relating to nonprofit research and education corporations
(NPCs).
NPCs were first authorized in 1988 in Public Law 100-322.
Prior to 1988, it was difficult for VA to accept private or
non-VA public funding for its research program. The methods in
place, such as the General Post Fund, were not well-suited to
this task. The General Post Fund was primarily designed to
accept and administer veterans' bequests, the regulations of
which made it difficult to flexibly disburse funds.
Additionally, university partners who could administer funds
for VA frequently had high overhead costs, reducing the amount
of funding available for actual research. NPCs were designed to
be a mechanism that could flexibly administer such funds, be
regulated and overseen by the Federal Government, and remain
affiliated with, but not part of, VA.
While NPCs were originally designed to support only VA
research, Congress has since expanded their role to include
support of education and training. Since that initial authority
was provided, the number of NPCs that have been established has
ranged from 96 to 84, with prior year revenues totaling more
than $240,000,000 reported in June 2008. NPCs play a central
role in VA research, making up 18 percent of VA's total
research funding. Through NPCs, VA researchers access funding
from, and collaborate with, DOD and the National Institutes of
Health of HHS. NPCs also give VA researchers access to research
support from foundations, corporations, and private
organizations.
NPCs were originally intended to support the research
programs of individual medical centers. This facility-specific
approach effectively supports individual programs, and NPCs are
essential components of many facilities' research efforts.
However, in the twenty years since the inception of NPCs, the
character of VA research has changed and the standards applied
to nonprofit corporation governance and management have become
more rigorous. Some facility research programs may simply be
too small to generate a revenue stream sufficient to support
the infrastructure and governance necessary to meet these
standards, but the facilities would nonetheless benefit from
having ready access to the benefits NPCs provide.
In general, the provisions of Title VI of the Committee
bill would alter the existing law to allow for multi-medical
center non-profit research corporations. Traditional NPCs are
chartered in the state in which they are physically located and
affiliated with one VA facility. In order to combine resources,
NPCs affiliated with nearby medical centers, possibly in
different states, need the ability to form higher-revenue
corporations, known as multi-medical center research
corporations, without unduly imposing on the VA a requirement
for multiple personnel from multiple facilities to serve on an
NPC board of directors.
The Committee bill would grant authority to the Secretary
to establish multi-medical center research corporations, to
approve the conversion of single-facility NPCs to multi-medical
center research corporations. It also details the composition
of the board of directors for such corporations. The bill also
would make permanent the authority of the Secretary to
establish NPCs, clarify the powers of such corporations to
allow them to more flexibly disburse their funds, and clarify
the purposes of NPCs to remove ambiguity about their role in
supporting education and training. Finally, this title would
improve the oversight of NPCs, and make a clerical amendment.
Sec. 601. General authorities on establishment of corporations.
Section 601 of the Committee bill, which is derived from S.
2926, would expand authorizations for the establishment of
NPCs, and clarify the definition and purpose of such
corporations.
Background. Current law relating to the authority to
establish NPCs, section 7361 of title 38, U.S.C., allows NPCs
to be established at one VA medical center, and in one state.
As discussed above, NPCs were originally intended to support
the research programs of individual medical centers but that
model is no longer optimal. Current law requires that NPCs be
tax exempt organizations but does not specify the specific
terms of that status, which has led to some confusion about the
tax and regulatory status of NPCs in some states and among some
stakeholders.
Committee Bill. Section 601 of the Committee bill would
amend section 7361 of title 38 in a number of ways, with the
principal focus on authorizing the creation of multi-medical
center research corporations.
Subsection (a)(1) of section 601 would amend section 7361
so as to insert a new subsection (b) that would expressly
authorize the establishment of ``multi-medical center research
corporations.'' The board of directors of a multi-medical
center research corporation would have to include the director
of each VA medical center involved in the corporation. A multi-
medical center research corporation would be authorized to
manage finances relating to research or education, or both,
performed at the VA medical centers involved.
Additionally, single-facility NPCs and multi-medical center
research corporations would retain unchanged their current
ability to administer funds for research programs conducted at
multiple facilities, regardless of whether those facilities are
served by a multi-medical center research corporation. NPCs
could also serve as pass-through entities for programs
performed at multiple facilities.
Subsection (a)(2) of section 601 would add a new subsection
(f) to section 7361 that would authorize an existing NPC to
become a multi-medical center research corporation if its board
of directors approves such an expansion and it is also approved
by the Secretary. Ms. Donna McCartney, Chair of the National
Association of Veterans' Research and Education Foundations
(NAVREF) and Executive Director of the Palo Alto Institute for
Research and Education, testified before the Committee on May
21, 2008, that this provision is necessary because:
``* * * it will allow interested VA facilities with
small research programs to join with larger ones. Or
several smaller facilities may pool their resources to
support management of one NPC with funds and staffing
adequate to ensure an appropriate level of internal
controls, including segregation of financial duties.''
Subsection (b) of section 601 would further amend section
7361 by adding a new subsection (c) which would consist of the
provisions of current section 7365, relating to the
applicability of State law to NPCs, modified so as to specify
that multi-medical center corporations operating in different
states would be created under and subject to the laws of one of
the States in which the corporation operates.
Subsection (c) of section 601 would further amend section
7361 by recasting as a new subsection (d)(1) a provision in
subsection (a) of current section 7361 relating to the
obligation of NPCs to comply only with those Federal laws,
regulations, and executive orders and directives that apply to
private non-profit corporations generally and by adding a new
paragraph (2) to subsection (d) which would expressly provide
that NPCs are not owned or controlled by, or are not an agency
or instrumentality of, the United States.
Subsection (d) of section 601 would further amend section
7361 by restoring the requirement that all NPCs must operate as
501(c)(3) tax exempt organizations. This amendment is designed
to eliminate confusion in some states and among some
stakeholders over the tax status of NPCs. In testimony, for the
record of the Committee's May 21, 2008, hearing, VA expressed
support for section 601 and specifically for permitting the
formation of multi-medical center research corporations.
Sec. 602. Clarification of purposes of corporations.
Section 602 of the Committee bill, which is derived from S.
2926, would clarify the purpose of NPCs to include specific
reference to their role as funding mechanisms for approved
research and education, in addition to their role in
facilitating research and education.
Background. Current law is not specific with respect to the
role of NPCs in supporting research and education, and does not
include multi-medical center corporations. Further, the statute
currently contains provisions that appear to allow NPCs to
offer residencies and similar programs, possibly in conflict
with the prohibition against nonprofit corporations conferring
personal benefits on individuals.
Committee Bill. Section 602 of the Committee bill would
amend section 7362 of title 38, U.S.C., in a number of ways,
with the principal focus on providing that, in addition to
supporting the conduct and administration of VA research
projects and education activities, NPCs may support functions
more generally related to VA research and education.
Subsection (a) of section 602 would amend subsection (a) of
section 7362 so as to clarify that NPCs are intended to provide
``a flexible funding mechanism'' for both the conduct of
approved research and education at one or more VA medical
centers and to fund ``functions'' relating to research and
education. These functions would include, but not be limited
to: travel to scientific conferences; recruitment of clinician
investigators; improvements in laboratories; procurement of
general use research equipment, and support for the
institutional review board; the animal laboratory and the
facility human protections program. Under current law, support
for such functions often cannot be tied to specific research
projects and, as such, may not be permitted.
Ms. McCartney's testimony noted that there have been
differences in interpretation regarding the permissibility of
NPC expenditures supporting VA research and education
generally, instead of being tied directly to an approved
project. This section of the Committee bill would clarify that
issue.
Subsection (b) of section 602 would amend subsection (b) of
section 7362 so as to make a technical modification to a
defined term relating to education and training.
Subsection (c) of section 602 would further amend
subsection (b) of section 7362 so as to strike a provision that
allows NPCs to include, under the education function of a
corporation, the employment of individuals as part of a
residency or similar program. By removing this language
relating to residencies and similar programs, it is not the
Committee's intent that this change diminish the authority of
NPCs to support elements of education and training activities
for VA trainees, such as VA residents, but simply to clarify
that NPCs cannot be chief sponsors of residencies, as they are
neither hospitals nor academic institutions and that function
may conflict with regulations governing 501(c)(3)
organizations. NPCs would still be able to support education
and training activities for VA trainees, and, for purposes of
this section, employees of the VHA include VA trainees.
Subsection (d) of section 602 would further amend
subsection (b) of section 7362 so as to clarify that NPCs are
authorized to provide education and training to patients as
well as families of patients. The Committee recognizes that
patients' families often play a central role in the care and
recovery of veteran patients. As such, education for family
members directly supports the care and recovery of these
veterans. The return of wounded service members from Iraq and
Afghanistan, many with severe TBI or debilitating multiple
traumas, is placing growing demands on family caregivers.
Clarifying that NPCs can provide such education would be an
important form of support for family caregivers.
Sec. 603. Modification of requirements for boards of directors of
corporations.
Section 603 of the Committee bill, which is derived from S.
2926, would address the requirements for the composition of NPC
boards of directors.
Background. Under current section 7363, certain non-VA
personnel who serve on the board of an NPC must be familiar
with issues involving medical and scientific research or
education. This limits the composition of boards of directors,
and prevents potential board members from serving who may have
valuable business, legal, or financial expertise.
In addition, subsection (c) of section 7363 requires that
members of NPC boards have no ``financial relationship'' with
any entity that is a source of funding for VA, with the
exception of governmental and non-profit entities. This phrase
has been interpreted by VA as an absolute prohibition on any
financial relationship on the part of a board member with a
precluded entity, either in the past or present. That
prohibition was included in the original NPC authorizing
legislation, Public Law 100-322, in 1988. Subsequently, the
Office of Government Ethics (OGE) promulgated government-wide
conflict of interest regulations in 5 CFR (Code of Federal
Regulations) Part 2635, and the waiver regulations required by
section 208 of title 18, U.S.C., in 5 CFR Part 2640 in August
1992, and December 1996, respectively. In light of those
actions by OGE, the requirements placed on NPC board members
have become more onerous than those applied to many government
and non-profit employees.
Further, the financial conflict of interest requirements of
current subsection (c) of section 7363(c) go beyond the
requirements in paragraph (1) of subsection (c) of section
7366, which state that NPC board members ``shall be subject to
Federal laws and regulations applicable to Federal employees
with respect to conflicts of interest in the performance of
official functions.'' Under that paragraph, NPC board members
are governed by the statutory criminal code, section 208 of
title 18, U.S.C., and conflict of interest regulations, 5 CFR
Sec. Sec. 2635.401-2635.403. Those regulations, in addition to
guidance from the Internal Revenue Service and the Office of
Government Ethics, provide for the permissibility of de minimus
affiliations, and for the ability to recuse oneself when
necessary to avoid conflicts of interest.
Committee Bill. The Committee bill would amend section 7363
of title 38, U.S.C., in a number of ways so as to describe
membership in boards of multi-medical center research
corporations, allow non-VA individuals with diverse backgrounds
to serve on NPC boards, and to modify the provisions relating
to conflicts of interest.
Subsection (a) of section 603 would amend paragraph (1) of
subsection (a) of section 7363 so as to restructure the current
law without changing the intent or effect except to provide
that the directors of each medical center affiliated with a
multi-medical center research corporation are to be members of
that corporation's board of directors.
Subsection (b) of section 603 would amend paragraph (2) of
subsection (a) of section 7363 so as to require that not less
than two non-VA personnel be members of the board, and, in
addition to those with medical or scientific expertise, would
permit individuals to be on an NPC board who have backgrounds
or business, legal, or financial expertise that would benefit a
board.
Ms. McCartney testified that this provision of the
Committee bill would substantially aid NPCs in acquiring the
expertise needed to efficiently run research corporations,
including legal and financial management expertise.
Subsection (c) of section 603 would amend subsection (c) of
section 7363 so as to eliminate the requirement in current law
that members of NPC boards have no financial relationship with
any entity that is a source of funding for research or
education by VA, with the exception of governmental and non-
profit entities. By eliminating the restrictions in current
law, this section of the Committee bill would bring NPCs into
conformity with other 501(c)(3) entities and Federal conflict
of interest regulations.
Ms. McCartney emphasized the importance of this change and
the Committee concurs with her view that there is no reason to
hold board members of NPCs to a higher standard than what
applies to similar organizations or to government employees.
Sec. 604. Clarification of powers of corporations.
Section 604 of the Committee bill, which is derived from S.
2926, would restate NPCs' authorities so as to clarify that
they may accept, administer, and transfer funds for various
purposes.
Background. Section 7364 of title 38, U.S.C., entitled
``General powers,'' sets forth the core authorities of NPCs.
Over the years, the incompleteness and imprecision of some of
these provisions have created obstacles to the conduct of NPC
business. In addition, current law is unclear and potentially
contradictory on some financial and personnel issues.
Current section 7364 does not fully address the financial
authorities necessary to NPCs. While the provision specifies
that NPCs may accept gifts and grants, it does not mention
other sources of funding common to NPCs, such as fees,
reimbursements, and bequests. In some situations, VA has
interpreted existing law to mean that NPCs may only accept the
types of income explicitly specified in current section 7364.
In addition, the authority of NPCs to utilize funds is poorly
defined, as it leaves out the administration, retention, and
spending of such funds.
Under current law, NPCs do not have the authority to charge
non-VA attendees fees for educational or training programs nor
do they have authority to retain such fees. While NPCs are
tasked with facilitating education and training, and to accept
funds in support of such activities, section 8154 of title 38
provides that only the Secretary has authority to conduct VA
educational programs, and to charge non-VA attendees fees for
such programs. That provision also specifies that the fees
collected be credited to the applicable VA medical
appropriation. As a result, even when non-VA attendees are
willing to pay fees to contribute to the costs of educational
or training events, NPCs do not have explicit authority to
charge or retain such funds, a result which presents a
significant obstacle to the conduct of such events.
Cooperative Research and Development Agreements (CRADAs)
are agreements mandated by VA to establish the terms and
conditions for certain industry-sponsored studies performed at
VA medical centers and administered by NPCs. Each CRADA must be
reviewed and approved by a VA attorney. Although NPCs generally
handle the preliminary negotiations relating to the development
of CRADAs, VA attorney review is often extensive, and can take
a number of hours, incurring significant costs. While NPCs
frequently have funds available to reimburse the Office of
General Counsel (OGC) for these costs, OGC does not have
authority to accept or retain reimbursement for its services.
Current section 7364 does not specifically address the
transfer of funds between VA and NPCs for costs associated with
personnel assignments under the Intergovernmental Personnel Act
(IPA), under subchapter VI of chapter 33 of title 5, U.S.C. IPA
assignments between VA medical centers and NPCs have been
common since the inception of NPCs. The assignment of NPC
employees to VA has proven to be of significant benefit to VA
research. In a May 2008 report titled, ``Audit of Veterans
Health Administration's Oversight of Nonprofit Research and
Education Corporations,'' the VA OIG found that under current
law, reimbursements from VA to NPCs, pursuant to the IPA,
constitute transfers of funds appropriated to VA prohibited by
subsection 7362(a) of title 38. This finding jeopardizes an
important element of the partnership between VA and NPCs.
Current section 7364 authorizes NPCs to spend funds only on
research projects that have been approved by the VA facility
Research and Development Committee. Requiring approval prior to
any expenditure of funds unduly hinders operations and planning
necessary to the application or preparation for research
projects, such as the costs of hiring a grant writer or study
coordinator to prepare a grant proposal.
Committee Bill. Section 604 of the Committee bill would
amend section 7364 of title 38, U.S.C., by striking the current
sections (a) through (c) and inserting new subsections (a)
through (e) which, collectively, would set forth the general
powers of NPCs and clarify the relationship between VA and
NPCs.
Proposed paragraph (1)(A) of new subsection (a) of section
7364 would allow NPCs to accept, administer, retain, and spend
funds derived from gifts, contributions, grants, fees,
reimbursements, and bequests from individuals and public and
private entities. New paragraph (1)(B) would authorize NPCs to
enter into contracts and agreements with individuals and public
and private entities. These changes make explicit the financial
authorities of NPCs, which the Committee views as consistent
with the intent of the original authorizing legislation.
Proposed new paragraph (1)(C) of new subsection (a) would
authorize NPCs to charge registration fees for education and
training programs they administer, and to retain such funds.
Proposed paragraph (2) subsection (a) would prohibit the
use of funds appropriated to VA to pay fees charged by NPCs.
Taken together, these provisions would enable NPCs, and the
research programs served by NPCs, to gain financial support for
their educational and training programs.
Proposed paragraph (1)(D) of new subsection (a) would
authorize NPCs to reimburse OGC for certain expenses of
providing legal services attributable to NPC research and
education agreements. With financial assistance from NPCs, OGC
would be better able to staff Regional Counsel offices and the
VA Central Office so as to meet the demand to review the
growing number of CRADAs. Proposed new paragraph (3) of
subsection (a) would further mandate that funds reimbursed to
OGC by NPCs are to be used only for staff and training, and
related travel, for the provision of legal services related to
review of research agreements such as CRADAs.
Proposed paragraph (1)(E) of new subsection (a) is a
renumbering of the text of subsection (a)(2) of current section
7364.
Proposed paragraph (1) of new subsection (b) is a
renumbering of the text of the second sentence of subsection
(a) of current section 7362. The language would be moved to new
section 7364 in order to group it with other provisions
addressing NPC funding issues.
Proposed new paragraph (2) of subsection (b) would
authorize VA to reimburse an NPC for all or a portion of the
pay or benefits, or both, of an NPC employee assigned to VA
under the IPA. The Committee believes that this authorization
will remove any uncertainty about the appropriateness of using
VA-appropriated funds to reimburse NPCs for personnel appointed
to VA pursuant to the IPA in the past and going forward.
Proposed new subsection (c) of section 7364 would grant
powers to NPCs allowing them to disburse limited funds for
essential activities that must be accomplished prior to
research project approval. Such activities would include grant
proposal writing, development, and review. Currently, NPCs are
not permitted to disburse any funds in support of a research
program until that program has been approved by VA. The
Committee believes that this restriction is impractically
rigid, and hinders NPC ability to appropriately prepare for
project proposals.
Proposed new subsection (d) of section 7364 would grant
powers to NPCs allowing them to disburse limited funds for
essential activities that must be accomplished prior to
education and training activity approval. Such essential
activities would include grant request writing, strategy
development, creating presentations and briefings and perhaps
even making deposits to reserve meeting space. Currently, NPCs
are not permitted to disburse any funds in support of an
education activity until that program has been approved. The
Committee believes that this restriction is impractically
rigid, and hinders NPCs' ability to appropriately prepare for
education activities.
Proposed new subsection (e) of section 7364 would permit
the USH to establish policies and procedures for the spending
of funds by NPCs. These policies and procedures would be
required to not only comply with applicable regulations, but
also to be designed to facilitate the mission of NPCs as
flexible funding mechanisms. Ms. McCartney voiced strong
support for these provisions in her testimony before the
Committee on May 21, 2008.
Sec. 605. Redesignation of section 7364A of title 38, U.S.C.
Section 605 of the Committee bill, which is derived from S.
2926, would redesignate section 7364A as section 7365, as a
conforming amendment to the provision in section (b)(2) of
section 601 of the Committee bill, which struck current section
7365 after moving the contents of that section to new
subsection (c) of section 7361.
Sec. 606. Improved accountability and oversight of corporations.
Section 606 of the Committee bill, which is derived from S.
2926, would strengthen VA oversight of NPCs.
Background. VA is responsible for oversight of the NPCs,
and a number of bodies carry out that duty. The Secretary
established the VA Nonprofit Corporation Oversight Board in
2004 to review the activities of VA NPCs for consistency with
VA policy and interests. Earlier, in 2003, VHA established the
Nonprofit Research and Education Corporation Program Office
(NPPO) to provide oversight of NPC activities. The NPPO is
responsible for providing oversight and guidance affecting
operations and financial management, performing substantive
reviews of the annual reports submitted by each NPC, compiling
the information for VA's annual submission to Congress,
improving accountability, and ensuring deficiencies are
corrected. In accordance with the Chief Financial Officers
(CFO) Act of 1990 (Public Law 101-576) and a 1994 General
Counsel opinion, VHA's CFO also has financial oversight
responsibility for NPCs.
The May 2008 OIG report discussed earlier found a number of
problems with VA oversight of NPCs. The OIG found that ``NPCs
did not implement adequate controls to properly manage funds''
and that VA failed to adequately implement ``effective
oversight procedures'' or require ``minimum control
requirements for NPC activities.'' While the OIG did not find
significant problems resulting from ineffective oversight, the
report concluded that ``VHA cannot be reasonably assured that
the NPCs are fully complying with applicable laws or
regulations or effectively managing research and education
funds.''
Committee Bill. Subsection (a) of section 606 of the
Committee bill would amend subsection (b) of section 7366 of
title 38, U.S.C., so as to require NPCs to include the
corporation's most recent IRS Form 990 ``Return of Organization
Exempt from Income Tax'' or equivalent documents, and the
applicable schedules, in an NPC's annual report to the
Secretary. The information in Form 990 is extensive, and would
be valuable to the Secretary in the conduct of thorough
oversight.
Subsection (b) of section 606 would amend subsection (c) of
section 7366 so as to make the laws and regulations governing
conflicts of interest within NPCs conform to laws governing
similar entities, and to those governing conflicts of interest
among Federal employees, as discussed above under section 603
of the Committee bill.
Subsection (c) of section 606 would amend subsection
(d)(3)(c) of section 7366 so as to raise the threshold for
reporting identifying information for payees from $35,000 to
$50,000. Current law requires the Secretary, in annual reports
to Congress, to provide identifying information on every payee
paid more than $35,000. The proposed increase would make the
statute governing NPC practices consistent with IRS standards
for scrutinizing compensation for higher paid employees. The
Committee believes that the original intent of this reporting
requirement was to scrutinize large payments and compensation
of higher paid employees, and that rising salaries over time
have simply overtaken the current statute.
Sec. 607. Repeal of sunset.
Section 607 of the Committee bill, which is derived from S.
2926, would repeal the existing sunset on the Secretary's
authority to establish NPCs.
Background. Section 7368 of title 38, U.S.C., precludes the
establishment of new NPCs after December 31, 2008. VA requested
that the authority to establish and administer these
corporations be extended.
Committee Bill. Section 607 of the Committee bill would
repeal section 7368 of title 38, U.S.C., thereby removing any
limitation on the Secretary's authority to establish NPCs. The
Committee believes that NPCs make a significant contribution to
VA research and medical capabilities and promote important
educational activity. It is the Committee's intent that the
Secretary develop approval criteria on the establishment of
NPCs. Such criteria should permit the establishment of an NPC
only when it would make a substantive contribution to research
or education activity or both, and when it is believed that the
NPC could generate sufficient revenue to support the necessary
management and compliance infrastructure.
TITLE VII--CONSTRUCTION
Sec. 701. Authorization of fiscal year 2009 major medical facility
projects.
Section 701 of the Committee bill, which is derived from S.
2797, would authorize the Secretary to conduct four major
medical facility projects during fiscal year 2009.
The first of these projects would be the construction of an
80-bed facility in Palo Alto, California, to replace the
existing acute psychiatric inpatient facility that is
seismically unsafe. This construction project would not exceed
$54,000,000.
The second project would be construction of an outpatient
clinic in Lee County, FL, which would not exceed $131,800,000
in construction costs. This facility would serve the increasing
demand for diagnostic procedures, ambulatory surgery, and
specialty care.
The third project would be the construction costs
associated with seismic corrections to Building 1 of the VA
Medical Center in San Juan, PR, which would not exceed
$225,900,000 in renovation costs.
The fourth project would be the construction of a state-of-
the-art polytrauma center in San Antonio, TX, which would not
exceed $66,000,000 in construction costs.
Sec. 702. Extension of authorization for Department of Veterans Affairs
Medical Center, New Orleans, LA, major medical facility
construction project already authorized.
Section 702 of the Committee bill, which is derived from S.
2797, would provide an extension in the previously enacted
authorization for a replacement VA medical center in New
Orleans, LA.
Background. The New Orleans VAMC was severely damaged by
flooding from Hurricane Katrina and it was determined that it
would be more cost-effective to construct a new hospital rather
than try to remediate the mold in, and repair the damage to,
the former hospital. A construction project to replace the
facility was previously authorized by section 801 of the
Veterans Benefits, Health Care, and Information Technology Act
of 2006, Public Law 109-461. Under that authorization, the
costs of this project were not to exceed $300,000,000.
This project has already been funded by Public Law 109-461.
At the time of the initial authorization, the Congress
understood that the replacement facility was intended to be co-
located with the Louisiana State University (LSU) Health
Sciences Center in New Orleans, and it is the Committee's
understanding that this is still VA's intent. However, this
current extension of the authorization has been requested by VA
without regard to whether the project is in fact co-located
with the LSU facility.
Committee Bill. Section 702 of the Committee bill would
extend, through fiscal year 2009, the authorization for the
previously authorized project to allow the renovation of the VA
medical center, or the construction of a new facility, in New
Orleans, Louisiana. This section would also increase the amount
authorized from $300,000,000 to $625,000,000.
Sec. 703. Authorization of fiscal year 2009 major medical facility
leases.
Section 703 of the Committee bill, which is derived from S.
2797, would authorize the Secretary to enter into major leases
for twelve VA medical facilities, as follows:
an outpatient clinic in Brandon, FL, for
$4,326,000;
a community-based outpatient clinic (CBOC) in
Colorado Springs, CO, for $10,300,000;
an outpatient clinic in Eugene, OR, for
$5,826,000;
the expansion of an outpatient clinic in Green
Bay, WI, for $5,891,000;
an outpatient clinic in Greenville, SC, for
$3,731,000;
a CBOC in Mansfield, OH, for $2,212,000;
a satellite outpatient clinic in Mayaguez, PR, for
$6,276,000;
a CBOC in Southeast Phoenix, Mesa, AZ, for
$5,106,000;
interim research space in Palo Alto, CA, for
$8,636,000;
expansion of a CBOC in Savannah, GA, for
$3,168,000;
a CBOC in Northwest Phoenix, Sun City, AZ, for
$2,295,000; and
a primary care annex in Tampa, FL, for $8,652,000.
Sec. 704. Authorization of appropriations.
Section 704 of the Committee bill, which is derived from S.
2797, would authorize appropriations for the total amounts of
the projects provided for in sections 701, 702, and 703 of the
Committee bill. Those amounts are $477,700,000 for section 701,
$625,000,000 for section 702, and $66,419,000 for section 703.
Section 704 also enumerates the constraints for spending the
funds allotted for sections 701 and 702, specifically that the
funding for sections 701 and 702 may only come from funds
appropriated for fiscal year 2009 for projects listed under
those sections; funds that remain available for Construction,
Major Projects for a fiscal year either before or after fiscal
year 2009, which are still available for obligation; and funds
appropriated for Construction, Major Projects, for fiscal year
2009 or a fiscal year either before or after fiscal year 2009
for a category of activity that is not specific to a project.
Sec. 705. Increase in threshold for major medical facility leases
requiring Congressional approval.
Section 705 of the Committee bill, which is derived from S.
2984, would increase the threshold at which a lease for a
medical facility is considered ``major'' and thus requiring
Congressional approval.
Background. Section 8104(a)(2) of title 38, U.S.C.,
requires Congressional authorization for all major medical
facility leases prior to appropriation of funds. Public Law
105-368, Section 704, amended subsection 8104(a)(3)(B) to
define a major medical facility lease as one whose annual rent
is greater than $600,000.
Section 8104(b) of title 38, U.S.C., requires VA to notify
and submit a prospectus for all major medical facility leases
exceeding the $600,000 threshold.
Committee Bill. Section 705 of the Committee bill would
amend section 8104(a)(3)(B) so as to increase to $1,000,000 the
threshold at which the lease of a medical facility by VA would
be considered a ``major medical facility lease'' under section
8104 of title 38, U.S.C., and, thus requiring Congressional
approval.
It is the Committee's view that this modification simply
reflects changes in the market costs and would give VA greater
flexibility to commence such projects.
Sec. 706. Conveyance of certain non-Federal land by City of Aurora, CO,
to Secretary for construction of veterans medical facility.
Section 706 of the Committee bill, which is derived from S.
3030, directs the Secretary of the Interior to take steps to
facilitate the transfer of a parcel of land in Aurora, CO, to
VA for use in connection with the construction of a VA medical
facility there.
Background. The parcel of land that is proposed for
transfer to VA under section 706 of the Committee bill was
originally Federal land, belonging to the U.S. Army Garrison
Fitzsimons, Adams County, CO, and was ceded to the city of
Aurora on May 24, 1999. In 2004, as part of the Capital Asset
Realignment for Enhanced Services (CARES) study of VA's
infrastructure, then-Secretary Anthony J. Principi submitted to
Congress a series of recommendations for closures,
consolidations, and new construction. The construction of a new
hospital in the Denver, CO, area was part of this new plan, to
be carried out in cooperation with DOD and the University of
Colorado.
However, due to the skyrocketing costs of the project and
the shifting trends in health care delivery from inpatient to
outpatient settings, VA conducted another review of needs in
the area and drew up a revised plan for the Denver area and
VISN 19 that included a large ambulatory clinic in Denver,
leasing two floors of inpatient space in a new University of
Colorado bed tower, and expansions of outlying clinics within
the Network. At this time, there has been no conclusion as to
which plan will move forward. Either way, the land transfer
must occur in order to give VA the flexibility to commence with
whichever project Congress authorizes.
Committee Bill. Section 706 of the Committee bill would
require the Secretary of the Interior, within 60 days of
enactment of this Act, to allow the city of Aurora, CO, to
donate an area of land to the Federal government for the
purposes of constructing a VA medical facility.
TITLE VIII--MISCELLANEOUS PROVISIONS
Sec. 801. Expansion of authority for Department of Veterans Affairs
police officers.
Section 801 of the Committee bill, which is derived from S.
2984, would expand certain authorities set out in title 38,
U.S.C., relating to VA police officers so as to better reflect
the current scope of their duties and responsibilities.
Background. When originally enacted, section 902 of title
38, U.S.C., was formulated in a manner that suited a health
care system that delivered the majority of its services in
centralized campus environments. As a result, VA police
officers rarely had official business off VA property. Today,
however, VA medical facilities now include large campuses,
urban hospitals, CBOCs, and storefront Vet Centers. VA's
increasingly decentralized delivery points for care necessitate
that VA police officers travel frequently among VA facilities
and off-campus sites. This includes travel off Department
property to conduct administrative portions of investigations,
such as interviewing witnesses or crime victims. It also
includes travel off-campus to bring about the safe return of
high-risk patients who have eloped and are a danger to
themselves or others. The responsibilities of VA police
officers also extend to responding to emergencies and disasters
at the local, regional, and national levels.
Because the jurisdiction of VA police officers is limited
by current law to Department property, VA police officers are
not able to carry their Department-issued weapons off property
when conducting official business or on official travel.
Committee Bill. Subsection (a)(1) of section 801 of the
Committee bill would amend section 902(a) of title 38, U.S.C.,
so as to permit VA police officers to: (1) carry VA-issued
weapons, including firearms, while off VA property in an
official capacity or while in official travel status; (2)
conduct investigations, on and off VA property, of offenses
that may have been committed on VA property, consistent with
agreements with affected local, state, or Federal law
enforcement agencies; (3) carry out, as needed and appropriate,
any of the duties described in section 902(a)(1), as revised,
when engaged in such duties pursuant to other Federal statutes;
and (4) execute any arrest warrant issued by a competent
judicial authority.
Subsection (a)(2) of section 801 would further amend
section 902 of title 38 to specify that the powers granted to
VA police officers be exercised in accordance with guidelines
approved by the Secretary and the Attorney General of the
United States.
Under current law, a VA officer who observes criminal
activity beyond Department property cannot legally respond when
a VA patient or provider is the victim. It is the Committee's
view that this limitation unduly restricts the ability of VA
police to fully carry out their assigned responsibilities.
Extending these authorities would be consistent with powers
Congress has granted to other Federal law enforcement officers,
such as those in the Federal Protective Service, the Department
of Homeland Security, Pentagon Force Protection Agency, and the
United States Capitol Police.
Sec. 802. Uniform allowance for Department of Veterans Affairs police
officers.
Section 802 of the Committee bill, which is derived from S.
2984, would amend title 38, U.S.C., so as to modify the
authority of VA to pay an allowance to VA police officers for
the purchase of uniforms.
Background. VA employs approximately 2,600 uniformed police
officers. VA uniformed police officers are generally paid
approximately $40,000 per year. Under current law, which was
enacted in 1991, VA may pay no more than $200 per fiscal year,
with authority to increase the amount to $400 in one fiscal
year. Because there has been no increase since 1991, VA
uniformed police officers have to pay out of their own funds to
supplement their initial uniform purchases and maintain their
uniforms. The Office of Personnel Management (OPM) has
published new regulations to increase the authorized uniform
allowance for other, non-VA Federal police officers to $800 for
initial and annual purchases.
Committee Bill. Section 802 of the Committee bill would
amend section 903(b) of title 38, U.S.C., which governs the
uniform allowance for VA police officers, to limit the
allowable amount to the lesser of: (1) the amount prescribed by
the OPM; or (2) the estimated or actual costs as determined by
periodic surveys conducted by VA. The provision would also
amend section 903(c) of title 38 to provide that the allowance
established under subsection (b) of section 902 of title 38, as
modified by the Committee bill, shall be paid at the beginning
of an officer's appointment for those appointed on or after
October 1, 2008, and for other officers at the request of the
officer, subject to the fiscal year limitations established in
subsection (b), as modified by the Committee bill.
The Committee believes that in order to compete for good
candidates to become VA police officers and to retain those
already employed by VA, there is a need to increase the uniform
allowance and for VA to ensure that the annual allowance
remains at an appropriate level.
Sec. 803. Conditions for treatment of veterans, their surviving
spouses, and their children as adjudicated mentally incompetent
for certain purposes.
Section 803 of the Committee bill, which is derived from S.
3167, would clarify the conditions under which veterans, their
surviving spouses, and their children may be treated as
adjudicated mentally incompetent for certain purposes.
Background. The Federal Gun Control Act of 1968
(hereinafter, ``GCA'') and subsequent amendments established
categories of persons who are prohibited from receiving or
possessing firearms. Included among the categories is any
person who has been ``adjudicated as a mental defective or who
has been committed to a mental institution.'' Part 478.11 of
title 27, Code of Federal Regulations (CFR), defines the
meaning of the phrase ``adjudicated as a mental defective'' as
follows:
(a) a determination by a court, board, commission, or
other lawful authority that a person, as a result of
marked subnormal intelligence, or mental illness,
incompetency, condition, or disease: (1) is a danger to
themselves or others; or (2) lacks the capacity to
contract or manage his own affairs.
The regulation was later codified with the enactment of
Section 3(2) of Public Law 110-180, the ``NICS Improvement
Amendments Act of 2007.''
The Brady Handgun Violence Prevention Act of 1993
(hereinafter, the ``Brady Act'') required the Attorney General
to establish a system to assist federally licensed gun dealers
in determining whether a gun buyer is prohibited under the GCA
from purchasing a firearm. The system developed pursuant to the
Brady Act, known as the National Instant Criminal Background
Check System (hereinafter, ``NICS''), is a computerized
database operated by the Federal Bureau of Investigation (FBI)
NICS Section. The NICS can be queried by gun dealers to
determine whether the name of a prospective buyer is on the
list and, therefore, legally prohibited from purchasing a
firearm.
The Brady Act also requires Federal agencies to, upon the
request of the Attorney General, submit to the NICS information
on persons prohibited from purchasing a firearm. The Attorney
General made such a request to VA in 1998. Under a memorandum
of understanding entered into between the FBI and VA, VA agreed
to make available for inclusion on the NICS database
information about VA beneficiaries who are determined to be
mentally incompetent on account of their inability to contract
or manage their own affairs pursuant to part 3.353 of title 38,
CFR. Determinations of incompetency under part 3.353 result in
an appointment of a fiduciary.
The evidence gathered to support a finding of incompetency
under part 3.353 of VA's regulations is used to inform a
judgment about whether a beneficiary is capable of managing
their VA benefit payments. No evidence is gathered as part of
this process to inform a judgment about whether a beneficiary
presents a danger to themselves or others, or whether they
should be prohibited from purchasing, possessing, or operating
a firearm. Furthermore, although beneficiaries are entitled to
a hearing once notified that it is proposed they will be
determined incompetent, the initial hearing is before VA
personnel, not an independent authority.
Since 1998, VA has shared information with NICS on over
116,325 beneficiaries for whom it has appointed a fiduciary,
including veterans, surviving spouses, and dependent children
of veterans. The total number of cases sent to NICS from all
Federal agencies as of April 30, 2008, is 117,280, meaning that
VA beneficiaries constitute the overwhelming majority of
individuals referred to NICS by the Federal government. This is
so despite the fact that other agencies, such as the Social
Security Administration, appoint fiduciaries to manage benefit
payments for their beneficiaries in a manner similar to VA's
process.
U.S. States and territories may also submit information to
the NICS about individuals who have been adjudicated mental
defective under the GCA. In total, 435,520 names have been
submitted as of April 30, 2008, although only eight states are
responsible for 99.5 percent of the submissions. California,
Virginia, and Michigan alone have sent 87 percent of the total.
A quick survey of the process used by some states to submit the
names of individuals to the NICS is illustrative of the
variation involved. For instance, in Michigan a court must
enter an order declaring someone a mental defective or
incompetent. In Texas, the NICS process is triggered after a
criminal court reports incompetency. California sends
information to the NICS on those who have been involuntarily
committed to a mental institution, afforded a hearing, and who
are held for a 3-day period at a mental institution.
The Committee is concerned that VA's process for sharing
beneficiary information with the NICS is not only uniquely
targeted within the Federal government, but it also appears to
be unique among states who share information with the NICS.
Whereas VA uses government employees to, indirectly, make NICS
decisions, many states rely on a judicial authority. Whereas
VA's threshold for determining an individual mentally
incompetent is whether they can manage their financial affairs,
many states rely on a far more stringent standard. The
Committee, therefore, proposes to raise the standard within VA
while still remaining faithful to the overarching purpose of
the NICS which is to keep people who are dangerous to
themselves or others from purchasing a firearm.
Committee Bill. Section 803 of the Committee Bill would
amend chapter 55 of title 38, U.S.C., by adding a new section
to clarify that in any case arising out of VA's administration
of benefits under title 38, a veteran, surviving spouse, or
child who is mentally incapacitated, deemed mentally
incompetent, or experiencing an extended loss of consciousness,
shall not be considered adjudicated as a mental defective under
the GCA without the order or finding of a judge, magistrate, or
other judicial authority of competent jurisdiction that such
individual is a danger to him- or herself or others.
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
discretionary spending by $7.2 billion over the 2009-2013
period, assuming appropriation of the specified and estimated
amounts. The Committee bill could affect direct spending and
revenues, but CBO estimates that impact would not be
significant. Enactment of the Committee bill would not affect
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:
Congressional Budget Office,
Washington, DC, August 11, 2008.
Hon. Daniel K. Akaka,
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. 2969, the Veterans
Health Care Authorization Act of 2008.
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 R. Orszag,
Director.
Enclosure.
S. 2969--Veterans Health Care Authorization Act of 2008
Summary: S. 2969 would make several changes to existing
veterans' health care programs and create a number of new
health care programs for veterans. The bill also would
authorize the Department of Veterans Affairs (VA) to construct
or lease several medical facilities. In total, CBO estimates
that implementing the bill would cost $7.2 billion over the
2009-2013 period, assuming appropriation of the specified and
estimated amounts. Enacting the bill could affect direct
spending and revenues, but CBO estimates that impact would not
be significant.
S. 2969 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 2969 is shown in the Table 1. The costs
of this legislation fall within budget function 700 (veterans
benefits and services).
Table 1.--Estimated Budgetary Impact of S. 2969, Veterans Health Care Authorization Act of 2008
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------
2009 2010 2011 2012 2013 2009-2013
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATIONa
Estimated Authorization Level................. 1,519 745 1,230 1,730 2,269 7,495
Estimated Outlays............................. 423 1,010 1,538 1,943 2,315 7,231
----------------------------------------------------------------------------------------------------------------
aIn addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
enacting section 801 of S. 2969 would increase direct spending and revenues by less than $500,000 a year.
Basis of estimate: For this estimate, CBO assumes that the
legislation will be enacted near the start of fiscal year 2009,
that the authorized and estimated amounts will be appropriated
each year, and that outlays will follow historical spending
patterns for similar programs. (S. 2969 also would authorize
the appropriation of $5 million in 2008 for a pilot program
providing assistance to veterans eligible for rehabilitation
programs; however, those amounts are not included in this cost
estimate because CBO assumes that no further appropriations
will be provided in 2008 for such programs.)
Spending subject to appropriation
CBO estimates that implementing S. 2969 would cost $7.2
billion over the 2009-2013 period, assuming appropriation of
the specified and estimated amounts (see Table 2). Most of the
bill's estimated costs stem from provisions that would extend
authorities related to providing nursing home care and
authorizations of appropriations for medical construction
projects.
Extension of Current Authorities. Sections 201, 202, and
203 would extend several authorities for VA to provide health
care to certain veterans and to perform certain audits. In
total, CBO estimates that implementing those provisions would
cost $3.8 billion over the 2009-2013 period, assuming
appropriation of the estimated amounts.
Table 2.--Components of Discretionary Spending Under S. 2969
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------
2009 2010 2011 2012 2013 2009-2013
----------------------------------------------------------------------------------------------------------------
Extension of Current Authorities
Estimated Authorization Level............. 136 355 739 1,157 1,609 3,996
Estimated Outlays......................... 122 333 701 1,115 1,564 3,835
Construction of Medical Facilities
Estimated Authorization Level............. 1,159 20 20 20 20 1,239
Estimated Outlays......................... 100 321 378 285 120 1,204
Testing for HIV
Estimated Authorization Level............. 43 114 188 265 343 953
Estimated Outlays......................... 38 107 181 257 335 918
Homeless Veterans
Authorization Level....................... 70 70 70 70 70 350
Estimated Outlays......................... 63 70 70 70 70 343
Pilot Program for Dental Insurance
Estimated Authorization Level............. 10 65 85 85 85 330
Estimated Outlays......................... 9 60 83 85 85 322
Education Assistance
Estimated Authorization Level............. 28 47 62 68 74 279
Estimated Outlays......................... 25 45 60 67 74 271
Medical Personnel
Estimated Authorization Level............. 27 27 28 28 28 139
Estimated Outlays......................... 24 27 27 28 28 134
Pilot Programs
Estimated Authorization Level............. 26 21 9 7 7 70
Estimated Outlays......................... 24 22 10 7 7 70
Health Care for Female Veterans
Estimated Authorization Level............. 6 12 14 15 15 62
Estimated Outlays......................... 6 11 13 14 15 59
Expanded Eligibility for Vet Centers
Estimated Authorization Level............. 6 6 5 4 4 25
Estimated Outlays......................... 5 6 5 4 4 24
Specialized Residential and Rehabilitation
Care
Estimated Authorization Level............. 2 3 5 6 8 24
Estimated Outlays......................... 2 3 5 6 8 24
Quality Assurance Officers
Estimated Authorization Level............. 3 3 3 3 3 15
Estimated Outlays......................... 2 3 3 3 3 14
Uniforms for Police Officers
Estimated Authorization Level............. 1 1 1 1 1 5
Estimated Outlays......................... 1 1 1 1 1 5
Hospice Care
Estimated Authorization Level............. * * * * * 2
Estimated Outlays......................... * * * * * 2
Study on Suicides
Estimated Authorization Level............. 1 * 0 0 0 1
Estimated Outlays......................... 1 * 0 0 0 1
Other Provisions
Authorization Level....................... 1 1 1 1 1 5
Estimated Outlays......................... 1 1 1 1 1 5
-----------------------------------------------------------------
Total Changes
Estimated Authorization Level......... 1,519 745 1,230 1,730 2,269 7,495
Estimated Outlays..................... 423 1,010 1,538 1,943 2,315 7,231
----------------------------------------------------------------------------------------------------------------
Notes: Components may not sum to totals because of rounding; * = less than $500,000.
Nursing Home Care. Section 202(a) would extend, through
December 31, 2013, a requirement that VA provide nursing home
care to veterans who have a disability rating of 70 percent or
greater or those who require such care for a service-connected
disability. Under current law, that requirement expires on
December 31, 2008.
According to VA, the department spent about $1.2 billion on
such care in 2007. VA provided nursing home care to disabled
veterans under other permanent authorities before the
requirement in current law was enacted, but that care was
provided at the discretion of the Secretary of Veterans
Affairs. CBO expects that if the requirements of 38 U.S.C.
1710A are not extended, VA would continue to provide care in
the near term to most disabled veterans eligible under that
authority, but that VA would gradually revert to providing more
limited nursing home care under previously used authorities.
Therefore, after adjusting for inflation, CBO estimates that
extending this requirement would have initial costs of about
$115 million in 2009 growing to $1.5 billion by 2013, assuming
appropriation of the estimated amounts.
Noninstitutional Extended Care. Section 201 would make
permanent a provision in current law that allows VA to provide
noninstitutional extended care to veterans through December 31,
2008. According to VA, the department spent about $45 million
on such care in 2007. VA has indicated that it has existing
authority under other provisions of current law to provide
noninstitutional extended care, but those authorities are
limited and would affect VA's ability to provide the current
level of services. After adjusting for inflation, CBO estimates
that extending this requirement would have initial costs of $5
million in 2009, growing to almost $60 million by 2013,
assuming appropriation of the estimated amounts.
Participants in Chemical and Biological Testing. From 1962
to 1973, the Department of Defense (DOD) conducted certain
tests to determine the vulnerability of personnel, buildings,
and ships to various biological and chemical threats. Veterans
who were exposed to agents used in those tests are eligible to
receive free health care from VA, though copayments are
required for treatment of diseases or injuries that are
obviously not related to military service. The authority to
provide this benefit expired on December 31, 2007. Section 203
would make this authority permanent.
Based on data from VA that about 300 such veterans received
health care in 2007 at an average cost of $5,800, CBO estimates
that implementing this section would cost $1 million in 2009
and $9 million over the 2009-2013 period, assuming
appropriation of the estimated amounts.
Audits of Medical Services Contracts. Section 202(b) would
extend through 2013 a provision in current law that allows VA
to perform audits of its contracts to provide medical care and
services outside the department. Under current law, the
authority will expire on September 30, 2008. Those audits are
designed to allow VA to reduce errors and fraud related to
payments under the contracts. Any additional collections
generated by audits are retained and spent by the department.
Based on information from VA regarding recent audits, CBO
estimates that extending this authority to conduct audits would
have no net budgetary impact, as it would allow VA to collect
and spend $9 million a year.
Construction of Medical Facilities. Title VII would
authorize funding for constructing, renovating, improving, or
leasing several medical facilities by VA. CBO estimates that
implementing title VII would cost $1.2 billion over the 2009-
2013 period, assuming appropriation of the authorized and
estimated amounts.
Section 704 would specifically authorize the appropriation
in 2009 of $1.1 billion for five large construction projects
and $56 million for leasing 11 clinics or other facilities.
Based on information from VA's 2009 budget request for leasing
medical facilities, CBO expects that VA would enter into 20-
year lease agreements for those facilities. As a result, CBO
estimates that in addition to the specified amounts authorized
to be appropriated in 2009, VA would have additional costs of
about $20 million a year starting in 2010. (Costs are higher in
2009 than in other years because VA would pay the lessors
additional amounts in the first year of the lease for necessary
improvements and upgrades.) In addition, section 705 would
increase the threshold for major construction projects that
require Congressional approval from $600 million to $1 billion.
Testing for Human Immunodeficiency Virus (HIV). Section 217
would eliminate a rule prohibiting VA from conducting
widespread testing for HIV infection in the population of
veterans who use VA health care facilities. It also would
eliminate current requirements for separate written consent for
HIV tests and pre- and post-test counseling.
Based on data from VA, CBO estimates that under section 217
the number of HIV tests administered by VA would increase
significantly, from the current annual level of about 125,000
tests to 200,000 in 2009 and to 250,000 a year over the 2010-
2013 period. Based on studies of veterans enrolled in VA health
care, CBO expects that increased testing would lead to an
increase in the number of newly diagnosed veterans and that
those veterans would be identified earlier in the course of the
disease.\1\ We expect that people who are tested for HIV at,
and receive general care in, VA health care facilities would
prefer to maintain continuity of care with VA health care
providers, and thus would be treated by VA for HIV disease.
Based on data from VA and the Kaiser Family Foundation, CBO
estimates that the average cost of treatment in 2009 would be
$18,000 per patient in the early stages of HIV infection, and
$35,000 per patient in the advanced stages of the disease.
---------------------------------------------------------------------------
\1\Ronald O. Valdiserri, Fred Rodriguez, and Mark Holodniy,
``Frequency of HIV Screening in the Veterans Health Administration:
Implications for Early Diagnosis of HIV Infection,'' AIDS Education and
Prevention, vol. 20, no. 3 (2008), pp. 258-264; and Douglas K. Owens
and others, ``Prevalence of HIV Infection Among Inpatients and
Outpatients in Department of Veterans Affairs Health Care Systems:
Implications for Screening Programs for HIV,'' American Journal of
Public Health, vol. 97, no. 12 (2007), pp. 2173-2178.
---------------------------------------------------------------------------
CBO estimates that under the bill, VA would start providing
comprehensive HIV treatment to an additional 1,600 newly
diagnosed veterans in 2009 at an average cost of $27,000 per
person. By 2013, CBO estimates that the number of additional
veterans being treated for HIV would grow to about 12,000.
Because an increasing proportion of those veterans would be
diagnosed in the early stages of the disease when treatment is
least expensive, the average cost of treatment, before
considering the effects of inflation, would decrease over time.
Adjusting for inflation, CBO estimates that implementing
section 217 would cost about $920 million over the 2009-2013
period, assuming appropriation of the necessary funds.
Homeless Veterans. Section 506 would authorize additional
appropriations of $70 million a year for existing programs to
care for homeless veterans. Under current law, VA makes grants
and per diem payments to entities that provide outreach,
rehabilitation, transitional housing, counseling, training, and
other assistance to homeless veterans. CBO estimates that
implementing this provision would cost about $345 million over
the 2009-2013 period, assuming appropriation of the specified
amounts.
Pilot Program for Dental Insurance. Section 223 would
require VA to implement a pilot program to provide dental
insurance to all enrolled veterans and their survivors and
dependents. VA would be directed to carry out the program in at
least two but no more than four Veterans Integrated Services
Networks (VISNs; regional networks of medical facilities). CBO
estimates that implementing this provision would cost about
$320 million over the 2009-2013 period, assuming appropriation
of the estimated amounts.
The bill would require VA to contract with a dental insurer
who would administer the program. However, the bill would grant
VA wide discretion in designing several critical parameters of
the pilot program, such as the covered benefits, requirements
for enrollment and disenrollment, and premiums. Veterans would
be required to pay premiums and copayments. For purposes of
this estimate, CBO assumes that the pilot program would be
carried out at three VISNs and that the pilot program would be
similar to the TRICARE Dental Program, which is available to
reservists, their family members, and active-duty
servicemembers. CBO expects that VA would experience an initial
surge in enrollment as people who may have delayed addressing
their dental needs would avail themselves of that opportunity,
but that those individuals would disenroll soon after their
needs were met.
CBO estimates that the program would begin accepting
enrollees around the middle of fiscal year 2009, and based on
the participation rates for the TRICARE program, that about
12,000 veterans, survivors, and dependents would join that
year. We estimate that enrollment would rise to 78,000 in 2010
and 97,000 in 2011 before stabilizing at a level of about
90,000 a year.
The TRICARE program pays an annual maximum of $1,200 for
nonorthodontic services, and many diagnostic and preventive
services do not count toward the cap. Based on costs for the
TRICARE program and for dental care provided by VA to a limited
number of veterans, CBO estimates that in 2009 VA would pay
about $800 per enrollee under the pilot program. After
adjusting for inflation, CBO estimates that the pilot program
would have initial costs of about $10 million in 2009 and that
costs would rise to around $60 million by 2010, before
stabilizing at $85 million a year thereafter.
Education Assistance. Three separate provisions in section
103 would authorize VA to provide scholarships and assistance
with education loans to certain employees. In total, CBO
estimates that enacting those provisions would cost about $270
million over the 2009-2013 period, assuming appropriation of
the estimated amounts.
Health Professionals Scholarship Program. Section 103(a)
would reinstate a scholarship program for health professionals
that expired in 1998. The provision would give VA the authority
to provide funds to cover tuition, fees, and other costs
related to their education. In exchange for financial
assistance, recipients would be obligated to work at VA for a
specified period of time.
Based on information from VA, CBO estimates that after a
six-month period to establish the program, VA would grant about
125 awards in 2009 with an average award of $46,000. In the
following years, CBO estimates VA would grant 250 new awards a
year. Based on information from VA, CBO expects that
scholarships would last an average of two years. After
adjusting for an estimated 6 percent annual increase in tuition
and other costs, CBO estimates that implementing this provision
would cost $6 million in 2009 and $105 million over the 2009-
2013 period, assuming appropriation of the estimated amounts.
Debt Reduction. Two other provisions of section 103 would
allow VA to assist its employees in repaying their education
loans. Subsection (b) would expand the use of VA's Education
Debt Reduction Program by increasing the maximum amounts
payable over a five-year period from $44,000 to $60,000 and
expanding eligibility from those recently appointed to all
employees involved in direct patient care. About 6,500
employees currently receive an average annual benefit of $5,800
under this program. Based on information from VA, CBO estimates
that 450 additional employees each year would receive an
average amount of $8,725 a year for five years and that
employees currently eligible (about 6,500) also would receive
the higher annual benefit. After adjusting for inflation, CBO
estimates that implementing this provision would cost $17
million in 2009 and $132 million over the 2009-2013 period,
assuming appropriation of the estimated amounts.
The second provision, subsection 103(c), would allow
certain clinical researchers at VA who have disadvantaged
backgrounds to use a National Institutes of Health (NIH)
program for repayment of education loans. The NIH program
provides up to $35,000 in assistance per employee. Based on
information from VA, CBO estimates that 100 employees each year
would receive an average amount of $30,000 a year over three
years. Assuming appropriation of the estimated amounts, CBO
estimates that implementing this provision would cost $3
million in 2009 and $35 million over the 2009-2013 period.
Medical Personnel. Section 101 contains several provisions
that would affect pay for medical personnel. In total, CBO
estimates that implementing those provisions would cost about
$135 million over the 2009-2013 period, assuming appropriation
of the estimated amounts.
Pay Comparable to Private Sector. Section 101(f) would
allow VA to pay additional compensation of up to $100,000 a
year to certain employees to match salary levels paid in the
private sector. Based on information from VA, CBO estimates
that the department would pay an average additional amount of
$62,500 a year to about 170 people, at a cost of about $11
million a year.
Overtime Pay. Section 101(m) would loosen certain pay
restrictions, thereby allowing nurses, physician assistants,
and certain other employees to earn additional pay for evening
or weekend work. Under current law, employees can earn
additional pay for working evenings or weekends only on their
regular tour of duty. The bill would allow such pay for any
evening or weekend hours worked, even if those were occasional
or ad-hoc. In 2007, such employees worked roughly 1.8 million
hours of overtime at an average overtime rate of about $50 an
hour. CBO estimates that under current law VA does not pay
night or weekend differentials for 75 percent of those hours
(1.4 million hours). After adjusting for inflation, CBO
estimates that under the bill VA would pay additional night
differentials of $5 per hour for about 485,000 hours and
weekend differentials of $13 per hour for 385,000 hours, for a
total annual costs of about $8 million over the 2009-2013
period, assuming appropriation of the estimated amounts.
Higher Pay for Nurses. Subsections 101(i) and 101(j) would
increase the pay caps for registered nurses and certified
registered nurse anesthetists. Based on information from VA,
CBO estimates that the department would pay an average
additional amount of $12,000 a year to about 400 nurses at a
cost of about $5 million a year. Subsection (l) would increase
the maximum special pay for nurse executives from $25,000 to
$100,000. Based on information from VA, CBO estimates that the
department would pay an average additional amount of $10,000 to
about 135 nurse executives at a cost of about $1 million a
year. In total, CBO estimates that implementing those three
provisions would increase pay for nurses by $6 million a year.
Incentive Pay for Pharmacist Executives. Section 101(g)
would allow VA to pay additional compensation of up to $40,000
a year to pharmacist executives as a recruitment and retention
tool. Based on information from VA, CBO estimates that the
department would pay an additional $40,000 a year to 40 people
at a cost of about $2 million a year.
Increased Pay Scale for Appointees. Section 101(e) would
allow VA to pay certain appointees using a higher pay scale.
Based on information from VA, CBO estimates that the department
would pay an average additional amount of $3,500 to about 70
people, at an annual cost of about $250,000 a year.
Pilot Programs. Several sections of S. 2969 would require
VA to carry out pilot programs to provide or pay for health
care and related benefits. In total, CBO estimates that
enacting those provisions (not including the dental pilot
program, which is discussed above) would cost about $70 million
over the 2009-2013 period, assuming appropriation of the
specified and estimated amounts.
Personal Care Attendants. Section 212 would require VA to
implement a pilot program to train and certify family
caregivers of veterans and servicemembers with Traumatic Brain
Injuries (TBI) to serve as personal care attendants, and to
compensate such family members for the care they would provide.
The program would operate at three VA facilities for a period
of three years. Based on information from VA, CBO expects that
the department would use existing contracts with home health
agencies to provide training and certification, that roughly 50
family members a year would become family care attendants, and
the department would pay them about $45,000 a year. CBO
estimates that implementing the pilot would cost $6 million
over the 2009-2013 period.
Respite Care. Section 213 would require VA to implement a
pilot program to use graduate students from schools affiliated
with VA to provide respite care to veterans and servicemembers
with TBI. VA has indicated that it would be unable to implement
this provision, as it would violate existing agreements for
academic affiliations. Therefore, CBO estimates this provision
would have no cost.
Transition Assistance. Section 214 would require VA to
implement a pilot program to provide grants to community-based
organizations and state and local entities that provide
assistance to veterans transitioning to civilian life. The
program would operate in five locations for a period of two
years. VA currently provides such assistance through Vet
Centers. Based on information from VA regarding spending on Vet
Centers, CBO estimates that implementing that pilot would cost
$6 million over the 2009-2013 period.
Caregiver Assistance. Section 222 would extend through
2009, and authorize the appropriation of $5 million for, an
existing pilot program to assist caregivers of veterans. The
program provides a variety of services such as education and
training, transportation, respite care, home care services,
adult-day health care (a therapeutically-oriented outpatient
program that provides health maintenance and rehabilitative
services), and hospice care. CBO estimates that extending that
pilot program by one year would cost $5 million over the 2009-
2013 period.
Counseling for Female Veterans. Section 305 would require
VA to implement a pilot program providing counseling in group
retreat settings to female veterans who have recently separated
after lengthy deployments, and would authorize the
appropriation of $2 million per year for 2009 and 2010 for that
purpose. CBO estimates that this pilot program would cost $4
million over the 2009-2013 period.
Child Care. Section 308 would require VA to implement a
pilot program providing child care for certain female veterans
who use VA medical facilities, and would authorize the
appropriation of $1.5 million per year for 2009 and 2010 for
that purpose. CBO estimates that this pilot program would cost
$3 million over the 2009-2013 period.
Homeless Veterans. Title V would require VA to carry out
four separate pilot programs to provide outreach and various
services to homeless veterans and would authorize the
appropriation of $45 million over the 2009-2013 period for
those purposes. CBO estimates that implementing those pilot
programs would cost $45 million over the 2009-2013 period.
Health Care for Female Veterans. Title III of the bill
would authorize several programs targeted to women veterans.
CBO estimates that implementing those provisions would cost
about $60 million over the 2009-2013 period, assuming
appropriation of the authorized and estimated amounts.
Training for Mental Health Providers. Section 304 would
require VA to educate, train, and certify mental health
professionals who specialize in treating sexual trauma. VA has
indicated that it has ongoing training for such providers
through 2009; under the bill, such training would be extended
permanently. Based on information from VA's Office of Mental
Health Services, CBO estimates that VA would need 40 employees
a year to provide training an annual cost of about $8 million a
year.
Care for Newborns. Section 309 would allow VA to provide
care for up to seven days to the newborn children of female
veterans who receive maternity care through the department.
Based on data from VA, CBO estimates that about 2,000 babies
would become eligible for such care in 2009 at an average cost
of $2,650 per baby. After adjusting for inflation and
population growth--the number of female veterans of child-
bearing age is expected to rise in future years--CBO estimates
that implementing this provision would cost $30 million over
the 2009-2013 period.
Study on Health Consequences of Service in Operation Iraqi
Freedom and Operation Enduring Freedom (OIF/OEF). Section 303
would require VA to contract with an outside entity to conduct
a study on the health consequences facing female OIF/OEF
veterans as a result of their service. Based on information
from VA, CBO estimates that implementing this provision would
cost $1 million over the 2009-2013 period.
Expanded Eligibility for Vet Centers. Section 401 would
allow members of the Armed Forces, including reservists, who
served in OIF/OEF to receive readjustment counseling and
related services through VA's Vet Centers. Vet Centers are
community-based counseling centers that provide free mental
health services to combat veterans and their families.
According to VA data, there are about 232 centers nationwide,
and they served roughly 165,000 veterans in 2007. In 2008, Vet
Centers received $131 million in appropriated funds.
DOD data on OIF/OEF deployments indicate that roughly 1
million servicemembers are currently or have previously been
deployed and are nonveterans. After adjusting for expected
separations (OIF/OEF veterans are eligible under current law)
and smaller expected deployments starting in 2009, CBO
estimates that of those remaining, about a third would seek
mental health services. However, DOD indicates that
servicemembers are already offered free on- and off-base
counseling similar to that provided through Vet Centers.
Therefore, CBO estimates that about 14,000 servicemembers (5
percent of those seeking mental health services) would use Vet
Centers in 2009 and that the number of users would decline to
about 6,000 in 2013. Using a per person cost of $415 in 2009
(about half the expected cost for veterans) and adjusting for
annual inflation, CBO estimates that implementing this
provision would cost about $24 million over the 2009-2013
period, assuming appropriation of the estimated amounts.
Specialized Residential and Rehabilitation Care. Section
215 would require VA to contract with appropriate entities to
provide specialized care to OIF/OEF veterans whose TBI are so
severe that they cannot live independently and would otherwise
require nursing home care. According to VA, some veterans with
TBI but without sufficient family support or financial means to
afford private residential care often end up in nursing homes
that do not provide appropriate care. Under the bill, VA would
place such veterans in specialized programs that would provide
appropriate residential and rehabilitation care.
Based on information from VA regarding the number of such
veterans and the cost of their care, CBO estimates that in
2009, VA would pay roughly $84,000 for care provided to 20
veterans with TBI. After adjusting for inflation, CBO estimates
that over the 2009-2013 period, VA would pay for care provided
to about 50 veterans a year at an average annual cost of $5
million, and that implementing this provision would cost $24
million over that period, assuming appropriation of the
estimated amounts.
Quality Assurance Officers. Section 210 would require VA to
designate board-certified physicians as quality assurance
officers in its 135 medical facilities. Under current law, VA
has nurses serving in those positions. Based on information
from VA, CBO expects that in most facilities the department
would be able to re-allocate clinical and administrative duties
to designate currently-employed physicians for those roles.
However, CBO estimates that about 25 facilities would need to
hire physicians at a net additional cost to the department of
$100,000 per person (the cost to replace a nurse with a
physician), and that implementing this provision would cost $14
million over the 2009-2013 period, assuming appropriation of
the estimated amounts.
Uniforms for Police Officers. Section 802 would double the
uniform allowances payable to about 2,600 department police
officers from $400 for initial purchases and $200 for recurring
purchases to $800 and $400 respectively. CBO estimates that
implementing this provision would cost about $1 million a year
over the 2009-2013 period, assuming availability of
appropriated funds.
Hospice Care. Section 216 would prohibit VA from collecting
copayments from veterans receiving hospice care. This
prohibition would apply to care received at both inpatient and
outpatient facilities. Depending upon where veterans receive
hospice care, copayments range from $15 per day to a maximum of
$97 per day. Most veterans receiving this type of care from VA
are not charged copayments--only veterans whose disabilities
are unrelated to their military service and whose incomes are
above a certain level are required to make copayments.
Based on information from VA that fewer than 450 veterans
made copayments averaging about $800 last year for hospice
care, CBO estimates that implementing this provision would
decrease collections by less than $500,000 each year and by
about $2 million over the 2009-2013 period. Those collections
are recorded as offsets to discretionary appropriations. As
part of the annual appropriations process, the Congress gives
VA authority to spend those collections. Therefore, maintaining
the same level of health care services for veterans would
necessitate additional funding each year to make up for the
loss of copayments under this bill. Thus, implementing this
provision would cost less than $500,000 in 2009 and about $2
million over the 2009-2013 period.
Study on Suicides. Section 403 would require VA to conduct
a study and report to the Congress on the number of veterans
who died by suicide between 1997 and the date of enactment of
the bill. VA would be required to coordinate with DOD, veterans
service organizations, the Centers for Disease Control and
Prevention, and state public health offices and veterans
agencies. Based on information from VA, CBO estimates that
implementing this provision would cost $1 million in 2009 and
less than $500,000 in 2010, assuming availability of
appropriated funds.
Other Provisions. Several sections of the bill, when taken
individually, would have no significant impact on spending
subject to appropriation (most would have costs, but a few
would have savings). Taken together, CBO estimates that
implementing the following provisions would cost $1 million a
year, assuming availability of appropriated funds:
Sections 204 would repeal a reporting requirement
pertaining to nurses' pay.
Section 205 would modify a reporting requirement
pertaining to Gulf War veterans.
Section 209 would require veterans receiving care
through the department to provide their Social Security number
as well as pertinent information about their coverage through
other health plans. Based on information from VA, CBO estimates
that under the bill the department would be able to better
match patient records with those of Internal Revenue Service
and the Social Security Administration, and would collect an
additional $100 each from roughly 36,500 veterans. Those
additional collections of $4 million a year would be retained
by the department and spent on medical care and services.
Section 211 would require annual reports on the
quality of the department's physicians and health care.
Section 218 would allow VA to disclose the names
and addresses of veterans and servicemembers who use VA care to
third-party insurers, so that VA can recover the costs of such
care. Based on a VA field survey, CBO estimates that under the
bill the department would collect an additional $9 million a
year. Those amounts would be retained by the department and
spent on medical care and services.
Section 219 would require an expanded study on the
health impact of chemical and biological testing conducted by
DOD in the 1960s and 70s.
Section 220 would modify authority granted to VA
under Public Law 110-181 to pay for care provided to veterans
with TBI to conform with how VA is implementing the program
under current law.
Section 306 would require a report on full-time
managers of programs for female veterans.
Section 404 would require VA to transfer $5
million to the Secretary of Health and Human Services for a
psychology education program.
Title VI would modify several authorities
pertaining to research and education corporations and
permanently extend VA's authority to establish such
corporations. According to VA, those corporations are private,
nonprofit entities that are prohibited from using appropriated
funds and rely solely on cash or in-kind donations.
Direct spending and revenues
Section 801 would enhance the law enforcement authorities
of VA police officers. Because those prosecuted and convicted
under section 801 of the bill could be subject to criminal
fines, the federal government might collect additional fines if
the legislation is enacted. Criminal fines are recorded as
revenues, then deposited in the Crime Victims Fund, and later
spent. CBO expects that any additional revenues and direct
spending would not be significant because of the relatively
small number of cases likely to be affected. Therefore,
enacting the bill would have no significant effects on direct
spending or revenues.
Intergovernmental and private sector impact
S. 2969 contains no intergovernmental or private-sector
mandates as defined in UMRA. State, local, and tribal
governments that provide assistance to veterans would benefit
from grant and program activities authorized in the bill.
Previous CBO estimate: On July 28, 2008, CBO transmitted a
cost estimate for H.R. 6445 as ordered reported by the House
Committee on Veterans' Affairs on July 16, 2008. Section 217 of
S. 2969 is similar to section 6 of H.R. 5856, and their
estimated costs are identical.
On May 12, 2008, CBO transmitted a cost estimate for H.R.
5856 as ordered reported by the House Committee on Veterans'
Affairs on April 30, 2008. Title VII of S. 2969 is similar to
H.R. 5856, but the House act would authorize funding for
additional facilities and CBO estimated it would cost $2.2
billion over the 2009-2013 period ($1 billion more than title
VII of S. 2969), assuming appropriation of the specified and
estimated amounts.
On August 23, 2007, CBO transmitted a cost estimate for S.
1233, as ordered reported by the Senate Committee on Veterans'
Affairs on June 27, 2007. Sections 103(a) and 216 of S. 2969
are similar to sections 601 and 309 of S. 1233 respectively.
CBO estimates that the scholarship program authorized by S.
2969 would require a six-month start-up period and would grant
fewer scholarships in the first year. The cost estimates for
the provisions affecting hospice care are identical; however S.
2969 assumes a later enactment date.
On July 27, 2007, CBO transmitted a cost estimate for H.R.
2874 as ordered reported by the House Committee on Veterans'
Affairs on July 17, 2007. Section 203 of S. 2969 is similar to
section 4 of H.R. 2874. The cost estimates are identical;
however S. 2969 assumes a later enactment date.
Estimate prepared by: Federal Costs: Sunita D'Monte and
Alexis Miller (2262840); Impact on State, Local, and Tribal
Governments: Lisa Ramirez-Branum (2253220); Impact on the
Private Sector: Daniel Frisk (2262900).
Estimate approved by: Theresa Gullo, 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 Committee on Veterans' Affairs at its
June 26, 2008, meeting ordered S. 2969, reported favorably to
the Senate by voice vote. One amendment was accepted by voice
vote.
Agency Report
On May 21, 2008, Gerald M. Cross, MD, Principal Deputy
Under Secretary for Health, Department of Veterans Affairs,
appeared before the Committee and submitted testimony on
various bills incorporated into the Committee bill. In
addition, on July 8, 2008, VA provided views on S. 2969.
Excerpts of both the testimony and Department views are
reprinted below:
STATEMENT OF GERALD M. CROSS, MD, FAAFP, PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS
Good morning Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to present the
Administration's views on a number of bills that would affect
Department of Veterans Affairs (VA) programs of benefits and
services. With me today are Walter A. Hall, Assistant General
Counsel, and Kathryn Enchelmayer, Director, Quality Standards,
Office of Quality and Performance. I am pleased to provide the
Department's views on 14 of the 17 bills under consideration by
the Committee. Unfortunately, we received S.2963 too late to
include in our written statement, but we will provide views and
costs for the record. In addition, the Administration's
position is currently under review for S.2969. Therefore, it is
not included in our written statement and we will forward those
views as they are available. Similarly, the Administration is
still developing its position on S.2926 and we will provide
those views for the record. I will now briefly describe the 14
bills, provide VA's comments on each measure and estimates of
costs (to the extent cost information is available), and answer
any questions you and the Committee members may have.
Mr. Chairman, today's agenda includes four bills that
consist of legislative proposals the Administration submitted
to the Congress: S.2273; S.2797; S.2889, and S.2984. Thank you
for introducing these bills at our request. We believe each
bill would significantly enhance the health care services we
provide to veterans as well as our means of furnishing these
benefits. I will begin my testimony by addressing the major
health care related provisions in these important bills.
* * * * * * *
S. 2273--``ENHANCED OPPORTUNITIES FOR FORMERLY HOMELESS VETERANS
RESIDING IN PERMANENT HOUSING ACT OF 2007''
S. 2273 would authorize VA to conduct two five-year pilot
grant programs under which public and non-profit organizations
(including faith-based and community organizations) would
receive funds for coordinating the provision of local
supportive services for very low income, formerly homeless
veterans who reside in permanent housing. Under one of the
pilot programs, VA would provide grants to organizations
assisting veterans residing in permanent housing located on
military property that the Secretary of Defense closed or
slated for closure as part of the 2005 Base Realignment and
Closure program and ultimately designated for use in assisting
the homeless. The other pilot program would provide grants to
organizations assisting veterans residing in permanent housing
on any property across the country. Both programs would require
the Secretary to promulgate regulations establishing criteria
for receiving grants and the scope of supportive services
covered by the grant program.
In 1987, when VA began its specific assistance to veterans
who were homeless, few recognized that long-term or permanent
housing with supportive services was necessary to return these
veterans to full function. It is now well understood that the
provision of long-term housing coupled with needed supportive
services is vital to enable them to lead independent lives in
their communities. Although supportive services are widely
available to these veterans through VA and local entities, most
housing assistance that is available to them is limited to
temporary or transitional housing. Generally sources of long-
term housing for these veterans are lacking. Military
facilities recently slated for closure or major mission changes
may provide an excellent site for long-term or permanent
housing for these vulnerable veterans who remain at risk of
becoming homeless. Local redevelopment authorities could take
these VA grant programs into account when designing their local
plans to convert the property for use in assisting formerly
homeless veterans. This would not only help the veterans but
also enhance the community's efforts at economic
revitalization. We estimate the costs associated with each of
these pilots to be $375,000 in Fiscal Year 2009 and $11,251,000
over a five-year period.
* * * * * * *
S. 2797--AUTHORIZATION OF FISCAL YEAR 2009 MAJOR MEDICAL FACILITY
PROJECTS
Section 1 would authorize the following four major medical
construction projects:
Construction of an 80-bed replacement facility in
Palo Alto, California, in an amount not to exceed $54,000,000;
Construction of an Outpatient Clinic in Lee
County, Florida to meet the increased demand for diagnostic
procedures, ambulatory surgery, and specialty care, in an
amount not to exceed $131,800,000;
Seismic Corrections on Building 1 in San Juan,
Puerto Rico, in an amount not to exceed $225,900,000; and,
Construction of a state-of-the-art polytrauma
health care and rehabilitation center in San Antonio, Texas, in
an amount not to exceed $66,000,000.
Section 2 would authorize the following major medical
facility projects:
Replacement of the VA Medical Center in Denver,
Colorado, in an amount not to exceed $769,200,000.
Restoration, new construction or replacement of
the medical center facility in New Orleans, Louisiana, in an
amount not to exceed $625,000,000.
VA received authorization for lesser sums under Public Law
109-461 for these two major projects. In February 2008 we
requested authorization in the amount of $769.2 million for the
Denver-replacement project. However, the Department has
identified an alternative option to purchase land and construct
the new Denver VA facility while also leasing beds from the
University of Colorado Hospital. Since our fiscal year 2009
major-facility-authorization request was submitted in February,
we met with officials of the University of Colorado and the new
University of Colorado Hospital (UCH) to discuss how best to
replace the services and improve the access now being provided
by the aging VA Medical Center in Denver. We are still
finalizing the details of this approach, but our preliminary
analysis shows that it would be better, for several reasons, to
lease space in the inpatient unit that UCH plans to build and
to have VA's new state-of-the- art health care facility focus
on the provision of primary and specialty care, outpatient
surgery, and nursing home care. This proposed and innovative VA
partnership with UCH would also extend to the sharing of
certain adjunct inpatient resources, such as laboratory and
medical-imaging services, and include VA's leasing research
space from the University of Colorado Denver. The leased
inpatient space would be staffed by VA health-care
professionals and accessed via a separate VA entrance and
lobby. In all respects to our patients, it would be a VA
facility. This change in construction plans would more
effectively increase and improve veterans' access to care
throughout the Rocky Mountain region. As part of this strategy,
we would need to additionally seek authority to enter into a
contract for a lease for an outpatient clinic in Colorado
Springs, Colorado; the revised amount for this lease would
exceed the current request. We will provide Committee the final
authorization amounts needed for these projects shortly.
Section 3 would authorize VA to enter into leases for the
following twelve facilities:
Brandon, Florida, Outpatient Clinic, $4,326,000;
Colorado Springs, Colorado, Community-Based
Outpatient Clinic, $3,995,000; (the final amount needed for
this project is pending)
Eugene, Oregon, Outpatient Clinic, $5,826,000;
Green Bay, Wisconsin, Expansion of Outpatient
Clinic, $5,891,000;
Greenville, South Carolina, Outpatient Clinic,
$3,731,000;
Mansfield, Ohio, Community-Based Outpatient
Clinic, $2,212,000;
Mayaguez, Puerto Rico, Satellite Outpatient
Clinic, $6,276,000;
Mesa, Arizona, Southeast Phoenix Community-Based
Outpatient Clinic, $5,106,000;
Palo Alto, California, Interim Research Space,
$8,636,000;
Savannah, Georgia, Expansion of Community-Based
Outpatient Clinic, $3,168,000;
Sun City, Arizona, Northwest Phoenix Community-
Based Outpatient Clinic, $2,295,000; and,
Tampa, Florida, Primary Care Annex, $8,652,000.
Section 4 would authorize for appropriation the sum of
$477,700,000 for fiscal year 2009 for construction of the four
major medical projects listed in Section 1 and $1,394,200,000
for the two projects listed in Section 2. Section 4 would also
authorize for appropriation for fiscal year 2009 $60,114,000
from the Medical Facilities account for the leases listed in
Section 3. However, we will likely revise our request for both
those Section 2 construction projects and the Section 3 leases.
Our final recommendation on the amounts will be provided to the
Committee shortly.
* * * * * * *
S. 2889--``VETERANS HEALTH CARE ACT OF 2008''
Mr. Chairman, you have asked us to testify on sections 2,
3, 4, 5, and 6, of S.2889. Section 2 would authorize VA to
contract for specialized residential care and rehabilitation
services for veterans of Operation Enduring Freedom and
Operation Iraqi Freedom (OEF/OIF) who: (1) suffer from
traumatic brain injury, (2) have an accumulation of deficits in
activities of daily living and instrumental activities of daily
living that affects their ability to care for themselves, and
(3) would otherwise receive their care and rehabilitation in a
nursing home. These veterans do not require nursing home care,
but they generally lack the resources to remain at home and
live independently. This legislation would enable VA to provide
them with long-term rehabilitation services in a far more
appropriate treatment setting than we are currently authorized
to provide. VA estimates the discretionary cost of section 2 to
be $1,427,000 in fiscal year 2009 and $79,156,000 over a 10-
year period.
Section 3 would require VA to provide full-time VA
physicians and dentists the opportunity to continue their
professional education through VA-sponsored continuing
education programs. It would also authorize VA to reimburse
these employees up to $1000 per year for continuing
professional education that is not available through VA-
sources. Currently, VA is required by statute to reimburse each
of these individuals up to $1000 per year for expenses they
incur in obtaining continuing education, even though VA has the
capacity and resources to meet most of their professional
continuing education needs in-house. Enactment of section 3
would result in cost-savings to VA, while serving as an
effective recruitment and retention tool for the Veterans
Health Administration. We estimate section 3 would result in
discretionary savings of $8,700,000 in fiscal year 2009 and a
total discretionary savings of $87,000,000 over a 10-year
period.
Section 4 would eliminate co-payment requirements for
veterans receiving VA hospice care either in a VA hospital or
at home on an outpatient basis. In 2004, Congress amended the
law to eliminate copayment requirements for hospice care
furnished in a VA nursing home. Section 4 would result in all
VA hospice care being exempt from copayment requirements,
regardless of setting. Projected discretionary revenue loss is
estimated to be $149,000 in fiscal year 2009 and $1,400,000
over 10 years.
Section 5 would repeal outdated statutory requirements that
require VA to provide a veteran with pre-test counseling and to
obtain the veteran's written informed consent prior to testing
the veteran for HIV infection. Those requirements are not in
line with current guidelines issued by the Centers for Disease
Control and Prevention and other health care organizations,
which, with respect to the issue of consent, consider HIV
testing to be similar to other blood tests for which a patient
need only give verbal informed consent. According to many VA
providers, the requirements for pre-test counseling and prior
written consent delay testing for HIV infection and, in turn,
VA's ability to identify positive cases that would benefit from
earlier medical intervention. As a result, many infected
patients unknowingly spread the virus to their partners and are
not even aware of the need to present for treatment until
complications of the disease become clinically evident and,
often, acute. Testing for HIV infection in routine clinical
settings no longer merits extra measures that VA is now
required by law to provide. Many providers now consider HIV to
be a chronic disease for which continually improving therapies
exist to manage it effectively. Repealing the 1988 statutory
requirements would not erode the patient's rights, as VA would,
just like with tests for all other serious conditions, still be
legally required to obtain the patient's verbal informed
consent prior to testing. VA estimates the discretionary costs
associated with enactment of section 5 to be $73,680,000 for
fiscal year 2009 and $301,401,000 over a 10-year period.
Section 6 would amend sections 5701 and 7332 of title 38,
United States Code, to authorize VA to disclose individually-
identifiable patient medical information without the prior
written consent of a patient to a third-party health plan to
collect reasonable charges under VA collections authority for
care or services provided for a non-service-connected
disability. The section 5701 amendment would specifically
authorize disclosure of a patient's name and address
information for this purpose. The section 7332 amendment would
authorize disclosure of both individual identifier information
and medical information for purposes of carrying out the
Department's collection responsibilities. VA estimates that
enactment of section 6 will result in net discretionary savings
of $9,025,000 in fiscal year 2009 and $108,858,000 over ten
years.
* * * * * * *
S. 2984--``VETERANS BENEFITS ENHANCEMENT ACT OF 2008''
This bill includes several important program authority
extensions, including VA's mandate to provide nursing home care
to veterans with service-connected disabilities rated 70
percent or more and to veterans whose service-connected
disabilities require such care; VA's authority to establish
research corporations; and VA's mandate to conduct audits of
payments made under fee basis agreements and other medical
services contracts. We urge the Committee to take action on all
of the expiring authorities contained in the bill. Costs
associated with these extensions will be paid from future
discretionary appropriations. In the case of the audit-recovery
program, we estimate discretionary recoveries in the amount of
$9 million for fiscal year 2008 and a ten-year total in
recoveries of $70 million.
A significant provision of S.2984 would permit VA health
care practitioners to disclose the relevant portions of VA
records of the treatment of drug abuse, alcoholism and alcohol
abuse, infection with the human immunodeficiency virus, and
sickle cell anemia to surrogate decision makers who are
authorized to make decisions on behalf of patients who lack
decision-making capacity, but to whom the patient had not
specifically authorized release of that legally protected
information prior to losing decision-making capacity. It would,
however, allow for such disclosure only under circumstances
when the practitioner deems such content necessary for the
representative to make an informed decision regarding the
patient's treatment. This provision is critical to ensure that
a patient's surrogate has all the clinically relevant
information needed to provide full and informed consent with
respect to the treatment decisions that the surrogate is being
asked to make.
Another key provision would authorize VA to require that
applicants for, and recipients of, VA medical care and services
provide their health-plan contract information and social
security numbers to the Secretary upon request. It would also
authorize VA to require applicants for, or recipients of, VA
medical care or services to provide their social security
numbers and those of dependents or VA beneficiaries upon whom
the applicant or recipient's eligibility is based. Recognizing
that some individuals do not have social security numbers, the
provision would not require an applicant or recipient to
furnish the social security number of an individual for whom a
social security number has not been issued. Under this
provision, VA would deny the application for medical care or
services, or terminate the provision of, medical care or
services, to individuals who fail to provide the information
requested under this section. However, the legislation provides
for the Secretary to reconsider the application for, or
reinstate the provision of, care or services once the
information requested under this section has been provided. Of
note, this provision makes clear that its terms may not be
construed to deny medical care and treatment to an individual
in a medical emergency.
Although VA has authority under 38 U.S.C. 1729 to recover
from health insurance carriers the reasonable charges for
treatment of a veteran's nonservice-connected disabilities,
there is no permanent provision in title 38 to require an
applicant for, or recipient of, VA medical care to provide
information concerning health insurance coverage. This
provision would ensure that VA obtains the health-plan contract
information from the applicant for, or recipient of, medical
care or services.
Moreover, social security numbers enable VHA to make
accurate and efficient medical care eligibility determinations
and to instantaneously associate medical information with the
correct patient by matching those social security numbers
against records of other entities. Medical care eligibility
determinations may be based on such factors as qualifying
military service, service-connected disabilities, and household
income. VHA may obtain or verify such information from internal
VA components such as the Veterans Benefits Administration
(VBA) which currently has authority to require social security
numbers for compensation and pension benefits purposes, and
outside sources, such as the Department of Defense (DOD),
Internal Revenue Service and Social Security Administration.
The availability of social security numbers ensures accurate
matches of an individual's information with both internal and
external sources. The income verification match programs are
wholly dependent on social security numbers.
Be assured that VA will provide the same high degree of
confidentiality for the beneficiaries' health plan information
and social security numbers as it provides to patients' medical
information in its records and information systems. There are
no direct costs associated with this provision other than
administrative costs associated with collecting revenue. Those
costs will be paid from future discretionary appropriations.
Mr. Chairman, I now move to address the other bills on the
agenda today.
* * * * * * *
S. 2377--``VETERANS HEALTH CARE QUALITY IMPROVEMENT ACT''
S. 2377 is an excessively prescriptive bill that would
impede the fundamental operations and structure of VHA. We have
very recently provided the Committee with a copy of the
Department's views on H.R. 4463, the identical House companion
bill. Our views letter provides our detailed discussion of
every provision. We would like to take this opportunity to
discuss the provisions that cause us the most concern.
The requirement that within one year of appointment each
physician practicing at a VA facility (whether through
appointment or privileging) be licensed to practice medicine in
the State where the facility is located is particularly
troubling and we believe harmful to the VA system. VA strongly
objects to enactment of this provision. VHA is a nationwide
health care system. By current statute, to practice in the VA
system, VA practitioners may be licensed in any State. If this
requirement were enacted, it would impede the provision of
health care across State borders and reduce VA's flexibility to
hire, assign and transfer physicians. This requirement also
would significantly undermine VA's capacity and flexibility to
provide telemedicine across State borders. VA makes extensive
use of telemedicine. In addition, VA's ability to participate
in partnership with our other Federal health care providers
would be adversely impacted in times such as the aftermath of
Hurricanes Katrina and Rita, where we are required to mobilize
members of our medical staff in order to meet regional crises.
Currently, physicians who provide medical care elsewhere in
the Federal sector (including the Army, Navy, Air Force, U.S.
Public Health Service Commissioned Corps, U.S. Coast Guard,
Federal Bureau of Prisons and Indian Health Service) need not
be licensed where they actually practice, so long as they hold
a valid State license. Requiring VA practitioners to be
licensed in the State of practice would make VA's licensure
requirements inconsistent with these other Federal health care
providers and negatively impact VA's recruitment ability
relative to those agencies. In addition, many VA physicians
work in both hospitals and community-based outpatient clinics.
Many of our physicians routinely provide care in both a
hospital located in one State and a clinic located in another
State. A requirement for multiple State licenses would place VA
at a competitive disadvantage in recruitment of physicians
relative to other health care providers.
Although the provision would allow physicians one year to
obtain licensure in the State of practice, many States have
licensing requirements that are cumbersome and require more
than one year to meet. Such a requirement could disrupt the
provision of patient care services while VA physicians try to
obtain licensure in the State where they practice or transfer
to VA facilities in States where they are licensed. The
potential costs of this disruption are unknown at this time.
Further, we are not aware of any evidence of a link between
differences in State licensing practices and quality of patient
care. In 1999, the General Accounting Office reviewed the
effect on VA's health care system that a requirement for
licensure in the State of practice would have. The GAO report
concluded, in part, that the potential costs to VA of requiring
physicians to be licensed in the State where they practice
would likely exceed any benefit, and that quality of care and
differences in State licensing practices are not directly
linked. See GAO/HEHS-99-106, ``Veterans' Affairs Potential
Costs of Changes in Licensing Requirement Outweigh Benefit''
(May 1999).
Another provision would provide that physicians may not be
appointed to VA unless they are board certified in the
specialties of practice. However, this requirement could be
waived (not to exceed one year) by the Regional Director for
individuals who complete a residency program within the prior
two year period and provide satisfactory evidence of an intent
to become board certified. VA strongly opposes this provision
of S.2377. Current law does not require board certification as
a basic eligibility qualification for employment as a VA
physician. VA policy currently provides that board
certification is only one means of demonstrating recognized
professional attainment in clinical, administrative or research
areas, for purposes of advancement. However, we actively
encourage our physicians to obtain board certification.
Facility directors and Chiefs of Staff must ensure that any
non-board certified physician, or physician not eligible for
board certification, is otherwise well qualified and fully
capable of providing high quality care for veteran patients. VA
should be given considerable flexibility regarding the
standards of professional competence that it requires of its
medical staff, including the requirement for specialty
certification. Were this measure enacted, it could have a
serious chilling effect on our ability to recruit very
qualified physicians. At this point in time, VA has physician
standards that are in keeping with those of the local medical
communities.
Moreover, the bill would provide that the board
certification and in-State licensure requirements would take
effect one year after the date of the Act's enactment for
physicians on VA rolls on the date of enactment. This would at
least temporarily seriously disrupt VA's operations if
physicians are unable to obtain board certification and in-
State licensure within one year, or are unable to transfer to a
State where they are licensed.
Mr. Chairman, we want to emphasize that we support the
intent of several provisions of S.2377 and have already been
taking actions to achieve many of the same goals. We would
welcome the opportunity to meet with the Committee to discuss
recent actions we have undertaken to improve the quality of
care across the system, including program oversight related
measures.
* * * * * * *
S. 2383--PILOT PROGRAM PROVIDING MOBILE HEALTH CARE AND OTHER SERVICES
S. 2383 would require the Secretary, acting through the
Director of the Office of Rural Health (DORH), to conduct a
pilot program to furnish outreach and health care services to
veterans residing in rural areas through the use of a mobile
system equipped with appropriate program staff and supplies.
The mobile system would have to be capable of furnishing the
following services:
counseling and education services on how to access
VA health care, educational, pension, and other VA benefits;
assistance to veterans in completing paperwork
needed to enroll in VA's health care system;
prescriptions for, and delivery of, medications;
mental health screenings to identify potential
mental health disorders, particularly for veterans returning
from deployment overseas in OEF/OIF;
job placement assistance and information on
employment or training opportunities;
substance abuse counseling; and
bereavement counseling for families of active duty
servicemembers who were killed in the line of duty while on
active service.
Staffing for the mobile system would be required to include
VA physicians; nurses; mental health specialists; casework
officers; benefits counselors, and such other personnel deemed
appropriate by the Secretary. To the extent practicable,
personnel and resources from area community-based outpatient
clinics could be used to assist in this effort. The bill sets
forth a number of requirements related to the development and
coordination of the pilot program as well as to the conduct of
the mobile system (including the minimum frequency of visits to
rural areas participating in the pilot programs).
S. 2383 would also mandate that the Secretary act jointly
with the Secretary of Defense to identify veterans not enrolled
in, or otherwise being cared for by, VA's health care system.
VA would be further required to coordinate efforts with county
and local veterans service officers to inform those veterans of
upcoming visits by the mobile unit and the concomitant
opportunity to complete paperwork for VA benefits. The bill
would authorize $10 million to be appropriated for the mobile
system each of fiscal years 2008 through 2010.
VA does not support S.2383, because it is not necessary and
is duplicative of ongoing efforts by the Department. VA's
Office of Rural Health is already in the process of standing up
a mobile system by which to provide medical care and services
to veterans residing in rural areas, and VA's Vet Centers are
already using mobile units to furnish readjustment counseling
services. The Vet Centers and VBA also have in place extensive
outreach program targeted at these veterans. VA has recently
created a Task Force to review the adequacy of the assets and
resources dedicated to these efforts thus far. Particularly
with respect to the mobile system, we urge the Committee to
refrain from taking action on the bill until we have sufficient
experience with this model of delivery to ascertain its
effectiveness and to identify and cure any deficiencies. We
would be glad to brief the Committee on our activities to date.
As a technical matter, the duration of the pilot program is
unclear, but we assume it is three years based on the terms of
the bill's provision authorizing appropriations for fiscal
years 2008-2010. Additionally, medications are currently mailed
to these veterans and so it is not necessary to provide those
benefits through a mobile system.
* * * * * * *
S. 2573--``VETERANS MENTAL HEALTH TREATMENT FIRST ACT''
Mr. Chairman, S.2573 is a very ambitious bill that would
provide the Department with significant new tools to maximize
and reward a veteran's therapeutic recovery from certain
service-related mental health conditions, and, to the extent
possible, reduce the veteran's level of permanent disability
from any of the covered conditions. The goal of the legislation
is to give the veteran the best opportunity to reintegrate
successfully and productively into the civilian community.
Specifically, S.2573 would require the Secretary to carry
out a mental health and rehabilitation program for a veteran
who has been diagnosed by a VA physician with any of the
following conditions:
Post Traumatic Stress Disorder (PTSD);
depression; or
anxiety disorder
that is service-related, as defined by the bill. The bill would
also cover a diagnosis of a substance use disorder related to
service-related PTSD, depression, or anxiety. For purposes of
this program, a covered condition would be considered to be
service-related if: (1) VA has previously adjudicated the
disability to be service-connected; or (2) the VA physician
making the diagnosis finds the condition plausibly related to
the veteran's active service. S.2573 would also require the
Secretary to promulgate regulations identifying the standards
to be used by VA physicians when determining whether a
condition is plausibly related to the veteran's active
military, naval, or air service.
The bill sets forth conditions of participation for the
veterans taking part in the program. If a veteran has not filed
a VA claim for disability for the covered condition, the
veteran would have to agree not to submit a VA claim for
disability compensation for the covered condition for one year
(beginning on the date the veteran starts the program) or until
the date on which the veteran completes his or her treatment
plan, whichever date is earlier.
If the veteran has filed a disability claim but it has not
yet been adjudicated by the Department, the veteran could elect
either to suspend adjudication of the claim until he or she
completes treatment or to continue with the claims adjudication
process. As discussed below, the stipend amounts payable to the
veteran under the program will depend on which election the
veteran makes.
If the veteran has a covered condition that has been
adjudicated to be service connected, then the individual would
have to agree not to submit a claim for an increase in VA
disability compensation for one year (beginning on the date the
veteran starts the program) or until the date the veteran
completes treatment, whichever is earlier.
S. 2573 would establish a financial incentive in the form
of ``wellness'' stipends to encourage participating veterans to
obtain VA care and rehabilitation before pursuing, or seeking
additional, disability compensation for a covered condition.
The amount of the stipend would depend on the status of the
veteran's disability claim. If the veteran has not filed a VA
disability claim, VA would pay the veteran $2000 upon
commencement of the treatment plan, plus $1500 every 90 days
thereafter upon certification by the VA clinician that the
veteran is in substantial compliance with the plan. This
recurring stipend would be capped at $6000. The veteran would
receive an additional $3000 at the conclusion of treatment or
one year after the veteran begins treatment, whichever is
earlier.
If the veteran has filed a disability claim that has not
yet been adjudicated, the participating veteran who elects to
suspend adjudication of the claim until he or she completes
treatment would receive ``wellness'' stipends in the same
amounts payable to veterans who have not yet filed a disability
claim. If the participating veteran elects instead to continue
with the claims adjudication process, the veteran would receive
``wellness'' stipends in the same amounts payable to veterans
whose covered disabilities have been adjudicated and found to
be service-connected: $667 payable upon the veteran's
commencement of treatment and $500 payable every 90 days
thereafter upon certification by the veteran's clinician that
the individual is in substantial compliance with the plan.
Recurring payments would be capped at $2000, and the veteran
would receive $1000 when treatment is completed or one year
after beginning treatment, whichever is earlier.
If the Secretary determines that a veteran participating in
the program has failed to comply substantially with the
treatment plan or any other agreed-upon conditions of the
program, the bill would require VA to cease payment of future
``wellness'' stipends to the veteran.
Finally, S.2573 would limit a veteran's participation in
this program to one time, unless the Secretary determines that
additional participation in the program would assist in the
remediation of the veteran's covered condition.
VA does not support S.2573. While philosophically we
discern and appreciate the aims of the bill, particularly the
holistic and integrated approach to the receipt of VA benefits,
this is a very complex proposal that requires further in-depth
study of all of the bill's implications, including those
related to cost. In addition, we have numerous concerns with
the bill as currently drafted.
S.2573 assumes that early treatment intervention by VA
health care professionals for a covered condition would be
effective in either reducing or stabilizing the veteran's level
of permanent disability from the condition, thereby reducing
the amount of VA disability benefits ultimately awarded for the
condition. No data exist to support or refute that assumption.
With the exception of substance abuse disorders, we are
likewise unaware of any data to support or refute the bill's
underlying assumption that paying a veteran a ``wellness
stipend'' will ensure the patient's compliance with his or her
treatment program. Although there is a growing trend among
health insurance carriers or employers to provide short-term
financial incentives for their enrollees or employees to
participate in preventive health care programs (e.g., reducing
premiums for an enrollee who participate in a fitness program,
loses weight, or quits smoking), we are unaware of any data
establishing that these and similar financial incentives
produce long-term cost-savings to the carrier or employer. It
would be extremely difficult, if not impossible, to quantify
savings or offsets because there is no way to know whether a
particular patient's health status would have worsened without
VA's intervention and whether the intervention directly
resulted in a certain or predictable total amount in health
care expenditure savings. We would experience the same
difficulties trying to identify what would have been the level
of disability and costs of care for a particular veteran had he
or she not participated in the early clinical intervention
program established by S.2573.
Providing these mental health care benefits independent of
the medical benefits package provided to enrolled veterans
gives rise to other concerns. A veteran's mental health and
physical health are integral, and it would be very difficult to
discern if certain conditions or physical manifestations that
may result from or be related to a mental health condition are
covered by S.2573. As a provider, VA would need to assume that
this bill would cover needed care for physical conditions that
result from, or are associated with, the covered mental health
condition under treatment. (Our approach would be similar to
the approach taken under the Department's authority in 38
U.S.C. 1720D to provide both counseling and care needed to
treat psychological conditions resulting from sexual trauma.)
For instance, recent scientific literature has linked heart
disease to stress. Heart disease might at some point be linked
to depression, PTSD and/or anxiety disorder. We believe that
unless the scientific literature conclusively rules out an
association between a covered mental health condition and the
veteran's physical condition, the veteran should receive the
benefit of the doubt. This could expand the scope of S.2573
beyond the drafter's intent, because the types of physical
conditions considered by the scientific community to be
associated with mental health conditions could expand over
time. Should this happen, S.2573 could lead to VA essentially
operating two different health care systems based on separate
sets of eligibility criteria, undermining the accomplishments
achieved under VA health care reform.
It is also troubling to us that S.2573 would require VA to
treat specific diseases and not the veteran as a whole. This
approach places VA practitioners in the difficult and untenable
position of being able to identify conditions they cannot
treat. This creates a particularly serious ethical dilemma for
the practitioner who knows that his or her veteran-patient has
no other access to the needed health care services. In our
view, authority to treat specific diseases--and not the
person--is counter to the principles of patient-centered and
holistic medicine.
The ``wellness'' stipends, themselves, raise several
complex issues. None of VA's current benefits systems is
equipped to administer such a novel benefit, and no current
account appears to be an appropriate funding source from which
to pay them. After much grappling with the issue, we have
concluded that because the bill would amend only chapter 17 of
title 38, United States Code, these stipends would have to be
administered by VHA and paid from funds made available for
medical care.
There would be significant indirect costs as well. VHA
currently lacks the IT infrastructure, expertise, and staff to
administer monetary benefits. Administering the easiest of
monetary benefits would be challenging for VHA, but it is
nearly insurmountable in connection with this bill, which calls
for a very complex, nationwide patient tracking and monitoring
system that also has the capacity to administer payments at
different points in time for veterans participating in the
program. The fact that the duration of each veteran's treatment
plan is highly individualized only complicates the requirements
of such a system-design, as does the fact that the bill would
permit some veterans to receive treatment (and payment)
extensions.
As a result, we do not believe that S.2573 would be cost-
effective as currently drafted. The maximum we could pay any
veteran under the bill would be $11,000; however, it is
reasonable to assume that the costs associated with designing,
operating, and administering such a complex benefit program
would far surpass the actual amounts we would pay out to the
veterans (individually or collectively).
S. 2573 also places our physicians and practitioners in the
difficult position of determining whether their patients will
receive wellness stipends available under the program. It is
quite atypical for a VA physician's clinical determination to
have direct financial implications or consequences for his or
her patients. VA physicians and practitioners seek to help
their veteran-patients attain maximum functioning as quickly as
clinically possible. S.2573 would create potential conflict for
our health care practitioners. They should focus solely on
issues of health care and not feel pressure to grant requests
for extensions of treatment in order to maximize the amount of
money patients receive under the program.
It would also be difficult to define ``substantial
compliance,'' for purposes of S.2573, in a way that is
measurable and objective as well as not easily amenable to
fraud or abuse. For instance, substantial compliance could be
defined in part by a veteran stating that he or she took
prescribed medications as ordered by the physician and VA could
confirm the veteran obtained refills in a timely manner. But
that information does not actually verify that the patient in
fact ingested the medication or did so as prescribed. There
would unavoidably be some patients whose motivation for
participating in this program is strictly financial, and they
would invariably find ways to circumvent whatever criteria we
establish in order to receive their stipends. Although these
payments would not be sizeable, they are sufficient to entice
some patients who would not otherwise access VA's health care
system to participate in the program. We fear these patients
would cease their treatment and stop accessing needed VA
services once their treatment and payments end.
Finally, if the use of ``wellness'' stipends were able to
produce reliable, positive results in terms of patients'
compliance or outcomes, there would then be a demand to extend
this reward system to other VA treatment programs. And once a
benefit is provided, it is difficult to ever repeal it. We say
this only to point out that the cost implications in the out-
years could be very difficult to estimate accurately.
Costing this bill is very complex, as there is no way for
us to determine the total number of veterans who would
participate in the pilot program, in which year they would
enter the program, their ultimate disability status, and the
amount of medical care they would each require. We estimate the
increase in medical administrative costs for every 40,000 new
veterans entering the VA system to be $280 million per year in
addition to $293,340,000 per year in maximum stipend payments.
The estimated one-time cost for eligible living veterans is
$6,712,891,046. These costs do not factor in the costs of
developing the IT infrastructure needed to administer the
benefit. In light of these serious concerns and the bill's
unknown total cost implications, we are unable to supports its
enactment.
* * * * * * *
S. 2639--``ASSURED FUNDING FOR VETERANS HEALTH CARE ACT''
S. 2639 would establish, by formula, the annual level of
funding for all VHA programs, activities, and functions
(excluding the construction, acquisition, and alteration of VA
medical facilities and provision of grants to assist States in
the construction or alteration of State home facilities).
VHA funding for fiscal year 2008 (the first fiscal year
covered by the bill) would be automatically established at 130
percent of the amounts obligated by VHA (for all its
activities, programs, and functions) for fiscal year 2006.
Thereafter, VHA funding would be automatically determined by a
fixed formula. The formula would, generally speaking, be based
on the number of enrollees each year and the number of other
persons receiving VA care during the preceding year multiplied
by a fixed per capita amount. The per capita amount would be
adjusted annually in accordance with increases in the Consumer
Price Index.
It has been VA's long-standing position that we do not
support the concept of using a fixed formula to determine VHA
funding. We believe that it is inappropriate and unworkable to
apply an inflexible formula to a health care system that, by
its very nature, is dynamic. The provision of care evolves
continually to reflect advances in state of the art
technologies (including pharmaceuticals) and medical practices.
It is not possible to estimate the concomitant costs or savings
resulting from those evolving changes. Moreover, patients'
health status, demographics, and usage rates are each subject
to distinct trends that are difficult to predict. The proposed
formula would not take into account any changes in these and
other important trends. As such, there is no certainty that the
amount of funding dictated by the proposed formula would be
appropriate to the demands that will be placed on VA's health
care system in the upcoming years.
Use of an automatic funding mechanism would also eliminate
the valuable opportunity that members of the Congress and the
Executive Branch have to carry out their responsibility to
identify and directly address the health care needs of veterans
through the budget process. It could also depress the
Department's incentive to improve its operations and be more
efficient. It is important to note that S.2639 would not ensure
open enrollment, as the Department would still be required to
make an annual enrollment decision. That decision would
directly affect the number of enrolled veterans and thus the
amount of funding calculated under the formula. Finally,
references to ``guaranteed funding'' in the legislation may
give the public the false impression that VA is being provided
full funding for VA health care. It is not possible to
determine whether the amount determined by the formula would be
adequate. Because of S.2639's potential for all of these
unanticipated and unintended serious consequences, we continue
to favor the current discretionary funding process that uses
actuarially-based budget estimates to project the future health
care needs of enrolled veterans.
* * * * * * *
S. 2796--PILOT PROGRAM USING COMMUNITY BASED ORGANIZATIONS TO INCREASE
THE COORDINATION OF VA SERVICES TO TRANSITIONING VETERANS
S. 2796 would require the Secretary to carry out a two-year
pilot grant program (at five VA medical centers) to assess the
feasibility of using community-based organizations to increase
the coordination of VA benefits and services to veterans
transitioning from military service to civilian life, to
increase the availability of medical services available to
these veterans, and to provide their families with their own
readjustment services. Specifically, grantees could use grant
funds to operate local telephone hotlines; organize veterans
for networking purposes; assist veterans in preparing
applications for VA benefits; provide readjustment assistance
to families of veterans transitioning from military life to
civilian life; provide outreach to veterans and their families
about VA benefits; and coordinate the provision of health care
and other benefits being furnished to transitioning veterans.
VA does not support S.2796, because it is duplicative of
the Department's ongoing efforts. Vet Centers are already
providing much of the outreach, readjustment counseling
services, and family support services that would be required by
this bill. Additionally, VA case managers and federal recovery
coordinators already coordinate the delivery of health care and
other VA services available to veterans transitioning from
military service to civilian life, including supportive
services for their families. VA is committing ever increasing
resources to these ends. Use of grant funds to establish local
hotlines would duplicate and dilute the effectiveness of VA's
central hotlines. The duplicated efforts required by the bill
would likely create significant confusion for the beneficiary.
Further, funding family readjustment services wholly unrelated
to the veteran's readjustment needs would divert medical care
funds needed for veterans' health care.
To the extent the Secretary determines external resources
are necessary to provide the services described in the bill, VA
already has the necessary authority to contract for them. We
favor using contracts instead of grants, as the former allow VA
to respond to changing local needs. That approach also gives us
an accurate way to project the cost of the services. S.2796, on
the other hand, would not. It would also not be cost-effective
as it is likely that a grant awarded under the program would be
for an amount significantly less than the cost VA incurs in
administering the grant. We also note the bill would not
include authority for VA to recapture unused grant funds in the
event a grantee fails to provide the services described in the
grant.
We note further that when selecting pilot sites the
Secretary would have to consider medical centers that have ``a
high proportion of minority groups and individuals who have
experienced significant disparities in the receipt of health
care.'' We are uncertain what this language means and on what
basis such a determination would be based.
Although the proposed pilot project is limited to five VA
medical centers, the scope of the uses for the grant funds is
very broad, and the bill does not specify the number and amount
of the grants to be awarded. We are unable to estimate the cost
estimate of S.2796 due to the bill's lack of specificity.
* * * * * * *
S. 2799--``WOMEN VETERANS HEALTH CARE IMPROVEMENT ACT
OF 2008''
In general, title I of S.2799 would require VA to conduct a
number of studies related to health care benefits for women
veterans. Section 101 would require VA, in collaboration with
VHA's War-Related Injury and Illness Study Centers, to contract
for an epidemiologic cohort (longitudinal) study on the health
consequences of combat service of women veterans who served in
OEF/OIF. The study would need to include information on their
general, mental, and reproductive health and mortality and
include the provision of physical examinations and diagnostic
testing to a representative sample of the cohort.
The bill would require VA to use a sufficiently large
cohort of women veterans and require a minimum follow-up period
of ten years. The bill also would require VA to enter into
arrangements with the Department of Defense (DOD) for purposes
of carrying out this study. For its part, DOD would be required
to provide VA with relevant health care data, including pre-
deployment health and health risk assessments, and to provide
VA access to the cohort while they are serving in the Armed
Forces.
Mr. Chairman, we do not support section 101. It is not
needed. A longitudinal study is already underway. In 2007, VA
initiated its own 10-year study, the ``Longitudinal
Epidemiologic Surveillance on the Mortality and Morbidity of
OIF/OEF Veterans including Women Veterans.'' Several portions
of the study mandated by section 101 are already incorporated
into this project and planning for the actual conduct of the
study is underway. The study has already been approved to
include 12,000 women veterans. However, section 101 would
require us to expand our study to include women active duty
servicemembers. We estimate the additional cost of including
these individuals in the study sample to be $1 million each
year and $3 million over a 10-year period.
Section 102 would require VA to conduct a comprehensive
assessment of the barriers to the receipt of comprehensive VA
health care faced by women veterans, particularly those
experienced by veterans of OEF/OIF. The study would have to
research the effects of 9 specified factors set forth in the
bill that could prove to be barriers to access to care, such as
the availability of child care and women veterans' perception
of personal safety and comfort provided in VA facilities.
Neither do we support section 102. It is not necessary
because a similar comprehensive study is already underway. VA
contracted for a ``National Survey of Women veterans in fiscal
year 2007-2008,'' which is a structured survey based on a pilot
survey conducted in VISN 21. This study is examining barriers
to care (including access) and includes women veterans of all
eras of service. Additionally, it includes women veterans who
never used VA for their care and those who no longer continue
to use VA for their health care needs. We estimate no
additional costs for section 102 because VA's own comparable
study is underway, with $975,000 in funding committed for
fiscal years 2007 and 2008.
Section 103 would require VA to conduct, either directly or
by contract, a comprehensive assessment of all VA programs
intended to address the health of women veterans, including
those related to PTSD, homelessness, substance abuse and mental
health, and pregnancy care. As part of the study, the Secretary
would have to determine whether the following programs are
readily available and easily accessed by women veterans: health
promotion programs, disease prevention programs, reproductive
health programs, and such other programs the Secretary
specifies. VA would also have to identify the frequency such
services are provided; the demographics of the women veteran
population seeking such services; the sites where the services
are provided; and whether waiting lists, geographic distance,
and other factors obstructed their receipt of any of these
services.
In response to the comprehensive assessment, section 103
would further require VA to develop a program to improve the
provision of health care services to women veterans and to
project their future health care needs. In so doing, VA would
have to identify the services available under each program at
each VA medical center and the projected resource and staffing
requirements needed to meet the projected workload demands.
Section 103 would require a very complex and costly study.
While we maintain data on veteran populations receiving VA
health care services that account for the types of clinical
services offered by gender, VA's Strategic Health Care Group
for Women Veterans already studies and uses available data and
analyses to assess and project the needs of women veterans for
the Under Secretary for Health. Furthermore, we lack current
resources to carry out such a comprehensive study within the
18-month time-frame. We would therefore have to contract for
such a study with an entity having, among other things,
significant expertise in evaluating large health care systems.
This is not to say that further assessment is not needed. We
recognize there may well be gaps in services for women
veterans, especially given that VA designed its clinics and
services based on data when women comprised a much smaller
percentage of those serving in the Armed Forces. However, the
study required by section 103 would unacceptably divert
significant funding from direct medical care. Section 103 would
have a cost of $4,354,000 in fiscal year 2008.
Section 104 would require VA to contract with the Institute
of Medicine (IOM) for a study on the health consequences of
women veterans' service in OEF/OIF. The study would need to
include a review and analysis of the relevant scientific
literature to ascertain environmental and occupational exposure
experienced by women who served on active duty in OEF/OIF. It
would then have to address whether any associations exist
between those environmental and occupational exposures and the
women veterans' general health, mental health, or reproductive
health.
We do not object to section 104. We suggest the language be
modified to allow VA to decide which organization is best
situated to carry out this study (taking into account the best
contract bid). While IOM has done similar studies in the past,
this provision would unnecessarily foreclose the possibility of
using other organizations. We estimate the one-time cost of
section 104 to be $1,250,000, which can be funded from existing
resources.
Section 201 would authorize VA to furnish care to a newborn
child of a woman veteran who is receiving VA maternity care for
up to 30 days after the birth of the child in a VA facility or
a facility under contract for the delivery services. We can
support this provision with modifications. As drafted, the
provision is too broadly worded. We believe this section should
be modified so that it applies only to cases where a covered
newborn requires neonatal care services immediately after
delivery. The bill language should also make clear that this
authority would not extend to routine baby well-baby services.
We are currently unable to estimate the costs associated
with section 201 without data on projected health care workload
demands and future utilization requirements. We have contracted
for that data and we will forward the estimated costs for this
section as soon as they are available.
Section 202 would require the Secretary to establish a
program for education, training, certification and continuing
medical education for VA mental health professionals furnishing
care and counseling services for military sexual trauma (MST).
VA would also be required to determine the minimum
qualifications necessary for mental health professionals
certified under the program to provide evidence-based
treatment. The provision would establish extremely detailed
reporting requirements. VA would also have to establish
education, training, certification, and staffing standards for
VA health care facilities for full-time equivalent employees
who are trained to provide MST services.
We do not support the training-related requirements of
section 202 because they are duplicative of existing programs.
In fiscal year 2007, VA funded a Military Sexual Trauma Support
Team, whose mission is, in part, to enhance and expand
MSTrelated training and education opportunities nationwide. VA
also hosts an annual four-day long training session for 30
clinicians in conjunction with the National Center for PTSD,
which focuses on treatment of the after-effects of MST. VA also
conducts training through monthly teleconferences that attract
130 to 170 attendees each month. VA has recently unveiled the
MST Resource Homepage, a Web page that serves as a
clearinghouse for MST-related resources such as patient
education materials, sample power point trainings, provider
educational opportunities, reports of MST screening rates by
facility, and descriptions of VA policies and benefits related
to MST. It also hosts discussion forums for providers. In
addition, VA primary care providers screen their veteran-
patients, particularly recently returning veterans, for MST,
using a screening tool developed by the Department. We are
currently revising our training program to further underscore
the importance of effective screening by primary care providers
who provide clinical care for MST within primary care settings.
We object strongly to the requirement for staffing
standards. Staffing-related determinations must be made at the
local level based on the identified needs of the facility's
patient population, workload, staffing, and other capacity
issues. Retaining this flexibility is essential to permit VA
and individual facilities to respond to changing needs and
available resources. Imposition of national staffing standards
would be an utterly inefficient and ineffective way to manage a
health care system that is dynamic and experiences continual
changes in workload, utilization rates, etc.
Section 203 would require the Secretary to establish,
through the National Center for PTSD, a similar education,
training, and certification program for health care
professionals providing evidence-based treatment of PTSD and
other co-morbid conditions associated with MST to women
veterans. It would require VA to provide these professionals
with continuing medical education, regular competency
evaluations, and mentoring.
VA does not support section 203 because it is duplicative
of, and would divert resources from, activities already
underway by the Department. VA is strongly committed to making
state-of-the-art, evidence-based psychological treatments
widely available to veterans and this is a key component of
VA's Mental Health Strategic Plan. We are currently working to
disseminate evidence-based psychotherapies for a variety of
mental health conditions throughout our health care system.
There are also two programs underway to provide clinical
training to VA mental health staff in the delivery of certain
therapies shown to be effective for PTSD, which are also
recommended in the VA/DOD Clinical Practice Guidelines for
PTSD. Each training program includes a component to train the
professional who will train others in this area, to promote
wider dissemination and sustainability over time.
Section 204 would require the Secretary, commencing not
later than six months after the date of enactment, to carry out
a two-year pilot program, at no fewer than three VISN sites, to
pay veterans the costs of child care they incur to travel to
and from VA facilities for regular mental health services,
intensive mental health services, or other intensive health
care services specified by the Secretary. The provision is
gender-neutral. Any veteran who is a child's primary caretaker
and who is receiving covered health care services would be
eligible to participate in the pilot program. VA does not
support this provision. Although the inability to secure child
care may be a barrier to access to care for some veterans,
funding such care would divert those funds from direct patient
care. We estimate the cost of section 204 to be $3 million.
Section 205 would require VA, not later than six months
after the date of enactment, to conduct a pilot program to
evaluate the feasibility of providing reintegration and
readjustment services in a group retreat setting to women
veterans recently separated from service after a prolonged
deployment. Participation in the pilot would be at the election
of the veteran. Services provided under the pilot would
include, for instance, traditional VA readjustment counseling
services, financial counseling, information on stress
reduction, and information and counseling on conflict
resolution.
VA has no objection to section 205; however, we are unclear
as to the purpose of and need for the bill. We note the term
``group retreat setting'' is not defined. We would not
interpret that term to include a VA medical facility, as we do
not believe that would meet the intent of the bill. We also
assume this term would not include Vet Centers as we could not
limit Vet Center access to any one group of veterans. Moreover,
many Vet Centers, such as the one in Alexandria, Virginia, are
already well designed to meet the individual and group needs of
women veterans. Section 205 would have no costs.
Section 206 would require the Secretary to ensure there is
at least one full-time employee at each VA medical center
serving as a women veterans program manager. We strongly
support this provision. The position of the women veterans
program manager has evolved from an overseer of local programs
to ensure access to care for women veterans to a position
requiring sophisticated management and administrative skills
necessary to execute comprehensive planning for women's health
issues and to ensure these veterans receive quality care as
evidenced, in part, by performance measures and outcome
measurements. The duties of this position will only continue to
grow as we strive to expand services to women veterans. Thus,
we believe there is support for the dedication of a full-time
employee equivalent at every VA medical center. We estimate
section 206 would result in additional costs of $7,131,975 for
fiscal year 2010 and $86,025,382 over a 10-year period.
Next, section 207 would require the Department's Advisory
Committee on Women Veterans, created by statute, to include
women veterans who are recently separated veterans. It would
also require the Department's Advisory Committee on Minority
Veterans to include recently separated veterans who are
minority group members. These requirements would apply to
committee appointments made on or after the bill's enactment.
We support section 207. Given the expanded role of women and
minority veterans serving in the Armed Forces, the Committees
should address the needs of these cohorts in carrying out their
reviews and making their recommendations to the Secretary.
Having their perspective may help project both immediate and
future needs.
* * * * * * *
S. 2824--COLLECTIVE BARGAINING RIGHTS FOR REVIEW OF
ADVERSE ACTIONS
The major provision of S.2824 would make matters relating
to direct patient care and the clinical competence of clinical
health care providers subject to collective bargaining. It
would repeal the current restriction on collective bargaining,
arbitrations, and grievances over matters that the Secretary
determines concern the professional conduct or competence, peer
review, or compensation of Title 38 employees. The Secretary
would also be required to bargain over direct patient care and
clinical competency issues, the processes VA uses to assess
Title 38 professionals' clinical skills, and the discretionary
aspects of Title 38 compensation, including performance pay,
locality pay, and market pay. Because they would be negotiable
these matters would also be subject to nonclinical, non-VA
third-party review.
VA strongly opposes this provision. Prior to 1991, Title 38
professionals did not have the right to engage in collective
bargaining at all. The current restriction on collective
bargaining rights is a sound compromise between VA's mission--
best serving the needs of our nation's veterans--and the
interest of Title 38 physicians, nurses, and other
professionals in engaging in collective bargaining.
Importantly, Congress recognized that the Secretary, as the
head of the VA health care system, would be in the best
position to decide when a particular proposal or grievance
falls within one of the statutory areas excluded from
bargaining. Such determinations should not be legislated.
Neither should they be made by a non-clinical third party who
is not accountable for assuring the health and safety of the
veterans the Department is responsible for. If the Secretary
and the Under Secretary for Health are going to be responsible
and accountable for the quality of care provided to and the
safety of veterans, they must be able to determine which
matters affect that care. They must be able to establish
standards of professional conduct by and competency of our
clinical providers based on what is best for our veterans
rather than what is the best that can be negotiated or what an
arbitrator decides is appropriate. The Under Secretary for
Health has been delegated the authority to make these
discretionary determinations. VA has not abused this
discretionary authority. Since 1992, there have been no more
than 13 decisions issued in a one-year period and, in most
cases, even far fewer decisions than that. This is particularly
striking given the number of VA health care facilities and
bargaining unit employees at those facilities. We are therefore
at a loss to understand the need for this provision.
S. 2824 would also transfer VA's Title 38 specific
authorities, namely the right to make direct patient care and
clinical competency decisions, assess Title 38 professionals'
clinical skills, and determine discretionary compensation for
Title 38 professionals, to independent third-party arbitrators
and other non-VA nonclinical labor third parties who lack
clinical training and understanding of health care management
to make such determinations. For instance, labor grievance
arbitrators and the Federal Service Impasses Panel would have
considerable discretion to impose a clinical or patient care
resolution on the parties. VA would have limited, if any,
recourse if such an external party erred in its consideration
of the clinical or patient care issue. The exceptions to
collective bargaining rights for Title 38 employees identify
areas that directly impact VA's ability to manage its health
care facilities and monitor the professional conduct and
competence of its employees; management actions concerning
these areas must be reserved for VA professionals.
This bill would allow unions to bargain over, grieve, and
arbitrate subjects that are even exempted from collective
bargaining under Title 5, including the manner by which an
employee is disciplined and the determination of the amount of
an employee's compensation. That would be unprecedented in the
Federal government. Such a significant change in VA's
collective bargaining obligations would adversely impact VA's
budget and management rights; it would also skew the current
balance maintained between providing beneficial working
conditions for Title 38 professionals and meeting patient care
needs, jeopardizing the lives of our veterans. There would be
no costs associated with this provision.
* * * * * * *
S. 2921--CARING FOR WOUNDED WARRIORS ACT OF 2008
Section 2 would require the Secretary to conduct up to
three pilot programs, in collaboration with the Secretary of
Defense, to assess the feasibility of training and certifying
family caregivers to be personal care attendants for veterans
and members of the of the Armed Forces suffering from TBI. VA
would be required to determine the eligibility of a family
member to participate in the pilot programs, and such a
determination would have to be based on the needs of the
veteran or servicemember as determined by the patient's
physician. The training curricula would be developed by VA and
include applicable standards and protocols used by
certification programs of national brain injury care specialist
organizations and best practices recognized by caregiver
organizations. Training costs would be borne by VA, with DOD
required to reimburse VA at TRICARE rates for the costs of
training family members of servicemembers. Family caregivers
certified under this program shall be eligible for VA
compensation and may receive assessments of their needs in the
role of caregiver and referrals to community resources to
obtain needed services.
VA does not support section 2. Currently, we are able to
contract for caregiver services with home health and similar
public and private agencies. The contractor trains and pays
them, affords them liability protection, and oversees the
quality of their care. This remains the preferable arrangement
as it does not divert VA from its primary mission of treating
veterans and training clinicians.
Section 3 would require VA, in collaboration with DOD, to
carry out a pilot program to assess the feasibility of
providing respite care to family caregivers of servicemembers
and veterans diagnosed with TBI, through the use of students
enrolled in graduate education programs in the fields of mental
health or rehabilitation. Students participating in the program
would, in exchange for graduate course credit, provide respite
relief to the servicemember's or veteran's family caregiver,
while also providing socialization and cognitive skill
development to the servicemember or veteran. VA would be
required to recruit these students, train them in the provision
of respite care, and work with the heads of their graduate
programs to determine the amount of training and experience
needed to participate in the pilot program.
We do not support section 3, which we recognize is an
effort to compel VA to use existing arrangements with
affiliated academic institutions as a novel means of providing
respite care to family caregivers of TBI patients. Individuals
providing respite care do not require advanced degrees, only
appropriate training. Respite care is an unskilled type of
service that does not qualify for academic credit or serve to
meet any curricula objectives in the graduate degree programs
related to mental health or rehabilitation. Further, section 3
would require VA to use graduate students in roles that are not
permissible under academic affiliation agreements, and we have
serious doubts this proposal would be acceptable to graduate
schools.
Moreover, VA has a comprehensive respite care program. We
also have specialized initiatives underway for TBI patients to
reduce the strain on their caregivers, which overlap with this
bill. Plus we provide respite care by placing the veteran in a
local VA facility for the duration of the respite period.
Veterans may receive up to 30 days of respite care per year. We
estimate the costs of S.2921 to be $39,929,000 for fiscal year
2010 and $790,374,000 over a ten-year period.
* * * * * * *
S. 2899--``VETERANS SUICIDE STUDY ACT''
S. 2899 would require the Secretary to conduct a study to
determine the number of veterans who have committed suicide
between January 1, 1997, and the date of the bill's enactment.
The study would have to be carried out in coordination with the
Secretary of Defense, Veterans Service Organizations, the
Centers for Disease Control and Prevention, and State public
health offices and veterans agencies. The bill would require
the Secretary to submit a report to Congress on his findings
within 180 days of the bill's enactment.
VA understands the intent of the Senate in proposing
S.2899. However, we would like to make the Senate aware of the
difficulties in accomplishing the legislation's intent--and
what VA is doing, and intends to do, to improve our ability to
obtain and report on suicide numbers.
At present, determining suicide rates among veterans is a
challenging puzzle. Multiple data sources must be used, and
data must be carefully checked and rechecked. Each system helps
obtain a piece of the complicated puzzle that constitutes the
process of accurately estimating rates of veteran suicides.
These are time-consuming processes--but they are the best ways
VA knows to obtain aggregate data on suicide.
VA relies on multiple sources of information to identify
deaths that are potentially due to suicide. This includes VA's
own Beneficiary Identification and Records Locator Subsystem,
called BIRLS; records from the Social Security Administration;
and data compiled by the National Center for Health Statistics
in its National Death Index (NDI).
Calculating suicide rates specifically for veterans is made
even more difficult by the fact that the National Death Index
does not include information about whether a deceased
individual is a veteran or not. NDI is simply a central
computerized index of death record information on file in the
vital statistics offices of every state. The Index is compiled
from computer files submitted by State vital statistics
offices. Death records are added to the file annually, about
twelve months after the end of a calendar year.
Given that the NDI does not indicate veteran status, VA
regularly submits requests for information to NDI. VA sends NDI
a list of all patients who have not been treated at any VA
medical centers in the past twelve months and before, to see if
they are still among the living. NDI checks this list against
their records, and tells VA which veterans have died, and the
cause of their death as listed on the veterans' death
certificates. From this information, VA is able to learn the
approximate number of veterans under its care who have died of
suicide, and to use that information to make comparisons on
rates of suicide among those veterans and all other Americans.
This information tells VA about the suicide rates among
veterans under its care, but says nothing about the rates of
suicide among veterans who are not currently in the system. For
those veterans, an even more complicated process has to be
followed in order to estimate rates. VA obtains regular updates
from the Department of Defense's Defense Manpower Data Center
on soldiers separating from the military. Those new veterans
immediately become part of total population and suicide
calculations.
Additionally, the Department will, among other things, also
systematically assess its efforts to inform funeral directors
about the importance of determining whether or not a person who
has died of suicide is or is not a veteran, and what sorts of
information to consider in making that determination. Finally,
VA will investigate working directly with state vital records
offices, as the NDI does, to obtain information on veteran
suicides directly from them.
VA asks that the Senate give us time to complete these
actions before requiring any study of the numbers of suicides
among veterans. We are ``pushing the envelope'' to get the most
accurate data available on suicides in the shortest possible
time frame, and we commit to sharing that data with Congress as
soon as it becomes available.
We estimate the cost of this bill to be $1,580,006 in
fiscal year 2008 and $2,078,667 over a 10-year period.
* * * * * * *
S. 2937--PERMANENT TREATMENT AUTHORITY FOR VETERANS WHO PARTICIPATED IN
CERTAIN DOD TESTING
Section 1 would make permanent the Secretary's authority to
provide needed inpatient, outpatient, and nursing home care to
a veteran who participated in a test conducted by the
Department of Defense (DOD) Deseret Test Center as part of its
chemical and biological warfare testing program conducted from
1962-1973, for any condition or illness possibly associated
with such testing at no cost to the veteran. This authority
will expire after December 31, 2008.
VA supports section 1, which we note is identical to our
own proposal in S.2984. We estimate the discretionary cost of
this provision to be $4,458,000 in fiscal year 2009 and
$144,434,000 over a 10-year period.
Section 2 would require the Secretary, not later than 90
days after the date of the Act's enactment, to enter into a
contract with IOM to conduct an expanded study on the health
impact of participation in Project Shipboard Hazard and Defense
(Project SHAD). Such a study should include, to the extent
practicable, all veterans who participated in Project SHAD. VA
does not support this provision, as we doubt that an expanded
study could be conducted by IOM or any other organization
because IOM has already thoroughly studied the health of SHAD
veterans and made a concerted attempt to identify all involved
veterans for its study.
Mr. Chairman, this concludes my prepared statement. I would
be pleased to answer any questions you or any of the members of
the Committee may have.
------
The Secretary of Veterans Affairs,
Washington, DC, July 21, 2008
Hon. Daniel A. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: On May 21, 2008, you chaired a hearing
to receive comments on 17 healthcare-related bills that were
before the Committee. At the hearing, the Department testified
on 14 of the bills. We stated that we needed additional time to
coordinate the Administration's positions on S. 2926, S. 2963,
and S. 2969. With this letter, we are providing views for the
record on S. 2926 and S. 2963. The Administration's views on S.
2969 are being transmitted to you by separate letter.
S. 2926--Veterans Research and Education Corporations Enhancement Act
of 2008
S. 2926 contains many clarifying and technical provisions;
however, we will discuss only the substantive provisions of the
bill. The most important change to be accomplished by S. 2926
is contained in Section 2. It would amend 38 U.S.C. 7361 to
allow two or more medical centers, with the concurrence of the
Secretary, to form a Multi-Medical Center Research Corporation
(MMCRC). The MMCRC would be authorized to support research and
education projects at the two or more medical centers that had
formed it. This section would also allow an existing non-profit
research corporation (NPC), with the approval of the medical
centers involved and the Secretary, to expand into a MMCRC.
Under current law, a VA medical center may establish an NPC
that is authorized to facilitate approved research and
education projects at that medical center.
This provision of section 2 would not change the
requirement that four members of senior management of one
medical center, the Director, the Chief of Staff and, as
appropriate, the Assistant Chiefs of Staff for Research and for
Education, will serve on the board of the NPC. Rather, it would
provide that this core group be augmented by the medical center
director from each of the other facilities to be served by that
NPC. This would provide VA with one official from each facility
served by the MMCRC who may be held accountable by VA. It would
require the NPC boards to decide whether their NPCs should
evolve into MMCRCs and require them to obtain VA approval. This
would ensure that the board has accepted the responsibilities
that an MMCRC entails and that VA has considered whether the
arrangement is reasonable and in the best interests of the
Department.
Section 2(c) would make clear that NPCs are subject to VA
oversight and regulation, but not under the direct control of
the Department. It would also expressly provide that the NPCs
are not ``owned or controlled by the United States'' or ``an
agency or instrumentality of the United States.'' This is
currently made clear only in the legislative history of the
statute.
Section 3 would clarify that NPCs may support VA research
and education generally. More specifically, it would amend 38
USC 7362 to state that NPCs may support ``functions related to
the conduct of'' VA research and education--but still only VA
research and education--not just administer approved research
or education projects. Currently, the corporations may
facilitate only VA-approved research and education projects.
Section 4 would broaden the qualifications for the non-VA
board members to include business, legal and financial
backgrounds, thus allowing NPCs to use these board positions to
acquire the legal and financial expertise needed to ensure
sound governance and financial management. Currently, the law
requires that there be members of the board of directors of an
NPC who are not Federal employees and who ``are familiar with
issues involving medical and scientific research or
education.''
Section 4 would also update the conflict of interest
provision currently in section 7363(c) of title 38, United
States Code, which prevents individuals from serving on the
board if they are ``affiliated with, employed by, or have any
other financial relationship with'' a for-profit entity that is
a source of funding for VA research.
Section 5 would enhance several powers of the NPCs. Section
5(a) collects in one place all discussion of NPC powers and
makes several important clarifications. First, it would provide
NPCs with authority to retain fees charged to non-VA attendees
for educational programs in order to cover the costs of
attendance by such participants. Current law authorizes NPCs to
facilitate education, but does not authorize them to retain
fees charged to non-VA attendees for educational programs they
administer.
Second, it would permit the NPCs to reimburse the VA Office
of General Counsel (OGC) for resources necessary for prompt
review of Cooperative Research and Development Agreements
(CRADAs). This would permit Regional Counsel offices to address
the growing volume of CRADAs, the form of agreement mandated by
VA to establish terms and conditions for industry-sponsored
studies performed at VA medical centers and administered by
NPCs. Under the bill, any such reimbursements would be used by
OGC for only staffing and training in connection with such
legal services.
Third, section 5(a) of the bill would permit NPCs to expend
funds for necessary planning purposes, prior to approval of a
research project or education program by VA, such as the
expenses of preparing a grant proposal. Currently, the NPCs can
assist VA with funding only for research or education projects
that have already been approved by VA.
Section 5(b) would continue the proscription on VA transfer
of appropriated funds to NPCs, but would make explicit the
authority of a medical center to ``reimburse the corporation
for all or a portion of the pay, benefits, or both of an
employee of the corporation who is assigned to the Department
medical center if the assignment is carried out pursuant to
subchapter VI of chapter 33 of title 5.'' This would codify
that reimbursements from VA to NPCs pursuant to
Intergovernmental Personnel Act (IPA) assignments are
allowable.
Section 7 would increase NPC reporting requirements to
include IRS Form 990, which contains a wealth of information
about revenues and expenditures as well as major programmatic
accomplishments. Section 8 would eliminate the sunset clause on
establishing new NPCs.
We support the provision in section 2 of S. 2926 that would
authorize the establishment of new multi-center non-profit
research corporations (NPCs) and the consolidation of existing
single facility NPCs into multi-facility NPCs. This would offer
the prospect of NPC-assistance in funding research projects to
VA medical centers (VAMCs) that are unable to support their own
dedicated corporation. This provision would also provide the
system with the tools needed to consolidate or close NPCs that
are too small to institute proper internal controls without the
loss of the funding support for VA research and education
programs that the NPCs provide. By requiring the Director of
all VAMCs supported by an NPC to sit on its board of directors,
the provision would provide this beneficial increased
flexibility without sacrificing VA oversight.
With respect to the draft bill's remaining provisions,
however, we ask the Committee to defer further action on this
draft bill in order to give the Department an opportunity to
address underlying structural issues and to formulate policy
related to the governance and finance of the VA affiliated non-
profit research corporations. A steering committee has been
chartered by the Veterans Health Administration Office of
Research and Development, to provide recommendations regarding
governance, oversight, and finance issues related to the
corporations by the end of the fiscal year. We will be happy to
provide you with a copy of their final report and
recommendations.
S. 2963--VA Mental Health and Other Benefits Extended to Members of the
Armed Forces
Section 1 of the bill would require the Secretary of the
Department of Veterans Affairs (VA), acting through the Under
Secretary for Health, to carry out a program to provide
scholarships to individuals pursuing education or training in
behavioral health care specialties critical to the operations
of the Department's Vet Centers. Individuals eligible for the
program would include those pursing education or training
leading to licensure or certification in behavioral health care
specialties, which the Secretary deems are critical to the
operation of the Vet Centers and who otherwise meet other
criteria or requirements established by the Secretary. The
amount of any scholarship provided under the program would be
determined by the Secretary; however, the total amount
available for all the scholarships provided under the program
in any fiscal year could not exceed $2 million.
In exchange for the scholarship, an individual
participating in the program would be required to enter into an
agreement with the Secretary and fulfill a service obligation
in a Vet Center, as specified in the agreement. Section 1 would
also require these agreements to include repayment provisions
in the event the individual does not fulfill the service
obligation. The bill would also specify that these scholarships
are to be paid from amounts made available to VA for the
provision of readjustment benefits.
VA supports the concept of using scholarships for this
purpose; however, this provision is unnecessary. Under existing
authority, we could establish by regulation a special
scholarship program for individuals pursuing degrees in mental
health specialties and require those individuals to agree to
serve for a specified period in VA's Vet Centers. The current
program is used very successfully to recruit individuals for
difficult-to-recruit and difficult-to-retain health care
positions throughout the country. We believe it is essential to
target scholarships to difficult-to-recruit and difficult-to-
retain occupations across the Veterans Health Administration
system, rather than limiting scholarships to specific
facilities.
We note that current law provides express terms governing a
participant's service obligation and liability if a breach
occurs at any phase in the program. These statutory provisions
help ensure that VA is able to reap the benefits of tangible
and intangible investments made by the Department. In addition,
current law imposes treble damages for a scholarship
participant who fails to complete the service obligation. In
sharp contrast, section 1 would require VA to promulgate
regulations relating to repayment of the amount of a
scholarship provided under this section. Imposing significant
penalties for those who breach their service obligations helps
VA to deter individuals from using VA as an interest-free, tax-
free educational loan program. Section 1 provides no effective
means of ensuring that VA will receive the benefit of the
participants' professional services as VA employees. Finally,
because Vet Centers are currently funded through the medical
care appropriations we believe the cost of such scholarship
program shall be funded from the same appropriations, rather
than the readjustment benefits program.
We estimate the cost of section 1 to be $2,313,938 for
fiscal year 2009 and $24,483,918 over a 10-year period.
Section 2 of S. 2963 would extend eligibility for VA's
readjustment counseling and related services provided through
the Department's Vet Centers to members of the Armed Forces,
including members of the National Guard or Reserve, who serve
on active duty in Operation Enduring Freedom or Operation Iraqi
Freedom (OEF/OIF). Service members would be eligible for the
readjustment counseling services even if they are on active
duty at the time they receive them. They would have to also
meet eligibility requirements prescribed jointly by the
Secretary of Veterans Affairs and the Secretary of Defense.
VA supports section 2. We can most effectively address the
readjustment needs of former combat-theater service members who
are still on active duty through early intervention--even
before they are discharged. With our expertise, we can help
prepare them for many of the common readjustment problems
experienced by veterans with combat service. Extending
readjustment counseling and related services to this population
may also help to resolve problems that otherwise might prevent
some of them from pursuing long-term military careers. We note
that VA provides these services in a confidential setting and
in a manner that helps to reduce any concern that an active-
duty military member may have about any stigma related to
seeking counseling or other mental health services. Thus, we
see significant benefits to this section.
We also note that, by operation of law, these service
members' immediate family members would remain eligible for
certain family-support services while the service member is on
active duty. These services would be provided only to the
extent that they are needed for, or in furtherance of, the
active-duty member's successful readjustment to civilian life.
The Department estimates the cost of section 2 to be
$14,791,000 for fiscal year 2009 and $178,418,309 over a 10-
year period. The increased fiscal year 2009 workload resulting
from this proposal can be absorbed within the fiscal year 2009
President's Budget request, which includes funding for the
establishment of 39 new Vet Centers.
Section 3 would require the Secretary to provide referral
services at Vet Centers to individuals who have been discharged
or released from active military, naval, or air service but who
are not eligible to receive readjustment counseling and related
services. It would also require VA to advise these individuals
of their right to apply to the appropriate military, naval, or
air service for review and upgrade of their discharge status.
VA does not support section 3. Vet Centers provide
readjustment counseling and related services to veterans who:
(1) meet the title 38 definition of veteran (i.e., ``a person
who served in the active military, naval, or air service, and
who was discharged or released therefore under conditions other
than dishonorable)''; and (2) served in a combat theater. It is
unclear whether this provision is intended to address all of
those with ``less than honorable'' discharges. If so, the
language of this section is exceptionally broad and would
broaden eligibility for these referral services to non-combat
veterans. These clarifications need to be made before VA can
develop a position and cost estimate for the provision.
Section 4 would require that the suicide by certain former
members of the Armed Forces that occurs during the two-year
period beginning on the date of separation or retirement from
the Armed Forces be treated as a death in the line of duty for
purposes of survivors' eligibility for certain benefits. The
former Armed Forces members who would be covered are those
``with a medical history of a combat-related mental health
condition or Post Traumatic Stress Disorder (PTSD) or Traumatic
Brain Injury (TBI).'' The benefits that would be covered under
section 4 are ``[b]urial benefits,'' Survivor Benefit Plan
benefits under title 10, United States Code, ``[b]enefits under
the laws administered by the Secretary of Veterans Affairs,''
and Social Security Act benefits. Furthermore, for purposes of
benefits under section 4, the date of death would be considered
to be the date of separation or retirement from the Armed
Forces, except that, for purposes of determining ``the scope
and nature of the entitlement,'' the date of death would be
considered to be the date of the suicide. We believe this last
provision would provide the date of death for purposes of
determining the effective date of an award or amount of
benefits, although this is not clear from the bill's language.
Essentially, under section 4, the suicide of a covered
individual would be treated as a service-connected death for VA
benefit purposes.
Although VA supports the concept of section 4 and
recognizes its compassionate intent, we cannot support this
provision because it may have a negative impact. In some cases,
the veterans' combat-related mental health conditions may make
them susceptible to considering suicide. Knowing survivor
benefits would be awarded to their spouses and children might
exacerbate their conditions, making them even more susceptible
to acting on their suicide ideations. Their illnesses may cause
them to reject any opportunity to obtain medical assistance,
believing instead that their families will benefit more from
their suicide. This might especially be the case for those who
feel overwhelmed by their obligation to provide for their
families.
We also have several technical concerns with section 4.
Subsection (b) identifies the covered former Armed Forces
members as those ``with a medical history of a combat-related
mental health condition or [PTSD] or [TBI].'' It is unclear
from the language whether the adjective ``combat-related'' is
meant to modify PTSD and TBI as well as mental health
condition. The statement of the bill's sponsor upon introducing
the bill suggests so. ``This legislation guarantees benefits *
* * provided they have a documented medical history of a
combat-related mental-health condition, including PTSD or
TBI.'' 154 Cong. Rec. S3716 (daily ed. May 1, 2008). However,
the bill language should be clarified.
Subsection (c)(1) identifies ``[b]urial benefits'' as one
of the covered benefits, but fails to specify from which
Federal department or agency. We note that subsection (c)(3)
identifies as covered benefits ``[b]enefits under the laws
administered by [VA],'' which would cover VA burial benefits
and therefore implies that subsection (c)(1) refers to another
agency. Again, the introductory statement of the bill's sponsor
suggests a solution to this interpretive question. ``The
Service Member's survivor will be entitled to the same * * *
active duty burial benefits that they would have received'' had
the former service member died on active duty, id., but
clarification of the bill language may be in order.
VA is still in the process of developing costs for section
4.
Section 5 would require DOD to carry out a grant program
for non-profit organizations furnishing support services to
survivors of deceased service members and veterans. As to this
section, VA defers to the views of the Secretary of Defense.
The Office of Management and Budget advises that there is
no objection to the submission of this report from the
standpoint of the Administration's program.
Sincerely yours,
James B. Peake, M.D.
* * * * * * *
The Secretary of Veterans Affairs,
Washington, DC, August 8, 2008.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: I am pleased to respond to your July 8,
2008, request for the views of the Department of Veterans
Affairs (VA) on the amendment proposed by Ranking Republican
Member Richard Burr to S. 2969, 110th Congress. As you are
aware, the Committee recently approved an amended version of S.
2969, which is now entitled the ``Veterans Health Care
Authorization Act of 2008.'' Senator Burr's amendment, which
was incorporated in the amended bill, would add a new section
5511 to title 38, United States Code, relating to the Brady
Handgun Violence Prevention Act, Public Law 103-159 (Brady
Act). Because the amendment in its current form does not
directly affect VA programs, such an amendment would be more
appropriate for inclusion in title 18 of the United States
Code.
The amendment relates to enforcement of 18 U.S.C. 922,
which is administered by the Department of Justice (DOJ).
Specifically, the amendment would affect the manner in which
DOJ implements 18 U.S.C. 922, which prohibits certain persons
from receiving firearms. The amendment does not affect VA's
provision of benefits to veterans and their families. Because
the substance of the amendment relates to matters within DOJ's
jurisdiction, as drafted, it is more appropriate for inclusion
in title 18.
At the request of the Attorney General pursuant to section
103(e)(1) of the Brady Act, VA provides DOJ with information
concerning persons VA finds to be ``mentally incompetent''--a
finding VA bases solely on a person's ability to contract or
manage his or her affairs in the context of VA benefits. VA's
role with respect to the Brady Act is limited to providing DOJ
such requested information; VA does not determine whether such
information should prohibit a person from possessing firearms.
DOJ is responsible for determining whether persons reported by
VA or other Federal agencies are prohibited by 18 U.S.C. 922
from possessing firearms.
The amendment would provide that a veteran, surviving
spouse, or child found mentally incompetent by VA would not be
deemed to fall within the prohibition of 18 U.S.C. 922 unless
a judicial authority has determined that the individual is a
danger to himself or herself or others. You have requested VA's
views concerning how this Department would implement the
requirement for a judicial finding. We note that the language
of the amendment would not direct VA to obtain such findings.
VA does not implement or enforce the provisions of 18 U.S.C.
922 that would be affected by the requirement for a judicial
finding under this amendment. Moreover, as VA's process for
making incompetency determinations is administrative, as
opposed to judicial, VA could not implement the requirement for
a judicial finding.
You have also requested information concerning the number
of instances per year in which VA determines that an individual
is a danger to himself or herself or others. As discussed
above, VA does not make such determinations. VA competency
determinations are made under 38 C.F.R. 3.353 based solely on
evaluation of whether the individual ``lacks the mental
capacity to contract or to manage his or her own affairs,
including disbursement of funds without limitation.'' Although
VA medical staff might, in isolated instances, offer opinions
regarding an individual's mental status and potential for harm
when requested with regard to state court proceedings, such
medical opinions, like VA's competency determinations, are
neither VA determinations of danger to self or others nor
adjudications of mental defectiveness under 18 U.S.C. 922.
Consequently, VA currently has no system for identifying or
collecting data on such matters.
Because the amendment itself would not impose any
additional reporting or implementation responsibilities, there
would be no direct costs associated with this amendment.
In summary, VA believes the amendment, as drafted, is more
appropriate for inclusion in title 18 of the United States Code
because it does not directly affect VA programs. Because the
amendment pertains directly to a title 18 program, the
Committee may wish to accord DOJ an opportunity to provide
views on this legislation.
We are sending a copy of this report to Ranking Member
Burr.
The Office of Management and Budget has advised that there
is no objection to the submission of this report from the
standpoint of the Administration's program.
Sincerely yours,
James B. Peake, M.D.
* * * * * * *
SUPPLEMENTAL VIEWS OF HON. DANIEL K. AKAKA, CHAIRMAN
I am submitting Supplemental Views to express my concerns
about section 803 of the Committee bill, which would change
VA's actions in fulfilling the Department's responsibilities
under the Brady Handgun Violence Prevention Act, Public Law
103-159, and that law's implementing regulations as set forth
in a Memorandum of Understanding between VA and the Department
of Justice.
This provision was added to the Committee bill by an
amendment offered by the Committee's Ranking Minority Member,
Senator Burr. Senator Burr's amendment was derived from S.
3167, which he introduced on June 19, 2008, after the Committee
had completed its legislative hearings related to the
Committee's June 26, 2008, markup. As a consequence of that
timeline, the Committee was unable to secure any testimony or
other input on the provision prior to the markup. Subsequent to
the markup, I sought official views on this provision, first
from the Department of Veterans Affairs and then, once those
views were received, from the Department of Justice. VA's
official views are included in this report.
I begin by noting that I am not on the Judiciary Committee
nor do I have any other reason to have strong familiarity with
the Brady Act. Because I do not have that background, there are
many questions that I would have sought to have answered in a
hearing, were it to be established that this measure belongs in
our Committee rather than in Judiciary. On that point, I agree
that S. 3167, as drafted, was appropriately referred to the
Veterans' Affairs Committee, but I do not agree that the
subject matter belongs in our Committee.
For example, one question--how do the changes made by the
NICS Improvement Amendments Act of 2007, Public Law 110-180,
which was just signed earlier this year, change VA's process
for providing names to the Department of Justice? I have seen
the changes made by that Act described as:
Prevent[ing] use of federal ``adjudications'' that
consist only of medical diagnoses without findings that
the people involved are dangerous or mentally
incompetent.
This description, which was applauding the new law, went on
to say that this change would ensure that purely medical
records are never used in NICS. Gun ownership rights would only
be lost as a result of a finding that the person is a danger to
themselves or others, or lacks the capacity to manage his own
affairs [emphasis added]. That last test seems to me to be
fully consistent with what VA has been doing for a number of
years. If that is correct--and I acknowledge, frankly, that I
am not certain, nor do I believe that the Veterans' Affairs
Committee knows, because there has been no hearing--the reason
for making a change to the current practice is not clear to me.
What effect will the standard included in the amendment--
requiring adjudication by ``a judge, magistrate, or other
judicial authority'' that someone is a ``danger to him- or
herself''--have on VA's ability to provide input to the NICS?
Will this change result in a delay in providing notification to
NICS of the names of individuals who are not in a position to
purchase a firearm? Is this the standard applied by other
governmental organizations? Again, I do not know the answer,
because there was no hearing.
VA's current actions to provide input to NICS are done in
accordance with provisions in title 27 of the Code of Federal
Regulations which spell out the requirements of the law. In the
relevant regulation, 27 CFR 478.11, the term in the law--
``adjudicated as a mental defective''--is defined to include
those determined by ``a lawful authority'' to lack ``mental
capacity to contract or manage his own affairs.'' It is the
names of those who VA has found meet that standard that VA has
been reporting to the Department of Justice. To characterize
VA's actions as arbitrary and unfair, as was done during the
Committee markup, is wrong. Perhaps the implementing
regulations should be changed--again, a task for a Committee
other than the Veterans' Affairs Committee--but it is hard to
fault VA's compliance with the regulations.
My last concern with this provision, and the process by
which it was brought before the Committee, goes to the question
of urgency. As I noted above, the legislation from which the
amendment was derived was introduced one week prior to a
previously-scheduled markup. The amendment addresses a practice
that dates back to 1998. What possible reason exists for
suggesting that there is an urgent need to address this issue?
Rather than proceeding in haste, and in the wrong Committee, I
believe that the legislation should have been considered in the
normal course by the Judiciary Committee.
* * * * * * *
Changes in Existing Law
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. VETERANS' BENEFITS
PART I. GENERAL PROVISIONS
* * * * * * *
CHAPTER 5. AUTHORITY AND DUTIES OF THE SECRETARY
* * * * * * *
Subchapter III. Advisory Committees
* * * * * * *
SEC. 542. ADVISORY COMMITTEE ON WOMEN VETERANS
(a)(1) The Secretary shall establish an advisory committee
to be known as the Advisory Committee on Women Veterans
(hereinafter in this section referred to as ``the Committee'').
(2)(A) The Committee shall consist of members appointed by
the Secretary from the general public, including--
(i) representatives of women veterans;
(ii) individuals who are recognized authorities in
fields pertinent to the needs of women veterans,
including the gender-specific health-care needs of
women; [and]
(iii) representatives of both female and male
veterans with service-connected disabilities, including
at least one female veteran with a service-connected
disability and at least one male veteran with a
service-connected disability[.] ; and
(iv) women veterans who are recently separated from
service in the Armed Forces.
* * * * * * *
SEC. 544. ADVISORY COMMITTEE ON MINORITY VETERANS
(a)(1) The Secretary shall establish an advisory committee
to be known as the Advisory Committee on Minority Veterans
(hereinafter in this section referred to as ``the Committee'').
(2)(A) The Committee shall consist of members appointed by
the Secretary from the general public, including--
(i) representatives of veterans who are minority
group members;
(ii) individuals who are recognized authorities in
fields pertinent to the needs of veterans who are
minority group members;
(iii) veterans who are minority group members and who
have experience in a military theater of operations;
[and]
(iv) veterans who are minority group members and who
do not have such experience[.] ; and
(v) women veterans who are minority group members and
are recently separated from service in the Armed
Forces.
* * * * * * *
CHAPTER 9. SECURITY AND LAW ENFORCEMENT ON PROPERTY UNDER THE
JURISDICTION OF THE DEPARTMENT
* * * * * * *
SEC. 902. ENFORCEMENT AND ARREST AUTHORITY OF DEPARTMENT POLICE
OFFICERS
(a)(1) Employees of the Department who are Department
police officers shall, with respect to acts occurring on
Department property[, enforce]--
(A) enforce Federal laws;
(B) enforce the rules prescribed under section 901 of
this title; [and]
(C) [subject to paragraph (2), traffic and motor
vehicle laws of a State or local government within the
jurisdiction of which such Department property is
located.] enforce traffic and motor vehicle laws of a
State or local government (by issuance of a citation
for violation of such laws) within the jurisdiction of
which such Department property is located as authorized
by an express grant of authority under applicable State
or local law;
(D) carry the appropriate Department-issued weapons,
including firearms, while off Department property in an
official capacity or while in an official travel
status;
(E) conduct investigations, on and off Department
property, of offenses that may have been committed on
property under the original jurisdiction of Department,
consistent with agreements or other consultation with
affected local, State, or Federal law enforcement
agencies; and
(F) carry out, as needed and appropriate, the duties
described in subparagraphs (A) through (E) of this
paragraph when engaged in duties authorized by other
Federal statutes.
[(2) A law described in subparagraph (C) of paragraph (1)
may be enforced under such subparagraph only as authorized by
an express grant of authority under applicable State or local
law. Any such enforcement shall be by the issuance of a
citation for violation of such law.]
(2) [(3)] Subject to regulations prescribed under
subsection (b), a Department police officer may make arrests on
Department property for a violation of a Federal law or any
rule prescribed under section 901(a) of this title , and on any
arrest warrant issued by competent judicial authority.
(b) * * *
(c) [The Secretary shall consult with the Attorney General
before prescribing regulations under paragraph (1) of
subsection (b).] The powers granted to Department police
officers designated under this section shall be exercised in
accordance with guidelines approved by the Secretary and the
Attorney General.
(d) * * *
SEC. 903. UNIFORM ALLOWANCE
(a) * * *
[(b) The amount of the allowance that the Secretary may pay
under this section--
[(1) may be based on estimated average costs or
actual costs;
[(2) may vary by geographic regions; and
[(3) except as provided in subsection (c), may not
exceed $ 200 in a fiscal year for any police officer.]
(b)(1) The amount of the allowance that the Secretary may
pay under this section is the lesser of--
(A) the amount currently allowed as prescribed by the
Office of Personnel Management; or
(B) estimated costs or actual costs as determined by
periodic surveys conducted by the Department.
(2) During any fiscal year no officer shall receive more
for the purchase of a uniform described in subsection (a) than
the amount established under this subsection.
(c) [The amount of an allowance under this section may be
increased to an amount up to $ 400 for not more than one fiscal
year in the case of any Department police officer. In the case
of a person who is appointed as a Department police officer on
or after January 1, 1990, an allowance in an amount established
under this subsection shall be paid at the beginning of such
person's employment as such an officer. In the case of any
other Department police officer, an allowance in an amount
established under this subsection shall be paid upon the
request of the officer.] The allowance established under
subsection (b) shall be paid at the beginning of a Department
police officer's employment for those appointed on or after
October 1, 2008. In the case of any other Department police
officer, an allowance in the amount established under
subsection (b) shall be paid upon the request of the officer.
PART II. GENERAL BENEFITS
* * * * * * *
CHAPTER 17. HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
SUBCHAPTER I. GENERAL
SEC.
1701. DEFINITIONS.
* * * * * * *
1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION AND
SOCIAL SECURITY NUMBER OF CERTAIN VETERANS
RECEIVING CARE.
* * * * * * *
SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS
* * * * * * *
1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING MATERNITY
CARE.
Subchapter I. General
SEC. 1701. DEFINITIONS
* * * * * * *
(6) The term ``medical services'' includes, in
addition to medical examination, treatment, and
rehabilitative services, the following:
(A) Surgical services.
(B) Dental services and appliances as
described in sections 1710 and 1712 of this
title.
(C) Optometric and podiatric services.
(D) Preventive health services.
(E) Noninstitutional extended care services,
including alternatives to institutional
extended care which the Secretary may furnish
directly, by contract, or through provision of
case management by another provider or payor.
(F) [(E)] In the case of a person otherwise
receiving care or services under this chapter--
(i) wheelchairs, artificial limbs,
trusses, and similar appliances;
(ii) special clothing made necessary
by the wearing of prosthetic
appliances; and
(iii) such other supplies or services
as the Secretary determines to be
reasonable and necessary.
(G) [(F)] Travel and incidental expenses
pursuant to section 111 of this title.
* * * * * * *
[(10)(A) During the period beginning on November 30,
1999, and ending on December 31, 2008, the term
``medical services'' includes noninstitutional extended
care services.
[(B) For the purposes of subparagraph (A), the term
``noninstitutional extended care services'' means such
alternatives to institutional extended care which the
Secretary may furnish (i) directly, (ii) by contract,
or (iii) (through provision of case management) by
another provider or payor.]
* * * * * * *
SEC. 1703. CONTRACTS FOR HOSPITAL CARE AND MEDICAL SERVICES IN NON-
DEPARTMENT FACILITIES
* * * * * * *
(d)(4) The authority of the Secretary under this subsection
terminates on [September 30, 2008] September 30, 2013.
* * * * * * *
SEC. 1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION
AND SOCIAL SECURITY NUMBER OF CERTAIN VETERANS
RECEIVING CARE
(a) Required Disclosure of Health-Plan Contracts.--(1) Any
individual who applies for or is in receipt of care described
in paragraph (2) shall, at the time of such application, or
otherwise when requested by the Secretary, submit to the
Secretary such current information as the Secretary may require
to identify any health-plan contract (as defined in section
1729(i) of this title) under which such individual is covered,
to include, as applicable--
(A) the name, address, and telephone number of such
health-plan contract;
(B) the name of the individual's spouse, if the
individual's coverage is under the spouse's health-plan
contract;
(C) the plan number; and
(D) the plan's group code.
(2) The care described in this paragraph is--
(A) hospital, nursing home, or domiciliary care;
(B) medical, rehabilitative, or preventive health
services; or
(C) other medical care under laws administered by the
Secretary.
(b) Required Disclosure of Social Security Number.--(1) Any
individual who applies for or is in receipt of care described
in paragraph (2) shall, at the time of such application, or
otherwise when requested by the Secretary, submit to the
Secretary--
(A) the individual's social security number; and
(B) the social security number of any dependent or
Department beneficiary on whose behalf, or based upon
whom, such individual applies for or is in receipt of
such care.
(2) The care described in this paragraph is--
(A) hospital, nursing home, or domiciliary care;
(B) medical, rehabilitative, or preventive health
services; or
(C) other medical care under laws administered by the
Secretary.
(3) This subsection does not require an individual to
furnish the Secretary with a social security number for any
individual to whom a social security number has not been
assigned.
(c) Failure to Disclose Social Security Number.--(1) The
Secretary shall deny an individual's application for, or may
terminate an individual's enrollment in, the system of patient
enrollment established by the Secretary under section 1705 of
this title, if such individual does not provide the social
security number required or requested to be submitted pursuant
to subsection (b).
(2) Following a denial or termination under paragraph (1)
with respect to an individual, the Secretary may, upon receipt
of the information required or requested under subsection (b),
approve such individual's application or reinstate such
individual's enrollment (if otherwise in order), for such
medical care and services provided on and after the date of
such receipt of information.
(d) Construction.--Nothing in this section shall be
construed as authority to deny medical care and treatment to an
individual in a medical emergency.
Subchapter II. Hospital, Nursing Home, or
Domiciliary Care and Medical Treatment
SEC. 1710. ELIGIBILITY FOR HOSPITAL, NURSING HOME, AND DOMICILIARY CARE
* * * * * * *
(e)(1)(A) * * *
* * * * * * *
(3) Hospital care, medical services, and nursing home care
may not be provided under or by virtue of subsection
(a)(2)(F)--
(A) in the case of care for a veteran described in
paragraph (1)(A), after December 31, 2002;
(B) in the case of care for a veteran described in
paragraph (1)(C), after December 31, 2002; and
(C) in the case of care for a veteran described in
paragraph (1)(D) who--
(i) is discharged or released from the active
military, naval, or air service after the date
that is five years before the date of the
enactment of the National Defense Authorization
Act for Fiscal Year 2008 [enacted Jan. 28,
2008], after a period of five years beginning
on the date of such discharge or release; or
(ii) is so discharged or released more than
five years before the date of the enactment of
that Act and who did not enroll in the patient
enrollment system under section 1705 of this
title before such date, after a period of three
years beginning on the date of the enactment of
that Act[; and].
[(D) in the case of care for a veteran described in
paragraph (1)(E), after December 31, 2007.]
(f)(1) The Secretary may not furnish hospital care or
nursing home care (except if such care constitutes 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) or (4) of this subsection.
* * * * * * *
(g)(1) The Secretary may not furnish medical services
(except if such care constitutes 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. 1710A. REQUIRED NURSING HOME CARE
* * * * * * *
(d) The provisions of subsection (a) shall terminate on
[December 31, 2008] December 31, 2013.
* * * * * * *
SEC. 1710E. TRAUMATIC BRAIN INJURY: USE OF NON-DEPARTMENT FACILITIES
FOR REHABILITATION
(a) Cooperative agreements.-- * * *
(b) Covered Individuals.--The care and services provided
under subsection (a) shall be made available to an individual--
(1) who is described in section 1710C(a) of this
title; and
(2)(A) to whom the Secretary is unable to provide
such treatment or services at the frequency or for the
duration prescribed in such plan; or
(B) for whom the Secretary determines that it is
optimal with respect to the recovery and rehabilitation
for such individual.''
(c) [(b)] Authorities of State protection and advocacy
systems.-- * * *
(d) Standards.--The Secretary may not provide treatment or
services as described in subsection (a) at a non-Department
facility under such subsection unless such facility maintains
standards for the provision of such treatment or services
established by an independent, peer-reviewed organization that
accredits specialized rehabilitation programs for adults with
traumatic brain injury.
SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL
HEALTH SERVICES.
* * * * * * *
(c) Upon receipt of a request for counseling under this
section from any individual who has been discharged or released
from active military, naval, or air service but who is not
otherwise eligible for such counseling, the Secretary shall--
(1) provide referral services to assist such
individual, to the maximum extent practicable, in
obtaining mental health care and services from sources
outside the Department; and
(2) if pertinent, advise such individual of such
individual's rights to apply to the appropriate
military, naval, or air service, and to the Department,
for review of such individual's discharge or release
from such service.
SEC. 1720. TRANSFERS FOR NURSING HOME CARE; ADULT DAY HEALTH CARE
* * * * * * *
(g) The Secretary may contract with appropriate entities to
provide specialized residential care and rehabilitation
services to a veteran of Operation Enduring Freedom or
Operation Iraqi Freedom who the Secretary determines suffers
from a traumatic brain injury, has an accumulation of deficits
in activities of daily living and instrumental activities of
daily living, and because of these deficits, would otherwise
require admission to a nursing home even though such care would
generally exceed the veteran's nursing needs.
* * * * * * *
SEC. 1720D. COUNSELING AND TREATMENT FOR SEXUAL TRAUMA
* * * * * * *
(d)(1) The Secretary shall implement a program for
education, training, certification, and continuing medical
education for mental health professionals to specialize in the
provision of counseling and care to veterans eligible for
services under subsection (a). In carrying out the program, the
Secretary shall ensure that all such mental health
professionals have been trained in a consistent manner and that
such training includes principles of evidence-based treatment
and care for sexual trauma.
(2) The Secretary shall determine the minimum
qualifications necessary for mental health professionals
certified by the program under paragraph (1) to provide
evidence-based treatment and therapy to veterans eligible for
services under subsection (a) in facilities of the Department.
(e) The Secretary shall submit to Congress each year a
report on the counseling and care and services provided to
veterans under this section. Each report shall include data for
the preceding year with respect to the following:
(1) The number of mental health professionals and
primary care providers who have been certified under
the program under subsection (d), and the amount and
nature of continuing medical education provided under
such program to professionals and providers who have
been so certified.
(2) The number of women veterans who received
counseling and care and services under subsection (a)
from professionals and providers who have been trained
or certified under the program under subsection (d).
(3) The number of training, certification, and
continuing medical education programs operating under
subsection (d).
(4) The number of trained full-time equivalent
employees required in each facility of the Department
to meet the needs of veterans requiring treatment and
care for sexual trauma.
(5) Such other information as the Secretary considers
appropriate.
(f) [(d)] In this section, the term ``sexual harassment''
means repeated, unsolicited verbal or physical contact of a
sexual nature which is threatening in character.
* * * * * * *
Subchapter VIII. Health Care of Persons
Other Than Veterans
SEC. 1781. MEDICAL CARE FOR SURVIVORS AND DEPENDENTS OF CERTAIN
VETERANS
(a) * * *
* * * * * * *
(e) Payment by the Secretary under this section on behalf
of a covered beneficiary for medical care shall constitute
payment in full and extinguish any liability on the part of the
beneficiary for that care.
* * * * * * *
SEC. 1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING
MATERNITY CARE
(a) In General.--The Secretary may furnish health care
services described in subsection (b) to a newborn child of a
woman veteran who is receiving maternity care furnished by the
Department for not more than 7 days after the birth of the
child if the veteran delivered the child in--
(1) a facility of the Department; or
(2) another facility pursuant to a Department
contract for services relating to such delivery.
(b) Covered Health Care Services.--Health care services
described in this subsection are all post-delivery care
services, including routine care services, that a newborn
requires.
CHAPTER 18. BENEFITS FOR CHILDREN OF VIETNAM VETERANS AND OTHER
VETERANS
Subchapter I. Children of Vietnam Veterans Born With Spina Bifida
* * * * * * *
SEC. 1803. HEALTH CARE
* * * * * * *
(b) * * *
(c) Where payment by the Secretary under this section is
less than the amount of the charges billed, the health care
provider or agent of the health care provider may 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 thereof would be eligible to
receive payment for such care or services from such third
party, but--
(1) the health care provider or agent for the health
care provider may not impose any additional charge on
the beneficiary who received the medical care, or the
family of such beneficiary, for any service or item for
which the Secretary has made payment under this
section;
(2) the total amount of payment a provider or agent
of the provider may receive for care and services
furnished under this section may not exceed the amount
billed to the Secretary; and
(3) the Secretary, upon request, shall disclose to
such third party information received for the purposes
of carrying out this section.
(d) [(c)] For the purposes of this section--
* * * * * * *
SEC. 1813. HEALTH CARE
* * * * * * *
(b) * * *
(c) Seeking Payment From Third Parties.--Where payment by
the Secretary under this section is less than the amount of the
charges billed, the health care provider or agent of the health
care provider may 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 health care
provider or agent thereof would be eligible to receive payment
for such care or services from such third party, but--
(1) the health care provider or agent for the health
care provider may not impose any additional charge on
the beneficiary who received medical care, or the
family of such beneficiary, for any service or item for
which the Secretary has made payment under this
section;
(2) the total amount of payment a provider or agent
of the provider may receive for care and services
furnished under this section may not exceed the amount
billed to the Secretary; and
(3) the Secretary, upon request, shall disclose to
such third party information received for the purposes
of carrying out this section.
(d) [(c)] Definitions.-- * * *
* * * * * * *
CHAPTER 20. BENEFITS FOR HOMELESS VETERANS
* * * * * * *
Subchapter II. Comprehensive Service Programs
* * * * * * *
SEC. 2013. AUTHORIZATION OF APPROPRIATIONS
There is authorized to be appropriated to carry out this
subchapter [$130,000,000] $200,000,000 for fiscal year 2007 and
each fiscal year thereafter.
* * * * * * *
PART IV. GENERAL ADMINISTRATIVE PROVISIONS
* * * * * * *
CHAPTER 51. CLAIMS, EFFECTIVE DATES, AND PAYMENTS
* * * * * * *
CHAPTER 55. MINORS, INCOMPETENTS, AND OTHER WARDS
SEC.
5501. COMMITMENT ACTIONS.
* * * * * * *
5510. ANNUAL REPORT.
5511. CONDITIONS FOR TREATMENT OF VETERANS, THEIR SURVIVING SPOUSES,
AND THEIR CHILDREN AS ADJUDICATED MENTALLY
INCOMPETENT FOR CERTAIN PURPOSES.
* * * * * * *
SEC. 5501. COMMITMENT ACTIONS
* * * * * * *
SEC. 5510. ANNUAL REPORT
* * * * * * *
SEC. 5511. CONDITIONS FOR TREATMENT OF VETERANS, SURVIVING SPOUSES, AND
CHILDREN AS ADJUDICATED MENTALLY INCOMPETENT FOR
CERTAIN PURPOSES
In any case arising out of the administration by the
Secretary of laws and benefits under this title, a veteran,
surviving spouse, or child who is mentally incapacitated,
deemed mentally incompetent, or experiencing an extended loss
of consciousness shall not be considered adjudicated as a
mental defective under subsection (d)(4) or (g)(4) of section
922 of title 18 without the order or finding of a judge,
magistrate, or other judicial authority of competent
jurisdiction that such veteran, surviving spouse, or child is a
danger to him- or herself or others.
* * * * * * *
CHAPTER 57. RECORDS AND INVESTIGATIONS
Subchapter I. Records
SEC. 5701. CONFIDENTIAL NATURE OF CLAIMS
* * * * * * *
(l) Under regulations that the Secretary shall prescribe,
the Secretary may disclose the name or address, or both, of any
individual who is a present or former member of the Armed
Forces, or who is a dependent of a present or former member of
the Armed Forces, to a third party, as defined in section
1729(i)(3)(D) of this title, in order to enable the Secretary
to collect reasonable charges under section 1729(a)(2)(E) of
this title for care or services provided for a non-service-
connected disability.
* * * * * * *
PART V. BOARDS, ADMINISTRATIONS, AND SERVICES
CHAPTER 73. VETERANS HEALTH ADMINISTRATION-ORGANIZATION AND FUNCTIONS
* * * * * * *
SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION
SEC.
7311. QUALITY ASSURANCE.
7311A. QUALITY ASSURANCE OFFICERS.
* * * * * * *
SUBCHAPTER IV. RESEARCH CORPORATIONS
* * * * * * *
7365. [7364A.] COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT CLAIMS
LAWS.
[7365. APPLICABLE STATE LAW]
* * * * * * *
[7368. EXPIRATION OF AUTHORITY.]
* * * * * * *
Subchapter II. General Authority and Administration
SEC. 7311. QUALITY ASSURANCE
* * * * * * *
(b)(1) * * *
* * * * * * *
(4) As part of the quality assurance program, the Under
Secretary for Health shall establish mechanisms through which
employees of Veterans Health Administration facilities may
submit reports, on a confidential basis, on matters relating to
quality of care in Veterans Health Administration facilities to
the quality assurance officers of such facilities under section
7311A(b) of this title. The mechanisms shall provide for the
prompt and thorough review of any reports so submitted by the
receiving officials.
* * * * * * *
SEC. 7311A. QUALITY ASSURANCE OFFICERS
(a) National Quality Assurance Officer.--(1) The Under
Secretary for Health shall designate an official of the
Veterans Health Administration to act as the principal quality
assurance officer for the quality assurance program required by
section 7311 of this title. The official so designated may be
known as the ``National Quality Assurance Officer of the
Veterans Health Administration'' (in this section referred to
as the ``National Quality Assurance Officer'').
(2) The National Quality Assurance Officer shall report
directly to the Under Secretary for Health in the discharge of
responsibilities and duties of the Officer under this section.
(3) The National Quality Assurance Officer shall be the
official within the Veterans Health Administration who is
principally responsible for the quality assurance program
referred to in paragraph (1). In carrying out that
responsibility, the Officer shall be responsible for--
(A) establishing and enforcing the requirements of
that program; and
(B) carrying out such other responsibilities and
duties relating to quality assurance in the Veterans
Health Administration as the Under Secretary for Health
shall specify.
(4) The requirements under paragraph (3) shall include
requirements regarding the following:
(A) A confidential system for the submittal of
reports by Veterans Health Administration personnel
regarding quality assurance at Department facilities.
(B) Mechanisms for the peer review of the actions of
individuals appointed in the Veterans Health
Administration in the position of physician.
(C) Mechanisms for the accountability of the facility
director and chief medical officer of each Veterans
Health Administration medical facility for the actions
of physicians in such facility.
(b) Quality Assurance Officers for VISNs.--(1) The Regional
Director of each Veterans Integrated Services Network (VISN)
shall appoint an official of the Network to act as the quality
assurance officer of the Network.
(2) The quality assurance officer for a Veterans Integrated
Services Network shall report to the Regional Director of the
Veterans Integrated Services Network, and to the National
Quality Assurance Officer, regarding the discharge of the
responsibilities and duties of the officer under this section.
(3) The quality assurance officer for a Veterans Integrated
Services Network shall--
(A) direct the quality assurance office in the
Network; and
(B) coordinate, monitor, and oversee the quality
assurance programs and activities of the Administration
medical facilities in the Network in order to ensure
the thorough and uniform discharge of quality assurance
requirements under such programs and activities
throughout such facilities.
(c) Quality Assurance Officers for Medical Facilities.--(1)
The director of each Veterans Health Administration medical
facility shall appoint a quality assurance officer for that
facility.
(2) The official appointed as a quality assurance officer
for a facility under this subsection shall be a practicing
physician at the facility. If the official appointed as quality
assurance officer for a facility has other clinical or
administrative duties, the director of the facility shall
ensure that those duties are sufficiently limited in scope so
as to ensure that those duties do not prevent the officer from
effectively discharging the responsibilities and duties of
quality assurance officer at the facility.
(3) The quality assurance officer for a facility shall
report directly to the director of the facility, and to the
quality assurance officer of the Veterans Integrated Services
Network in which the facility is located, regarding the
discharge of the responsibilities and duties of the quality
assurance officer under this section.
(4) The quality assurance officer for a facility shall be
responsible for designing, disseminating, and implementing
quality assurance programs and activities for the facility that
meet the requirements established by the National Quality
Assurance Officer under subsection (a).
* * * * * * *
Subchapter III. Protection of Patient Rights
SEC. 7332. CONFIDENTIALITY OF CERTAIN MEDICAL RECORDS
* * * * * * *
(b)(2) * * *
(A) * * *
* * * * * * *
(F)(i) To a representative of a patient who lacks
decision-making capacity, when a practitioner deems the
content of the given record necessary for that
representative to make an informed decision regarding
the patient's treatment.
(ii) In this subparagraph, the term
``representative'' means an individual, organization,
or other body authorized under section 7331 of this
title and its implementing regulations to give informed
consent on behalf of a patient who lacks decision-
making capacity.
(G) To a third party, as defined in section
1729(i)(3)(D) of this title, to collect reasonable
charges under section 1729(a)(2)(E) of this title for
care or services provided for a non-service-connected
disability.
* * * * * * *
Subchapter IV. Research Corporations
SEC. 7361. AUTHORITY TO ESTABLISH; STATUS
(a) The Secretary may authorize the establishment at any
Department medical center of a nonprofit corporation to provide
a flexible funding mechanism for the conduct of approved
research and education at the medical center. [Except as
otherwise required in this subchapter or under regulations
prescribed by the Secretary, any such corporation, and its
directors and employees, shall be required to comply only with
those Federal laws, regulations, and executive orders and
directives which apply generally to private nonprofit
corporations.] Such a corporation may be established to
facilitate either research or education or both research and
education.
(b)(1) Subject to paragraph (2), a corporation established
under this subchapter may facilitate the conduct of research,
education, or both at more than one medical center. Such a
corporation shall be known as a ``multi-medical center research
corporation''.
(2) The board of directors of a multi-medical center
research corporation under this subsection shall include the
official at each Department medical center concerned who is, or
who carries out the responsibilities of, the medical center
director of such center as specified in section
7363(a)(1)(A)(i) of this title.
(3) In facilitating the conduct of research, education, or
both at more than one Department medical center under this
subchapter, a multi-medical center research corporation may
administer receipts and expenditures relating to such research,
education, or both, as applicable, performed at the Department
medical centers concerned.
(c) Any corporation established under this subchapter shall
be established in accordance with the nonprofit corporation
laws of the State in which the applicable Department medical
center is located and shall, to the extent not inconsistent
with any Federal law, be subject to the laws of such State. In
the case of any multi-medical center research corporation that
facilitates the conduct of research, education, or both at
Department medical centers located in different States, the
corporation shall be established in accordance with the
nonprofit corporation laws of the State in which one of such
Department medical centers is located.
(d)(1) Except as otherwise provided in this subchapter or
under regulations prescribed by the Secretary, any corporation
established under this subchapter, and its officers, directors,
and employees, shall be required to comply only with those
Federal laws, regulations, and executive orders and directives
that apply generally to private nonprofit corporations.
(2) A corporation under this subchapter is not--
(A) owned or controlled by the United States; or
(B) an agency or instrumentality of the United
States.
(e) [(b)] If by the end of the four-year period beginning
on the date of the establishment of a corporation under this
subchapter the corporation is not recognized as an entity the
income of which is exempt from taxation under section 501(c)(3)
of the Internal Revenue Code of 1986, the Secretary shall
dissolve the corporation.
(f) A corporation established under this subchapter may act
as a multi-medical center research corporation under this
subchapter in accordance with subsection (b) if--
(1) the board of directors of the corporation
approves a resolution permitting facilitation by the
corporation of the conduct of research, education, or
both at the other Department medical center or medical
centers concerned; and
(2) the Secretary approves the resolution of the
corporation under paragraph (1).
SEC. 7362. PURPOSE OF CORPORATIONS
(a) [Any corporation established under this subchapter
shall be established solely to facilitate] A corporation
established under this subchapter shall be established to
provide a flexible funding mechanism for the conduct of
approved research and education at one or more Department
medical centers and to facilitate functions related to the
conduct of research as described in section 7303(a) of this
title and education and training as described in sections 7302,
7471, 8154, and 1701(6)(B) of this title in conjunction with
the applicable Department medical center or centers. [Any funds
received by the Secretary for the conduct of research or
education at the medical center other than funds appropriated
to the Department may be transferred to and administered by the
corporation for these purposes.]
(b) For purposes of this section, the term [``education and
training''] ``education'' includes education and training and
means the following:
(1) In the case of employees of the Veterans Health
Administration, such term means work-related
instruction or other learning experiences to--
(A) improve performance of current duties;
(B) assist employees in maintaining or
gaining specialized proficiencies; and
(C) expand understanding of advances and
changes in patient care, technology, and health
care administration.
[Such term includes (in the case of such employees)
education and training conducted as part of a residency
or other program designed to prepare an individual for
an occupation or profession.]
(2) In the case of veterans under the care of the
Veterans Health Administration, such term means
instruction or other learning experiences related to
improving and maintaining the health of veterans [to
patients and to the families] and includes education
and training for patients and families and guardians of
patients.
SEC. 7363. BOARD OF DIRECTORS; EXECUTIVE DIRECTOR
(a) The Secretary shall provide for the appointment of a
board of directors for any corporation established under this
subchapter. The board shall include--
(1) [the director of the medical center, the chief of
staff of the medical center, and as appropriate, the
assistant chief of staff for research for the medical
center and the assistant chief of staff for education
for the medical center, or, in the case of a facility
at which such positions do not exist, those officials
who are responsible for carrying out the
responsibilities of the medical center director, chief
of staff, and, as appropriate, the assistant chief of
staff for research and the assistant chief of staff for
education; and] with respect to the Department medical
center--
(A)(i) the director (or directors of each
Department medical center, in the case of a
multi-medical center research corporation);
(ii) the chief of staff; and
(iii) as appropriate for the activities of
such corporation, the associate chief of staff
for research and the associate chief of staff
for education; or
(B) in the case of a Department medical
center at which one or more of the positions
referred to in subparagraph (A) do not exist,
the official or officials who are responsible
for carrying out the responsibilities of such
position or positions at the Department medical
center; and
(2) subject to subsection (c), not less than two
members who are not officers or employees of the
Federal Government [and who are familiar with issues
involving medical and scientific research or education,
as appropriate] and who have backgrounds, or business,
legal, financial, medical, or scientific expertise, of
benefit to the operations of the corporation.
(b) * * *
(c) An individual appointed under subsection (a)(2) to the
board of directors of a corporation established under this
subchapter may not be affiliated with[, employed by, or have
any other financial relationship with] or employed by any
entity that is a source of funding for research or education by
the Department unless that source of funding is a governmental
entity or an entity the income of which is exempt from taxation
under the Internal Revenue Code of 1986.
SEC. 7364. GENERAL POWERS
[(a) A corporation established under this subchapter may--
[(1) accept gifts and grants from, and enter into
contracts with, individuals and public and private
entities solely to carry out the purposes of this
subchapter; and
[(2) employ such employees as it considers necessary
for such purposes and fix the compensation of such
employees.
[(b) A corporation established under this subchapter may
not spend funds for a research project unless the project is
approved in accordance with procedures prescribed by the Under
Secretary for Health for research carried out with Department
funds. Such procedures shall include a peer review process.
[(c)(1) A corporation established under this subchapter may
not spend funds for an education activity unless the activity
is approved in accordance with procedures prescribed by the
Under Secretary for Health.
[(2) The Under Secretary for Health shall prescribe
policies and procedures to guide the expenditure of funds by
corporations under paragraph (1) consistent with the purpose of
such corporations as flexible funding mechanisms.]
(a)(1) A corporation established under this subchapter may,
solely to carry out the purposes of this subchapter--
(A) accept, administer, retain, and spend funds
derived from gifts, contributions, grants, fees,
reimbursements, and bequests from individuals and
public and private entities;
(B) enter into contracts and agreements with
individuals and public and private entities;
(C) subject to paragraph (2), set fees for education
and training facilitated under section 7362 of this
title, and receive, retain, administer, and spend funds
in furtherance of such education and training;
(D) reimburse amounts to the appropriation account of
the Department for the Office of General Counsel for
any expenses of that Office in providing legal services
attributable to research and education agreements under
this subchapter; and
(E) employ such employees as the corporation
considers necessary for such purposes and fix the
compensation of such employees.
(2) Fees charged under paragraph (1)(C) for education and
training described in that paragraph to individuals who are
officers or employees of the Department may not be paid for by
any funds appropriated to the Department.
(3) Amounts reimbursed to the Office of General Counsel
under paragraph (1)(D) shall be available for use by the Office
of the General Counsel only for staff and training, and related
travel, for the provision of legal services described in that
paragraph.
(b)(1) Except as provided in paragraph (2), any funds
received by the Secretary for the conduct of research or
education at a Department medical center or centers, other than
funds appropriated to the Department, may be transferred to and
administered by a corporation established under this subchapter
for such purposes.
(2) A Department medical center may reimburse the
corporation for all or a portion of the pay, benefits, or both
of an employee of the corporation who is assigned to the
Department medical center if the assignment is carried out
pursuant to subchapter VI of chapter 33 of title 5.
(c) Except for reasonable and usual preliminary costs for
project planning before its approval, a corporation established
under this subchapter may not spend funds for a research
project unless the project is approved in accordance with
procedures prescribed by the Under Secretary for Health for
research carried out with Department funds. Such procedures
shall include a scientific review process.
(d) Except for reasonable and usual preliminary costs for
activity planning before its approval, a corporation
established under this subchapter may not spend funds for an
education activity unless the activity is approved in
accordance with procedures prescribed by the Under Secretary
for Health.
(e) The Under Secretary for Health may prescribe policies
and procedures to guide the spending of funds by corporations
established under this subchapter that are consistent with the
purpose of such corporations as flexible funding mechanisms and
with Federal and State laws and regulations, and executive
orders, circulars, and directives that apply generally to the
receipt and expenditure of funds by nonprofit organizations
exempt from taxation under section 501(c)(3) of the Internal
Revenue Code of 1986.
SEC. 7365. [7364A.] COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT
CLAIMS LAWS
* * * * * * *
[SEC. 7365. APPLICABLE STATE LAW
[Any corporation established under this subchapter shall be
established in accordance with the nonprofit corporation laws
of the State in which the applicable medical center is located
and shall, to the extent not inconsistent with any Federal law,
be subject to the laws of such State.]
SEC. 7366. ACCOUNTABILITY AND OVERSIGHT
(a) * * *
[(b) Each such corporation shall submit to the Secretary an
annual report providing a detailed statement of its operations,
activities, and accomplishments during that year. A corporation
with revenues in excess of $300,000 for any year shall obtain
an audit of the corporation for that year. A corporation with
annual revenues between $10,000 and $300,000 shall obtain an
independent audit of the corporation at least once every three
years. Any audit under the preceding sentences shall be
performed by an independent auditor. The corporation shall
include the most recent such audit in the corporation's report
to the Secretary for that year.]
(b)(1) Each corporation shall submit to the Secretary each
year a report providing a detailed statement of the operations,
activities, and accomplishments of the corporation during that
year.
(2)(A) A corporation with revenues in excess of $300,000
for any year shall obtain an audit of the corporation for that
year.
(B) A corporation with annual revenues between $10,000 and
$300,000 shall obtain an audit of the corporation at least once
every three years.
(C) Any audit under this paragraph shall be performed by an
independent auditor.
(3) The corporation shall include in each report to the
Secretary under paragraph (1) the following:
(A) The most recent audit of the corporation under
paragraph (2).
(B) The most recent Internal Revenue Service Form 990
``Return of Organization Exempt from Income Tax'' or
equivalent and the applicable schedules under such
form.
(c)(1) Each member of the board of directors of a
corporation established under this subchapter, each officer and
each employee of such a corporation[, and each employee of the
Department who is involved in the functions of the corporation
during any year] shall be subject to Federal [laws and]
regulations applicable to Federal employees with respect to
conflicts of interest in the performance of official functions.
(2) Each corporation established under this subchapter
shall each year submit to the Secretary a statement signed by
the executive director of the corporation verifying that each
officer, director and employee has certified awareness of the
laws and regulations referred to in paragraph (1) and of the
consequences of violations of those [laws and] regulations [in
the same manner as Federal employees are required to so
certify].
(d) * * *
* * * * * * *
(3) * * *
* * * * * * *
(C) if the amount expended with respect to
any payee exceeded [$35,000] $50,000,
information that identifies the payee.
[SEC. 7368. EXPIRATION OF AUTHORITY
[No corporation may be established under this subchapter
after December 31, 2008.]
CHAPTER 74. VETERANS HEALTH ADMINISTRATION--PERSONNEL
SUBCHAPTER I. APPOINTMENTS
SEC.
7401. * * *
7402. * * *
7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS.
* * * * * * *
SUBCHAPTER IV. PAY FOR NURSES AND OTHER HEALTH-CARE PERSONNEL
* * * * * * *
7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY.
* * * * * * *
Subchapter I. Appointments
* * * * * * *
SEC. 7401. APPOINTMENTS IN VETERANS HEALTH ADMINISTRATION
* * * * * * *
(3) Audiologists, speech pathologists, and
audiologist-speech pathologists, biomedical engineers,
certified or registered respiratory therapists,
dietitians, licensed physical therapists, licensed
practical or vocational nurses, nurse assistants,
medical instrument technicians, medical records
administrators or specialists, medical records
technicians, medical technologists, dental hygienists,
dental assistants, nuclear medicine technologists,
occupational therapists, occupational therapy
assistants, kinesiotherapists, orthotist-prosthetists,
pharmacists, pharmacy technicians, physical therapy
assistants, prosthetic representatives, psychologists,
diagnostic radiologic technologists, therapeutic
radiologic technologists, social workers, marriage and
family therapists, licensed professional mental health
counselors, blind rehabilitation specialists, [and
blind rehabilitation outpatient specialists] blind
rehabilitation outpatient specialists, and such other
classes of health care occupations as the Secretary
considers necessary for the recruitment and retention
needs of the Department subject to the following
requirements:
(A) Not later than 45 days before the
Secretary appoints any personnel for a class of
health care occupations that is not
specifically listed in this paragraph, the
Secretary shall submit to the Committee on
Veterans' Affairs of the Senate, the Committee
on Veterans' Affairs of the House of
Representatives, and the Office of Management
and Budget notice of such appointment.
(B) Before submitting notice under
subparagraph (A), the Secretary shall solicit
comments from any labor organization
representing employees in such class and
include such comments in such notice.
* * * * * * *
SEC. 7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS
(a) In General.--The Secretary shall, acting through the
Under Secretary for Health, prescribe standards to be met by
individuals in order to qualify for appointment in the Veterans
Health Administration in the position of physician and to
practice as a physician in medical facilities of the
Administration. The standards shall incorporate the
requirements of this section.
(b) Disclosure of Certain Information Before Appointment.--
Each individual seeking appointment in the Veterans Health
Administration in the position of physician shall do the
following:
(1) Provide the Secretary a full and complete
explanation of the following:
(A) Each lawsuit, civil action, or other
claim (whether open or closed) brought against
the individual for medical malpractice or
negligence (other than a lawsuit, action, or
claim closed without any judgment against or
payment by or on behalf of the individual).
(B) Each payment made by or on behalf of the
individual to settle any lawsuit, action, or
claim covered by subparagraph (A).
(C) Each investigation or disciplinary action
taken against the individual relating to the
individual's performance as a physician.
(2) Submit a written request and authorization to the
State licensing board of each State in which the
individual holds or has held a license to practice
medicine to disclose to the Secretary any information
in the records of such State on the following:
(A) Each lawsuit, civil action, or other
claim brought against the individual for
medical malpractice or negligence covered by
paragraph (1)(A) that occurred in such State.
(B) Each payment made by or on behalf of the
individual to settle any lawsuit, action, or
claim covered by subparagraph (A).
(C) Each medical malpractice judgment against
the individual by the courts or administrative
agencies or bodies of such State.
(D) Each disciplinary action taken or under
consideration against the individual by an
administrative agency or body of such State.
(E) Any change in the status of the license
to practice medicine issued the individual by
such State, including any voluntary or
nondisciplinary surrendering of such license by
the individual.
(F) Any open investigation of the individual
by an administrative agency or body of such
State, or any outstanding allegation against
the individual before such an administrative
agency or body.
(G) Any written notification by the State to
the individual of potential termination of a
license for cause or otherwise.
(c) Disclosure of Certain Information Following
Appointment.--(1) Each individual appointed in the Veterans
Health Administration in the position of physician after the
date of the enactment of this section shall, as a condition of
service under the appointment, disclose to the Secretary, not
later than 30 days after the occurrence of such event, the
following:
(A) A judgment against the individual for medical
malpractice or negligence.
(B) A payment made by or on behalf of the individual
to settle any lawsuit, action, or claim disclosed under
paragraph (1) or (2) of subsection (b).
(C) Any disposition of or material change in a matter
disclosed under paragraph (1) or (2) of subsection (b).
(2) Each individual appointed in the Veterans Health
Administration in the position of physician as of the date of
the enactment of this section shall do the following:
(A) Not later than the end of the 60-day period
beginning on the date of the enactment of that Act and
as a condition of service under the appointment after
the end of that period, submit the request and
authorization described in subsection (b)(2).
(B) Agree, as a condition of service under the
appointment, to disclose to the Secretary, not later
than 30 days after the occurrence of such event, the
following:
(i) A judgment against the individual for
medical malpractice or negligence.
(ii) A payment made by or on behalf of the
individual to settle any lawsuit, action, or
claim disclosed pursuant to subparagraph (A) or
under this subparagraph.
(iii) Any disposition of or material change
in a matter disclosed pursuant to subparagraph
(A) or under this subparagraph.
(3) Each individual appointed in the Veterans Health
Administration in the position of physician shall, as part of
the biennial review of the performance of the physician under
the appointment, submit the request and authorization described
in subsection (b)(2). The requirement of this paragraph is in
addition to the requirements of paragraph (1) or (2), as
applicable.
(d) Investigation of Disclosed Matters.--(1) The Director
of the Veterans Integrated Services Network (VISN) in which an
individual is seeking appointment in the Veterans Health
Administration in the position of physician shall perform an
investigation (in such manner as the standards required by this
section shall specify) of each matter disclosed under
subsection (b) with respect to the individual.
(2) The Director of the Veterans Integrated Services
Network in which an individual is appointed in the Veterans
Health Administration in the position of physician shall
perform an investigation (in a manner so specified) of each
matter disclosed under subsection (c) with respect to the
individual.
(3) The results of each investigation performed under this
subsection shall be fully documented.
(e) Approval of Appointments by Directors of VISNs.--(1) An
individual may not be appointed in the Veterans Health
Administration in the position of physician without the
approval of the Director of the Veterans Integrated Services
Network in which the individual will first serve under the
appointment.
(2) In approving the appointment under this subsection of
an individual for whom any matters have been disclosed under
subsection (b), a Director shall--
(A) certify in writing the completion of the
performance of the investigation under subsection
(d)(1) of each such matter, including the results of
such investigation; and
(B) provide a written justification why any matters
raised in the course of such investigation do not
disqualify the individual from appointment.
(f) Enrollment of Physicians With Practice Privileges in
Proactive Disclosure Service.--Each medical facility of the
Department at which physicians are extended the privileges of
practice shall enroll each physician extended such privileges
in the Proactive Disclosure Service of the National
Practitioners Data Base.
(g) Encouraging Hiring of Physicians With Board
Certification.--(1) The Secretary shall, for each performance
contract with a Director of a Veterans Integrated Services
Network (VISN), include in such contract a provision that
encourages such director to hire physicians who are board
eligible or board certified in the specialty in which the
physicians will practice.
(2) The Secretary may determine the nature and manner of
the provision described in paragraph (1).
SEC. 7403. PERIOD OF APPOINTMENTS; PROMOTIONS
* * * * * * *
(b)(1) [Appointments] Except as otherwise provided in this
subsection, appointments described in subsection (a) shall be
for a probationary period of two years.
(2) An appointment of a registered nurse under this
chapter, whether on a full-time basis or a part-time basis,
shall be for a probationary period ending upon the completion
by the person so appointed of a number of hours of work
pursuant to such appointment that the Secretary considers
appropriate for such appointment but not more than 4,180 hours.
(3) An appointment described in subsection (a) on a part-
time basis of a person who has previously served on a full-time
basis for the probationary period for the position concerned
shall be without a probationary period.
(4) [(2)] The record of each person serving under such an
appointment in the Medical, Dental, and Nursing Services shall
be reviewed from time to time by a board, appointed in
accordance with regulations of the Secretary. If such a board
finds that such person is not fully qualified and satisfactory,
such person shall be separated from the service.
* * * * * * *
SEC. 7404. GRADES AND PAY SCALES
(a)(1) The annual [The annual] rates or ranges of rates of
basic pay for positions provided in section 7306 of this title
shall be prescribed from time to time by Executive order as
authorized by chapter 53 of title 5 or as otherwise authorized
by law.
(2) The pay [The pay] of physicians and dentists serving in
positions to which an Executive order applies [under the
preceding sentence] under paragraph (1) shall be determined
under subchapter III of this chapter instead of such Executive
order.
(3) The minimum rate of basic pay for a position to which
an Executive order applies under paragraph (1) and is not
described by paragraph (2) may not be less than the lowest rate
of basic pay payable for a Senior Executive Service position
under section 5382 of title 5.
* * * * * * *
SEC. 7405. TEMPORARY FULL-TIME APPOINTMENTS, PART-TIME APPOINTMENTS,
AND WITHOUT-COMPENSATION APPOINTMENTS
* * * * * * *
(g)(1) Employment of a registered nurse on a temporary
part-time basis under subsection (a)(1) shall be for a
probationary period ending upon the completion by the person so
employed of a number of hours of work pursuant to such
employment that the Secretary considers appropriate for such
employment but not more than 4,180 hours.
(2) Upon completion by a registered nurse of the
probationary period described in paragraph (1)--
(A) the employment of such nurse shall--
(i) no longer be considered temporary; and
(ii) be considered an appointment described
in section 7403(a) of this title; and
(B) the nurse shall be considered to have served the
probationary period required by section 7403(b).
(h)(1) The Secretary may waive the application of sections
8344 and 8468 of title 5 (relating to annuities and pay on
reemployment) or any other similar provision of law under a
Government retirement system on a case-by-case basis for an
annuitant reemployed on a temporary basis under the authority
of subsection (a) in a position described under paragraph (1)
of that subsection.
(2) An annuitant to whom a waiver under paragraph (1) is in
effect shall not be considered an employee for purposes of any
Government retirement system.
(3) An annuitant to whom a waiver under paragraph (1) is in
effect shall be subject to the provisions of chapter 71 of
title 5 (including all labor authority and labor representative
collective bargaining agreements) applicable to the position to
which appointed.
(4) In this subsection:
(A) The term ``annuitant'' means an annuitant under a
Government retirement system.
(B) The term ``employee'' has the meaning under
section 2105 of title 5.
(C) The term ``Government retirement system'' means a
retirement system established by law for employees of
the Government of the United States.
* * * * * * *
SEC. 7410. ADDITIONAL PAY AUTHORITIES
(a) In General.--The Secretary may [The Secretary may]
authorize the Under Secretary for Health to pay advance
payments, recruitment or relocation bonuses, and retention
allowances to the personnel described in paragraph (1) of
section 7401 of this title, or interview expenses to candidates
for appointment as such personnel, in the same manner, and
subject to the same limitations, as in the case of the
authority provided under sections 5524a, 5706b, 5753, and 5754
of title 5.
(b) Comparability Pay for Appointees to the Office of the
Under Secretary for Health.--(1) The Secretary may authorize
the Under Secretary for Health to provide comparability pay of
not more than $100,000 per year to individuals of the Veterans
Health Administration appointed under section 7306 of this
title who are not physicians or dentists and to individuals who
are appointed to Senior Executive Service positions (as such
term is defined in section 3132(a) of title 5) to achieve
annual pay levels for such individuals that are comparable with
annual pay levels of individuals with similar positions in the
private sector.
(2) Comparability pay under paragraph (1) for an individual
is in addition to all other pay, awards, and performance
bonuses paid to such individual under this title.
(3) Except as provided in paragraph (4), comparability pay
under paragraph (1) for an individual shall be considered basic
pay for all purposes, including retirement benefits under
chapters 83 and 84 of title 5, and other benefits.
(4) Comparability pay under paragraph (1) for an individual
shall not be considered basic pay for purposes of adverse
actions under subchapter V of this chapter.
(5) Comparability pay under paragraph (1) may not be
awarded to an individual in an amount that would result in an
aggregate amount of pay (including bonuses and awards) received
by such individual in a year under this title that is greater
than the annual pay of the President.
(c) Special Incentive Pay for Department Pharmacist
Executives.--(1) In order to recruit and retain highly
qualified Department pharmacist executives, the Secretary may
authorize the Under Secretary for Health to pay special
incentive pay of not more than $40,000 per year to an
individual of the Veterans Health Administration who is a
pharmacist executive.
(2) In determining whether and how much special pay to
provide to such individual, the Under Secretary shall consider
the following:
(A) The grade and step of the position of the
individual.
(B) The scope and complexity of the position of the
individual.
(C) The personal qualifications of the individual.
(D) The characteristics of the labor market
concerned.
(E) Such other factors as the Secretary considers
appropriate.
(3) Special incentive pay under paragraph (1) for an
individual is in addition to all other pay (including basic
pay) and allowances to which the individual is entitled.
(4) Except as provided in paragraph (5), special incentive
pay under paragraph (1) for an individual shall be considered
basic pay for all purposes, including retirement benefits under
chapters 83 and 84 of title 5, and other benefits.
(5) Special incentive pay under paragraph (1) for an
individual shall not be considered basic pay for purposes of
adverse actions under subchapter V of this chapter.
(6) Special incentive pay under paragraph (1) may not be
awarded to an individual in an amount that would result in an
aggregate amount of pay (including bonuses and awards) received
by such individual in a year under this title that is greater
than the annual pay of the President.
* * * * * * *
Subchapter III. Pay for Physicians and Dentists
SEC. 7431. PAY
* * * * * * *
(b) * * *
* * * * * * *
(5) The non-foreign cost of living adjustment
allowance authorized under section 5941 of title 5 for
physicians and dentists whose pay is set under this
section shall be determined as a percentage of base pay
only.
* * * * * * *
(c) * * *
* * * * * * *
(4)(A) * * *
(B)(i) In determining the amount of the market pay
for a particular physician or dentist under this
subsection, and in determining a tier (if any) to apply
to a physician or dentist under subsection (e)(1)(B),
the Secretary shall consult with and consider the
recommendations of an appropriate panel or board
composed of physicians or dentists (as applicable). The
Secretary may exempt physicians and dentists occupying
administrative or executive leadership positions from
the requirements of the previous sentence.
* * * * * * *
(7) No adjustment of the amount of market pay of a
physician or dentist under paragraph (6) may result in
a reduction of the amount of market pay of the
physician or dentist while in the same position or
assignment at the medical facility of the Department
[concerned.] concerned, unless there is a change in
board certification or reduction of privileges.
* * * * * * *
Subchapter IV. Pay for Nurses and Other Health-Care Personnel
SEC. 7451. NURSES AND OTHER HEALTH-CARE PERSONNEL: COMPETITIVE PAY
* * * * * * *
(c)(1) * * *
(2) The maximum rate of basic pay for any grade for a
covered position may not exceed the maximum rate of basic pay
established for positions in [level V] level IV of the
Executive Schedule under section 5316 of title 5. The maximum
rate of basic pay for a grade for the position of certified
registered nurse anesthetist pursuant to an adjustment under
subsection (d) may exceed the maximum rate otherwise provided
in the preceding sentence.
* * * * * * *
(d)(3)(A) * * *
* * * * * * *
(F) The Under Secretary for Health shall provide
appropriate education, training, and support to directors of
Department health care facilities in the conduct and use of
surveys, including the use of third-party surveys, under this
paragraph.
* * * * * * *
(e)(4) * * *
* * * * * * *
(D) In any case in which the director conducts such a
wage survey during the period covered by the report and
makes adjustment in rates of basic pay applicable to
one or more covered positions at the facility,
information on the methodology used in making such
adjustment or adjustments.
(E) [(D)] In any case in which the director, after
finding that there is, or is likely to be, in
accordance with criteria established by the Secretary,
a significant pay-related staffing problem at that
facility for any covered position, determines not to
conduct a wage survey with respect to that position, a
statement of the reasons why the director did not
conduct such a survey.
* * * * * * *
(e)(5) * * *
(6)(A) Upon the request of an individual described in
subparagraph (B) for a report provided under paragraph (4) with
respect to a Department health-care facility, the Under
Secretary for Health or the director of such facility shall
provide to the individual the most current report for such
facility provided under such paragraph.
(B) An individual described in this subparagraph is--
(i) an individual in a covered position at a
Department health-care facility; or
(ii) a representative of the labor organization
representing that individual who is designated by that
individual to make the request.
* * * * * * *
[(f) Not later than March 1 of each year, the Secretary
shall submit to the Committees on Veterans' Affairs of the
Senate and House of Representatives a report regarding any pay
adjustments under the authority of subsection (d) effective
during the 12 months preceding the submission of the report.
Each such report shall set forth, by health-care facility, the
percentage of such increases and, in any case in which no
increase was made, the basis for not providing an increase.]
(f) [(g)] For the purposes of this section, the term
``health-care facility'' means a medical center, an independent
outpatient clinic, or an independent domiciliary facility.
SEC. 7452. NURSES AND OTHER HEALTH-CARE PERSONNEL: ADMINISTRATION OF
PAY
* * * * * * *
(g)(1) * * *
(2) The amount of special pay paid to a nurse executive
under paragraph (1) shall be not less than $10,000 or more than
[$25,000] $100,000.
* * * * * * *
SEC. 7453. NURSES: ADDITIONAL PAY
(a) In addition to the rate of basic pay provided for
nurses, [a nurse] a full-time nurse or part-time nurse shall
receive additional pay as provided by this section.
(b) A nurse performing service [on a tour of duty], any
part of which is within the period commencing at 6 postmeridian
and ending at 6 antemeridian, shall receive additional pay for
each hour of [service on such tour] such service at a rate
equal to 10 percent of the nurse's hourly rate of basic pay if
at least four hours [of such tour] of such service fall between
6 postmeridian and 6 antemeridian. When less than four hours
[of such tour] of such service fall between 6 postmeridian and
6 antemeridian, the nurse shall be paid the differential for
each hour of service performed between those hours.
(c) A nurse performing service [on a tour of duty], any
part of which is within the period commencing at midnight
Friday and ending at midnight Sunday, shall receive additional
pay for each hour of [service on such tour] such service at a
rate equal to 25 percent of such nurse's hourly rate of basic
pay.
(d) * * *
(e)(1) A nurse performing officially ordered or approved
hours of service in excess of 40 hours in an administrative
workweek, or in excess of [eight hours in a day] eight
consecutive hours, shall receive overtime pay for each hour of
such additional service. The overtime rates shall be one and
one-half times such nurse's hourly rate of basic pay.
* * * * * * *
(5) * * *
(A) such travel occurs during such nurse's [tour of
duty] period of service; or
* * * * * * *
SEC. 7454. PHYSICIAN ASSISTANTS AND OTHER HEALTH CARE PROFESSIONALS:
ADDITIONAL PAY
(b)(1) * * *
* * * * * * *
(3) Employees appointed under section 7408 of this title
[shall be entitled to additional pay on the same basis as
provided for nurses in section 7453(c) of this title.]
performing service on a tour of duty, any part of which is
within the period commencing at midnight Friday and ending at
midnight Sunday, shall receive additional pay in addition to
the rate of basic pay provided such employees for each hour of
service on such tour at a rate equal to 25 percent of such
employee's hourly rate of basic pay.
(c) * * *
SEC. 7455. INCREASES IN RATES OF BASIC PAY
* * * * * * *
(c)(1) The amount of any increase under subsection (a) in
the maximum rate for any grade may not (except in the case of
nurse anesthetists, licensed practical nurses, licensed
vocational nurses, and nursing positions otherwise covered by
title 5, pharmacists, and licensed physical therapists) exceed
by two times the amount by which the maximum for such grade
(under applicable provisions of law other than this subsection)
exceeds the minimum for such grade (under applicable provisions
of law other than this subsection), and the maximum rate as so
increased may not exceed the rate paid for individuals serving
as Assistant Under Secretary for Health.
* * * * * * *
SEC. 7456. NURSES: SPECIAL RULES FOR WEEKEND DUTY
* * * * * * *
[(c) A nurse described in subsection (b)(1) who is absent
on approved sick leave or annual leave during a regularly
scheduled 12-hour tour of duty shall be charged for such leave
at a rate of five hours of leave for three hours of absence.]
(c) [(d)] The Secretary shall prescribe regulations for the
implementation of this section.
SEC. 7456A. NURSES: ALTERNATE WORK SCHEDULES
(a) * * *
(b) [36/40] 72/80 work schedule.
(1)(A) Subject to paragraph (2), if the Secretary
determines it to be necessary in order to obtain or
retain the services of registered nurses at any
Department health-care facility, the Secretary may
provide, in the case of nurses employed at such
facility, that such nurses who work [three regularly
scheduled 12-hour tours of duty within a work week
shall be considered for all purposes to have worked a
full 40-hour basic work week.] six regularly scheduled
12-hour periods of service within a pay period shall be
considered for all purposes to have worked a full 80-
hour pay period.
(B) A nurse who works under the authority in
subparagraph (A) shall be considered a 0.90 full-time
equivalent employee in computing full-time equivalent
employees for the purposes of determining compliance
with personnel ceilings.
(2)(A) Basic and additional pay for a nurse who is
considered under paragraph (1) to have worked a full
[40-hour basic work week] 80-hour pay period shall be
subject to subparagraphs (B) and (C).
(B) The hourly rate of basic pay for a nurse covered
by this paragraph for service performed as part of a
[regularly scheduled 36-hour tour of duty within the
work week] scheduled 72-hour period of service within
the bi-weekly pay period shall be derived by dividing
the nurse's annual rate of basic pay by 1,872.
(C) The Secretary shall pay overtime pay to a nurse
covered by this paragraph who--
(i) performs a period of service in excess of
such nurse's [regularly scheduled 36-hour tour
of duty within an administrative work week]
scheduled 72-hour period of service within an
administrative pay period;
(ii) for officially ordered or approved
service, performs a period of service in excess
of 8 hours on a day other than a day on which
such nurse's [regularly scheduled 12-hour tour
of duty] scheduled 12-hour period of service
falls;
(iii) performs a period of service in excess
of 12 hours for any day included in the
[regularly scheduled 36-hour tour of duty work
week] scheduled 72-hour period of service pay
period; or
(iv) performs a period of service in excess
of 40 hours during an administrative work week.
(D) The Secretary may provide a nurse to whom this
subsection applies with additional pay under section
7453 of this title for any period included in a
[regularly scheduled 12-hour tour of duty] scheduled
12-hour period of service.
(3) A nurse who works a work schedule described in
this subsection who is absent on approved sick leave or
annual leave during a [regularly scheduled 12-hour tour
of duty] scheduled 12-hour period of service shall be
charged for such leave at a rate of ten hours of leave
for every nine hours of absence.
7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY
(a) Limitation.--Except as provided in subsection (c), the
Secretary may not require nursing staff to work more than 40
hours (or 24 hours if such staff is covered under section 7456
of this title) in an administrative work week or more than
eight consecutive hours (or 12 hours if such staff is covered
under section 7456 or 7456A of this title).
(b) Voluntary Overtime.--(1) Nursing staff may on a
voluntary basis elect to work hours otherwise prohibited by
subsection (a).
(2) The refusal of nursing staff to work hours prohibited
by subsection (a) shall not be grounds to discriminate (within
the meaning of section 704(a) of the Civil Rights Act of 1964
(42 U.S.C. 2000e-3(a))) against the staff, dismissal or
discharge of the staff, or any other adverse personnel action
against the staff.
(c) Overtime Under Emergency Circumstances.--(1) Subject to
paragraph (2), the Secretary may require nursing staff to work
hours otherwise prohibited by subsection (a) if--
(A) the work is a consequence of an emergency that
could not have been reasonably anticipated;
(B) the emergency is non-recurring and is not caused
by or aggravated by the inattention of the Secretary or
lack of reasonable contingency planning by the
Secretary;
(C) the Secretary has exhausted all good faith,
reasonable attempts to obtain voluntary workers;
(D) the nurse staff have critical skills and
expertise that are required for the work; and
(E) the work involves work for which the standard of
care for a patient assignment requires continuity of
care through completion of a case, treatment, or
procedure.
(2) Nursing staff may not be required to work hours under
this subsection after the requirement for a direct role by the
staff in responding to medical needs resulting from the
emergency ends.
(d) Nursing Staff Defined.--In this section, the term
``nursing staff'' includes the following;
(1) A registered nurse.
(2) A licensed practical or vocational nurse.
(3) A nurse assistant appointed under this chapter or
title 5.
(4) Any other nurse position designated by the
Secretary for purposes of this section.
* * * * * * *
CHAPTER 76. HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM
* * * * * * *
Subchapter II. Scholarship Program
* * * * * * *
SEC. 7612. ELIGIBILITY; APPLICATION; AGREEMENT
* * * * * * *
(b)(1) * * *
(2) A qualifying field of education or training for
purposes of this subchapter is education or training leading to
employment [(under section 7401 of this title) as any of the
following:] as an appointee under paragraph (1) or (3) of
section 7401 of this title.
[(A) A physician, dentist, podiatrist, optometrist,
nurse, physician assistant, or expanded function dental
auxiliary.
[(B) A psychologist described in section 7401(3) of
this title or a certified or registered respiratory
therapist, licensed physical therapist, or licensed
practical or vocational nurse.]
* * * * * * *
SEC. 7618. EXPIRATION OF PROGRAM
The Secretary may not furnish scholarships to new
participants in the Scholarship Program after [December 31,
1998] December 31, 2013.
* * * * * * *
Subchapter VII. Education Debt Reduction Program
SEC. 7681. AUTHORITY FOR PROGRAM
(a) In general.--
(1) * * *
(2) The purpose of the Education Debt Reduction
Program is to assist in the recruitment and retention
of qualified health care professionals for positions in
the Veterans Health Administration for which
recruitment or retention of an adequate supply of
qualified personnel is difficult.
(b) * * *
SEC. 7682. ELIGIBILITY
(a) Eligibility.--An individual is eligible to participate
in the Education Debt Reduction Program if the individual--
(1) is [a recently appointed] an employee in the
Veterans Health Administration serving in a position
(as determined by the Secretary) providing direct-
patient care services or services incident to direct-
patient care services for which recruitment or
retention of qualified health-care personnel (as so
determined) is difficult; and
* * * * * * *
[(c) Recently appointed individuals.--For purposes of
subsection (a), an individual shall be considered to be
recently appointed to a position if the individual has held
that position for less than 6 months.]
SEC. 7683. EDUCATION DEBT REDUCTION
* * * * * * *
(d) Maximum annual amount.--(1) Subject to paragraph (2),
the amount of education debt reduction payments made to a
participant under the Education Debt Reduction Program may not
exceed [$44,000] $60,000 over a total of five years of
participation in the Program, of which not more than [$10,000]
$12,000 of such payments may be made in each of the fourth and
fifth years of participation in the Program.
* * * * * * *
PART VI. ACQUISITION AND DISPOSITION OF PROPERTY
CHAPTER 81. ACQUISITION AND OPERATION OF HOSPITAL AND DOMICILIARY
FACILITIES; PROCUREMENT AND SUPPLY; ENHANCED-USE LEASES OF REAL
PROPERTY
SUBCHAPTER I. ACQUISITION AND OPERATION OF MEDICAL FACILITIES
SEC.
* * * * * * *
[8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES.]
* * * * * * *
SUBCHAPTER III. STATE HOME FACILITIES FOR FURNISHING DOMICILIARY,
NURSING HOME, AND HOSPITAL CARE
* * * * * * *
8133A. TRIBAL ORGANIZATIONS.
* * * * * * *
Subchapter I. Acquisition and Operation of
Medical Facilities
* * * * * * *
SEC. 8104. CONGRESSIONAL APPROVAL OF CERTAIN MEDICAL FACILITY
ACQUISITIONS
(a)(1) * * *
(2) * * *
(3) * * *
(A) * * *
(B) The term ``major medical facility lease'' means a
lease for space for use as a new medical facility at an
average annual rental of more than [$600,000]
$1,000,000.
* * * * * * *
[SEC. 8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES
[(a) In order to promote effective planning for the
efficient provision of care to eligible veterans, the
Secretary, based on the analysis and recommendations of the
Under Secretary for Health, shall submit to each committee an
annual report regarding long-range health planning of the
Department. The report shall be submitted each year not later
than the date on which the budget for the next fiscal year is
submitted to the Congress under section 1105 of title 31.
[(b) Each report under subsection (a) shall include the
following:
[(1) A five-year strategic plan for the provision of
care under chapter 17 of this title to eligible
veterans through coordinated networks of medical
facilities operating within prescribed geographic
service-delivery areas, such plan to include provision
of services for the specialized treatment and
rehabilitative needs of disabled veterans (including
veterans with spinal cord dysfunction, blindness,
amputations, and mental illness) through distinct
programs or facilities of the Department dedicated to
the specialized needs of those veterans.
[(2) A description of how planning for the networks
will be coordinated.
[(c) The Secretary shall submit to each committee not later
than January 31 of each year a report showing the location,
space, cost, and status of each medical facility (1) the
construction, alteration, lease, or other acquisition of which
has been approved under section 8104(a) of this title, and (2)
which was uncompleted as of the date of the last preceding
report made under this subsection.
[(d)(1) The Secretary shall submit to each committee, not
later than January 31 of each year, a report showing the
current priorities of the Department for proposed major medical
construction projects. Each such report shall identify the 20
projects, from within all the projects in the Department's
inventory of proposed projects, that have the highest priority
and, for those 20 projects, the relative priority and rank
scoring of each such project and the projected cost of such
project (including the projected operating costs, including
both recurring and nonrecurring costs). The 20 projects shall
be compiled, and their relative rankings shall be shown, by
category of project (including the categories of ambulatory
care projects, nursing home care projects, and such other
categories as the Secretary determines).
[(2) The Secretary shall include in each report, for each
project listed, a description of the specific factors that
account for the relative ranking of that project in relation to
other projects within the same category.
[(3) In a case in which the relative ranking of a proposed
project has changed since the last report under this subsection
was submitted, the Secretary shall also include in the report a
description of the reasons for the change in the ranking,
including an explanation of any change in the scoring of the
project under the Department's scoring system for proposed
major medical construction projects.]
* * * * * * *
Subchapter III. State Home Facilities for Furnishing Domiciliary,
Nursing Home, and Hospital Care
* * * * * * *
SEC. 8131. DEFINITIONS
* * * * * * *
(5) The term ``tribal organization'' has the meaning
given such term in section 3765 of this title.
SEC. 8132. DECLARATION OF PURPOSE
The purpose of this subchapter is to assist the several
States and tribal organizations to construct State home
facilities (or to acquire facilities to be used as State home
facilities) for furnishing domiciliary or nursing home care to
veterans, and to expand, remodel, or alter existing buildings
for furnishing domiciliary, nursing home, adult day health, or
hospital care to veterans in State homes.
SEC. 8133. AUTHORIZATION OF APPROPRIATIONS
* * * * * * *
SEC. 8133A. TRIBAL ORGANIZATIONS
(a) Authority to Award Grants.--The Secretary may award a
grant to a tribal organization under this subchapter in order
to carry out the purposes of this subchapter.
(b) Manner and Condition of Grant Awards.--(1) Grants to
tribal organizations under this section shall be awarded in the
same manner, and under the same conditions, as grants awarded
to the several States under the provisions of this subchapter,
subject to such exceptions as the Secretary shall prescribe for
purposes of this subchapter to take into account the unique
circumstances of tribal organizations.
(2) For purposes of according priority under subsection
(c)(2) of section 8135 of this title to an application
submitted under subsection (a) of such section, an application
submitted under such subsection (a) by a tribal organization of
a State that has previously applied for award of a grant under
this subchapter for construction or acquisition of a State
nursing home shall be considered under subparagraph (C) of such
subsection (c)(2) an application from a tribal organization
that has previously applied for such a grant.
* * * * * * *
SEC. 8138. TREATMENT OF CERTAIN HEALTH FACILITIES AS STATE HOMES
* * * * * * *
(d) * * *
(e)(1) A health facility (or certain beds in a health
facility) of a tribal organization is treatable as a State home
under subsection (a) in accordance with the provisions of that
subsection.
(2) Except as provided in paragraph (3), the provisions of
this section shall apply to a health facility (or certain beds
in such facility) treated as a State home under subsection (a)
by reason of this subsection to the same extent as health
facilities (or beds) treated as a State home under subsection
(a).
(3) Subsection (f) shall not apply to the treatment of
health facilities (or certain beds in such facilities) of
tribal organizations as a State home under subsection (a).
(f) [(e)] The Secretary may not treat any new health
facilities (or any new certain beds in a health facility) as a
State home under subsection (a) after September 30, 2009.
* * * * * * *
VETERANS' BENEFITS AND SERVICES ACT OF 1988
(Public Law 100-322, as amended; 38 U.S.C. 7333 Note)
TITLE I. HEALTH-CARE PROGRAMS
* * * * * * *
Part C. Matters Relating to AIDS
* * * * * * *
[SEC. 124. RESTRICTION ON TESTING FOR INFECTION WITH THE HUMAN
IMMUNODEFICIENCY VIRUS.
[(a) General rule.--Except as provided in subsection (b),
the Secretary of Veterans Affairs may not during any fiscal
year conduct a widespread testing program to determine
infection of humans with the human immunodeficiency virus
unless funds have been appropriated to the Department of
Veterans Affairs specifically for such a program during the
fiscal year.
[(b) Voluntary testing.--(1) The Secretary shall provide
for a program under which the Department of Veterans Affairs
offers each patient to whom the Department is furnishing health
care or services and who is described in paragraph (2) the
opportunity to be tested to determine whether such patient is
infected with the human immunodeficiency virus.
[(2) Patients referred to in paragraph (1) are--
[(A) patients who are receiving treatment for
intravenous drug abuse,
[(B) patients who are receiving treatment for a
disease associated with the human immunodeficiency
virus, and
[(C) patients who are otherwise at high risk for
infection with such virus.
[(3) Subject to the consent requirement in paragraph (4)
and unless medically contraindicated, the test shall be
administered to each patient requesting to be tested for
infection with such virus.
[(4) A test may not be conducted under this subsection
without the prior informed and separate written consent of the
patient tested. The Secretary shall provide pre- and post-test
counseling regarding the acquired immune deficiency syndrome
and the test to each patient who is administered the test.]
* * * * * * *
PERSIAN GULF WAR VETERANS' HEALTH STATUS ACT
(Public Law 102-585; 106 Stat. 4943; 38 U.S.C. 527 Note)
* * * * * * *
TITLE VII. PERSIAN GULF WAR VETERANS' HEALTH STATUS
* * * * * * *
SEC. 707. COORDINATION OF HEALTH-RELATED GOVERNMENT ACTIVITIES ON THE
PERSIAN GULF WAR
* * * * * * *
(c) Reports.--
(1) [Not later than March 1 of each year] Not later
than July 1, 2008, and July 1 of each of the
fivefollowing years, the head of the department or
agency designated under subsection (a) shall submit to
the Committees on Veterans' Affairs of the Senate and
House of Representatives a report on--
(A) the status and results of all such
research activities undertaken by the executive
branch during the previous year; and
(B) research priorities identified during
that year.
* * * * * * *
VETERANS BENEFITS, HEALTH CARE, AND INFORMATION TECHNOLOGY ACT OF 2006
(Public Law 109-461; 38 U.S.C. 1710B Note)
* * * * * * *
TITLE II. HEALTH MATTERS
* * * * * * *
SEC. 214. PILOT PROGRAM ON IMPROVEMENT OF CAREGIVER ASSISTANCE
SERVICES.
* * * * * * *
(d) Authorization of Appropriations.--There are authorized
to be appropriated to the Department of Veterans Affairs
$5,000,000 for [each of fiscal years 2007 and 2008] each of the
fiscal years 2007 through 2009 to carry out the pilot program
authorized by this section.
* * * * * * *
CONSOLIDATED APPROPRIATIONS ACT, 2008
(Public Law 110-161; 121 Stat. 2276)
* * * * * * *
DIVISION I. MILITARY CONSTRUCTION AND VETERANS AFFAIRS AND RELATED
AGENCIES APPROPRIATIONS ACT, 2008
* * * * * * *
TITLE IV. GENERAL PROVISIONS
* * * * * * *
SEC. 410. CONVEYANCE OF CERTAIN NON-FEDERAL LAND.
[(a) In this section:
[(1) The term ``City'' means the City of Aurora,
Colorado.
[(2) The term ``deed'' means the quit claim deed--
[(A) conveyed by the Secretary to the City;
and
[(B) dated May 24, 1999.
[(3) The term ``non-Federal land'' means--
[(A) parcel I of the Fitzsimons Army Medical
Center, Colorado; and
[(B) the parcel of land described in the
deed.
[(4) The term ``Secretary'' means the Secretary of
the Interior.
[(b)(1) In accordance with paragraph (2), to allow the City
to convey by donation to the United States the non-Federal land
to be used by the Secretary of Veterans Affairs for the
construction of a veterans medical facility.
[(2) In carrying out paragraph (1), with respect to the
non-Federal land, the Secretary shall forego exercising any
rights provided by the--
[(A) deed relating to a reversionary interest of the
United States; and
[(B) any other reversionary interest of the United
States.
[This division may be cited as the ``Military Construction
and Veterans Affairs and Related Agencies Appropriations Act,
2008''.]
(a) Definitions.--In this section:
(1) City.--The term ``City'' means the City of
Aurora, Colorado.
(2) Deed.--The term ``deed'' means the quit-claim
deed--
(A) conveyed to the City by the Secretary
(acting through the Director of the National
Park Service); and
(B) dated May 24, 1999.
(3) Non-federal land.--The term ``non-Federal land''
means--
(A) parcel I of the former United States Army
Garrison Fitzsimons, Adams County, Colorado, as
more specifically described in the deed; and
(B) the parcel of land described in the deed.
(4) Secretary.--The term ``Secretary'' means the
Secretary of the Interior.
(b) Duty of Secretary.--To allow the City to convey by
donation to the United States the non-Federal land to be used
by the Secretary of Veterans Affairs for the construction of a
veterans medical facility, not later than 60 days after the
date of enactment of this section, the Secretary shall execute
each instrument that is necessary to release all rights,
conditions, and restrictions re-tained by the United States in
and to the non-Federal land conveyed in the deed.
* * * * * * *