[Senate Report 111-286]
[From the U.S. Government Publishing Office]


                                                       Calendar No. 557
111th Congress                                                   Report
                                 SENATE
 2d Session                                                     111-286

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



 
      VETERANS TELEHEALTH AND OTHER CARE IMPROVEMENTS ACT OF 2010

                                _______
                                

               September 2, 2010.--Ordered to be printed

  Filed, under authority of the order of the Senate of August 5, 2010

                                _______
                                

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

                              R E P O R T

                             together with

                           SUPPLEMENTAL VIEWS

                         [To accompany S. 3325]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee"), to which was referred the bill (S. 3325), a bill 
to amend title 38, United States Code, to authorize the waiver 
of the collection of copayments for telehealth and telemedicine 
visits of veterans, 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 6, 2010, Senator Begich introduced S. 3325. S. 3325 
would authorize the Secretary of Veterans Affairs (hereinafter, 
``the Secretary'') to waive the collection of copayments for 
telehealth and telemedicine visits of veterans.
    Earlier, on November 9, 2009, Senator Cornyn introduced 
S. 2751, to name the Department of Veterans Affairs medical 
center in Big Spring, Texas as the ``George H. O'Brien Jr., 
Department of Veterans Affairs Medical Center.''
    On February 24, 2010, Senator Baucus introduced S. 3035, 
the proposed ``Veterans Traumatic Brain Injury Care Improvement 
Act of 2010.'' S. 3035 would require the Secretary to report to 
the Congress on the feasibility and advisability of 
establishing a polytrauma rehabilitation center or polytrauma 
network site in the Dakotas or northern Rockies.
    On May 5, 2010, Senator Brown of Ohio introduced S. 3314. 
S. 3314 would require the Secretary of Veterans Affairs and the 
Appalachian Regional Commission to carry out a program of 
outreach for veterans who reside in Appalachia.
    On May 7, 2010, Senator Casey introduced S. 3330, the 
proposed ``Veterans' Health and Radiation Safety Act of 2010.'' 
S. 3330 would require an annual report on low volume programs, 
training on use of radioactive isotopes, and enhanced oversight 
of care provided by contractors.
    On May 12, 2010, Senator Klobuchar introduced S. 3355, the 
proposed ``Veterans One Source Act of 2010.'' S. 3355 would 
require the Secretary to establish an internet website designed 
to provide an interactive one-stop source of information on 
benefits, health care, and services for which veterans may be 
eligible.
    On May 14, 2010, Senator Burr introduced S. 3377. S. 3377 
would improve the multifamily transitional housing loan program 
of the Department of Veterans Affairs by requiring the 
Secretary of Veterans Affairs to issue loans for the 
construction of, rehabilitation of, or acquisition of, land for 
multifamily transitional housing projects instead of 
guaranteeing loans for such purposes.
    On April 5, 2010, the Committee held a field hearing on 
benefits and services for veterans in Appalachia. Testimony was 
offered by: Kim Graves, Eastern Area Director, Veterans 
Benefits Administration, Department of Veterans Affairs, 
accompanied by Joyce Cange, Director, Cleveland Regional 
Office, Jack Hetrick, Director, VA Health care System of Ohio, 
and Jeffrey Gering, Director, Chillicothe VA Medical Center; 
Bill Hartnett, Director, Ohio Department of Veterans Services; 
Rich Greenlee, MSW, PhD, Dean, Ohio University Eastern Campus; 
Lucinda Maupin, Veterans Service Officer, Belmont County; Ed 
Acevedo, U.S. Army Veteran, Operation Enduring Freedom and 
Operation Iraqi Freedom; and Andrea Neutzling, U.S. Army 
Veteran, Operation Iraqi Freedom.
    On May 5, 2010, the Committee held an oversight hearing on 
traumatic brain injury. Testimony was offered by: Lucille Beck, 
PhD, Chief Consultant, Rehabilitation Services, Department of 
Veterans Affairs, accompanied by Karen Guice, MD, MPP, 
Director, Federal Recovery Coordination Program, Joel Scholten, 
MD, Associate Chief of Staff for Physical Medicine and 
Rehabilitation, Washington DC VA Medical Center, and Sonja 
Batten, PhD, Deputy Director, Department of Defense Center of 
Excellence for Psychological Health and Traumatic Brain Injury; 
Colonel Michael S. Jaffee, MD, National Director, Defense and 
Veterans Brain Injury Center; Karen Bohlinger, Second Lady, 
State of Montana; Jonathan Barrs, Operation Iraqi Freedom 
Veteran; Bruce M. Gans, MD, Executive Vice President and Chief 
Medical Officer, Kessler Institute for Rehabilitation; Michael 
F. Dabbs, President, Brain Injury Association of Michigan; and 
Michelle C. LaPlaca, PhD, Associate Professor, Wallace H. 
Coulter Department of Biomedical Engineering, Georgia Institute 
of Technology.
    On May 19, 2010, the Committee held a hearing on pending 
health and benefits legislation. Testimony was offered by: 
Thomas J. Pamperin, Associate Deputy Under Secretary for Policy 
and Program Management, Veterans Benefits Administration, 
Department of Veterans Affairs, and Robert Jesse, MD, Acting 
Principal Deputy Under Secretary for Health, Veterans Health 
Administration, accompanied by Richard J. Hipolit, Assistant 
General Counsel, and Walter A. Hall, Assistant General Counsel; 
The Honorable Raymond Jefferson, Assistant Secretary of 
Veterans' Employment and Training Service, Department of Labor; 
Ian DePlanque, Assistant Director, Veterans Affairs and 
Rehabilitation Commission, The American Legion; Eric A. 
Hilleman, National Legislative Director, Veterans of Foreign 
Wars; Rick Weidman, Executive Director for Policy and 
Government Affairs, Vietnam Veterans of America, accompanied by 
Alan Oates, Chairman, Agent Orange/Dioxin and Other Toxic 
Substances Committee; and Tom Tarantino, Legislative Associate, 
Iraq and Afghanistan Veterans of America.
    On June 16, 2010, the Committee held a hearing on VA health 
care in rural areas. Testimony was offered by: Robert Jesse, 
MD, Acting Principal Deputy Under Secretary for Health, 
Department of Veterans Affairs, accompanied by Glen W. Grippen, 
Network Director, Veterans Integrated Service Network 19; 
Adrian Atizado, Assistant National Legislative Director, 
Disabled American Veterans; James F. Ahrens, Chairman, Veterans 
Rural Health Advisory Committee, Department of Veterans 
Affairs; Ronald Putnam, Veteran Service Officer, Haywood 
County, North Carolina; William Schoenhard, Deputy Under 
Secretary for Health for Operations and Management, Department 
of Veterans Affairs; Dan Winkelman, Vice President for 
Administration & General Counsel, the Yukon-Kuskokwim Health 
Corporation, Alaska; and Brigadier General Deborah McManus, 
Assistant Adjutant General of Air, Joint Forces Headquarters, 
Alaska, and Commander, Alaska Air National Guard, accompanied 
by Verdie Bowen, Director, Office of Veterans Affairs, Alaska 
Department of Military and Veterans Affairs.

                           Committee Meeting

    After carefully reviewing the testimony from the forgoing 
hearings, the Committee met in open session on August 5, 2010, 
to consider, among other legislation, an amended version of 
S. 3325, consisting of S. 3325 as introduced and provisions 
derived from the other legislation noted above, as well as 
freestanding provisions. The Committee voted unanimously to 
report favorably S. 3325, as amended.

                     Summary of S. 3325 as Reported

    S. 3325, as reported (hereinafter, ``the Committee bill''), 
would improve the quality of health care provided by the 
Department of Veterans Affairs (hereinafter, ``VA'' or ``the 
Department''), to increase access to health care and benefits 
provided by the Department, to authorize major medical facility 
construction projects of the Department, and for other 
purposes.

              TITLE I--QUALITY OF CARE AND ACCESS MATTERS

    Section 101 would waive the collection of copayments from 
veterans for telehealth and telemedicine visits.
    Section 102 would require the Secretary to carry out a 
program of outreach to veterans who reside in a region served 
by one of the Federally chartered regional commissions or 
authorities, as well as other non-Federally chartered 
development boards or authorities, and would authorize the 
Secretary to partner with such a commission or authority in 
order to carry out such a program of outreach.
    Section 103 would require an annual report on low volume 
procedures involving the use of radioactive isotopes at 
Department facilities.
    Section 104 would require all VA employees who handle or 
perform procedures utilizing radioactive isotopes to receive 
appropriate training.
    Section 105 would provide further oversight of medical 
services provided by contractors at Department facilities.
    Section 106 would improve the multifamily transitional 
housing loan program of the Department by requiring the 
Secretary to issue loans for the construction of, 
rehabilitation of, or acquisition of land for multifamily 
transitional housing projects.
    Section 107 would require a report on the establishment of 
a Polytrauma Rehabilitation Center or Polytrauma Network Site 
of the Department in the northern Rockies or Dakotas.
    Section 108 would authorize the Secretary to create an 
Internet website for information on benefits, resources, 
services, and opportunities for veterans and their families and 
caregivers.

               TITLE II--CONSTRUCTION AND NAMING MATTERS

    Section 201 would authorize fiscal year 2011 major medical 
facility projects previously appropriated, but not authorized.
    Section 202 would make an additional authorization for a 
fiscal year 2007 major medical facility project previously 
authorized.
    Section 203 would authorize fiscal year 2011 major medical 
facility leases.
    Section 204 would authorize appropriations to carry out the 
provisions of sections 201 through 203.
    Section 205 would require the Secretary to submit a report 
to Congress on the use of energy efficient technologies and 
best practices in Department facilities.
    Section 206 would designate the VA medical center in Big 
Spring, Texas, as the ``George H. O'Brien, Jr., Department of 
Veterans Affairs Medical Center.''
    Section 207 would require that savings realized from bid 
negotiation be used for major medical facility projects already 
authorized.

                       Background and Discussion


              TITLE I--QUALITY OF CARE AND ACCESS MATTERS

    Title I of the Committee bill contains a variety of 
provisions that are designed to improve VA outreach efforts to 
veterans and the quality of VA health care delivery.

Sec. 101. Waiver of Collection of Copayments for Telehealth and 
        Telemedicine Visits of Veterans.

    Section 101 of the Committee bill, derived from S. 3325 as 
introduced, would waive the collection of copayments from 
veterans for telehealth and telemedicine visits.
    Background. For purposes of providing greater access to 
care and reducing the amount of travel required for patients, 
especially in rural areas, VA delivers care through telehealth 
modalities such as telephone consultations, videoconferencing, 
and use of robotic technology. Telehealth visits can be made 
from patient homes or community-based outpatient clinics.
    In December 2008, Adam Darkins, MD, VA Office of Care 
Coordination Services, spearheaded a study entitled, ``Care 
Coordination/Home Telehealth: The Systematic Implementation of 
Health Informatics, Home Telehealth, and Disease Management to 
Support the Care of Veteran Patients with Chronic Conditions.'' 
That study found that VA patients using home telehealth 
experienced a 19 percent reduction in hospitalizations and a 25 
percent reduction in days hospitalized. A RAND Corporation 
study, ``Health Insurance and the Demand for Medical Care'' 
(Manning et al, 1988), found that copayment rates were highly 
influential on the likelihood that an enrollee would use any 
medical care. Under current law, VA charges full copayments for 
care delivered through telehealth technologies. Currently, VA 
patients are charged fifteen dollars for primary care 
telehealth visits and fifty dollars for specialty care 
telehealth visits.
    Committee Bill. Section 101 of the Committee bill would add 
a new section 1722B to title 38, United States Code. New 
section 1722B, entitled ``Copayments: waiver of collection of 
copayments for telehealth and telemedicine visits of 
veterans,'' would prohibit VA from collecting any copayments 
for a veteran's utilization of telehealth or telemedicine. The 
new section 1722B would contain a five-year sunset on the 
waiver of these copayments, and would require the Secretary to 
report to the Committees on Veterans' Affairs of the Senate and 
of the House of Representatives on whether the waiver of such 
copayments has resulted in higher utilization of telehealth by 
veterans, and on the costs or savings realized by the 
Department as a result of the waiver of such copayments.

Sec. 102. Program of Outreach to Veterans.

    Section 102 of the Committee bill, which is derived from 
S. 3314 as introduced, would require the Secretary to carry out 
a program of outreach to veterans who reside in a region served 
by one of the Federally chartered regional commissions or 
authorities, as well as other non-Federally chartered 
development boards or authorities, and would authorize the 
Secretary to partner with such a commission or authority in 
order to carry out the required program of outreach.
    Background. There are seven Federally chartered regional 
commissions or authorities: the Appalachian Regional 
Commission, established in 1965 by Public Law 89-4; the Delta 
Regional Authority, established in 1988 by Public Law 100-460; 
the Northern Great Plains Regional Authority, established in 
1994 by Public Law 103-318; the Denali Commission, established 
in 1998 by Public Law 105-277; the Southeast Crescent Regional 
Commission, established in 2008 by Public Law 110-246; the 
Southwest Border Regional Commission, established in 2008 by 
Public Law 110-246; and the Northern Border Regional 
Commission, established in 2008 by Public Law 110-246.
    These commissions are regional economic development 
entities that represent a partnership of federal, state, and 
local governments and are intended to coordinate the efforts of 
agencies and community organizations to promote economic 
development and infrastructure improvements in certain 
underdeveloped or economically distressed areas. A 2005 study 
by Ohio University's Appalachian Rural Health Institute found 
that:

        Residents living in the ARHI project counties have 
        health access problems related to availability of 
        medical resources, especially health care providers and 
        medical specialists * * *. Constraints to obtaining 
        medical care related to access also include personal 
        perceptions related to family traditions, cultural 
        traits, and individual motivation * * *. Rural 
        residents could benefit from the formation of 
        collaborative partnerships with local agencies, 
        institutions, and health care providers, faculty and 
        researchers from academia, and consider possibilities 
        of multi-county coalitions.

    At a Committee field hearing on April 5, 2010, in Cambridge 
Ohio, Richard W. Greenlee, MSW, PhD, Associate Professor of 
Social Work and Dean of Ohio University Eastern Campus, stated:

        Military veterans have been found to be less likely 
        than the general population to seek mental health 
        services due to perceived stigma (Hoge, Castro, Messer, 
        McGurk, Cotting, & Koffman, 2004). Combine this with 
        the Appalachians' resistance to seeking mental health 
        treatment or help of any kind (Behringer and Friedell, 
        2006), and the combination of the two cultures, one 
        military, the other regional affiliation, and it is 
        highly unlikely that Appalachian veterans will 
        voluntarily seek help for depression, anxiety or post 
        traumatic stress disorder that they may be experiencing 
        upon returning home from the service.

    There are other regions that have similar socio-economic 
characteristics to Appalachia, and consequently have poor 
access to, and low utilization of, health care. On June 16, 
2010, at a Committee hearing on rural health, Dan Winkelman, 
Vice President for Administration and General Counsel of the 
Yukon-Kuskokwim Health Corporation, described remote western 
Alaska as a region faced with an unemployment rate of over 20 
percent, an average per capita income of $15,000, and where 
over 6,000 homes do not have access to safe drinking water. He 
stated:

        This is the environment where many Alaska Native 
        veterans were born and raised and then return to after 
        serving our great Country. For Alaska Native/American 
        Indian veterans, who serve at the highest per capita 
        rate of any U.S. race, to lack access upon their return 
        from duty to culturally appropriate and quality health 
        care services by the Veterans Administration (VA) is a 
        shame. In Alaska, highly rural veterans must break 
        through several barriers in order to receive care. 
        There are almost no VA facilities in rural Alaska. The 
        existing IHS and tribal facilities, managed by tribal 
        health organizations like YKHC, are underfunded 
        according to the IHS by approximately 50 percent.

    Committee Bill. Section 102 of the Committee bill would 
require the Secretary to carry out a program of outreach for 
veterans who reside in a region served by one of the Federally 
chartered regional commissions or authorities, as well as other 
non-Federally chartered development boards or authorities 
located in areas that are severely economically distressed or 
face unusual economic challenges, such as areas separated from 
the mainland United States. In carrying out this program of 
outreach, the Secretary would be authorized to partner with 
such commissions or authorities. The program would be required 
to increase veterans' awareness of, access to, and use of 
benefits and services for which they are eligible. The 
commissions would be authorized to provide technical 
assistance, award grants, or enter into contracts with 
individuals or entities in their respective region for these 
purposes. The Department would be authorized to enter into 
agreements with Federal, State, or local agencies to achieve 
these purposes. There would be a five-year sunset on the 
program of outreach, and the Secretary would be required to 
provide a comprehensive report to the Committees on Veterans' 
Affairs of the Senate and of the House of Representatives on 
the Department's outreach activities and the efficacy of those 
activities. This program would be authorized to receive 
appropriations of an amount not to exceed $7 million in the 
first year and of an amount not to exceed $35 million over five 
years.

Sec. 103. Annual Report on Low Volume Procedures Involving Use of 
        Radioactive Isotopes at Department of Veterans Affairs Medical 
        Facilities.

    Section 103 of the Committee bill, which is derived from 
S. 3330 as introduced, would require the Department to submit 
an annual report to Congress on low volume procedures that 
involve the use of radioactive isotopes, at each medical 
facility.
    Background. On May 5, 2008, a patient of the Philadelphia 
VAMC (hereinafter, ``PVAMC'') underwent prostate brachytherapy 
in treatment for prostate cancer. Brachytherapy is a procedure 
in which radioactive metal seeds are implanted in a patient in 
order to kill cancerous cells. The patient was implanted with 
radioactive seeds of the wrong strength, and this error was not 
discovered until seven days later. An Office of Inspector 
General (hereinafter, ``OIG'') investigation, published on May 
3, 2010 (hereinafter, ``the report''), found that several 
patients at PVAMC were implanted with radioactive seeds of 
incorrect strength resulting in patients receiving a dose lower 
than was prescribed by the oncologist. This event triggered a 
comprehensive review of PVAMC's entire brachytherapy program by 
the Veterans Health Administration's (hereinafter, ``VHA'') 
National Health Physics Program (hereinafter, ``NHPP''), the 
entity to which the U.S. National Regulatory Commission 
(hereinafter, ``NRC'') delegates responsibility for providing 
regulatory oversight of VA nuclear medicine.
    NHPP found that of the 114 patients who underwent prostrate 
brachytherapy at PVAMC, 97 experienced what are considered 
``medical events'' wherein either patients received underdosing 
to the prostrate, or, overdosing to non-prostatic tissue. On 
June 29, 2009, the Committee held a field hearing in 
Philadelphia, Pennsylvania to examine the PVAMC cancer 
treatment program. Ultimately, VA suspended the PVAMC's 
prostrate brachytherapy program, and a $227,500 fine was levied 
against the facility by the NRC, the second largest fine ever 
imposed by NRC to that date.
    Committee Bill. Section 103 of the Committee bill would 
require the Department to submit an annual report for three 
years, beginning not later than 270 days after the enactment of 
the legislation, on low volume procedures involving the use of 
radioactive isotopes carried out in such year, at each medical 
facility.
    For purposes of this section, the Secretary would establish 
a minimum threshold for each type of procedure involving 
radioactive isotopes, carried out at Department facilities. A 
``low volume procedure'' would be defined as a procedure 
performed on fewer patients than the minimum threshold 
prescribed by the Secretary. It is the Committee's intent that 
in making such determination, the Secretary may consider the 
minimum number of procedures of a specific type that a provider 
must carry out annually to be considered competent in that 
procedure. Each annual report would be required to include 
evaluations of and findings regarding low volume procedures 
involving radioactive material, and how to incorporate 
consideration of such procedures in quality assurance plans at 
the facility level.

Sec. 104. Use of Radioactive Isotopes at Department of Veterans Affairs 
        Hospitals.

    Section 104 of the Committee bill, which is derived from 
S. 3330 as introduced, would require all employees who handle 
or perform procedures utilizing radioactive isotopes at a VA 
facility to receive appropriate training on what constitutes a 
medical event.
    Background. VHA holds a Master Materials License issued by 
NRC. VA administers its nuclear medicine program under the 
authority of that license. Although VA establishes its own 
procedure for how and when a physician will measure the 
radiation dose given to a patient, it is the NRC's 
responsibility to ensure patients receive the physician's 
intended dose of radiation. Though VA has the authority and 
responsibility to ensure proper quality management and safety 
in using radioactive materials in medical treatment, the 
Department is also responsible for reporting medical events to 
the NRC. In the May 3, 2010 report OIG found a number of 
concerns on the part of both VA and NRC with respect to the 
operating definition of a ``medical event,'' and recommended VA 
and NRC senior leadership work to resolve these discrepancies.
    Committee Bill. Section 104 of the Committee bill would 
require every employee, including those hired under a contract 
with a non-government entity, who handles or performs 
procedures involving radioactive material, to receive 
appropriate training on the definition of a medical event, and 
when and to whom such a medical event should be reported. Under 
this section, should the Secretary find that a facility has 
failed to provide the required training to any employee, that 
employee would be barred from using radioactive isotopes until 
the training is completed.
    It is the Committee's intent to ensure all VA employees 
involved in any procedure involving radioactive materials are 
aware of what constitutes a medical event, as a safeguard to 
ensure that any future adverse outcomes for procedures 
involving radioactive isotopes are detected and resolved in a 
timely and efficient manner.

Sec. 105. Requirements Relating to Contracts for the Provision of 
        Medical Services.

    Section 105 of the Committee bill, which is derived from 
S. 3330 as introduced, would provide further oversight of 
medical services provided by contractors.
    Background. Radiation therapy services have been provided 
by the University of Pennsylvania Health System (hereinafter, 
``UPHS'') to PVAMC since 1996. The first contract was awarded 
in May 1996 for one year with an additional two option years. 
However, OIG found that PVAMC paid UPHS for radiation therapy 
services from May 1999 to April 2005 without a contract or 
other agreement authorizing payment for such services, and from 
April 2005 through 2009, PVAMC paid UPHS for radiation therapy 
services under an Interim Agreement that violated VA policy 
limits on the length and extensions of contracts, as mandated 
in VA Directive 1663.
    OIG also found that, ``quality management processes 
pertaining to PVAMC's practice of prostrate brachytherapy were 
deficient,'' and that, ``from 2002 to 2006, no peer review or 
quality assessments took place at PVAMC for prostrate 
brachytherapy.'' OIG also found that, from November 2006 to 
November 2007, PVAMC experienced an information technology 
failure where brachytherapists were unable to perform a 
standard post-operative computed tomography scan so as to 
measure the amount of radiation given to the patient in order 
to ensure the procedure was properly performed. The OIG 
identified similar quality management deficiencies in other VHA 
brachytherapy programs as well. After a national assessment of 
VHA prostate brachytherapy programs, such programs were 
suspended at the Washington, DC VAMC in September 2008, the 
Philadelphia VAMC in June 2008, and the Jackson VAMC in 
September 2008, due to possible under-dosing of radiation. In 
October 2008, the program at the Cincinnati VAMC was suspended 
as well but was subsequently approved to restart in February 
2010.
    Committee Bill. Section 105 of the Committee bill would add 
a new section 1703A to title 38, United States Code, entitled 
``Oversight of medical services provided by contractors.'' This 
new section would require that Department quality management 
include oversight of medical services provided under contracts 
with non-government entities. Such oversight would include 
periodic peer reviews, periodic written evaluations by 
supervisors of the individual providing services, and any other 
evaluation the Secretary deems necessary. The Secretary would 
also be required to gather and analyze data on the quality of 
medical services provided under contract at every Department 
facility and any Department contracting officer would be 
required to consider such data prior to extending or renewing a 
contract, 270 days after enactment of the legislation. The 
Committee expects that the collection of detailed information 
at this level of specificity will help avoid a similar future 
incident.

Sec. 106. Conversion of Multifamily Transitional Housing Loan Program 
        to Loan Issuance Program.

    Section 106 of the Committee bill, which is derived from 
S. 3377 as introduced, would improve the multifamily 
transitional housing loan program of the Department by 
requiring the Secretary to issue loans for the construction of, 
rehabilitation of, or acquisition of land for multifamily 
transitional housing projects.
    Background. In section 601 of Public Law 105-368, the 
Veterans Programs Enhancement Act of 1998, Congress authorized, 
under subchapter VI of chapter 20 of title 38, the Loan 
Guarantee for Multifamily Transitional Housing Program. Under 
this program VA was authorized to guarantee up to 15 secured 
loans with an aggregate dollar amount of $100 million to 
develop transitional housing with onsite supportive services 
for homeless veterans. In 1999, Public Law 106-74, the 
Departments of Veterans Affairs and Housing and Urban 
Development, and Independent Agencies Appropriations Act of 
2000 provided $48 million in appropriations for the original 
loan guarantee program. Because only one loan has been 
guaranteed since the program's inception, most of that funding, 
approximately $43 million, remains available for obligation.
    The Loan Guarantee for Multifamily Transitional Housing 
Program was designed to encourage lenders to make low-interest 
loans, backed by a VA guarantee, available to homeless 
providers for the acquisition, construction, and improvement of 
transitional housing units. Only one provider, St. Leo Campus 
for Veterans in Chicago, Illinois, operated by Catholic 
Charities, received a VA-backed housing loan.
    St. Leo Campus has been faced with numerous operational 
challenges that are typical for a provider servicing the 
homeless population. What exacerbates the challenge is the 
rigidity of the original VA loan program. Without flexibility 
in loan terms and conditions, St. Leo Campus struggles to make 
ends meet, which has brought into question the sustainability 
of the project. To provide the necessary services to homeless 
veterans, St. Leo Campus has relied on one-time grants and 
donations which, in a difficult economy, are a highly volatile 
source of revenue. Flexibility in the terms of its VA loan 
would give St. Leo Campus and other homeless providers a chance 
to weather cyclical funding challenges.
    In 2009, VA terminated the Loan Guarantee for Multifamily 
Transitional Housing Program pursuant to a recommendation made 
in the 2008 Annual Report of its Advisory Committee on Homeless 
Veterans. However, prior to terminating the program, VA issued 
a report detailing how the program might be modified and made 
more attractive to providers. The Committee bill tracks the 
recommendations made in VA's report.
    Committee Bill. Section 106 of the Committee bill would 
transform the program under subchapter VI of chapter 20 of 
title 38 from a loan guarantee program to a program that 
actually issues loans. As a result, the title of this 
subchapter would be amended to read ``Multifamily Transitional 
Housing.'' Although this transformation of the program would 
not affect the validity of any loan guaranteed before the date 
of the enactment, it would prohibit, under subsection (a)(3) of 
section 106, the Secretary from guaranteeing any loans under 
this program from that date forward.
    As part of the new loan issuing program, section 106 would 
create a revolving fund, under subsection (b), which would 
serve as the source of loans under the new authority. The 
assets of the new revolving fund would consist of all amounts 
received by the Secretary from operations relating to the 
issuance of loans under this program. These amounts include, 
among other things, any fees imposed on a loan recipient under 
any provision of law or regulation which is established by the 
Secretary. The revolving fund would also include all amounts 
previously appropriated for the loan guarantee program. This 
would allow the Secretary to access and utilize the $43 million 
remaining from the terminated loan guarantee program to fund 
new issued loans.
    In addition, section 106 would make improvements to the 
terms and conditions of the loan program. These improvements 
would give the Secretary greater flexibility in the types of 
loans VA may offer and the conditions attached to repayment. 
Subsection (a)(2) of section 106 would authorize the Secretary 
to delegate loan approval to a State or local government 
entity. Subsection (c) of section 106 would allow the Secretary 
to consider reasonable terms and conditions of the loan to 
include payment deferral, forbearance, and debt forgiveness. 
Subsection (d) of section 106 would clarify that projects 
financed with a VA loan may include space for job training 
programs, other types of residential units, neighborhood retail 
or other commercial activities, or other uses that the 
Secretary determines necessary for the sustainability of the 
multifamily transitional housing projects. Subsection (e) of 
section 106 would give VA the authority to sell, rent, operate, 
or otherwise dispose of a multifamily transitional housing 
project in the event of default. Lastly, subsection (f) of 
section 106 would preempt any Federal, State, or local housing 
statute that limits a project from offering preferential 
treatment to veterans.

Sec. 107. Report on Establishment of a Polytrauma Rehabilitation Center 
        or Polytrauma Network Site of the Department of Veterans 
        Affairs in the Northern Rockies or Dakotas.

    Section 107 of the Committee bill, which is derived from 
S. 3035 as introduced, would require a report on the 
feasibility and advisability of establishing a VA polytrauma 
rehabilitation center (hereinafter, ``PRC'') or polytrauma 
network site in the northern Rockies or Dakotas.
    Background. Polytrauma refers to the cumulative state of 
health resulting from exposure to a single event which has 
caused multiple and complex injuries. Such injuries can impact 
the brain, limbs, spinal cord, and musculoskeletal system, and 
in turn, can adversely affect hearing, vision, and cognition.
    The VA Polytrauma System of Care provides treatment to 
veterans with polytrauma through four PRCs, located in Palo 
Alto, Tampa, Richmond, and Minneapolis, which offer 
comprehensive inpatient and outpatient treatment. A fifth PRC 
is, as of the date of this report, being constructed at the 
VAMC in San Antonio, Texas. There are also 22 polytrauma 
network sites which provide a full range of comprehensive 
follow-on medical and rehabilitative services, both inpatient 
and outpatient. This system of care covers most of the nation; 
however, according to testimony the Committee received during a 
May 5, 2010 hearing on VA care for traumatic brain injury 
(hereinafter, ``TBI''), there is a gap in availability of care 
in the northern Rockies and Dakotas, an area that encompasses 
approximately 740,000 square miles.
    An April 2008 RAND Corporation study estimated that 320,000 
veterans may have suffered brain injuries, from mild 
concussions to severe wounds, and that 57 percent of those who 
reported experiencing a probable TBI were never evaluated by a 
physician. Veterans with severe polytrauma who do not live in 
proximity of a polytrauma care presence face difficulties in 
receiving necessary treatment. In testimony before the 
Committee, Karen Bohlinger, Second Lady of Montana, testified 
that she had to fly from Montana to Seattle, Washington every 
ten days, at personal expense, in order to follow up on care 
for her son, an Army Special Forces officer who had sustained a 
TBI. She further testified that there were insufficient 
Department resources in Montana that would have allowed her son 
to be treated close to their home.
    Committee Bill. Section 107 of the Committee bill would, in 
a freestanding provision, require the Secretary to conduct a 
study and report to the Congress, within 180 days after 
enactment, on the feasibility and advisability of establishing 
a PRC or polytrauma network site in the northern Rockies or 
Dakotas. This section would specify that the Fort Harrison VAMC 
be one of the sites evaluated for potential placement of a PRC 
or a polytrauma network site.
    The report would be required to include an assessment of 
the adequacy of existing services provided at Department 
facilities, and of the availability of the types of services 
that would otherwise be provided by a PRC or polytrauma network 
site. The report would also be required to include a 
comparative assessment of the effectiveness of TBI 
rehabilitation programs in urban versus rural settings, an 
assessment of whether the low cost of living in the region 
could reduce the financial burden on families of a veteran 
undergoing TBI care and thereby improve that care, and whether 
any stress caused by living in an urban area can impede 
therapies to prevent or remediate the development of secondary 
neurologic conditions related to TBI. The Department would be 
required to consult with State and local government entities in 
preparing this report.

Sec. 108. One-Stop Internet Website for Information on Benefits, 
        Resources, Services, and Opportunities for Veterans and their 
        Families and Caregivers.

    Section 108 of the Committee bill, which is derived from 
S. 3355 as introduced, would authorize the Secretary to 
establish an Internet website for information on benefits, 
resources, services, and opportunities for veterans and their 
families and caregivers.
    Background. Currently, VA's website and other related sites 
have a wealth of information regarding the benefits for which 
veterans may be eligible, including health care services, 
education and employment assistance, pension, home loan 
guaranties, and life insurance. While an extensive array of 
benefits and services are available to veterans, there is no 
single-source information repository that veterans can use to 
easily find information on the benefits and services for which 
they may be eligible, or how to access such benefits and 
services. As veterans of Operation Enduring Freedom and 
Operation Iraqi Freedom (hereinafter, ``OEF and OIF'') return 
home, it is important that the Department help ease their 
transition and assist them in adapting to civilian life.
    Committee Bill. Section 108 of the Committee bill would, in 
a freestanding provision, authorize the Secretary to create an 
interactive, comprehensive internet website to provide 
information on benefits, resources, services, and opportunities 
for veterans and family members. It is the Committee's 
expectation that such a website be user-friendly and increase 
interoperability and the sharing of information.
    This information would be required to include benefits 
provided by the Department, the Department of Labor, the Small 
Business Administration, as well as tax and social security 
benefits. Additionally, the website would be required to 
include information on resources for families, caregivers, 
education and mental health professionals, and others that 
provide services for veterans. Information on child care, home 
care, stress management, mental health care, discounts, 
volunteer opportunities, and community events, as well as links 
to state and local resources and veterans service organizations 
would also be required to be included. Finally, the website 
would be required to assist veterans and family members in 
applying for and receiving these benefits.
    In implementing this section, the Secretary would be 
required to consult with the Secretary of Defense, the 
Secretary of Labor, the Secretary of Education, the 
Commissioner of Internal Revenue, the Commissioner of Social 
Security, the Administrator of the Small Business 
Administration, other Federal officials, appropriate advisory 
committees, and other appropriate individuals. Additionally, 
the Secretary would both report on the status and impact of the 
website, in the Department's biennial plan for outreach, as 
mandated by Public Law 109-233.
    It is the Committee's intent that such a website be 
functionally similar to the Military One-Source website of the 
Department of Defense, and that it would serve as a single, 
all-inclusive source of information on, or references to 
information on, benefits, resources, services, and 
opportunities for veterans, and their families and caregivers.

               TITLE II--CONSTRUCTION AND NAMING MATTERS

    Title II of the Committee bill contains a variety of 
provisions that are designed to provide authorization for both 
leases and the construction of Department medical facilities.

Sec. 201. Authorization of fiscal year 2011 major medical facility 
        construction projects previously appropriated but not 
        authorized.

    Section 201 of the Committee bill would authorize the 
Secretary to carry out the construction of a new major medical 
facility project in New Orleans, Louisiana for which some 
funding has been appropriated but for which only $300,000,000 
was authorized in Public Law 109-461.
    Background. The VAMC in New Orleans, Louisiana sustained 
catastrophic damage as a result of Hurricane Katrina. The 
facility was closed and a system of leased clinics was created 
to continue the provision of outpatient services, while 
surgical procedures and inpatient care are purchased through 
local providers or referred to VA facilities outside of New 
Orleans. The proposed project would be a tertiary care medical 
complex that would reestablish a full continuum of medical 
services, including acute and long-term inpatient beds, primary 
care, mental health, specialty care, surgical capabilities, 
expanded treatment, diagnostic, and ancillary services, and a 
parking structure, all in compliance with hurricane hardening 
and federal security standards.
    This project received $75,000,000 of budget authority in 
fiscal year 2006 through the Department of Defense, Emergency 
Supplemental Appropriations to Address Hurricanes in the Gulf 
of Mexico, and Pandemic Influenza Act, 2006, Public Law 109-
148, and an additional $550,000,000 through the Emergency 
Supplemental Appropriations Act for Defense, the Global War on 
Terror, and Hurricane Recovery, 2006, Public Law 109-234.
    Committee Bill. Section 201 of the Committee bill would 
authorize appropriations of an amount not to exceed 
$995,000,000 to construct a new major medical facility in New 
Orleans, Louisiana.

Sec. 202. Additional authorization for a 2007 major medical facility 
        construction project previously authorized.

    Section 202 of the Committee bill would authorize the 
Secretary to carry out seismic corrections for Buildings 7 and 
126 at the Long Beach, California VAMC.
    Background. The Long Beach, California Seismic Corrections 
for Buildings 7 and 126 project would involve the seismic 
upgrade and modernization of two seismically deficient 
buildings at the Long Beach VAMC. These buildings would house 
the pharmacy and multiple specialty medical and surgical 
outpatient clinics in line with the projected growth in 
outpatient demand and consolidate administrative, support 
service, and research administration staff in a single 
building. This project will also create a 24-bed Blind 
Rehabilitation Center adjacent to the Spinal Cord Injury 
Center.
    This project received $51,700,000 of budget authority in 
fiscal year 2001 through the Veterans Benefits and Health Care 
Improvement Act of 2000, Public Law 106-419; an additional 
$10,300,000 of budget authority in fiscal year 2004 through the 
Veterans Health Care, Capital Asset, and Business Improvement 
Act of 2003, Public Law 108-170; and an additional $107,800,000 
of budget authority in fiscal year 2007 through the Veterans 
Benefits, Health Care, and Information Technology Act of 2006, 
Public Law 109-461.
    Committee Bill. Section 202 of the Committee bill would 
authorize an amount not to exceed $129,545,000 to conduct 
seismic corrections at the VAMC in Long Beach, California.

Sec. 203. Authorization of fiscal year 2011 major medical facility 
        leases.

    Section 203 of the Committee bill would authorize five 
leases for fiscal year 2011: a community based outpatient 
clinic (hereinafter, ``CBOC'') in Billings, Montana; an 
outpatient clinic in Boston, Massachusetts; a CBOC in San 
Diego, California; a research laboratory in San Francisco, 
California; and a mental health facility in San Juan, Puerto 
Rico.
    Background. Section 8104 of title 38, United States Code 
requires authorization of any major medical facility 
construction project or lease. The Department has requested 
authorization for five pending leases in order to improve 
health care. The existing Billings CBOC is facing significant 
space shortages. According to the Department, expansion would 
enable the clinic to provide more comprehensive outpatient 
services and would allow veterans to get medical treatment 
locally rather than traveling to the Fort Harrison VAMC.
    The Boston, Massachusetts replacement outpatient clinic 
lease would address the significant space shortage at the 
existing clinic and allow space for growing primary care and 
mental health programs.
    The Administration has indicated that the San Diego, 
California replacement CBOC would enhance existing outpatient 
services by housing newly created programs such as a women's 
health clinic, blind services, dental services, and ambulatory 
surgery. It would also consolidate services into a single, 
larger location, closer to where veterans reside.
    The San Francisco VAMC houses VA's largest research program 
but its facilities are deficient in terms of available space 
and compliance with VA's seismic safety policy. The Department 
determines the amount of space needed for research programs 
based on the amount of grant dollars awarded. Using that 
analysis, VA estimates a need for approximately 400,000 square 
feet of research space at the San Francisco VAMC. The proposed 
50,000 square foot lease would not entirely resolve the current 
shortfall in space, but would help alleviate some of the 
pressure.
     The San Juan, Puerto Rico VAMC currently lacks a mental 
health residential rehabilitation treatment program and a 
psychosocial residential rehabilitation center. Both programs 
are integral to assist veterans in transitioning between 
inpatient and outpatient services and the community. Veterans 
who need services from either program are currently referred to 
other VISN 8 facilities in the continental United States, where 
they sometimes lack the family support and linguistic fluency 
to fully profit from the programs. VA's proposed lease will 
allow the Department to provide more comprehensive care for the 
veterans who live in Puerto Rico.
    Committee Bill. Section 203 of the Committee bill would 
authorize the lease of a replacement outpatient clinic in 
Billings, Montana. The new clinic will support the parent 
facility at the Fort Harrison VAMC through the acquisition of 
approximately 70,000 net usable square feet of clinical space. 
The Committee bill would fully authorize the lease in the 
amount of $7,149,000.
    The Boston, Massachusetts replacement outpatient clinic 
lease will support the Boston VA Health Care System through the 
lease of approximately 29,000 net usable square feet of 
clinical space. The Committee bill would fully authorize the 
lease in the amount of $3,316,000.
    The San Diego, California replacement CBOC lease will 
support the parent facility at the San Diego VAMC through the 
lease of approximately 164,000 net usable square feet for a 
replacement CBOC. The Committee bill would fully authorize the 
lease in the amount of $21,495,000.
    The San Francisco, California Biomedical Research Complex 
lease would consist of approximately 50,000 net usable square 
feet for wet labs and research space. This would partially 
alleviate the San Francisco VAMC's space shortage. The 
Committee bill would fully authorize the lease in the amount of 
$10,055,000.
    The San Juan, Puerto Rico Mental Health Residential and 
Psychosocial Rehabilitation Program lease will provide an 
approximately 52,000 net usable square foot facility that will 
house 40 beds and will provide a smoother transition from 
treatment back to the community. The Committee bill would fully 
authorize the lease in the amount of $5,323,000.

Sec. 204. Authorization of appropriations.

    Section 204 of the Committee bill would authorize 
appropriations for the projects authorized in sections 201 
through 203 of the Committee bill.
    Committee Bill. Section 204 of the Committee bill would 
authorize an appropriation for fiscal year 2011 of 
$1,124,545,000 from the Construction, Major Projects account 
for projects authorized in sections 201 and 202 of the 
Committee bill. It would also authorize an appropriation for 
fiscal year 2011 of $47,338,000 from the Medical Facilities 
account for the leases authorized in section 203 of the 
Committee bill.

Sec. 205. Report on use of energy efficient technologies and best 
        practices in Department of Veterans Affairs medical facilities.

    Section 205 of the Committee bill would require the 
Secretary to submit a report to Congress on the use of energy 
efficient technologies and best practices in Department 
facilities.
    Background. On October 5, 2009, President Obama signed 
Executive Order 13514, ``Federal Leadership in Environmental, 
Energy, and Economic Performance,'' which expanded on energy 
reduction and ecological performance requirements contained in 
Executive Order 13423, ``Strengthening Federal Environmental, 
Energy, and Transportation Management.'' Executive Order 13514 
establishes targets for federal agencies regarding 
accountability and transparency, strategic sustainability 
performance planning, greenhouse gas management, sustainable 
buildings and communities, water efficiency, electronic 
products and services, fleet and transportation management, and 
pollution prevention and waste reduction. Such key targets 
include reducing government-wide greenhouse gas emissions by 28 
percent by 2020 and for agency sustainability plans to be 
released in August 2010.
    Committee Bill. Section 205 of the Committee bill would 
require the Secretary to submit a report to Congress regarding 
the use of energy efficient technologies and best practices in 
VA medical facilities. The report would include a description 
of the technologies and best practices the Department currently 
employs to make facilities more energy efficient; an assessment 
of the energy efficiency of VA medical facilities' heating, 
ventilation, air conditioning systems, lighting, elevators, 
water heating, information technology and electronics, and any 
other features related to energy efficiency the Secretary deems 
appropriate; and, a description of the Department medical 
facilities' compliance with current law, as it relates to 
energy efficiency. The Secretary would be required to 
collaborate with private sector experts and industry leaders in 
energy efficiency, such as the American Society of Heating, 
Refrigeration, and Air-Conditioning Engineers, the Illuminating 
Engineering Society of North America, and the American 
Institute of Architects, in developing the report.

Sec. 206. Designation of George H. O'Brien Jr., Department of Veterans 
        Affairs Medical Center.

    Section 206 of the Committee bill, which is derived from 
S. 2751 as introduced, would designate the Department of 
Veterans Affairs medical center in Big Spring, Texas, as the 
George H. O'Brien, Jr., Department of Veterans Affairs Medical 
Center.
    Background. George H. O'Brien, Jr. served as a seaman in 
the United States Merchant Marine from December 1944 until May 
1946. In July 1946, while attending college at Texas Technical 
College (now known as Texas Tech University), he enlisted in 
the United States Marine Corps Reserve. After graduating 
college in 1950, he was ordered to active duty and served in 
the Korean War until September 1952. He was awarded the Medal 
of Honor for his heroic actions during the Battle of the Hook 
on October 27, 1952, as detailed in the citation accompanying 
his award. He also received the Purple Heart Medal with gold 
star in lieu of a second award, the Korean Service Medal with 
two bronze stars, and the United Nations Service Medal, among 
other military honors. After his active duty service, O'Brien 
began a career as a petroleum geologist in Texas, while serving 
on the Marine Corps Scholarship Foundation as well as in the 
Medal of Honor Society.
    Committee Bill. Section 206 of the Committee bill would 
name the VAMC in Big Spring, Texas the ``George H. O'Brien, 
Jr., Department of Veterans Affairs Medical Center.'' Since all 
members of the Texas Congressional delegation have expressed 
their support for naming this facility, in writing, and the 
Texas chapters of all veterans service organizations with 
national memberships of at least 500,000 individuals have 
endorsed this facility being named in honor of George H. 
O'Brien, this provision meets the Committee rules regarding the 
naming of Department facilities.

Sec. 207. Requirement that bid savings on major medical facility 
        projects of Department of Veterans Affairs be used for other 
        major medical facility construction projects of the Department.

    Section 207 of the Committee bill would require that bid 
savings from major medical facility projects be utilized for 
other major medical facility construction projects.
    Background. Due to a favorable bid environment, VA has been 
able to save money on several authorized major construction 
projects. As of May 2010, VA estimated that the Department 
would realize $103 million in bid savings from 12 major 
construction projects. It is the Committee's intent, given the 
importance of long-term planning and the size of the 
Department's construction backlog, that projects that have 
already been vetted and prioritized be funded accordingly.
    Committee Bill. Section 207 of the Committee bill would add 
a new section 8104(d) to title 38, United States Code. This 
section would require that, for any fiscal year, unobligated 
funds resulting from major medical facility project bid savings 
be obligated only for other major medical facility projects 
authorized for that fiscal year or a previous fiscal year.

                      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 Congressional Budget Office 
(hereinafter, ``CBO''), estimates that implementing the bill 
would cost $690 million over the 2011-2015 period, assuming 
appropriation of the specified and estimated amounts. CBO 
further estimates that enacting the bill would increase direct 
spending by $43 million over the 2011-2015 period as a result 
of reallocating funds, but would not increase budget authority 
or affect revenues. Enactment of the Committee bill would not 
affect receipts and though the Committee bill would affect 
state and local laws, it would have minimal effect on 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 6, 2010
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. 3325, the Veterans 
Telehealth and Other Care Improvements Act of 2010.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                      Douglas W. Elmendorf,
                                                          Director.

  Enclosure.

S. 3325--Veterans Telehealth and Other Care Improvements Act of 2010

    Summary: S. 3325 would authorize the construction, 
renovation, or leasing of several medical facilities and make 
other changes to health care programs offered by the Department 
of Veterans Affairs (VA). In total, CBO estimates that 
implementing the bill would cost $690 million over the 2011-
2015 period, assuming appropriation of the specified and 
estimated amounts. In addition, CBO estimates that enacting the 
bill would increase direct spending by $43 million over the 
2011-2020 period but would not affect revenues.
    Pay-as-you-go procedures apply because enacting the 
legislation would affect direct spending.
    S. 3325 contains an intergovernmental mandate as defined in 
the Unfunded Mandates Reform Act (UMRA) because it would 
preempt state and local laws. CBO estimates the cost of 
complying with the mandate would be small and would fall well 
below the threshold established in UMRA for intergovernmental 
mandates ($70 million in 2010, adjusted annually for 
inflation). S. 3325 contains no new private-sector mandates as 
defined in UMRA.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 3325 is shown in the following table. 
The costs of this legislation fall within budget function 700 
(veterans benefits and services).
    Basis of estimate: For this estimate, CBO assumes the 
legislation will be enacted in 2010, that the necessary amounts 
will be appropriated each year, and that outlays will follow 
historical patterns for similar and existing programs.


----------------------------------------------------------------------------------------------------------------
                                                            By fiscal year, in millions of dollars--
                                               -----------------------------------------------------------------
                                                   2011       2012       2013       2014       2015    2011-2015
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Medical Construction Projects
    Estimated Authorization Level.............        547         25         25         25         25        647
    Estimated Outlays.........................         65        162        187        145         71        630
Outreach
    Estimated Authorization Level.............          7          7          7          7          7         35
    Estimated Outlays.........................          7          7          7          7          7         35
Loss of Copayments for Telehealth and
 Telemedicine Programs
    Estimated Authorization Level.............          2          3          4          6          8         23
    Estimated Outlays.........................          2          3          4          6          8         23
Veterans' Resources Web Site
    Estimated Authorization Level.............          *          *          *          *          *          1
    Estimated Outlays.........................          *          *          *          *          *          1
Other Provisions
    Estimated Authorization Level.............          *          *          *          *          *          1
    Estimated Outlays.........................          *          *          *          *          *          1
                                               -----------------------------------------------------------------
      Total Changes
        Estimated Authorization Level.........        556         35         36         38         40        707
        Estimated Outlays.....................         74        172        198        158         86        690

                                           CHANGES IN DIRECT SPENDING

    Estimated Budget Authority................          0          0          0          0          0          0
    Estimated Outlays.........................          8          8          9          9          9         43
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000.

Spending subject to appropriation

    S. 3325 would authorize funding for the construction, 
renovation, or leasing of several medical facilities and make 
other changes in VA health care programs. In total, CBO 
estimates that implementing the bill would add $690 million to 
discretionary spending over the 2011-2015 period, assuming 
appropriation of the specified and estimated amounts.
    Medical Construction Projects. Title II would authorize 
funding to construct, renovate, or lease several medical 
facilities. CBO estimates that implementing those provisions 
would cost $630 million over the 2011-2015 period, assuming 
appropriation of the authorized and estimated amounts.
    Section 204 would authorize the appropriation of $995 
million to construct a new medical center in New Orleans, 
Louisiana and $130 million for seismic corrections at 
facilities in Long Beach, California. Public Laws 109-148 and 
109-234 provided $75 million and $550 million respectively to 
plan and construct the New Orleans facility. Based on VA's 
current estimated construction costs for that facility of $995 
million, CBO estimates that VA would require additional funding 
of $370 million for the New Orleans facility. Adding in the 
specified authorization of $130 million for the Long Beach 
facilities, CBO estimates a total authorization of $500 million 
for both projects; carrying out those projects would cost $485 
million over the 2011-2015 period, assuming appropriation of 
the authorized and estimated amounts.
    Section 204 also would authorize the appropriation of $47 
million for leasing five medical facilities. Based on 
information from VA's 2011 budget request for leasing medical 
facilities, CBO expects that VA would enter into 20-year lease 
agreements for those facilities. CBO estimates that in addition 
to the specified amounts authorized to be appropriated in 2011, 
VA would incur additional costs of $25 million a year starting 
in 2012. (Costs are higher in the first year than in other 
years because VA would pay up front for necessary 
improvements.) CBO estimates that entering into those leases 
would cost $145 million over the 2011-2015 period, assuming 
appropriation of the authorized and estimated amounts.
    Outreach. Section 102 would require VA to establish an 
outreach program designed to increase veterans' awareness of 
and access to federal, state, and local programs providing 
compensation and benefits to veterans. Section 102 also would 
allow VA to enter into agreements with federal and state 
agencies for that purpose. VA also would be authorized to enter 
into agreements with and to provide technical assistance and 
award grants to certain commissions and authorities. Those 
commissions and authorities include the Appalachian Regional 
Commission; the Delta Regional Authority; the Denali 
Commission; the Northern Great Plains Regional Authority; the 
Southeast Crescent, Southwest Border, and Northern Border 
Regional Commission; and certain nonfederally chartered 
entities that serve Native Americans, Alaska Natives, or native 
Hawaiians.
    Under this section, $35 million would be authorized over 
the 2011-2015 period to carry out those programs. CBO estimates 
that implementing section 102 would cost $35 million over the 
2011-2015 period, subject to appropriation of the necessary 
amounts.
    Loss of Copayments for Telehealth and Telemedicine 
Programs. Section 101 would prohibit VA from charging 
copayments to veterans for any telehealth or telemedicine 
consultations and would require VA to report to the Congress on 
the effects of that change. Under current law, VA charges 
copayments of $15 for primary care visits and $50 for specialty 
care visits. Based on information from the department, CBO 
estimates that in 2011 VA will have a workload of 60,000 such 
consultations for which it will receive $2 million in 
copayments. In recent years those programs have experienced a 
30 percent annual rate of growth in workload. Some of that 
growth represents new workload in terms of medical visits that 
would not have been made for reasons of distance or other 
difficulty in accessing VA care. The remainder of the growth is 
accounted for by veterans using telehealth and telemedicine in 
place of physical visits to a VA facility. CBO expects that 
eliminating the copayments for virtual visits will accelerate 
the shift from regular visits, which will still incur 
copayments. CBO estimates that implementing this provision 
would decrease collections by $2 million in 2011, growing to $8 
million by 2015.
    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 $23 
million over the 2011-2015 period, assuming appropriation of 
the necessary amounts.
    Veterans' Resources Web site. Section 108 would grant VA 
the authority to establish and maintain a Web site with the 
purpose of providing information and links from other Web sites 
referring to benefits, resources, services, and opportunities 
for veterans. VA would be required to consult with other 
federal agencies to determine a comprehensive list of benefits 
and links for veterans' benefits and resources. CBO assumes 
that VA would either hire an individual to develop and maintain 
the Web site or hire a contractor to do so; therefore, we 
estimate that implementing section 102 would cost $1 million 
over the 2011-2015 period, subject to appropriation of the 
necessary amounts.
    Other Provisions. Several sections of the bill, when taken 
individually, would increase spending subject to appropriation 
by less than $500,000 a year. Taken together, CBO estimates 
that implementing the following provisions would have a total 
cost of $1 million over the 2011-2015 period, assuming 
availability of appropriated funds:

     Section 103 would require an annual report on the 
use of radioactive isotopes at VA medical facilities.
     Section 104 would require certain training on the 
use of radioactive isotopes; CBO estimates that VA would be 
able to incorporate those requirements into existing training 
programs at minimal cost.
     Section 105 would require certain oversight of 
medical services provided by contractors; VA already complies 
with most of those requirements.
     Section 107 would require a report on the 
feasibility of establishing a polytrauma center in the northern 
Rockies or the Dakotas.
     Section 205 would require a report on the use of 
energy-efficient technologies in VA medical facilities.

Direct spending

    Section 106 would direct VA to provide up to five direct 
loans to help nonprofit organizations acquire, construct, 
modify, or rehabilitate transitional housing for veterans and 
their families. It also would establish the Multifamily 
Transitional Housing Loan Program Revolving Fund to cover the 
subsidy costs of those loans. (Transitional housing provides 
temporary lodging for homeless individuals and families, and is 
used in combination with services such as education, job 
training and placement, substance abuse counseling, and child 
care, to help residents transition to permanent housing.)
    The Veterans Programs Enhancement Act of 1998 (Public Law 
105-368) authorized VA to provide guaranteed loans for 
transitional housing and provided permanent, indefinite budget 
authority for the subsidy cost of those loans. Subsequently, 
the Department of Veterans Affairs and Housing and Urban 
Development, and Independent Agencies Appropriations Act, 2000 
(Public Law 106-74) provided $48 million in mandatory budget 
authority for the loan guarantees, of which $43 million remains 
available. The department has indicated that it will not use 
the remaining budget authority to guarantee any more loans for 
transitional housing because there are no applicants for the 
program. Section 106 would terminate the authority to guarantee 
loans and transfer the unobligated balances from the specific 
mandatory appropriation to the direct loan revolving fund.
    Because the guaranteed loan program is moribund, CBO 
expects no further outlays for that purpose under current law. 
Thus, new outlays would arise from authorizing VA to use the 
remaining budget authority to make direct loans.
    Section 106 would credit the repayments of principal and 
interest on the direct loans to the revolving fund, and make 
those amounts available for new direct loans, without further 
Congressional action. However, the concept of reusing loan 
repayments for new loans is inconsistent with the proper 
budgetary accounting of direct loans as specified in the 
Federal Credit Reform Act (FCRA). CBO estimates that 
redirecting those payments to a purpose other than retiring the 
debt for the original loan would increase the estimated subsidy 
costs of the loans to 100 percent of the face value of those 
loans.
    Under FCRA, projected cash flows associated with direct 
loans--such as disbursements of loan proceeds, collections of 
principal and interest repayments, and recoveries of amounts 
subsequent to any defaults--are discounted using the average 
interest rate on Treasury securities of similar maturity to the 
loan cash flows. The net present value of those cash flows is 
recorded as the subsidy cost of the loans.
    Repayments of loans are unavailable for spending and new 
loan obligations may be made only to the extent that new budget 
authority is provided in advance to cover anticipated credit 
subsidy costs. Thus, direct loan repayments are not available 
to ``revolve'' into new loans. Instead, such repayments are a 
means of financing the original loans, and the availability of 
repayments only for that purpose is implicit in the usual 
subsidy calculation. If principal and interest repayments are 
not returned to the Treasury, but are instead used for new 
loans, the net cost to the federal government is the total 
amount disbursed for the original loans.
    CBO expects that VA would use the amounts transferred to 
the revolving fund to issue one direct loan annually over the 
next five years. Outlays are recorded in the year in which the 
loan is disbursed; thus, enacting section 106 would increase 
direct spending by $43 million over the 2011-2015 period.
    Pay-As-You-Go Considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. S. 3325 would authorize VA to provide direct loans to 
organizations providing transitional housing to veterans. The 
net changes in outlays that are subject to those pay-as-you-go 
procedures are shown in the following table.


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                    By fiscal year, in millions of dollars--
                                                      --------------------------------------------------------------------------------------------------
                                                        2010   2011   2012   2013   2014   2015   2016   2017   2018   2019   2020  2010-2015  2010-2020
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                       NET INCREASE OR DECREASE (-) IN THE DEFICIT

Statutory Pay-As-You-Go Impact.......................      0      8      8      9      9      9      0      0      0      0      0       43         43
--------------------------------------------------------------------------------------------------------------------------------------------------------

Estimated impact on State, Local, and Tribal Governments

    S. 3325 contains an intergovernmental mandate as defined in 
UMRA because it would preempt state laws that prohibit certain 
transitional housing programs from offering preferential 
treatment to veterans. While the preemption would limit the 
application of state and local laws, it would impose no duty 
that would result in significant additional spending. 
Consequently, CBO estimates that the costs would fall well 
below the threshold established in the UMRA for 
intergovernmental mandates ($70 million in 2010, adjusted 
annually for inflation).

Estimated impact on the Private Sector

    S. 3107 contains no new private-sector mandates as defined 
in UMRA.

Previous CBO estimate

    On July 29, 2010, CBO transmitted an estimate for H.R. 
5226, the Appalachian Veterans Outreach Improvement Act, as 
ordered reported by the House Committee on Transportation and 
Infrastructure on July 1, 2010. Section 102 of S. 3325 contains 
language similar to that in H.R. 5226 but also includes 
additional commissions and agencies for VA to partner with in 
order to improve their outreach efforts in various regions. 
Also, S. 3325 would authorize specified amounts to implement 
the outreach efforts while H.R. 5226 would not. The estimates 
reflect those differences.
    Estimate prepared by: Federal Costs: VA Housing Loan 
Program--David Newman; VA Outreach Programs--Dwayne Wright; 
Other VA Programs--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.

                      Regulatory Impact Statement

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

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7 of rule XXVI of the Standing 
Rules of the Senate, the following is a tabulation of votes 
cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its August 5, 2010, meeting. On that date, 
the Committee ordered S. 3325, as amended, reported favorably 
to the Senate by voice vote with no dissent. One amendment was 
accepted by voice vote. The following senators were present: 
Mr. Rockefeller, Mrs. Murray, Mr. Sanders, Mr. Brown of Ohio, 
Mr. Webb, Mr. Tester, Mr. Begich, Mr. Burris, Mr. Specter, Mr. 
Burr, Mr. Isakson, Mr. Wicker, Mr. Johanns, Mr. Brown of 
Massachusetts, and Chairman Akaka.

                             Agency Report

    On May 19, 2010, Thomas J. Pamperin, Associate Deputy Under 
Secretary for Policy and Program Management, Veterans Benefits 
Administration, and Robert Jesse, MD, Acting Principal Deputy 
Under Secretary for Health, Veterans Health Administration, 
appeared before the Committee and submitted written testimony 
on various provisions of S. 3325 incorporated into the 
Committee bill. Pursuant to Mr. Pamperin's request to provide 
official views on additional legislation, enumerated below, 
Secretary Shinseki submitted additional views in writing to the 
Committee on July 29, 2010. Excerpts of the testimony and the 
additional views are reprinted below:

 STATEMENT OF THOMAS J. PAMPERIN, ASSOCIATE DEPUTY UNDER SECRETARY FOR 
 POLICY AND PROGRAM MANAGEMENT, VETERANS BENEFITS ADMINISTRATION, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

    Mr. Chairman, I am pleased to be here today to provide the 
Department of Veterans Affairs' (VA) views on pending 
legislation. Also testifying this morning is Dr. Robert Jesse, 
Acting Principal Deputy Under Secretary for Health, Veterans 
Health Administration, and accompanying us are Assistant 
General Counsels Richard J. Hipolit and Walter A. Hall.
    I will not be able to address a few of the bills on today's 
agenda because we did not have sufficient time to develop and 
coordinate the Administration's position and cost estimates, 
but with your permission we will provide that information in 
writing for the record. Those bills are S. 3286, S. 3314, 
S. 3325, S. 3330, S. 3348, S. 3352, S. 3355, S. 3367, S. 3368, 
S. 3370, and Senator Burr's draft bill to improve VA's 
multifamily transitional housing program. Similarly, for most 
of the bills that I will address on today's agenda, we request 
permission to provide cost estimates for the record at a later 
date.

           *       *       *       *       *       *       *


                                S. 3325

    S. 3325 would authorize VA to waive the imposition or 
collection of copayments for telehealth and telemedicine visits 
of Veterans. The mission of VA's Telehealth program office is 
to expand access to care for Veterans through telehealth 
technologies. Telehealth is a new modality of care. We believe 
it would be inappropriate to waive copayments for Veterans who 
receive telehealth services at a VA facility while Veterans who 
see their VA provider in person in the same facility would be 
charged a copayment.
    VA is examining the impact of copayments for care provided 
by video telehealth in a patient's home. A video consultation 
into the home is used to provide remote case management, health 
promotion/disease prevention, enhancement of patient self-
management, and early recognition of deleterious symptoms and 
signs of patient deterioration from chronic disease conditions. 
The use of video consultation into the home is analogous to 
that of telephone call for which no co-payment is required, and 
not comparable to a clinic visit.
    Recent VA experience demonstrates that co-payments for 
home-telehealth may have resulted in a reduced use of this 
intervention. To ensure convenient and cost-effective care to 
populations of patients who will otherwise delay care and incur 
larger costs from emergency room visits and hospital admissions 
VA will take the appropriate action to waive or modify 
copayments for in-home video telehealth care for Veterans. 
Because VA already has the authority to waive or modify the 
imposition of co-payments for such care, legislation is not 
required.
    VA estimates a revenue loss of $2 million in the first 
year, $17.7 million over 5 years and $83.4 million over 10 
years if VA stops collecting copayments for all telehealth 
visits.

           *       *       *       *       *       *       *


                                S. 3314

    S. 3314 would require VA and the Appalachian Regional 
Commission to jointly carry out a program of outreach to 
Veterans who reside in the Appalachian region for purposes of 
increasing access and use by Veterans of Federal, state, and 
local Veterans benefits programs and increasing awareness of, 
and eligibility for, such programs.
    VA supports the objective of improving outreach to Veterans 
and other potential claimants, but does not support this bill 
because it would mandate outreach to only one geographic area 
and because it is unnecessary in light of VA's ongoing efforts 
to provide outreach in this area.
    VA is currently making special efforts to provide medical 
care and access in the Appalachian region. Throughout the 
states and counties within this region, VA has set up an 
extensive and diverse array of rural initiatives, including 
Outreach Clinics, Community-Based Outpatient Clinics, expanded 
Care Coordination Home Telehealth initiatives, and the use of 
unscheduled Mobile Medical Units to perform assessments and 
physicals at events.
    VA has also taken aggressive steps to ensure awareness of 
the facilities, initiatives, and benefits available to 
Veterans. Examples include partnering with states such as 
Maryland to use unoccupied offices in rural areas to conduct 
mental health assessments and provide services; collaborating 
with rural community health centers, such as the community 
health center in Harrisonburg, Virginia, to increase enrollment 
and improve coordination of care; and activating rural health 
literacy outreach, such as in the Asheville, North Carolina, 
area, where events were held or scheduled in an area covering 
the 20 counties of Western North Carolina. This is only the 
beginning. VA plans to continue its outreach efforts to 
Veterans and their families in this region. Because of VA's 
substantial outreach efforts to Veterans in this region, we do 
not believe this bill is necessary and thus do not support it. 
However, VA would be happy to meet with the Committee to 
discuss the special needs of Appalachian Veterans.
    VA cannot estimate costs for this program without 
additional information because it is unclear to what extent VA 
would need to enter into contracts for the outreach that this 
bill would mandate.

           *       *       *       *       *       *       *


                                S. 3330

    S. 3330, the ``Veterans' Health and Radiation Safety Act of 
2010,'' would require VA to report to Congress annually on low-
volume programs (defined as programs that treat 100 patients or 
fewer annually) at VA medical facilities. The report would have 
to include the Secretary's evaluation and findings with respect 
to such programs. Additionally, S. 3330 would require employees 
working at VA hospitals where radioactive isotopes are used to 
receive training on recognizing and reporting medical events. 
Hospitals failing to provide this training would be prohibited 
from using radioactive isotopes for a period of time determined 
by the Secretary. Lastly, the bill would require VA to evaluate 
non-government medical services contractors through weekly 
independent peer reviews, written evaluations, and other 
evaluations VA determines are appropriate. A contracting 
officer would be required to review and consider the results of 
these evaluations before VA renews any contracts with non-
government medical services contractors.
    We are aware of a very unfortunate lapse that occurred at a 
brachytherapy program at one of our facilities. We testified 
about this incident before the House Committee on Veterans' 
Affairs on July 22, 2009. On May 3, 2010, the Office of the 
Inspector General (OIG) issued a report on this incident with 
five recommendations. Specifically, the OIG recommended that 
the Veterans Health Administration (VHA) standardize, to a 
practical extent, the privileging, delivery of care, and 
quality controls for the procedures required to provide this 
treatment. This has been accomplished. Standardized procedures 
have been developed, and site visits have verified that they 
are uniformly in place at all facilities and that steps have 
been taken to ensure that patients who received low radiation 
doses in the course of brachytherapy are evaluated to ensure 
that their cancer treatment plan is appropriate. We have 
contacted all Veterans who were potentially impacted for 
follow-up testing and monitoring at other VA and private 
facilities and are reviewing the controls that are in place to 
ensure that VA contracts for health care comply with applicable 
laws and regulations. Where necessary, we will make 
organizational and/or procedural changes to bring this 
contracting effort into compliance. A template that outlines 
basic requirements for all contracts is currently in 
development.
    The OIG also recommended that senior VA leadership meet 
with senior Nuclear Regulatory Commission leadership to 
determine if there is a way forward that will ensure the goals 
of both organizations are achieved. VA is currently working to 
arrange this meeting. Finally, the OIG recommended that VHA 
work with the OIG to develop a list of documents that should 
routinely be provided to the OIG when an outside agency is 
notified of a possible untoward medical event. VHA will work 
closely with the OIG to meet this recommendation.
    We appreciate the intent behind S. 3330, but for a number 
of reasons we do not support it. First, we note that section 2 
would require the Secretary to submit annual reports to 
Congress on low volume programs. However, the definition of a 
``program'' is not clear. Any treatment ``program'' could be 
defined so narrowly that no facility treats 100 patients or 
more per year in a particular program or so broadly that almost 
every program includes more than 100 patients annually. 
Moreover, treatment quality is not always related to patient 
volume or patient volume just within a given VA facility. Many 
VA facilities have on staff specialist providers who also work 
elsewhere in the community. If all care provided by a 
specialist is combined, the volume can be, and many times is, 
significantly more than can be accounted for just within VA 
workload. In addition, standard credentialing, privileging, and 
review of quality of care are required at every facility 
regardless of the size of a program.
    All procedures that are performed and all medical care that 
is provided at any VA facility involve quality assessment and 
oversight. The first procedure each year has precisely the same 
quality assessment requirements as the last, whether the annual 
procedure total is 5, 50, or 500. Further, each procedure is 
performed by a fully credentialed and privileged physician. 
Instead of the requirement to provide an annual report on ``low 
volume'' programs, we would like to work with Congress to 
identify what information would be useful for Congress to 
receive annually.
    The mandatory training that would be required by section 3 
would apply to all VHA staff and would not be limited to staff 
directly involved in the use of radioactive materials. Nuclear 
Regulatory Commission regulations already require all staff 
involved in the use of radioactive materials to have training 
and facilities to provide evidence of that training. Competency 
and training requirements for staff are based upon their 
defined duties and risks associated with those duties. In VHA, 
radiation safety training and education are provided annually, 
through the VA Learning Management System, to all staff 
involved in the use or handling of radioactive material. This 
includes all contract staff or physicians working in VA Nuclear 
Medicine services as a condition of their authorization to 
practice at a VA medical center. The definition of a medical 
event and reporting requirements are taught to, and reviewed 
annually with, all Nuclear Medicine technologists and 
physicians. VA's National Health Physics Program provides a 
mechanism to ensure that the training provided is completed as 
required by VA policy. In addition, VA currently supports and 
trains all staff in reporting any untoward events or potential 
events consistent with guidance provided by the National Center 
for Patient Safety and the facility safety programs. As a 
result, many of the requirements of section 3 are duplicative 
of current VA policy.
    The requirement in section 4 to obtain weekly independent 
peer reviews of all medical services provided pursuant to a 
contract, and written evaluations of the services carried out 
by the supervisor or manager of the employee providing the 
services, is excessive and would add unwarranted cost in staff 
time spent procuring and developing the reports. The 
requirement to undertake peer reviews each week may be 
ineffective if the number of procedures in a week is 
insufficient to carry out a statistically valid review. The 
requirement for additional reporting and oversight of all 
medical services provided by contract, most of which have not 
reported adverse events, would be a waste of resources. Given 
current VA procedures related to peer review and reporting, 
some of the provisions in this bill are not necessary. We are 
available to meet with Committee staff to discuss these issues 
in more detail.
    While VA appreciates the Committee's focus on this issue, 
we believe that these additional measures are not necessary in 
view of the above regulatory requirements, safeguards, and 
training. VA estimates that costs for this bill, if enacted, 
would be $64.2 million for the first year, $347.5 million over 
5 years, and $770.5 million over 10 years.

           *       *       *       *       *       *       *


                                S. 3377

    S. 3377 would convert VA's multifamily transitional housing 
loan guarantee program into one that would instead provide 
direct loans to qualified organizations. Under current 
subchapter VI of chapter 20, title 38, United States Code, the 
Secretary is authorized to guarantee not more than 15 loans, or 
an aggregate amount of $100 million, for multifamily 
transitional housing projects. This bill would terminate the 
Secretary's authority to issue any new guarantees under section 
2051, but would require the Secretary to make at least five 
direct loans to qualified organizations that plan to develop 
multifamily housing projects. The source of funds for the 
program would be the Multifamily Transitional Housing Loan 
Program Revolving Fund, established under section 1(b) of the 
bill.
    VA does not support enactment of S. 3377. VA spent the 
better part of a decade testing the model and trying to make 
the multifamily transitional housing loan guarantee program 
work. During that time, the marketplace repeatedly revealed 
that there was a strong need for more programs that provide 
low-cost housing, including those offering supportive services 
for Veterans returning to gainful employment. There were three 
main reasons why organizations did not seek project financing 
through the VA program, which led them to try to instead find 
funding from other Federal, state, and local programs: (1) a 
lack of available operating subsidies (i.e., formerly homeless 
veterans cannot pay enough rent to generate sufficient project 
revenue to cover operating expenses and support services); (2) 
the debt repayment requirement (many local government entities 
offer either low-interest, interest-only, deferred, and/or 
forgivable debt products, which are more appealing to project 
sponsors than the VA loan guarantee program); and (3) the large 
project size requirement (large projects are difficult to site, 
and there is a growing trend towards developing mixed-tenancy 
projects). In addition, other sources of funding needed to 
create housing are almost exclusively tied to non-transitional 
housing. Persons living in transitional housing are normally 
still considered homeless.
    Additionally, we have concerns how the program would be 
implemented, as it is not clear that the program structure 
would be consistent with other existing legislation, such as 
the Federal Credit Reform Act. Furthermore, the provision that 
would authorize the Secretary to delegate to a State or local 
government entity the authority to approve a loan might 
constitute an unconstitutional delegation of Federal authority. 
The statutory language should make clear that a delegation of 
approval authority to a State or local government entity 
remains subject to the Secretary's continuing supervision.
    VA's 2011 Budget includes $4.2 billion to prevent and 
reduce homelessness among Veterans--over 3.4 billion for 
medical services and nearly $800 million for specific homeless 
programs.
    VA estimates that this bill would not create any demand for 
multifamily transitional housing direct loans, but would result 
in administrative expenses of $1.05 million in year one, and 
$7.8 million over 10 years. If direct loans were made, they 
would likely be very expensive given the anticipated terms and 
conditions on the underlying loans. Therefore, it is not clear 
that Federal credit assistance is the most efficient or 
effective means of achieving the policy objective.

           *       *       *       *       *       *       *


                                S. 3035

    S. 3035, the ``Veterans Traumatic Brain Injury Care 
Improvement Act of 2010,'' would require the Secretary to 
submit to Congress a report on the feasibility and advisability 
of establishing a Polytrauma Rehabilitation Center or 
Polytrauma Network Site for VA in the northern Rockies or the 
Dakotas.
    VA shares the concern for providing treatment facilities 
for polytrauma in this region and has already completed an 
assessment of need. VA has determined that an enhanced 
Polytrauma Support Clinic Team with a strong telehealth 
component at the Ft. Harrison, Montana, VA facility would meet 
the needs and the workload volume of Veterans with mild to 
moderate traumatic brain injury (TBI) residing in the catchment 
area of the Montana Health care System. It would also 
facilitate access to TBI rehabilitation care for other Veterans 
from the northern Rockies and the Dakotas through telehealth. 
However, establishment of a Polytrauma Rehabilitation Center or 
Polytrauma Network Site, which would focus on the treatment of 
moderate to severe TBI, is not feasible or advisable in this 
area based on the needs of the population served. Because of 
the action already being taken by VA, this bill is not 
necessary, and we do not support it.
    The estimated cost of staffing the Polytrauma Support 
Clinic Team at Ft. Harrison would be $1 million in the first 
year, $6.1 million for five years, and approximately $13 
million over 10 years.
    Mr. Chairman, we would be pleased to provide the Committee 
with more detailed information about our findings and decisions 
regarding the northern Rockies and the Dakotas.

           *       *       *       *       *       *       *


                                S. 3355

    S. 3355, the ``Veterans One Source Act of 2010,'' would 
require VA to establish and maintain an interactive Internet 
Web site that provides information on the benefits, resources, 
services, and opportunities provided by VA, other Federal 
agencies, and other sources.
    VA supports the objective of S. 3355. However, VA has 
already collaborated with the Department of Defense (DOD) in 
the creation of a joint eBenefits Internet portal in response 
to the recommendations of the President's Commission on Care of 
America's Returning Wounded Warriors (Dole-Shalala), made in 
March 2007. This new Web site (www.ebenefits.va.gov) provides 
Servicemembers, Veterans, family members, and care providers a 
single transparent access point to online information about 
benefits, services, and other resources. It provides a 
consolidated catalog of links to existing information on VA, 
DOD, and other Federal and state agency Web sites concerning 
benefits, services, and related resources. Obtaining a Defense 
Self-Service log-on account in order to access eBenefits has 
recently become mandatory for all Servicemembers and allows 
them to carry their eBenefits account through their life cycle 
and concurrently allows VA and DOD to regularly update benefit-
related information. Because the eBenefits portal meets the 
intent and nearly all of the requirements of S. 3355, VA 
believes this bill is unnecessary.
    Much of the information the bill would call for is 
available now in the eBenefits portal. Current topics include 
compensation, pension, health care, education benefits, home 
loans, financial services, employment assistance, reemployment 
rights, memorial benefits, Social Security benefits, DOD 
programs, state benefits, and Veterans Service Organizations. 
The eBenefits portal offers quick access to online application 
tools and other assistance to claimants. Secure access 
capabilities allow for personalization of content and services.
    Self-service capabilities the eBenefits portal offers 
include the ability to apply for many benefits online, to check 
the status of compensation and pension claims, to apply for a 
home loan certificate of eligibility, to view VA e-health 
records, and to access and retrieve official military personnel 
records. Access to blogs and online communities is also 
provided.
    In committing to the eBenefits portal, VA and DOD have 
already undertaken a multi-year project that will continue to 
add self-service transactional capabilities and to enlarge and 
refine online access to benefits, services, resources, and 
opportunities for Servicemembers, Veterans, family members, and 
caregivers. Some of these features will include the ability to: 
opt into the VA/DOD virtual electronic lifetime health record; 
transfer Chapter 33 (Post-9/11 GI Bill) benefits to dependents; 
change an address in both VA and DOD systems of records; 
communicate personally via a messaging center; receive 
automatic notification of benefits; view information on, and 
apply for, all VA benefits; and self-select to receive state 
benefit information. VA is confident that the capabilities of 
the eBenefits portal will meet the objectives of S. 3355.
    Funding for the eBenefits portal in FY 2010 is 
approximately $7.4 million, which includes contract support, 
operating costs, and FTE. VA estimates that overall operating 
costs, contract support, and FTE will be $12 million in FY 
2011. The estimated cost for the capabilities required by the 
bill that are not included in the eBenefits portal is $1.1 
million. This estimate includes costs for the following 
features: an animated virtual user guide; resources for 
caregivers (currently provided at a minimal level); information 
on discounts for veterans; facilitation of ride sharing for 
appointments; memorial notices; opportunities for volunteering; 
and information on community events.

           *       *       *       *       *       *       *


                                S. 2751

    S. 2751 would designate the VAMC in Big Spring, Texas, as 
the George H. O'Brien, Jr., Department of Veterans Affairs 
Medical Center. Mr. O'Brien was awarded the Medal of Honor for 
his actions in battle in Korea and, following service, 
volunteered at the VAMC in Big Spring. He died in 2005. We 
defer to Congress in the naming of Federal property in honor of 
individuals.

           *       *       *       *       *       *       *


                SUPPLEMENTAL VIEWS OF HON. RICHARD BURR,
                             RANKING MEMBER

    I offered the text of legislation I introduced, S. 1518, 
the Caring for Camp LeJeune Veterans Act of 2009, as an 
amendment to the Committee bill at the August 5, 2010, markup. 
The amendment, which would give veterans and family members 
exposed to contaminated drinking water at Camp LeJeune VA 
health care eligibility for conditions related to the exposure, 
was, regrettably, defeated on a party-line vote. At the 
Committee's January 28, 2010, markup I offered the same 
amendment, also defeated on a party-line vote, in favor of an 
approach advanced by my colleagues in the majority which put 
the onus of providing for sick Camp LeJeune family members on 
the Department of Defense (DOD). I argued then that the 
majority's approach would not advance because of a number of 
problems, and that the Committee's action gave false hope to 
sick veterans and family members. That bill has yet to advance 
in the Senate, and the Senate Armed Services Committee has 
signaled it has no intention of moving the majority's bill.
    My colleagues in the majority continue to assert that DOD 
must first take responsibility for the contamination at Camp 
LeJeune, but this view ignores the fact that DOD continues to 
view this issue through the prism of litigation and has no 
incentive to address the plight of veterans and their families 
exposed to environmental hazards while working and living on a 
DOD installation. In the absence of DOD acceptance of 
responsibility or formal consideration for the veterans and 
their families, this Committee should recognize that VA is the 
logical and desirable provider of health care. Furthermore, I 
have argued that precedent exists in VA to care for veterans 
and dependents suffering from the effects of harmful exposures. 
No such precedent exists at DOD.
    I remain committed to enacting legislation providing those 
affected by the LeJeune water contamination with medical care 
for any disease associated with the water contaminants. They 
have waited long enough for the Congress to act. I will 
continue to be vocal about their plight until we finally have 
given them this small measure of recognition for what they have 
endured.

                        Changes in Existing Law

    In compliance with paragraph 12 of Rule XXVI of the 
Standing Rules of the Senate, 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. VETERANS' BENEFITS

                       PART II. GENERAL BENEFITS

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

                         SUBCHAPTER I. GENERAL

SEC.

1701. DEFINITIONS.

1702. PRESUMPTIONS: PSYCHOSIS AFTER SERVICE IN WORLD WAR II AND 
                    FOLLOWING PERIODS OF WAR; MENTAL ILLNESS FOLLOWING 
                    SERVICE IN THE PERSIAN GULF WAR.

1703. CONTRACTS FOR HOSPITAL CARE AND MEDICAL SERVICES IN NON-
                    DEPARTMENT FACILITIES.

1703A. OVERSIGHT OF MEDICAL SERVICES PROVIDED BY CONTRACTORS.

           *       *       *       *       *       *       *


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

1721. POWER TO MAKE RULES AND REGULATIONS.

1722. DETERMINATION OF INABILITY TO DEFRAY NECESSARY EXPENSES; INCOME 
                    THRESHOLDS.

1722A. COPAYMENT FOR MEDICATIONS.

1722B. COPAYMENTS: WAIVER OF COLLECTION OF COPAYMENTS FOR TELEHEALTH 
                    AND TELEMEDICINE VISITS OF VETERANS.

           *       *       *       *       *       *       *


Subchapter I. General

           *       *       *       *       *       *       *


SEC. 1703. CONTRACTS FOR HOSPITAL CARE AND MEDICAL SERVICES IN NON-
                    DEPARTMENT FACILITIES

           *       *       *       *       *       *       *


SEC. 1703A. OVERSIGHT OF MEDICAL SERVICES PROVIDED BY CONTRACTORS

    (a) In General.--(1) The Secretary shall ensure that the 
quality assessment program of the Department includes 
appropriate oversight of medical services provided pursuant to 
a contract entered into by the Secretary with a non-government 
entity.
    (2) Oversight of a medical service required by paragraph 
(1) shall include, as appropriate to the service, the 
following:
          (A) Periodic peer reviews of such service.
          (B) Periodic written evaluations of the oversight 
        provided by the supervisor or manager of the individual 
        providing the service.
          (C) Such other evaluations as the Secretary 
        determines are appropriate.
    (3) The Secretary shall ensure that sufficient data is 
collected and analyzed by an employee of the Department in 
order to evaluate the quality of medical services provided 
pursuant to a contract entered into by the Secretary with a 
non-government entity.
    (b) Requirements Relating to Extension of Certain 
Contracts.--Before any contracting officer of the Department 
may extend or renew any contract entered into by the Secretary 
with a non-government entity for the provision of medical 
services, the contracting officer shall review and take into 
consideration the results of the evaluations carried out under 
subsection (a).

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


SEC. 1722A. COPAYMENT FOR MEDICATIONS

           *       *       *       *       *       *       *


SEC. 1722B. COPAYMENTS: WAIVER OF COLLECTION OF COPAYMENTS FOR 
                    TELEHEALTH AND TELEMEDICINE VISITS OF VETERANS

    The Secretary may waive the imposition or collection of 
copayments for telehealth and telemedicine visits of veterans 
under the laws administered by the Secretary.

           *       *       *       *       *       *       *


CHAPTER 20. BENEFITS FOR HOMELESS VETERANS

           *       *       *       *       *       *       *


  SUBCHAPTER VI. [LOAN GUARANTEE FOR] MULTIFAMILY TRANSITIONAL HOUSING

SEC.

2051. GENERAL AUTHORITY

2052. REQUIREMENTS

2053. DEFAULT

2054. AUDIT

2055. MULTIFAMILY TRANSITIONAL HOUSING LOAN PROGRAM REVOLVING FUND.

2056. PREFERENTIAL TREATMENT OF VETERANS.

           *       *       *       *       *       *       *


  Subchapter VI. [Loan Guarantee for] Multifamily Transitional Housing

SEC. 2051. GENERAL AUTHORITY

    (a)(1) The [The] Secretary may guarantee the full or 
partial repayment of a loan that meets the requirements of this 
subchapter.
    (2) The Secretary shall, utilizing funds available in the 
Multifamily Transitional Housing Loan Program Revolving Fund 
under section 2055 of this title, issue not more than five 
loans that meet the requirements of this subchapter.
    (b)(1) Not more than 15 loans may be guaranteed [under 
subsection (a)] under subsection (a)(1), of which not more than 
five such loans may be guaranteed during the 3-year period 
beginning on the date of the enactment of this subchapter.
    (2) A guarantee of a loan [under subsection (a)] under 
subsection (a)(1) shall be in an amount that is not less than 
the amount necessary to sell the loan in a commercial market.
    (3) Not more than an aggregate amount of $100,000,000 in 
loans may be guaranteed or issued under subsection (a).
    (c)(1) A loan [A loan] may not be guaranteed or issued 
under this subchapter unless, before closing such loan, the 
Secretary has approved the loan.
    (2) The Secretary may delegate approval under paragraph (1) 
to a State or local government entity.
    (3) Approval activity of a State or local government entity 
under paragraph (2) shall be subject to the supervision of the 
Secretary.

           *       *       *       *       *       *       *

    (g) Notwithstanding any other provision of law, a 
multifamily transitional housing project that is funded by a 
loan guaranteed or issued under this subchapter may accept 
uncompensated voluntary services performed by any eligible 
entity (as that term is defined in section 2011(d) of this 
title) in connection with the construction, alteration, or 
repair of such project.
    (h) Nothing in this subchapter shall be construed to 
provide for a minimum or maximum size of a multifamily 
transitional housing project that may be financed with a loan 
under this subchapter.
    (i) The Secretary may not guarantee under subsection (a)(1) 
any loan that is closed after the date of the enactment of this 
subsection. The termination by this subsection of the authority 
to guarantee loans under this subsection shall not affect the 
validity of any loan guaranteed under this subchapter before 
the date of the enactment of this subsection and is in force on 
that date.

SEC. 2052. REQUIREMENTS

    (a) * * *
          (1) * * *

           *       *       *       *       *       *       *

          (6) The loan is subject to such terms and conditions 
        as the Secretary determines are reasonable, including 
        with respect to forbearance, deferral, and loan 
        forgiveness, taking into account other housing projects 
        with similarities in size, location, population, and 
        services provided.
    (b) * * *
          (1) * * *
          (2) provides supportive services and [counselling] 
        counseling services (including job [counselling] 
        counseling) at the project site with the goal of making 
        such veterans self-sufficient;

           *       *       *       *       *       *       *

    (c) Such a project--
          (1) may include space for neighborhood retail 
        services, other commercial activities, [or job training 
        programs] job training programs, other types of 
        residential units, or other uses that the Secretary 
        considers necessary for the sustainability of the 
        project; and

           *       *       *       *       *       *       *

    (d) In determining whether to guarantee or issue a loan 
under this subchapter, the Secretary shall consider--
          (1) * * *
          (2) the extent to which needs of homeless veterans 
        are met in a community[, as assessed under section 107 
        of Public Law 102-405].

SEC. 2053. DEFAULT

    (a) The Secretary shall take such steps as may be necessary 
to obtain repayment on any loan that is in default and that is 
guaranteed or issued under this subchapter.

           *       *       *       *       *       *       *

    (c) The Secretary may impose such penalties or require such 
collateral as the Secretary considers necessary--
          (1) to discourage default on a loan issued under this 
        subchapter; or
          (2) to mitigate harm to the Department from default 
        on a loan issued under this subchapter.
    (d) The Secretary shall administer any property coming 
under the jurisdiction of the Secretary by reason of default on 
a loan issued or guaranteed under this subchapter in accordance 
with regulations prescribed by the Secretary for that purpose. 
Such administration of property may include selling, renting, 
or otherwise disposing of property as the Secretary considers 
appropriate.

SEC. 2054. AUDIT

    (a) During each of the first 3 years of operation of a 
multifamily transitional housing project with respect to which 
a loan is guaranteed or issued under this subchapter, there 
shall be an annual, independent audit of such operation. Such 
audit shall include a detailed statement of the operations, 
activities, and accomplishments of such project during the year 
covered by such audit. The party responsible for obtaining such 
audit (and paying the costs therefor) shall be determined 
before the Secretary issues a guarantee or loan under this 
subchapter.
    (b) * * *

SEC. 2055. MULTIFAMILY TRANSITIONAL HOUSING LOAN PROGRAM REVOLVING FUND

    (a) Establishment.--There is established in the Treasury of 
the United States a revolving fund known as the ``Department of 
Veterans Affairs Multifamily Transitional Housing Loan Program 
Revolving Fund'' (in this section referred to as the ``Fund'').
    (b) Elements.--There shall be deposited in the Fund the 
following, which shall constitute the assets of the Fund:
          (1) Amounts paid into the Fund under any provision of 
        law or regulation established by the Secretary imposing 
        fees on persons or entities issued a loan under this 
        subchapter.
          (2) All other amounts received by the Secretary 
        incident to operations relating to the issuance of 
        loans under this subchapter, including--
                  (A) collections of principal and interest on 
                loans issued by the Secretary under this 
                subchapter;
                  (B) proceeds from the sale, rental, use, or 
                other disposition of property acquired under 
                this subchapter; and
                  (C) penalties collected pursuant to this 
                subchapter.
          (3) Amounts appropriated or otherwise made available 
        before the date of the enactment of this section for 
        purposes of activities under this subchapter, including 
        amounts appropriated for such purposes under title I of 
        the Department of Veterans Affairs and Housing and 
        Urban Development, and Independent Agencies 
        Appropriations Act, 2000 (Public Law 106-74; 113 Stat. 
        1049).
    (c) Use of Funds.--The Fund shall be available to the 
Secretary, without fiscal year limitation, for all operations 
relating to the issuance of loans under this subchapter, 
consistent with the Federal Credit Reform Act of 1990 (2 U.S.C. 
661 et seq.).

SEC. 2056. PREFERENTIAL TREATMENT OF VETERANS

    No provision of Federal or State law may prohibit a 
multifamily transitional housing project described in section 
2052(b) of this title from offering preferential treatment to 
veterans.

           *       *       *       *       *       *       *


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. 8104. CONGRESSIONAL APPROVAL OF CERTAIN MEDICAL FACILITY 
                    ACQUISITIONS

    (a)(1) * * *

           *       *       *       *       *       *       *

    (d)(1) Except as provided in paragraph (2), in any case [In 
any case] in which the Secretary proposes that funds be used 
for a purpose other than the purpose for which such funds were 
appropriated, the Secretary shall promptly notify each 
committee, in writing, of the particulars involved and the 
reasons why such funds were not used for the purpose for which 
appropriated.
    (2) In any fiscal year, unobligated amounts in the 
Construction, Major Projects account that are a direct result 
of bid savings from a major medical facility project may only 
be obligated for other major medical facility projects 
authorized for that fiscal year or a previous fiscal year.

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