[House Report 111-223]
[From the U.S. Government Publishing Office]


111th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 1st Session                                                    111-223

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



 
      VETERANS' INSURANCE AND HEALTH CARE IMPROVEMENTS ACT OF 2009

                                _______
                                

 July 23, 2009.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

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

                              R E P O R T

                        [To accompany H.R. 3219]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 3219) to amend title 38, United States Code, to 
make certain improvements in the laws administered by the 
Secretary of Veterans Affairs relating to insurance and health 
care, and for other purposes, having considered the same, 
report favorably thereon without amendment and recommend that 
the bill do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     3
Hearings.........................................................     9
Subcommittee Consideration.......................................    10
Committee Consideration..........................................    10
Committee Votes..................................................    10
Committee Oversight Findings.....................................    10
Statement of General Performance Goals and Objectives............    10
New Budget Authority, Entitlement Authority, and Tax Expenditures    11
Earmarks and Tax and Tariff Benefits.............................    11
Committee Cost Estimate..........................................    11
Congressional Budget Office Estimate.............................    11
Federal Mandates Statement.......................................    14
Advisory Committee Statement.....................................    14
Constitutional Authority Statement...............................    14
Applicability to Legislative Branch..............................    14
Section-by-Section Analysis of the Legislation...................    14
Changes in Existing Law Made by the Bill as Reported.............    16

                          Purpose And Summary

    H.R. 3219 was introduced by Representative Bob Filner of 
California, Chairman of the Committee on Veterans' Affairs, on 
July 15, 2009. H.R. 3219 would improve U.S. Department of 
Veterans Affairs (VA) insurance programs. This legislation 
would make permanent the two-year extension of the free 
Servicemembers' Group Life Insurance (SGLI) coverage period for 
totally disabled veterans following separation from active or 
reserve duty. In addition, H.R. 3219 would enable veterans 
insured under the Veterans' Group Life Insurance program to 
increase the amount of their coverage under this program. This 
legislation also would eliminate the reduction in the amount of 
accelerated death benefits for terminally-ill persons insured 
under the SGLI and Veterans' Group Life Insurance programs 
(VGLI).
    H.R. 3219 would provide for key expansions and improvements 
in the provision of health care. This includes eliminating 
copayments for veterans who are catastrophically disabled, 
providing health care for certain Medal of Honor recipients who 
are not eligible for enrollment under the current VA priority 
group schedule, and providing enhanced treatment authority for 
certain Vietnam-era herbicide exposed veterans and veterans of 
the Persian Gulf War. It would also establish a Director of 
Physician Assistants within the office of the Under Secretary 
of Veterans Affairs for Health and would require the VA to 
create a new Committee on Care of Veterans with Traumatic Brain 
Injury.
    H.R. 3219 would authorize, subject to the availability of 
appropriations, a $1,000 monthly payment to all civilian 
fighter groups of World War II who were given veteran status 
under the G.I. Bill Improvement Act of 1977, Public Law 95-202 
(91 Stat. 1433).
    H.R. 3219 is comprised of a number of bills introduced in 
the first session of the 111th Congress. These bills include 
H.R. 1197, the Medal of Honor Health Care Equity Act of 2009, 
introduced by Representative Harry E. Mitchell of Arizona; H.R. 
1302, to establish the position of Director of Physician 
Assistant Services in the office of the Under Secretary for 
Health of the VA, introduced by representative Phil Hare of 
Illinois; H.R. 1335, to prohibit the VA from collecting certain 
copayments from catastrophically disabled veterans, introduced 
by Representative Deborah L. Halvorson of Illinois; H.R. 1546, 
the Caring for Veterans with Traumatic Brain Injury Act of 
2009, introduced by Representative Jerry McNerney of 
California; H.R. 2270, the Benefits for Qualified World War II 
Veterans Act of 2009, introduced by Representative Steve Buyer 
of Indiana; H.R. 2379, the Veterans' Group Life Insurance 
Improvement Act of 2009, introduced by Representative Steve 
Buyer of Indiana; H.R. 2774, the Families of Veterans Financial 
Security Act, introduced by Representative Deborah L. Halvorson 
of Illinois; H.R. 2926, to provide without expiration health 
care services to certain Vietnam-era veterans exposed to 
herbicide and to veterans of the Persian Gulf War, introduced 
by Representative Glenn C. Nye of Virginia; and, H.R. 2968, to 
eliminate the required reduction in the amount of the 
accidental death benefit payable to certain terminally-ill 
veterans insured under the Servicemembers' Group life Insurance 
or Veterans' Group life Insurance programs, introduced by 
Representative Ann Kirkpatrick of Arizona.

                  Background and Need for Legislation


                 TITLE I--MATTERS RELATING TO INSURANCE

    Section 101 of H.R. 3219 would provide a permanent 
extension of duration of SGLI coverage for totally disabled 
veterans.
    The SGLI program provides up to $400,000 of life insurance 
coverage for individuals currently serving in the uniformed 
services and for certain specified periods after separation or 
release from periods of reserve duty. The program is supervised 
by the VA but is administered by the Office of Servicemembers' 
Group Life Insurance under terms specified in a group insurance 
contract. Individuals eligible for full-time coverage are 
commissioned, warrant and enlisted members of the Army, Navy, 
Air Force, Marine Corps and Coast Guard; commissioned members 
of the National Oceanic and Atmospheric Administration and the 
Public Health Service; cadets or midshipmen of the four United 
States Service Academies; and Ready Reservists, including 
members of the National Guard, scheduled to perform at least 12 
periods of inactive duty.
    Public Law 109-233 (120 Stat. 397) extended the duration of 
the free SGLI coverage period from one to two years for 
servicemembers who are totally disabled on the date of their 
separation from active duty or reserve status. This extension 
in coverage was effective on the date of enactment for members 
released prior to October 1, 2011. The law reduces the duration 
of coverage for members released on or after October 1, 2011, 
from two years to 18 months. The reduction to 18 months of 
disability extension in 2011 will place totally disabled 
veterans at a disadvantage and substantively interfere with 
their ability to retain affordable life insurance coverage 
during the period immediately after their separation from 
service.
    Maintaining the extension period at its current two-year 
period for veterans would guarantee that those most in need, 
who have been seriously disabled as a result of their service, 
will be fully covered under the SGLI program during this 
extended transition period. It would also maximize the 
opportunity for totally disabled veterans, who have limited or 
no opportunity of obtaining commercial insurance, to obtain 
insurance coverage, thereby providing financial security for 
their families. It also would allow the VA Insurance Special 
Outreach Program for Disabled Veterans the additional time 
needed to contact veterans and provide them with the 
information they need to make informed decisions concerning 
their life insurance options. Additionally, it would allow 
automatic conversion at the end of the two-year total 
disability extension period, when the member's SGLI coverage is 
automatically converted to VGLI (subject only to the member's 
timely remittance of premiums), thereby providing improved 
financial security for their families. This permanent extension 
would apply to those servicemembers released or separated on or 
after June 15, 2005.
    Section 102 of H.R. 3219 would provide for increased 
insurance coverage under the VGLI program.
    The VGLI program is administered by the VA. The purpose of 
this program is to give veterans the option to convert their 
SGLI coverage that they carry when they are in service to a 
competitive life insurance product for them and their families 
in post-military life. The VGLI program provides group term 
life insurance coverage in amounts ranging from $10,000 to 
$400,000; no more than $400,000 of combined SGLI and VGLI can 
be carried at one time. VGLI is available to all veterans 
separated from active duty or the Reserves, usually at the end 
of their 120-day free SGLI coverage.
    Under current law, veterans have up to one year to convert 
the amount of SGLI coverage they carry to VGLI. Many separating 
servicemembers are young and often do not see the need to carry 
a large amount of life insurance coverage. However, as they get 
older and have a family, many of these servicemembers have 
expressed a desire to purchase additional coverage but are 
barred from doing so according to current law. Since evidence 
of health is not required, conversion is a valuable right to a 
disabled veteran who might otherwise be required to pay an 
extra premium to obtain commercial insurance or might be 
uninsurable at any price.
    This provision of H.R. 3219 would provide that veterans 
insured under the VGLI program would be eligible to increase 
coverage by $25,000 no more than once in each five-year period, 
if the veteran is under 60 years of age and the total amount of 
coverage does not exceed $400,000 (the limit authorized for a 
veteran under SGLI). The costs of such increases in coverage 
would be offset by the premiums veterans pay to the program, so 
there is no direct cost to the Federal government.
    Section 103 of H.R. 3219 would eliminate the reduction in 
amount of accelerated death benefit for terminally-ill persons 
insured under SGLI and VGLI.
    The current SGLI/VGLI Accelerated Benefits Option (ABO) 
regulation requires VA to discount or reduce the payout 
available under both the SGLI and VGLI programs for terminally-
ill servicemembers and veterans who exercise the option to use 
up to half of their policy in any way they see fit, such as 
paying medical bills or otherwise improving the quality of 
their remaining life. Currently, VA discounts this payment by 
an amount commensurate with the interest rate earned by the 
program on its investment in effect at the time that a 
servicemember or veteran applies for the benefits, thereby 
often significantly reducing the amount of the ABO payment. The 
Committee firmly believes that individuals who qualify for the 
ABO payment have financial needs that should not be further 
exacerbated by reduction of the insurance coverage or eligible 
payments that they are relying on to provide financial security 
for themselves and their families.
    H.R. 3219 would amend section 1980 of title 38, United 
States Code by eliminating the requirement that the lump sum 
payment be ``reduced by an amount necessary to assure that 
there is no increase in the actuarial value of the benefit 
paid.'' This change would eliminate any disparities between VA 
and the commercial insurance industry in this regard and 
provide a greater benefit to servicemembers, veterans and their 
families by not discounting these payments.

               TITLE II--MATTERS RELATING TO HEALTH CARE

    Section 201 of H.R. 3219 would assign Medal of Honor 
recipients to a priority group status equal to that of former 
Prisoners of War (POWs) or Purple Heart recipients for seeking 
health care through the VA.
    Under the VA priority group schedule for enrollment, 
veterans who are former POWs and veterans awarded a Purple 
Heart medal are classified under Priority Group 3. Under 
current law, Medal of Honor recipients are subject to standard 
VA eligibility requirements, which include service-connected 
disabilities and income limits. They are not expressly covered 
in the priority group schedule. This legislation is anticipated 
to affect a small population of veterans since the 
Congressional Medal of Honor Society documents that there are 
3,447 total recipients of the Medal of Honor, of which, only 96 
are living.
    Section 202 of H.R. 3219 would provide for enhanced 
treatment authority for certain Vietnam-era veterans exposed to 
herbicide and veterans of the Persian Gulf War.
    Agent Orange was one of the defoliants used by the United 
States military in the Vietnam War. In the 1970's, some 
veterans became concerned about the delayed adverse health 
effects potentially resulting from their exposure to Agent 
Orange. Agent Orange contained dioxin and recent studies 
suggest a link between dioxin and cancer and other disorders. 
The VA has a list of diseases, which it presumes resulted from 
exposure to herbicides such as Agent Orange. However, the full 
impact of herbicides remains unknown and Vietnam-era veterans 
continue to face challenges in linking their conditions to 
herbicide exposure.
    Similarly, veterans returning from the Gulf War faced 
health problems. Symptoms included persistent memory and 
concentration problems, chronic headaches, widespread pain, 
gastrointestinal problems, and other chronic abnormalities not 
explained by well-established diagnoses. Veterans were unable 
to link these conditions to their service in the Gulf War and 
thus, unable to establish a service connected disability 
rating.
    On November 17, 2008, the Research Advisory Committee on 
Gulf War Veterans' Illnesses released a report entitled ``Gulf 
War Illness and the Health of Gulf War Veterans: Scientific 
Findings and Recommendations.'' The report indicated that Gulf 
War Illness is real for some of the military personnel who 
served in the 1990-1991 Gulf War and were exposed to some 
potentially hazardous substances. With this report linking 
symptoms of Gulf War Illness to the war, veterans of the Gulf 
war era may now seek to establish service-connected 
disabilities.
    In 1981, Public Law 97-72 (95 Stat. 1047) provided the VA 
with a special treatment authority to provide health care to 
Vietnam veterans who may have been exposed to herbicides, 
notwithstanding that there was insufficient medical evidence to 
conclude that their disabilities were associated with exposure 
to herbicides while serving in Vietnam. This authority was 
extended through 1996 with Public Law 104-262 (110 Stat. 3177). 
Similarly, Public Law 103-210 (102 Stat. 2760) provided special 
treatment authority to veterans who served in the Persian Gulf 
War in the Southwest Asia theater of operations who were 
exposed to toxic substances or environmental hazards. In 1997, 
Public Law 105-114 (111 Stat. 2277) removed the requirement 
that the veteran had to be exposed to toxic substances or 
environmental hazards and only required service in the 
Southwest Asia theatre of operations during the Persian Gulf 
War. In 1998, Public Law 105-368 (112 Stat. 3315) extended the 
authority through 2001 and Public Law 107-135 (115 Stat. 2446) 
provided for another extension through 2002.
    Although this special treatment authority has lapsed, the 
VA has continued to treat these veterans within Priority Group 
6. H.R. 3219 would provide permanent authorization for the 
special treatment authority of Vietnam-era herbicide exposed 
veterans and Gulf War era veterans who have insufficient 
medical evidence to establish a service-connected disability.
    Section 203 of this legislation would help veterans who are 
catastrophically disabled from non-service-connected causes and 
who have income above the means tested levels by waiving 
certain copayments.
    Under the current law, these veterans are placed in 
Priority Group 4 for enrollment purposes, but are required to 
pay all health care fees and copayments as though they are in a 
lower eligibility category. H.R. 3219 would prohibit the VA 
from collecting copayments for hospital, nursing home, 
outpatient, and other medical care from non-service-connected 
veterans who are catastrophically disabled. Catastrophically 
disabled veterans are defined as having a permanent, severely 
disabling injury, disorder, or disease that compromises their 
ability to carry out the activities of daily living to such a 
degree that the individual requires personal or mechanical 
assistance to leave home or bed or requires constant 
supervision to avoid physical harm to self or others. As such, 
the nature and severity of the disabilities experienced by 
these veterans often precludes them from employment and a 
steady form of income. This legislation would alleviate the 
undue financial hardship that catastrophically disabled 
veterans may face.
    Section 204 of H.R. 3219 would create a full-time position 
of the Director of Physician Assistant Services within the VA 
Central Office, who reports to the Veterans Health 
Administration's Under Secretary for Health.
    Physician assistants (PAs) are health professionals who 
practice medicine as members of a team with supervising 
physicians. They deliver a broad range of medical and surgical 
services which include conducting physical exams, diagnosing 
and treating illnesses, ordering and interpreting tests, 
providing counsel on preventive health care, assisting in 
surgery, and prescribing medications. In addition, physicians 
may delegate to PAs, the medical duties that are within the 
physician's scope of practice, as allowed by the law. PAs are 
certified by the National Commission on Certification of 
Physician Assistants (NCCPA) and also are state-licensed. 
According to the estimates of the American Association of 
Physician Assistants (AAPA), about 68,124 people were in 
clinical practice as PAs at the beginning of 2008. Also in 
2008, about 257 million patients visited PAs and about 332 
million medications were prescribed or recommended by PAs.
    Of the PAs who work for the government, the VA is the 
single largest employer. As of January 31, 2009, there were 
1,842 PAs in medical centers and outpatient clinics of the VA 
health care system. Throughout the 1990s, VA joined other 
Federal entities in relying heavily on PAs to bolster medical 
staff. Recognizing the potential of PAs, the PA Advisor 
position was authorized by the Veterans Benefits and Health 
Care Improvement Act of 2000, Public Law 106-419 (114 Stat. 
1822). While the advisor has furthered the increased 
utilization of PAs, it is a part-time, field-based position. 
Therefore, there continues to be inconsistencies in the way 
that PAs are used across the VA system. A Director of Physician 
Assistant Services would help ensure efficient utilization and 
full integration of the VA's PA workforce in VA patient care 
programs and initiatives. The Director also would address 
issues of education and training, and employment, as well as 
ensure appropriate utilization and optimal participation of 
physician assistants in the VA health care system.
    Section 205 would create a committee to better assist 
veterans with traumatic brain injury (TBI).
    According to a 2008 RAND report, ``Invisible Wounds of War: 
Summary and Recommendations for Addressing Psychological and 
Cognitive Injuries,'' about a third of the returning troops 
from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/
OIF) reported symptoms of mental health or cognitive condition. 
At the writing of the report, a total of 1.64 million 
servicemembers had been deployed to Iraq and Afghanistan since 
October 2001. Of this, about 300,000 returning veterans were 
suffering from post-traumatic stress disorder (PTSD) or major 
depression and about 320,000 may have experienced TBI during 
deployment.
    Although the VA has increased their capacity to provide 
health services substantially for mental health and TBI, there 
are gaps in access. The RAND study found that returning 
servicemembers may face long wait times for medical 
appointments at VA facilities. As such, 57 percent of returning 
troops who sought medical attention had not been evaluated by a 
physician for a brain injury. Those with untreated TBI 
conditions are not only at higher risk for other psychological 
problems, but are more likely to attempt suicide. They also 
have higher rates of unhealthy behavior leading to physical 
health problems and mortality. RAND also sought to measure the 
total cost to society, including treatment costs, losses or 
gains in productivity, and costs associated with suicide. 
Despite much uncertainty surrounding the true cost of TBI, RAND 
estimated that the total annual cost ranges between $591 
million and $910 million.
    Because brain injury is considered a signature wound of 
OEF/OIF, this war will produce a generation of veterans with 
life changing invisible wounds of war. In addition, there is 
room for improvement in the diagnosis and treatment of veterans 
with TBI as evidenced by the RAND report. This is why H.R. 3219 
would direct the VA to establish a Committee on Care of 
Veterans with Traumatic Brain Injury to assess and advise how 
the VA can better meet the treatment and rehabilitation needs 
of veterans with TBI.
    Section 206 of H.R. 3219 would clarify the requirements of 
a pilot program which was authorized in Public Law 110-387 (114 
Stat. 1822), the Veterans' Mental Health and Other Care 
Improvements Act of 2008.
    This law authorized the VA to establish a pilot program for 
highly rural veterans facing hardship so that they may receive 
health care in non-VA facilities. Section 206 of H.R. 3219 
would remove the ``highly rural'' and ``hardship'' 
requirements, and would define covered veterans by driving time 
rather than distance to the nearest VA health care facility. 
The Committee provided this clarification because of the VA's 
concerns that it would have to undergo a lengthy process of 
developing and issuing regulations to define the hardship 
provision. In addition, the VA faced challenges in reconciling 
the conflicting definition of a highly rural veteran as defined 
by Public Law 110-387 versus the traditional definition based 
on Census data. Section 206 of H.R. 3219 would help to ensure 
timely implementation of the rural health pilot program.

                TITLE III--MATTERS RELATING TO BENEFITS

    Section 301 of H.R. 3219 would provide a $1,000 monthly 
payment to all civilian groups of World War II (WWII) who were 
given veteran status under the G.I Bill Improvement Act of 
1977.
    Those individuals who received benefits under the 
Servicemen's Readjustment Act of 1944, Public Law 78-346 ( 
Stat. ), the G.I. Bill of Rights of 1944, would not be eligible 
to receive benefits provided under this section. One group of 
veterans who would be included under H.R. 3219 is the American 
Volunteer Group known as the Flying Tigers. The Flying Tigers 
were a group of American pilots and ground crews who helped 
defend Rangoon and parts of China against Japan before and 
after the attack on Pearl Harbor. The Flying Tigers are 
credited with destroying an impressive 297 enemy aircraft and 
had one of the best kill ratios of any air group in the Pacific 
theater. There were approximately 80 pilots that flew for the 
Flying Tigers, of which 21 died in service and 19 became aces. 
Those members of the Flying Tigers who subsequently served in 
the U.S. Armed Forces during WWII who received benefits 
provided under the Servicemen's Readjustment Act of 1944 would 
not qualify for the benefit that this section would provide.
    Another group that would benefit from this amendment is the 
Women Air Force Service Pilots (WASPS). These were female 
pilots who flew every type of mission that any Army Air Force 
male pilot flew during WWII, except combat missions. They freed 
up male pilots for combat by flying planes from factories to 
airfields and overall flew 60 million miles in every type of 
aircraft in the Army Air Force arsenal from the fastest 
fighters to the heaviest bombers. More than 25,000 women 
applied for WASP service, and less than 1,900 were accepted. 
After completing months of military flight training, 1,078 of 
them earned their wings and became the first women in history 
to fly American military aircraft. Thirty-eight of these brave 
pilots died while serving their country.
    The Congressional Budget Office estimates that this 
provision of H.R. 3219 would cost $855 million in discretionary 
funding over a five-year period. Notably, this cost reflects 
the inclusion of the Merchant Mariners of WWII. The Committee 
notes that Merchant Mariners would be entitled to receive a 
$1,000 monthly payment under H.R. 23, the Belated Thank You to 
the Merchant Mariners of WWII Act of 2009, which passed the 
House of Representatives on May 12, 2009. H.R. 23 includes the 
Merchant Mariners who served between August 15, 1945, and 
December 31, 1946, a group not covered in section 301 of this 
measure. It is not the intention of the Committee to require 
two $1,000 monthly payments to the Merchant Mariners of WWII. 
This would create inequity between the Merchant Mariners and 
the other groups included in this provision.

                                Hearings

    On May 21, 2009, the Subcommittee on Disability Assistance 
and Memorial Affairs held a legislative hearing on several 
bills introduced during the 111th Congress, including H.R. 
2270. The following witnesses testified: The Honorable Nita M. 
Lowey of New York, accompanied by Elizabeth Yeznach, a World 
War II Cadet Nurse, as presented by Anne R. (Mandzak) Kakos of 
Yonkers, New York; The Honorable Carolyn C. Kilpatrick of 
Michigan; Major Ed Stiles, Sr., USAFR (Ret.), on behalf of the 
American Volunteer Group (Flying Tigers); Bradley G. Mayes, 
Director, Compensation and Pension Service, Veterans Benefits 
Administration, U.S. Department of Veterans Affairs, 
accompanied by Richard Hipolit, General Counsel, Office of 
General Counsel, U.S. Department of Veterans Affairs. Those 
submitting statements for the record included the American 
Federation of Government Employees, AFL-CIO; The Honorable 
Steve Buyer of Indiana; and, John L. Wilson, Associate National 
Legislative Director, Disabled American Veterans.
    On June 18, 2009, the Subcommittee on Health held a 
legislative hearing on several bills introduced during the 
111th Congress, including H.R. 1197, H.R. 1302, H.R. 1335, H.R. 
1546, and H.R. 2926. The following witnesses testified: The 
Honorable Harry Mitchell of Arizona; The Honorable Phil Hare of 
Illinois; The Honorable Deborah L. Halvorson of Illinois; The 
Honorable Jerry McNerney of California; The Honorable Thomas 
S.P. Perriello of Virginia; The Honorable Harry Teague of New 
Mexico; and, Fred Cowell, Senior Health Policy Analyst, 
Paralyzed Veterans of America. Those submitting statements for 
the record included: The Honorable Steve Buyer of Indiana; The 
Honorable Jerry Moran of Kansas; Joy J. Ilem, Deputy National 
Legislative Director, Disabled American Veterans; Joseph L. 
Wilson, Deputy Director, Veterans Affairs and Rehabilitation 
Commission, The American Legion; Chris Needham, Senior 
Legislative Associate, Veterans of Foreign Wars of the United 
States; Bernard Edelman, Deputy Director for Policy and 
Government Affairs, Vietnam Veterans of America; the American 
Academy of Physician Assistants; the National Association of 
Veterans' Research and Education Foundation; the Wounded 
Warrior Project; Barbara Cohoon, Ph.D., RN, Government 
Relations Deputy Director, National Military Family 
Association; and, Robert A. Petzel, M.D., Acting Principal 
Deputy Under Secretary for Health, Veterans Health 
Administration, U.S. Department of Veterans Affairs.
    On June 24, 2009, the Subcommittee on Disability Assistance 
and Memorial Affairs held a legislative hearing on several 
bills introduced during the 111th Congress, including H.R. 
2379, H.R. 2774, and H.R. 2968. The following witnesses 
testified: The Honorable Joe Donnelly of Indiana; The Honorable 
Deborah L. Halvorson of Illinois; The Honorable Ann Kirkpatrick 
of Arizona; Bonnie Carroll, Chairman and Executive Director, 
Tragedy Assistance Program for Survivors, Inc.; John Wilson, 
Associate National Legislative Director, Disabled American 
Veterans; Thomas M. Lastowka, Director, Veterans Affairs 
Regional Office and Insurance Center, U.S. Department of 
Veterans Affairs, accompanied by Richard J. Hipolit, Assistant 
General Counsel, Office of General Counsel, U.S. Department of 
Veterans Affairs. Those submitting statements for the record 
included The Honorable Steve Buyer of Indiana and the Paralyzed 
Veterans of America.

                       Subcommittee Consideration

    On June 3, 2009, the Subcommittee on Disability Assistance 
and Memorial Affairs met in open markup session and ordered 
favorably forwarded to the full Committee H.R. 2270.
    On July 9, 2009, the Subcommittee on Health met in open 
markup session and ordered favorably forwarded to the full 
Committee H.R. 1197, H.R. 1302, H.R. 1335, H.R. 1546, and H.R. 
2926. During consideration of these bills the following 
amendments were offered:
          An amendment to H.R. 1335 by Ms. Halvorson of 
        Illinois to further eliminate copayments for medical 
        services for veterans who are catastrophically disabled 
        was agreed to by voice vote.
          An amendment to H.R. 2926 by Mr. Michaud of Maine to 
        provide enhanced treatment authority for veterans of 
        Persian Gulf War I and clarifying the terms of a rural 
        health pilot program authorized in Public Law 110-387 
        was agreed to by voice vote.
    On July 9, 2009, the Subcommittee on Disability Assistance 
and Memorial Affairs met in open markup session and ordered 
favorably forwarded to the full Committee H.R. 2379, H.R. 2774, 
and H.R. 2968. During consideration of these bills the 
following amendments were offered:
          An amendment in the nature of a substitute to H.R. 
        2968 by Ms. Kirkpatrick of Arizona was agreed to by 
        voice vote.

                        Committee Consideration

    On July 15, 2009, the full Committee met in an open markup 
session, a quorum being present, and ordered H.R. 3219 reported 
favorably to the House of Representatives, by voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report the legislation and amendments thereto. 
There were no record votes taken on amendments or in connection 
with ordering H.R. 3219 reported to the House. A motion by Mr. 
Buyer of Indiana to order H.R. 3219 reported favorably to the 
House of Representatives was agreed to by voice vote.

                      Committee Oversight Findings

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

         Statement Of General Performance Goals and Objectives

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

   New Budget Authority, Entitlement Authority, and Tax Expenditures

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

                  Earmarks and Tax and Tariff Benefits

    H.R. 3219 does not contain any congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9(d), 9(e), or 9(f) of rule XXI of the Rules of the 
House of Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
3219 prepared by the Director of the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 3219 provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 23, 2009.
Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 3219, the 
Veterans' Insurance and Health Care Improvement Act of 2009.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Dwayne M. 
Wright.
            Sincerely,
                                              Douglas W. Elmendorf.
    Enclosure.

H.R. 3219--Veterans' Insurance and Health Care Improvement Act of 2009

    Summary: H.R. 3219 would affect several veterans' programs 
dealing with medical care and insurance. H.R. 3219 also would 
establish a new fund to provide benefits to certain veterans of 
World War II. CBO estimates that implementing H.R. 3219 would 
cost $229 million in 2010 and $895 million over the 2010-2014 
period, assuming appropriation of the specified and estimated 
amounts. Enacting the bill would have no impact on direct 
spending or revenues.
    H.R. 3219 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would not affect the budgets of state, local, or tribal 
governments.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of H.R. 3219 is shown in the following table. 
The costs of this legislation fall within budget function 700 
(veterans benefits and services). For the purpose of this 
estimate, CBO assumes that H.R. 3219 will be enacted near the 
start of fiscal year 2010 and that the necessary funds for 
implementing the bill will be provided each year.

----------------------------------------------------------------------------------------------------------------
                                                                   By fiscal year in millions of dollars--
                                                           -----------------------------------------------------
                                                                                                          2010-
                                                              2010     2011     2012     2013     2014     2014
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Benefits to Qualified World War II Veterans:
    Authorization level...................................      222      193      170      146      124      855
    Estimated Outlays.....................................      222      193      170      146      124      855
Copayments from Certain Disabled Veterans:
    Estimated Authorization level.........................        8        8        8        8        8       40
    Estimated Outlays.....................................        7        8        8        8        8       39
Other Health Care Provisions:
    Estimated Authorization level.........................        *        *        *        *        *        1
    Estimated Outlays.....................................        *        *        *        *        *        1
    Total Changes:
        Estimated Authorization Level.....................      230      201      178      154      132      896
        Estimated Outlays.................................      229      201      178      154      132     895
----------------------------------------------------------------------------------------------------------------
Notes: * = less than $500,000.
      Numbers many not sum to totals because of rounding.

    Basis of estimate: H.R. 3219 would affect several programs 
administered by the Department of Veterans Affairs (VA), 
including those providing medical care and insurance and would 
establish a new fund to pay benefits to qualified World War II 
veterans. CBO estimates that implementing H.R. 3219 would cost 
$895 million over the 2010-2014 period, assuming appropriation 
of the specified and estimated amounts.

Benefits to qualified World War II veterans

    Under section 301 certain individuals who served during 
World War II would be eligible to receive a monthly benefit of 
$1,000, subject to the availability of funds provided for that 
purpose. The benefit would be provided to veterans who were 
retroactively deemed to have served on active duty by the GI 
Bill Improvement Act of 1977 (Public Law 95-202) if they apply 
within a year of the enactment of H.R. 3219.
    To provide those benefits, section 301 would establish the 
Qualified World War II Veterans Equity Compensation Fund. 
Amounts in the fund would be used to pay the monthly benefit to 
eligible individuals, on a first-come, first-served basis. The 
bill would specifically authorize appropriations for each year 
as shown in the table.
    Based on information from VA and the Department of Defense 
(DoD) on the number of qualified veterans that served during 
the specified period, their average age, and on mortality rates 
from DoD, CBO estimates that, in 2010, about 74,000 veterans 
would qualify for the benefit. We estimate that one-quarter of 
them, about 18,500, would apply for the benefit. The amount 
authorized in section 301 ($222 million) would allow all of 
those applicants to receive the full monthly benefit in 2010, 
assuming appropriation of that amount.
    Using the DoD mortality rates, CBO estimates that the 
amounts authorized for 2011 through 2014, if appropriated, 
would be sufficient to continue providing monthly payments to 
surviving beneficiaries. In total, CBO estimates that 
implementing section 301 would cost $855 million over the 2010-
2014 period.

Copayments from certain disabled veterans

    Section 203 would prohibit the collection of copayments and 
other fees from catastrophically disabled veterans who receive 
hospital care or medical services from VA. Catastrophically 
disabled veterans are those who have a permanent, severely 
disabling condition that affects their ability to carry out the 
activities of daily living to such a degree that they require 
constant supervision or assistance to leave their homes.
    In 2008, VA collected $8 million in copayments for medical 
care and prescription drugs from such veterans; implementing 
this provision would result in a loss of those collections. 
Such collections are 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, CBO estimates 
that implementing this provision would cost $40 million over 
the 2010-2014 period.
    Other Health Care Provisions. Taken together, CBO estimates 
that implementing the following provisions would cost about $1 
million over the 2010-2014 period, assuming availability of 
appropriated funds:
     Section 201 would authorize VA to provide medical 
care to recipients of the Congressional Medal of Honor under 
its third-highest priority category. According to the 
Congressional Medal of Honor Society, there are fewer than 100 
living recipients.
     Section 204 would establish the position of a 
Director of Physician Assistant Services within the VA. A 
similar position already exists. (Thus, any additional costs 
for the new position would be negligible.)
     Section 205 would authorize VA employees to serve 
on a committee to assess and advise the agency on treatment of 
traumatic brain injuries.

Insurance programs

    H.R. 3219 would make several changes to veterans insurance 
programs, specifically Servicemembers Group Life Insurance 
(SGLI) and Veterans Group Life Insurance (VGLI). Any costs 
associated with these provisions in the short run would be 
absorbed by the SGLI or VGLI fund. Over the long term, such 
costs would be covered by increased premiums and would 
therefore have no budgetary impact.
    Intergovernmental and private-sector impact: H.R. 3219 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would not affect the budgets of state, 
local, or tribal governments.
    Previous CBO estimate: On May 7, 2009, CBO transmitted a 
cost estimate for H.R. 23, the Belated Thank You to the 
Merchant Mariners of World War II Act of 2009, as ordered 
reported by the House Committee on Veterans' Affairs on May 6, 
2009. Section 301 of H.R. 3129 and H.R. 23 would both create 
funds to provide monthly benefits to certain World War II 
veterans who were deemed retroactively to have served on active 
duty. H.R. 3129 would provide benefits to several such 
categories of veterans including Merchant Mariners, while H.R. 
23 would only provide payments for Merchant Mariners. 
Differences in the estimates reflect that difference in the 
legislation.
    Estimate prepared by: Federal costs: World War II Veterans 
and Insurance--Dwayne M. Wright; Medical Care--Sunita D'Monte; 
Impact on state, local, and tribal governments: Lisa Ramirez-
Branum; Impact on the private sector: Elizabeth Bass.
    Estimate approved by: Theresa Gullo, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 3219 prepared by the Director of the 
Congressional Budget Office pursuant to section 423 of the 
Unfunded Mandates Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
3219.

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that the 
Constitutional authority for H.R. 3219 is provided by Article 
I, section 8 of the Constitution of the United States.

                  Applicability to Legislative Branch

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

             Section-by-Section Analysis of the Legislation


                 TITLE I--MATTERS RELATING TO INSURANCE

Section 101. Permanent extension of duration of Servicemembers' Group 
        Life Insurance coverage for totally disabled veterans

    This section amends section 1968 of title 38, United States 
Code, to permanently extend coverage under SGLI to two years 
for separating servicemembers who are totally disabled.

Section 102. Increased amount of Veterans' Group Life Insurance

    This section would amend section 1977 of title 38, United 
States Code, to provide veterans insured under VGLI additional 
opportunities to increase their amount of coverage.
    This section provides that not more than once in each five-
year period, a veteran under the age of 60 may increase the 
amount of coverage by $25,000 if the total amount of coverage 
does not exceed $400,000 (the limit authorized for a veteran 
under SGLI).

Section 103. Elimination of reduction in amount of accelerated death 
        benefit for terminally-ill persons insured under the 
        Servicemembers' Group Life Insurance and Veterans' Group Life 
        Insurance

    This section would amend section 1980 of title 38, United 
States Code, to eliminate the reduction in amount of 
accelerated death benefit for terminally-ill persons insured 
under SGLI and VGLI.

               TITLE II--MATTERS RELATING TO HEALTH CARE

Section 201. Higher priority status for certain veterans who are Medal 
        of Honor recipients

    This section assigns priority status for Medal of Honor 
recipients equal to that of former prisoners of war or Purple 
Heart recipients with respect to the provision of veterans' 
hospital care and medical services provided through the VA.

Section 202. Provision of hospital care, medical services, and nursing 
        home care for certain Vietnam-era veterans exposed to herbicide 
        and veterans of the Persian Gulf War

    This section provides permanent authorization for the VA to 
provide hospital care, medical services, and nursing home care 
to Vietnam-era herbicide exposed veterans and Gulf-War era 
veterans who have insufficient medical evidence to establish a 
service-connected disability.

Section 203. Prohibition on collection of copayments from 
        catastrophically disabled veterans

    This section prohibits the collection by the VA of 
copayments or other fees for hospital, nursing home, and 
medical care for veterans who are catastrophically disabled 
from non-service connected causes and who have income above the 
means tested levels.

Section 204. Establishment of Director of Physician Assistant Services 
        at Veterans Health Administration of Department of Veterans 
        Affairs

    This section establishes the position of Director of 
Physician Assistant Services within the Veterans Health 
Administration (VHA) of the VA who reports to the Under 
Secretary for Health on all matters relating to the education 
and training, employment, appropriate utilization, and optimal 
participation of physician assistants within VHA programs and 
initiatives. It also requires the Secretary of Veterans Affairs 
to ensure that an individual is serving in such position no 
later than 120 days after the enactment of this Act.

Section 205. Committee on Care of Veterans with Traumatic Brain Injury

    This section establishes a ``Committee on Care of Veterans 
with Traumatic Brain Injury'' within the Veterans Health 
Administration. Committee members would consist of VA employees 
with expertise in TBI who would be appointed by the Under 
Secretary for Health. The Committee would evaluate the care, 
identify system-wide problems, identify specific facilities in 
need of improvement, and identify model programs for the 
successful treatment and rehabilitation of veterans with TBI, 
as well as provide recommendations to the Under Secretary for 
Health on improving programs of care for TBI. It also requires 
an annual report to Congress, due no later than June 1, 2010.

Section 206. Revision of certain requirements for the pilot program of 
        enhanced contract care authority for health care needs of 
        veterans in highly rural areas

    This section clarifies Section 403 of Public law 110-387, 
the Veterans' Mental Health and Other Care Improvements Act of 
2008, which provided for a rural health pilot program. It 
removes the requirement that the veteran resides in highly 
rural areas and defines hardship by driving time to the nearest 
VA health care facility. Specifically, ``hardship'' is defined 
as a veteran who resides more than 60 minutes driving distance 
from the nearest VA health care facility providing primary care 
services; more than 120 minutes driving distance from the 
nearest VA facility providing acute hospital care; and more 
than 240 minutes driving distance from the nearest VA facility 
providing tertiary care.

                TITLE III--MATTERS RELATING TO BENEFITS

Section 301. Benefits for qualified World War II veterans

    This section would amend title 38, United States Code, by 
adding a new section creating, subject to the availability of 
appropriations, a Qualified World War II Veterans Equity 
Compensation Fund. The Secretary of VA would be required to 
make a monthly payment of $1,000 out of the compensation fund 
to eligible individuals in the order of receipt of applications 
Eligible veterans are those given veteran status under the G.I 
Bill Improvement Act of 1977 who have not received benefits 
under the Servicemen's Readjustment Act of 1944.

         Changes in Existing Law Made by the Bill, as Reported

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

TITLE 38, UNITED STATES CODE

           *       *       *       *       *       *       *



PART I--GENERAL PROVISIONS

           *       *       *       *       *       *       *



            CHAPTER 5--AUTHORITY AND DUTIES OF THE SECRETARY


                    SUBCHAPTER I--GENERAL AUTHORITIES

Sec.
501.  Rules and regulations.
     * * * * * * *

                   SUBCHAPTER II--SPECIFIED FUNCTIONS

     * * * * * * *
533.  Qualified World War II Veterans Equity Compensation Fund.
     * * * * * * *

SUBCHAPTER II--SPECIFIED FUNCTIONS

           *       *       *       *       *       *       *


Sec. 533. Qualified World War II Veterans Equity Compensation Fund

  (a) Compensation Fund.--(1) There is in the general fund of 
the Treasury a fund to be known as the ``Qualified World War II 
Veterans Equity Compensation Fund'' (in this section referred 
to as the ``compensation fund'').
  (2) Subject to the availability of appropriations for such 
purpose, amounts in the compensation fund shall be available to 
the Secretary without fiscal year limitation to make payments 
to eligible individuals in accordance with this section.
  (b) Eligible Individuals.--(1) An eligible individual is an 
individual who--
          (A) during the 1-year period beginning on the date of 
        the enactment of the Benefits for Qualified World War 
        II Veterans Act of 2009, submits to the Secretary an 
        application containing such information and assurances 
        as the Secretary may require;
          (B) has not received benefits under the Servicemen's 
        Readjustment Act of 1944 (Public Law 78-346); and
          (C) has engaged in qualified service.
  (2) For purposes of paragraph (1), a person has engaged in 
qualified service if the service of the person has been 
determined to have been active duty service pursuant to section 
1401 of the GI Bill Improvement Act of 1977 (38 U.S.C. 106 
note).
  (c) Amount of Payments.--The Secretary shall make a monthly 
payment out of the compensation fund in the amount of $1,000 to 
an eligible individual. The Secretary shall make such payments 
to eligible individuals in the order in which the Secretary 
receives the applications of the eligible individuals.
  (d) Authorization of Appropriations.--(1) There are 
authorized to be appropriated to the compensation fund amounts 
as follows:
          (A) For fiscal year 2010, $222,000,000.
          (B) For fiscal year 2011, $193,000,000.
          (C) For fiscal year 2012, $170,000,000.
          (D) For fiscal year 2013, $146,000,000.
          (E) For fiscal year 2014, $124,000,000.
  (2) Funds appropriated to carry out this section shall remain 
available until expended.
  (e) Reports.--The Secretary shall include, in documents 
submitted to Congress by the Secretary in support of the 
President's budget for each fiscal year, detailed information 
on the operation of the compensation fund, including the number 
of applicants, the number of eligible individuals receiving 
benefits, the amounts paid out of the compensation fund, the 
administration of the compensation fund, and an estimate of the 
amounts necessary to fully fund the compensation fund for that 
fiscal year and each of the three subsequent fiscal years.
  (f) Regulations.--The Secretary shall prescribe regulations 
to carry out this section.

           *       *       *       *       *       *       *


PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


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

                          SUBCHAPTER I--GENERAL

Sec.
1701.  Definitions.
     * * * * * * *

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

     * * * * * * *
1730A.  Prohibition on collection of copayments from catastrophically 
          disabled veterans.

           *       *       *       *       *       *       *


SUBCHAPTER I--GENERAL

           *       *       *       *       *       *       *


Sec. 1705. Management of health care: patient enrollment system

  (a) In managing the provision of hospital care and medical 
services under section 1710(a) of this title, the Secretary, in 
accordance with regulations the Secretary shall prescribe, 
shall establish and operate a system of annual patient 
enrollment. The Secretary shall manage the enrollment of 
veterans in accordance with the following priorities, in the 
order listed:
          (1) * * *

           *       *       *       *       *       *       *

          (3) Veterans who are former prisoners of war or who 
        were awarded the Purple Heart, veterans who were 
        awarded the medal of honor under section 3741, 6241, or 
        8741 of title 10 or section 491 of title 14, veterans 
        with service-connected disabilities rated 10 percent or 
        20 percent, and veterans described in subparagraphs (B) 
        and (C) of section 1710(a)(2) of this title.

           *       *       *       *       *       *       *


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

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

  (a) * * *

           *       *       *       *       *       *       *

  (e)(1)(A) * * *

           *       *       *       *       *       *       *

  (C) Subject to [paragraphs (2) and (3)] paragraph (2) of this 
subsection, a veteran who served on active duty between August 
2, 1990, and November 11, 1998, in the Southwest Asia theater 
of operations during the Persian Gulf War is eligible for 
hospital care, medical services, and nursing home care under 
subsection (a)(2)(F) for any disability, notwithstanding that 
there is insufficient medical evidence to conclude that such 
disability may be associated with such service.

           *       *       *       *       *       *       *

  (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] subsection (a)(2)(F) in the case of 
        of care for a veteran described in paragraph (1)(D) 
        who--
          [(i)] (A) 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, after a period of five years beginning on the 
        date of such discharge or release; or
          [(ii)] (B) 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.

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


Sec. 1730A. Prohibition on collection of copayments from 
                    catastrophically disabled veterans

  Notwithstanding subsections (f) and (g) of section 1710 of 
this title, subsection (a) of section 1722A of this title, and 
any other provision of law, the Secretary may not require a 
veteran who is catastrophically disabled to make any copayment 
for the receipt of hospital care or medical services under the 
laws administered by the Secretary.

           *       *       *       *       *       *       *


CHAPTER 19--INSURANCE

           *       *       *       *       *       *       *


SUBCHAPTER III--SERVICEMEMBERS' GROUP LIFE INSURANCE

           *       *       *       *       *       *       *


Sec. 1968. Duration and termination of coverage; conversion

  (a) Each policy purchased under this subchapter shall contain 
a provision, in terms approved by the Secretary, to the effect 
that any insurance thereunder on any member of the uniformed 
services, and any insurance thereunder on any insurable 
dependent of such a member, unless discontinued or reduced upon 
the written request of the insured (or discontinued pursuant to 
section 1969(a)(2)(B) of this title), shall continue in effect 
while the member is on active duty, active duty for training, 
or inactive duty training scheduled in advance by competent 
authority during the period thereof, or while the member meets 
the qualifications set forth in subparagraph (B) or (C) of 
section 1965(5) of this title and such insurance shall cease as 
follows:
          (1) With respect to a member on active duty or active 
        duty for training under a call or order to duty that 
        does not specify a period of less than 31 days, 
        insurance under this subchapter shall cease as follows:
                  (A) 120 days after the separation or release 
                from active duty or active duty for training, 
                unless on the date of such separation or 
                release the member is totally disabled, under 
                criteria established by the Secretary, in which 
                event the insurance shall cease on the earlier 
                of the following dates (but in no event before 
                the end of 120 days after such separation or 
                release):
                          (i) * * *
                          [(ii) The date that is--
                                  [(I) two years after the date 
                                of separation or release from 
                                such active duty or active duty 
                                for training, in the case of 
                                such a separation or release 
                                during the period beginning on 
                                the date that is one year 
                                before the date of the 
                                enactment of Veterans' Housing 
                                Opportunity and Benefits 
                                Improvement Act of 2006 and 
                                ending on September 30, 2011; 
                                and
                                  [(II) 18 months after the 
                                date of separation or release 
                                from such active duty or active 
                                duty for training, in the case 
                                of such a separation or release 
                                on or after October 1, 2011.]
                          (ii) The date that is two years after 
                        the date of separation or release from 
                        such active duty or active duty for 
                        training.

           *       *       *       *       *       *       *

          (4) With respect to a member of the Ready Reserve of 
        a uniformed service who meets the qualifications set 
        forth in subparagraph (B) or (C) of section 1965(5) of 
        this title, insurance under this subchapter shall cease 
        120 days after separation or release from such 
        assignment, unless on the date of such separation or 
        release the member is totally disabled, under criteria 
        established by the Secretary, in which event the 
        insurance shall cease on the earlier of the following 
        dates (but in no event before the end of 120 days after 
        separation or release from such assignment):
                  (A) * * *
                  [(B) The date that is--
                          [(i) two years after the date of 
                        separation or release from such 
                        assignment, in the case of such a 
                        separation or release during the period 
                        beginning on the date that is one year 
                        before the date of the enactment of 
                        Veterans' Housing Opportunity and 
                        Benefits Improvement Act of 2006 and 
                        ending on September 30, 2011; and
                          [(ii) 18 months after the date of 
                        separation or release from such 
                        assignment, in the case of such a 
                        separation or release on or after 
                        October 1, 2011.]
                  (B) The date that is two years after the date 
                of separation or release from such assignment.

           *       *       *       *       *       *       *


Sec. 1977. Veterans' Group Life Insurance

  (a)(1) Except as provided in paragraph (3), Veterans' Group 
Life Insurance shall be issued in the amounts specified in 
section 1967(a) of this title. In the case of any individual, 
the amount of Veterans' Group Life Insurance may not exceed the 
amount of Servicemembers' Group Life Insurance coverage 
continued in force after the expiration of the period of duty 
or travel under section 1967(b) or 1968(a) of this title. No 
person may carry a combined amount of Servicemembers' Group 
Life Insurance and Veterans' Group Life Insurance at any one 
time in excess of the maximum amount for Servicemembers' Group 
Life Insurance in effect under section 1967(a)(3)(A)(i) of this 
title.

           *       *       *       *       *       *       *

  (3) Not more than once in each five-year period beginning on 
the date a person becomes insured under Veterans' Group Life 
Insurance, such person may elect in writing to increase the 
amount for which the person is insured if--
          (A) the person is under the age of 60;
          (B) the increased amount is not more than $25,000; 
        and
          (C) the amount for which the person is insured does 
        not exceed the amount provided for under section 
        1967(a)(3)(A)(i) of this title.

           *       *       *       *       *       *       *


Sec. 1980. Option to receive accelerated death benefit

  (a) * * *
  (b)(1) A terminally ill person insured under Servicemembers' 
Group Life Insurance or Veterans' Group Life Insurance may 
elect to receive in a lump-sum payment a portion of the face 
value of the insurance as an accelerated death benefit [reduced 
by an amount necessary to assure that there is no increase in 
the actuarial value of the benefit paid, as determined by the 
Secretary].

           *       *       *       *       *       *       *


PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

           *       *       *       *       *       *       *


CHAPTER 73--VETERANS HEALTH ADMINISTRATION - ORGANIZATION AND FUNCTIONS

                       SUBCHAPTER I--ORGANIZATION

Sec.
7301. Functions of Veterans Health Administration: in general.
     * * * * * * *

           SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION

     * * * * * * *
7321A. Committee on Care of Veterans with Traumatic Brain Injury.
     * * * * * * *

SUBCHAPTER I--ORGANIZATION

           *       *       *       *       *       *       *


Sec. 7306. Office of the Under Secretary for Health

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

           *       *       *       *       *       *       *

          [(9) The Advisor on Physician Assistants, who shall 
        be a physician assistant with appropriate experience 
        and who shall advise the Under Secretary for Health on 
        all matters relating to the utilization and employment 
        of physician assistants in the Administration.]
          (9) The Director of Physician Assistant Services, who 
        shall serve in a full-time capacity at the Central 
        Office of the Department and who shall be a qualified 
        physician assistant, who shall be responsible to and 
        report directly to the Under Secretary for Health on 
        all matters relating to the education and training, 
        employment, appropriate utilization, and optimal 
        participation of physician assistants within the 
        programs and initiatives of the Administration.

           *       *       *       *       *       *       *


SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION

           *       *       *       *       *       *       *


Sec. 7321A. Committee on Care of Veterans with Traumatic Brain Injury

  (a) Establishment.--The Secretary shall establish in the 
Veterans Health Administration a committee to be known as the 
``Committee on Care of Veterans with Traumatic Brain Injury''. 
The Under Secretary for Health shall appoint employees of the 
Department with expertise in the care of veterans with 
traumatic brain injury to serve on the committee.
  (b) Responsibilities of Committee.--The committee shall 
assess, and carry out a continuing assessment of, the 
capability of the Veterans Health Administration to meet 
effectively the treatment and rehabilitation needs of veterans 
with traumatic brain injury. In carrying out that 
responsibility, the committee shall--
          (1) evaluate the care provided to such veterans 
        through the Veterans Health Administration;
          (2) identify systemwide problems in caring for such 
        veterans in facilities of the Veterans Health 
        Administration;
          (3) identify specific facilities within the Veterans 
        Health Administration at which program enrichment is 
        needed to improve treatment and rehabilitation of such 
        veterans; and
          (4) identify model programs which the committee 
        considers to have been successful in the treatment and 
        rehabilitation of such veterans and which should be 
        implemented more widely in or through facilities of the 
        Veterans Health Administration.
  (c) Advice and Recommendations.--The committee shall--
          (1) advise the Under Secretary regarding the 
        development of policies for the care and rehabilitation 
        of veterans with traumatic brain injury; and
          (2) make recommendations to the Under Secretary--
                  (A) for improving programs of care of such 
                veterans at specific facilities and throughout 
                the Veterans Health Administration;
                  (B) for establishing special programs of 
                education and training relevant to the care of 
                such veterans for employees of the Veterans 
                Health Administration;
                  (C) regarding research needs and priorities 
                relevant to the care of such veterans; and
                  (D) regarding the appropriate allocation of 
                resources for all such activities.
  (d) Annual Report.--Not later than June 1 of 2010, and each 
subsequent year, the Secretary shall submit to the Committees 
on Veterans' Affairs of the Senate and House of Representatives 
a report on the implementation of this section. Each such 
report shall include the following for the calendar year 
preceding the year in which the report is submitted:
          (1) A list of the members of the committee.
          (2) The assessment of the Under Secretary for Health, 
        after review of the initial findings of the committee, 
        regarding the capability of the Veterans Health 
        Administration, on a systemwide and facility-by-
        facility basis, to meet effectively the treatment and 
        rehabilitation needs of veterans with traumatic brain 
        injury.
          (3) The plans of the committee for further 
        assessments.
          (4) The findings and recommendations made by the 
        committee to the Under Secretary for Health and the 
        views of the Under Secretary on such findings and 
        recommendations.
          (5) A description of the steps taken, plans made (and 
        a timetable for the execution of such plans), and 
        resources to be applied toward improving the capability 
        of the Veterans Health Administration to meet 
        effectively the treatment and rehabilitation needs of 
        veterans with traumatic brain injury.

           *       *       *       *       *       *       *

                              ----------                              


SECTION 403 OF THE VETERANS' MENTAL HEALTH AND OTHER CARE IMPROVEMENTS 
                              ACT OF 2008

SEC. 403. PILOT PROGRAM OF ENHANCED CONTRACT CARE AUTHORITY FOR HEALTH 
                    CARE NEEDS OF VETERANS IN HIGHLY RURAL AREAS.

  (a) * * *
  [(b) Covered Veterans.--
          [(1) In general.--For purposes of the pilot program 
        under this section, a covered veteran is any highly 
        rural veteran who is--
                  [(A) enrolled in the system of patient 
                enrollment established under section 1705(a) of 
                title 38, United States Code, as of the date of 
                the commencement of the pilot program under 
                subsection (a)(2); or
                  [(B) eligible for health care under section 
                1710(e)(3)(C) of title 38, United States Code.
          [(2) Highly rural veterans.--For purposes of this 
        subsection, a highly rural veteran is any veteran who--
                  [(A) resides in a location that is--
                          [(i) more than 60 miles driving 
                        distance from the nearest Department 
                        health care facility providing primary 
                        care services, if the veteran is 
                        seeking such services;
                          [(ii) more than 120 miles driving 
                        distance from the nearest Department 
                        health care facility providing acute 
                        hospital care, if the veteran is 
                        seeking such care; or
                          [(iii) more than 240 miles driving 
                        distance from the nearest Department 
                        health care facility providing tertiary 
                        care, if the veteran is seeking such 
                        care; or
                  [(B) in the case of a veteran who resides in 
                a location less than the distance specified in 
                clause (i), (ii), or (iii) of subparagraph (A), 
                as applicable, experiences such hardship or 
                other difficulties in travel to the nearest 
                appropriate Department health care facility 
                that such travel is not in the best interest of 
                the veteran, as determined by the Secretary 
                pursuant to regulations prescribed for purposes 
                of this subsection.]
  (b) Covered Veterans.--For purposes of the pilot program 
under this section, a covered veteran is any veteran who--
          (1) is--
                  (A) enrolled in the system of patient 
                enrollment established under section 1705(a) of 
                title 38, United States Code, as of the date of 
                the commencement of the pilot program under 
                subsection (a)(2); or
                  (B) eligible for health care under section 
                1710(e)(3)(C) of title 38, United States Code; 
                and
          (2) resides in a location that is--
                  (A) more than 60 minutes' driving distance, 
                as determined by the Secretary, from the 
                nearest Department health care facility 
                providing primary care services, in the case of 
                a veteran seeking such services;
                  (B) more than 120 minutes' driving distance, 
                as determined by the Secretary, from the 
                nearest Department health care facility 
                providing acute hospital care, in the case of a 
                veteran seeking such care; or
                  (C) more than 240 minutes' driving distance, 
                as determined by the Secretary, from the 
                nearest Department health care facility 
                providing tertiary care, in the case of a 
                veteran seeking such care.

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