[Senate Report 111-60]
[From the U.S. Government Publishing Office]


                                                       Calendar No. 128
111th Congress                                                   Report
                                 SENATE
 1st Session                                                     111-60

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



 
            VETERANS' HEALTH CARE AUTHORIZATION ACT OF 2009

                                _______
                                

                 July 24, 2009.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                          [To accompany S.252]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (S.252), to amend 
title 38, United States Code, to enhance the capacity of the 
Department of Veterans Affairs to recruit and retain nurses and 
other critical health-care professionals, to improve the 
provision of health care to veterans, and for other purposes, 
reports favorably thereon, with an amendment, and recommends 
that the bill, as amended, do pass.

                              Introduction

    On January 15, 2009, Chairman Akaka introduced S.252, the 
proposed ``Veterans' Health Care Authorization Act of 2009.'' 
S.252 as introduced would enhance the capacity of the 
Department of Veterans Affairs (hereinafter, ``VA'') to recruit 
and retain nurses and other critical health care professionals. 
This bill included a majority of provisions from S.2969, 
legislation introduced on May 1, 2008 by Chairman Akaka in the 
110th Congress. S.2969 was reported favorably by the Committee, 
S. Rpt. 110-473, with an amendment in the nature of a 
substitute, and was subsequently placed on the Senate 
Legislative Calendar on September 18, 2008. It was not taken up 
by the Senate prior to the adjournment of the 110th Congress.
    S.2969 as reported and S.252 as introduced include 
provisions derived from a number of other bills, described 
below.
    On October 31, 2007, Chairman Akaka introduced, by request, 
S.2273, the proposed ``Enhanced Opportunities for Formerly 
Homeless Veterans Residing in Permanent Housing Act of 2007.'' 
S.2273 would enhance services for previously homeless veterans 
and for veterans at risk of becoming homeless. S.2969 as 
reported included similar provisions as did S.252 as 
introduced.
    On April 2, 2008, Senator Murray introduced S.2799, the 
proposed ``Women Veterans Health Care Improvement Act of 
2008.'' S.2799 would require studies of the health care needs 
of women veterans and of the services available to them from 
VA, and would require expansion of the services available to 
women veterans. S.2969 as reported contained similar provisions 
as did S.252 as introduced. Senator Murray introduced S.597 on 
March 16, 2009, which contained provisions similar to those in 
S.2799.
    On April 2, 2008, Chairman Akaka introduced S.2796. S.2796 
would require VA to conduct a pilot program on the use of 
community-based organizations to ensure that transitioning 
veterans and their families receive the care and benefits to 
which they are entitled. S.2969 as reported contained this 
program as did S.252 as introduced.
    On April 22, 2008, Senator Harkin introduced S.2899, the 
proposed ``Veterans Suicide Study Act.'' S.2899 would direct VA 
to conduct a study on suicides among veterans. S.2969 as 
reported included similar provisions as did S.252 as 
introduced.
    On April 28, 2008, Chairman Akaka introduced S.2926, the 
proposed ``Veterans Nonprofit Research and Education 
Corporations Enhancement Act of 2008.'' S.2926 would authorize 
multi-medical center nonprofit research corporations 
(hereinafter, ``NPCs''), clarify existing authorities, and 
strengthen VA oversight of NPCs. S.2969 as reported included 
similar provisions as did S.252 as introduced.
    On April 29, 2008, Senator Tester introduced S.2937. S.2937 
would provide VA with permanent authority to provide health 
care for participants in certain Department of Defense chemical 
and biological tests, and would expand the study of the impact 
of Project Shipboard Hazard and Defense (hereinafter, ``SHAD'') 
on veterans' health. S.2969 as reported included similar 
provisions as did S.252 as introduced.
    On May 1, 2008, Senator Bond introduced S.2963. S.2963 
would, among other things, enhance the mental health care 
services available to members of the Armed Forces and veterans, 
and enhance counseling and other benefits available to 
survivors of members of the Armed Forces and veterans. S.2969 
as reported included similar provisions as did S.252 as 
introduced. S.772, introduced April 1, 2009, by Senator Bond, 
includes provisions similar to S.2963.
    On May 6, 2008, Chairman Akaka introduced, by request, 
S.2984, the proposed ``Veterans' Benefits Enhancement Act of 
2008.'' S.2984 contained a number of provisions since enacted 
into law, but also included modifications to a number of 
reporting requirements, authorizations to disclose certain 
personal information in limited circumstances, and authorities 
for the operation and upkeep of the VA police force. S.2969 as 
reported included similar provisions as did S.252 as 
introduced.
    On May 8, 2008, Chairman Akaka introduced S.3000, the 
proposed ``Native American Veterans Access Act of 2008.'' 
S.3000 would include federally recognized tribal organizations 
in certain programs for State veterans homes. S.2969 as 
reported included similar provisions as did S.252 as 
introduced.
    On June 23, 2008, Ranking Member Burr introduced S.3178. 
S.3178 would authorize a dental insurance program for veterans 
and survivors and dependents of veterans. S.2969 as reported 
included provisions derived from this legislation as did S.252 
as introduced. On February 26, 2009, Senator Burr again 
introduced S.498, a bill similar to S.3178.
    On April 22, 2009, the Committee held a hearing on pending 
health care legislation. Testimony was offered by: Gerald M. 
Cross, M.D., FAPP, Principal Deputy Under Secretary for Health, 
Department of Veterans Affairs; Walter A. Hall, Assistant 
General Counsel, Department of Veterans Affairs; Joleen Clark, 
Chief Officer for Workforce Management and Consulting, Veterans 
Health Administration; Adrian Atizado, Assistant National 
Legislative Director, Disabled American Veterans; Ammie 
Hilsabeck, R.N., Oscar G. Johnson VA Medical Center (Iron 
Mountain, MI), on behalf of American Federation of Government 
Employees; Ralph Ibson, Health Policy Senior Fellow, Wounded 
Warrior Project; and Blake Ortner, Senior Legislative Director, 
Paralyzed Veterans of America.

                           Committee Meeting

    The Committee met in open session on May 21, 2009, to 
consider, among other legislation, S.252, consisting of S.252 
as introduced with a number of modifications following 
testimony provided at the foregoing hearing. The Committee 
voted by roll call to report favorably S.252 without dissent.

                      Summary of S.252 as Reported

    S.252, as reported, (hereinafter, ``the Committee bill'') 
would amend the title of the original bill, and would make 
numerous enhancements and expansions to VA health care and 
services. This legislation is similar to S.2969, which was 
reported by the Committee on September 18, 2008, but not taken 
up by the Senate. Changes from S.2969 include: refinements to 
the personnel sections; deletions to reflect provisions that 
were enacted as Pub. L. 110-387; and deletions of provisions 
that were introduced in S.801.

                 TITLE I--DEPARTMENT PERSONNEL MATTERS

    Section 101 would authorize VA to extend title 38, United 
States Code (U.S.C.), employment status to certain employees 
under limited circumstances; amend salary authorities for 
certain VA positions; amend the statute governing certain work 
schedules; amend the statute governing transparency and conduct 
of locality pay surveys; and enhance other authorities to 
improve recruitment and retention of medical professionals.
    Section 102 would impose limitations on overtime duty and 
would amend the statutes governing weekend duty and alternative 
work schedules for nurses.
    Section 103 would reauthorize and expand certain 
educational assistance programs to improve recruitment and 
retention.
    Section 104 would establish standards for the appointment 
and practice of physicians in VA medical facilities.

                     TITLE II--HEALTH CARE MATTERS

    Section 201 would repeal the annual reporting requirements 
on nurse pay and long-term planning.
    Section 202 would amend the annual Gulf War research report 
by changing the report due date.
    Section 203 would mandate that payment by VA on behalf of a 
covered beneficiary for the Civilian Health and Medical Program 
of VA (hereinafter, ``CHAMPVA'') medical care shall constitute 
payment and eliminate any liability on the part of the 
beneficiary for that care.
    Section 204 would authorize VA to make disclosures from 
certain medical records under limited circumstances.
    Section 205 would require the disclosure to the Secretary 
of health plan contract information and social security numbers 
of certain veterans receiving care from VA.
    Section 206 would require the designation of a National 
Quality Management Officer, and a Quality Management Officer 
for each VA facility, would describe the responsibilities of 
such Officers, and would require VA to establish mechanisms for 
employees to submit confidential reports on matters related to 
quality of care in VA facilities. Further, this provision 
requires certain reports regarding VA quality programs and 
implementation of this section.
    Section 207 would require a report on Department health 
care quality management.
    Section 208 would require VA to establish a pilot program 
on the use of community-based organizations to ensure that 
transitioning veterans and their families receive the care and 
benefits they need.
    Section 209 would authorize VA to contract with appropriate 
entities for specialized residential care and rehabilitation 
for certain Operation Iraqi Freedom or Operation Enduring 
Freedom (hereinafter, ``OIF/OEF'') veterans with TBI.
    Section 210 would require VA to establish an expanded study 
on the health impact of Project SHAD.
    Section 211 would require VA to provide care and services 
to certain individuals in non-Department facilities under 
limited circumstances.
    Section 212 would authorize tribal organizations to access 
the construction grants and per diem payments provided under 
the State Veterans Home Program in the same manner as other 
eligible entities.
    Section 213 would require VA to establish a pilot program 
on the provision of dental insurance plans to veterans, 
survivors, and dependents of veterans.

                 TITLE III--WOMEN VETERANS HEALTH CARE

    Section 301 would require VA to report on the barriers to 
women veterans' access to VA health care.
    Section 302 would require VA to develop a plan to improve 
the provision of health care services to women veterans.
    Section 303 would require an independent study on the 
health consequences of service in OIF/OEF for women veterans.
    Section 304 would require VA to implement a program of 
training and certification for VA mental health care providers 
on care for veterans suffering from military sexual trauma.
    Section 305 would require VA to establish a pilot program 
on counseling in retreat settings for women veterans newly 
separated from service in the Armed Forces.
    Section 306 would require a report on full-time women 
veterans' program managers at VA medical centers.
    Section 307 would require the Advisory Committees on Women 
Veterans and Minority Veterans to include women veterans 
recently separated from service in the Armed Forces.
    Section 308 would require VA to establish a pilot program 
on child care for certain veterans receiving health care from 
VA.
    Section 309 would authorize VA to provide health care 
services to the newborn children of woman veterans under 
certain circumstances.

                      TITLE IV--MENTAL HEALTH CARE

    Section 401 would establish eligibility for members of the 
Armed Forces who served in OIF/OEF for readjustment counseling 
and related mental health services through the Readjustment 
Counseling Service of the Veterans Health Administration.
    Section 402 would restore the authority of the Readjustment 
Counseling Service to provide referral and other assistance to 
former members of the Armed Forces, not otherwise authorized 
for counseling.
    Section 403 would require VA to conduct a study on suicides 
among veterans since January 1, 1999, and report to Congress on 
their findings.
    Section 404 would require VA to transfer $5,000,000 to the 
Secretary of Health and Human Services for the Graduate 
Psychology Education program.

                       TITLE V--HOMELESS VETERANS

    Section 501 would authorize VA to establish a pilot program 
to make grants to public and nonprofit organizations that 
coordinate the provision of supportive services to formerly 
homeless veterans residing on certain military property.
    Section 502 would authorize VA to establish a pilot program 
to make grants to public and nonprofit organizations that 
coordinate the provision of supportive services to formerly 
homeless veterans residing in permanent housing.
    Section 503 would authorize VA to establish a pilot program 
to make grants to public and nonprofit organizations that 
provide outreach to inform low-income and elderly veterans who 
reside in rural areas about pension benefits.
    Section 504 would require assessments of the pilot programs 
described in Sections 501-503.

        TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS

    Section 601 would authorize multi-medical center nonprofit 
research and education corporations (``NPCs''), expand existing 
corporations to multi-medical center research corporations, 
amend authorities on the applicability of state law, clarify 
the status of corporations, and reinstate the requirement of 
501(c)(3) status of corporations.
    Section 602 would clarify the purpose of NPCs.
    Section 603 would amend the requirements for VA and non-VA 
Board members.
    Section 604 would amend and clarify the provision on 
general powers of NPCs.
    Section 605 would redesignate section 7364A of title 38, 
U.S.C., as section 7365.
    Section 606 would amend the provision on reporting by 
adding additional information to be reported on; amend the 
provision related to the confirmation of application of 
conflict of interest regulations to include appropriate 
corporation positions; and authorize the establishment of an 
appropriate payee reporting threshold.

                        TITLE VII--OTHER MATTERS

    Section 701 would expand the authority for VA police 
officers.
    Section 702 would provide a uniform allowance for VA police 
officers.

                       Background and Discussion


                 TITLE I--DEPARTMENT PERSONNEL MATTERS

    Title I of the Committee bill contains a number of 
provisions that would amend specific personnel authorities in 
title 38, United States Code (U.S.C), so as to give the 
Secretary of Veterans Affairs additional tools to retain health 
care personnel, expand scholarship programs for the purposes of 
recruitment and retention; and authorize additional pay for 
executive positions within VHA, and for certain nursing 
positions.

Section 101. Enhancement of authorities for retention of medical 
        professionals.

    Section 101 of the Committee bill contains provisions that 
would amend title 38 to remove salary restrictions at nurse and 
executive grades to improve recruitment and retention; 
improving the methodology and transparency of the computation 
of the locality pay scale; and establishing guidelines on the 
use of mandatory overtime for nurses in emergency situations.
            Subsection 101(a)--Secretarial authority to extend title 38 
                    status to additional positions.
    Background. The unique features of the title 5, title 38, 
and title 38 hybrid personnel systems have resulted in uneven 
conditions of employment for some employees working in the same 
occupational series and occupational groups. For example, 
corrective therapy assistants, hired under title 5, provide 
services under the same occupational series as occupational 
therapy assistants and physical therapy assistants, hired as 
title 38 hybrids. All three work in the same organizational 
units providing rehabilitation therapy, but are hired and 
employed under different conditions.
    Committee Bill. Subsection (a)(1) of section 101 of the 
Committee bill would amend section 7401(3) of title 38, so as 
to give the Secretary of VA the authority to apply the title 38 
hybrid employment system to additional health care occupations 
when such action is deemed necessary to meet recruitment or 
retention needs. The Committee bill limits the application of 
title 38 hybrid status to those providing direct patient care 
services or services incident to direct patient-care services, 
not otherwise available to provide medical care and treatment 
for veterans.
    The Secretary would be required to notify the House and 
Senate Committees on Veterans' Affairs and the Office of 
Management and Budget (OMB) 45 days prior to implementing a 
decision to convert an occupation to the hybrid system. Prior 
to Congressional and OMB notification, VA would be required to 
notify labor organizations representing VHA employees in 
occupations being considered for inclusion, in order to seek 
their comments.
    In testimony submitted for the record of the Committee's 
April 22, 2009, hearing, VA supported the provisions of this 
subsection as this change would give the Secretary the ability 
to react quickly, through the title 38 hiring process, to bring 
on additional employees.
    Subsection (a)(2) of section 101 of the Committee bill 
would further amend section 7401(3) by adding nurse assistants 
to the list of occupations eligible for appointment under title 
38. By bringing this position under the title 38 hiring 
process, the Department will have the ability to expedite 
hiring to fill nurse assistant positions.
    In accordance with the original purpose for a separate 
title 38 hiring system, it is the Committee's intent that VA 
continue to have the ability to expedite the hiring of certain 
health care personnel. The Committee is aware that, as 
presently implemented, the hiring process under title 38 has 
not proven as expeditious as intended and that concerns have 
been raised that adding additional professions to the list of 
hybrid positions could overburden the title 38 hybrid 
employment system. It is the Committee's belief, however, that 
the Department has the capacity, resources, and responsibility 
to resolve the obstacles to expedited hiring under title 38.
    In addition, testimony submitted by VA for the record of 
the April 22, 2009, Committee hearing, stated that nurse 
assistants, in particular, are high priority positions that 
have proven difficult to fill. VA supported the provisions of 
subsection (a)(2) of this section in its testimony, citing 
turnover rates of 11.1 percent for 2007 and 10.96 percent for 
2008, which illustrate the great difficulty VA experiences in 
retaining nurse assistants.
    Professional organizations have also recognized VA's need 
for better tools to enhance recruitment of allied health 
professionals. On May 26, 2009, the Committee received a letter 
from the Joint Commission on Allied Health Personnel in 
Ophthalmology (JCAHPO) supporting Section 101(a) because it 
would increase VA's ability to recruit and retain qualified eye 
care technicians. According to JCAHPO, a qualified eye care 
technician can improve the workload of an ophthalmologist by an 
average of 36%.
            Subsection 101(b) and (c)--Probationary periods for 
                    registered nurses, and prohibition on temporary 
                    part-time registered nurse appointments in excess 
                    of two years.
    Subsections (b) and (c) of section 101 of the Committee 
bill are addressed below together, as they are dependent upon 
each other, and address similar issues.
    Subsection (b) would modify the terms of the probationary 
period that registered nurses must serve upon employment by the 
Department, and subsection (c) would limit the extent of a 
temporary appointment of part-time registered nurses.
    Background. Subsection 7403(b) of title 38, provides that 
appointments of health care providers under that section shall 
be for a probationary period of two years. The probationary 
period serves to ensure an appropriate time of observation and 
vetting before an employee becomes permanent.
    Currently, part-time registered nurses (``RNs'') are 
employed by the Department on a temporary basis under section 
7405 of title 38. As temporary employees, they are not eligible 
for the same job protection and grievance rights as employees 
appointed under section 7403 who have completed the 
probationary periods. Further, when employees transition from 
full to part-time, they are considered employees under 7405, 
with commensurate loss of rights and protections. Valerie 
O'Meara, R.N., representing the American Federation of 
Government Employees, testified before the Committee on April 
9, 2008, about her experience switching from full to part-time 
status to raise a family. She explained that she lost her 
grievance and arbitration rights, and was not permitted to 
contest Reductions-In-Force decisions. Further, she described 
the cases of older nurses who have worked a decade or more for 
the VA who switch to part-time because of the stress of their 
job or to care for their aging parents. The Committee believes 
VA would benefit from retaining the expertise of these 
registered nurses, even on a part-time basis.
    VA has been challenged to fill RN positions due to rising 
demand for these professionals. A March 2009 Memorandum from 
the Congressional Research Service indicated that VA had 1700 
vacancies for registered nurses, with a projected loss of 
another 7600 VA Registered Nurses due to retirement by the year 
2013.
    Committee Bill. Subsections (b) and (c) of section 101 of 
the Committee bill would clarify the terms of a probationary 
period under section 7403 of title 38, and address the inequity 
faced by part-time nurses under section 7405 of title 38.
    Subsection (b) would amend section 7403(b) by adding two 
new paragraphs. New paragraph (2) would mandate that an 
appointment of a registered nurse under the section, whether on 
a full- or part-time basis, shall be for a probationary period 
of two years. The intent of this provision is to ensure 
equitable treatment for full and part-time nurses, which is 
vital to the Department's ability to recruit and retain part-
time nurses.
    New paragraph (3) would mandate that an appointment under 
section 7403 on a part-time basis of a health care professional 
who has previously served on a full-time basis shall be without 
a probationary period. This provision would clarify that no RN 
who has already served a probationary period would be required 
to serve a probationary period upon switching from a full-time 
to a part-time appointment. The Committee sees no utility in 
requiring an RN who has served a probationary period on a full-
time basis to serve an additional probationary period.
    Subsection (c) of section 101 would amend section 7405 of 
title 38, to add a new subsection (g). The proposed new 
subsection would specify that the appointment of an RN on a 
temporary part-time basis under section 7405 would be for a 
probationary period, as defined under section 7403(b), as would 
be amended by subsection (b) of section 101 of the Committee 
bill. Upon completion of the probationary period, the 
appointment would no longer be considered temporary, and would 
instead be considered an appointment under 7403(a), unless the 
part-time appointment resulted from an academic affiliation, a 
research proposal or grant, or was used for non-citizens in 
accordance with 38 U.S.C. 7407(a). Subject to these exceptions, 
and the completion of the probationary period, all temporary 
part-time appointments of RNs would be considered permanent.
    It is the Committee's intent that the amendments to 
sections 7403 and 7405 will eliminate disincentives to part-
time employment of RNs in VA. Many RNs, after serving a full 
career in VA, or in response to family concerns, are faced with 
the decision to either retire from VA or transition to part-
time service. Informed by the testimony presented at the 
Committee hearings on April 9 and May 21, 2008, the Committee 
believes VA would benefit from the service that these 
registered nurses would provide on a part-time basis. Further, 
increased use of part-time registered nurses will help VA fully 
staff facilities, and better meet the rising demand for health 
care services.
    It is not the intent of the Committee bill to prevent or 
limit the hiring of part-time nurses beyond the probationary 
period. Rather, the Committee intends that upon completion of 
such period, the appointment be considered permanent, with all 
accompanying benefits and privileges.
    In written testimony provided to the Committee for its 
April 22, 2009 legislative hearing, the American Federation of 
Government Employees testified in support of transitioning 
part-time temporary employees to an appointment under 7403(a) 
following completion of a probationary period. Carl Blake, 
National Legislative Director, Paralyzed Veterans of America, 
in testimony before the Committee on May 21, 2008, also voiced 
support for the provision to eliminate the probationary period 
for RNs who transition from full-time to part-time.
            Subsection 101(d)--Waiver of offset from pay for certain 
                    reemployed annuitants.
    Subsection (d) of section 101 of the Committee bill would 
authorize VA to waive salary offsets for retirees who are 
reemployed in the Veterans Health Administration.
    Background. Under current law, the salary of a VHA employee 
rehired after retirement from the Federal Government is reduced 
according to the amount of their annuity under a government 
retirement system. The reduction is required by sections 8344 
and 8468 of title 5, U.S.C., which deal with annuity payments 
upon reemployment.
    VHA faces a growing wave of retirements at all levels of 
administration and health care providers. According to the 
Department, at the end of 2006, 56 percent of Medical Center 
Directors were eligible for retirement, and by 2013 over 90 
percent of these key personnel will be eligible for retirement. 
Many of the likely successors for the director positions, 
current Associate Directors, are also retirement eligible. VA 
projects that by 2013, 95,019 VHA employees will be eligible to 
retire, including 97 percent of current senior executives, 81 
percent of facility Chiefs of Staff, and 91 percent of nurse 
executives. This rate of retirement eligibility is 
unprecedented, and the sudden loss of the experience and 
expertise of these employees would seriously limit VA's ability 
to deliver care.
    Because reemployed annuitants receive only that portion of 
their salary that is above their annuity payment, there is 
little incentive under the current employment system to return 
to VA employment. Annuitants who wish to continue working are 
able to receive full pay from a non-government employer, in 
addition to their annuity, something they cannot do at VA.
    In testimony before the Committee on May 21, 2008, Cecilia 
McVey, MHA, RN, former President of the Nurses Organization of 
Veterans Affairs, said that ``During this time of a critical 
nursing shortage, it is more important than ever to keep these 
valuable resources to provide the best care to veterans.''
    Rehiring annuitants addresses issues arising from the high 
number of retirements facing VA. Increased employment of 
annuitants would potentially limit costs by reducing the use of 
expensive contract agreements. Retaining experienced 
professionals while younger employees develop their 
capabilities would also ensure the transfer of valuable 
institutional knowledge from one generation of leaders to 
another within VA.
    A program which allows the Government Accountability Office 
to temporarily hire retirees, without a salary offset, for the 
purposes of training, education, and mentoring, has proven 
successful.
    Committee Bill. Subsection (d) of section 101 of the 
Committee bill would amend section 7405 of title 38 so as to 
add a new subsection (g) which would authorize the Secretary to 
waive sections 8344 and 8468 of title 5, U.S.C., on a case-by-
case basis when reemploying an annuitant on a temporary basis. 
This section would further require that an annuitant to whom a 
waiver under the proposed new section (g) is granted be subject 
to the provisions of chapter 71 of title 5, relating to the 
protection of government employees from discrimination and 
retaliation.
    By authorizing the Secretary to waive these two sections of 
title 5, the Committee intends to encourage retirees to return 
to work at VHA. At present, many VA employees go on to work 
outside of the Department after retiring from VA, with some 
even returning to work at VA on a contract basis. By 
eliminating the salary offset, it is the Committee's hope that 
there will be a significant pay incentive that will encourage 
annuitants to return to VA, rather than seeking employment 
elsewhere.
            Subsection 101(e)--Rate of basic pay for appointees to the 
                    office of the under secretary for health set to 
                    rate of basic pay for senior executive service 
                    positions.
    Subsection (e) of section 101 of the Committee bill would 
amend section 7404(a) of title 38, to set the rate of basic pay 
for appointees to the Office of the Under Secretary of Health.
    Background. Under current law, non-physician and non-
dentist appointees under section 7306 of title 38, which 
relates to the composition of the Office of VA's Under 
Secretary for Health, including the Director of Pharmacy 
Benefits Management Strategic Health Group, the Director of 
Dietetics, the Director of Podiatry, and the Director of 
Optometry, among others, serve in executive level positions 
that are equivalent in scope and responsibility to positions in 
the Senior Executive Service (SES), which includes senior 
managers and administrators in the VA Central Office, among 
others. The pay level for section 7306 appointees is adjusted 
each year by Executive Order, as authorized by chapter 53 of 
title 5, and is capped, by subsection 7404(d) of title 38, at 
the pay rate for Level V of the Executive Schedule, currently 
at $143,500 including locality pay. VA employees in the SES, on 
the other hand, can receive pay up to Level II of the Executive 
Schedule, currently $177,000.
    According to VA, the disparity between pay levels for SES 
and non-SES employees serving in similar capacities has led to 
difficulties in recruiting and retaining non-SES executive 
level managers. Executives in these positions provide valuable 
input to the Under Secretary for Health, and manage significant 
elements of the Veterans Health Administration.
    Committee Bill. Subsection (e) of section 101 of the 
Committee bill would amend section 7404(a) of title 38 so as to 
add a paragraph that would mandate that pay for certain 
appointees to the Office of the Under Secretary for Health be 
set according to the SES. This change would be effective on the 
first day of the first pay period beginning the day after 180 
days after the date of enactment of this legislation.
    This change would effectively establish that, for the 
purposes of basic pay, all senior executives in the Office of 
the Under Secretary for Health would receive pay based on Level 
II or Level III of the Executive Schedule. The Secretary would 
be required to meet the same OPM certification criteria as is 
currently utilized for SES pay scales. By implementing a 
uniform pay scale for all senior executives in that office, the 
Committee believes VA will be better able to recruit and retain 
highly qualified individuals.
    This provision was developed in close cooperation with the 
Department, and the Department indicated its support for this 
subsection in testimony submitted for the Committee's April 22, 
2009, hearing.
    In testimony before the Committee on May 21, 2008, Thomas 
Berger, PhD, Chair of the National PTSD and Substance Abuse 
Committee, Vietnam Veterans of America (VVA), expressed VVA's 
support for additional pay ``to enhance recruitment and 
retention of top professionals to run the VA health care 
system.''
            Subsection 101(f)--Special incentive pay for department 
                    pharmacist executives.
    Background. VA is challenged to match the compensation 
offered by non-Federal employers to senior executives, 
including National Pharmacist Executives (NPEs). NPEs include 
managers of the VA National Formulary, Directors of the 
Consolidated Mail Outpatient Pharmacies, consultants to the 
Secretary for pharmacy issues, Network Pharmacy Benefits 
Managers, and the Director of Emergency Pharmacy Services. 
Under current law, basic salaries for NPEs are set according to 
the General Schedule, which caps salaries for these positions 
at $153,200. According to surveys conducted by VA, salary 
ranges for national and regional pharmacy executives are 
between $180,000 and $225,000. Further inducements commonly 
available in the private sector include profit sharing or stock 
options, yearly bonuses more generous than those currently 
available from VA, recruitment and retention bonuses, and 
corporate vehicles for individuals in regional positions.
    VA has been challenged to fill NPE positions in recent 
years, due largely to the pay disparity between VA and the 
private sector, and the lack of financial incentives to take on 
responsibilities at the national and regional level. In 
addition, applications for Chief of Pharmacy positions at VA 
facilities, the primary source of future NPEs, have fallen off 
dramatically. The Workforce Succession Strategic Plan for VHA 
FY 2006-2010 (October, 2005), listed pharmacists second only to 
RNs as national priorities for recruitment and retention.
    Committee Bill. Subsection 101(f) of the Committee bill 
would amend section 7410 of title 38, relating to additional 
pay authorities, to authorize recruitment and retention special 
incentive pay for pharmacist executives of up to $40,000. The 
determination of whether to provide such pay, and its amount, 
would be based on: grade, step, scope and complexity of the 
position, personal qualifications, characteristics of the labor 
market concerned, and such other factors as the Secretary 
considers appropriate. This provision would provide that such 
pay would be in addition to other pay, awards, and bonuses. In 
testimony submitted for the Committee's April 22, 2009, 
hearing, VA supported this provision.
            Subsection 101(g)--Pay for physicians and dentists.
    Subsection 101(g) of section 101 of the Committee bill 
would make three separate amendments to section 7431 of title 
38, relating to pay for physicians and dentists.
    Committee Bill. Paragraph (1) of subsection (g) would 
clarify the determination of the non-foreign cost of living 
adjustment (COLA), authorized by section 7431(b). The COLA is 
provided to employees in locations with substantially higher 
costs of living than those of Washington, DC, and or 
environmental conditions that differ substantially from those 
in the continental United States. Similar provisions, which are 
applicable to other government employees, are in section 5941 
of title 5, U.S.C.
    Paragraph (1) of subsection 101(g) of the Committee bill 
would amend section 7431(b) so as to add a new paragraph that 
would provide that the non-foreign cost of living adjustment 
allowance authorized under section 5941 of title 5, U.S.C., 
shall, in the case of VA physicians and dentists, be determined 
as a percentage of base pay only. Section 7431(b) currently 
does not specify the basis for the determination of the 
allowance, which has led to inconsistent determinations.
    Paragraph (2) of subsection (g) would amend section 
7431(c)(4)(B)(i) to exempt physicians and dentists in executive 
leadership provisions from the panel process in determining the 
amount of market pay and tiers for such physicians and 
dentists. Market pay is ``pay intended to reflect the 
recruitment and retention needs for the specialty or assignment 
* * * of a particular physician or dentist'' in a VA facility. 
Under current law, the Secretary is to take into account the 
views of ``an appropriate panel or board'' in determining the 
amount of market pay for an individual physician or dentist. In 
cases where such physicians or dentists occupy executive 
leadership positions such as chief officers, network directors, 
and medical center directors, the consultation of a panel has 
some limitations. The small number of providers who would 
qualify as peers for the executive leaders results in their 
serving on each other's compensation panels. This amendment 
will provide the Secretary with discretion to identify 
executive physician/dentist positions that do not require a 
panel process.
    Paragraph (3) of subsection (g) would amend section 
7431(c)(7) so as to allow an exception to the prohibition in 
current law on a reduction in market pay when a physician or 
dentist remains in the same position or assignment. The 
exception would allow for a reduction in market pay when there 
has been a change in board certification or a reduction of 
privileges, even when the individual remains in a position or 
assignment. By allowing such reduction in market pay, the 
Committee bill would prevent a physician or dentist from 
receiving additional market compensation for credentials and or 
privileges he or she may no longer possess.
    In testimony submitted for the Committee hearing on April 
22, 2009, VA indicated support for the provisions in subsection 
101(g) of the Committee bill.
            Subsection 101(h)--Adjustment of pay cap for nurses.
    Subsection (h) of section 101 of the Committee bill relates 
to pay for RNs.
    Background. Under current law, section 7451 of title 38 
governs basic pay levels for VA RNs, and certain other VA 
employees. Section 7451(c)(2) mandates that the maximum rate of 
basic pay for any grade for a covered position, including RNs, 
may not exceed the maximum rate of basic pay established for 
positions in level V of the Executive Schedule under section 
5316 of title 5, U.S.C. Level V is currently set at $143,500.
    In testimony submitted for the Committee's April 9, 2008, 
hearing, Ms. Converso of United American Nurses cited a 
``crisis in our country regarding the shortage of registered 
nurses.'' At the same hearing, Marisa W. Palkuti, MEd, 
Director, Healthcare Retention and Recruitment Office, Veterans 
Health Administration, cited a growing inadequacy in the number 
of health care workers, including RNs nationwide, and suggested 
that ``[t]his shortfall will grow exponentially over the next 
20 years.''
    During that hearing, Sheila M. Cullen, the then-Director of 
the San Francisco VA Medical Center, testified about her 
efforts to retain nurses. To compete with other health care 
employers in the region, and to address the high cost of 
living, Ms. Cullen instituted salary increases for RNs between 
5 and 8 percent annually in recent years.
    The current level V cap often prevents VA registered nurses 
from receiving locality pay. Locality pay, which is in addition 
to basic pay, is based on compensation levels in a local labor 
market. When a nurse's basic pay is equal to the level V cap, 
no additional locality pay can be awarded, regardless of 
conditions in local labor market, a result that has a 
detrimental effect on recruitment and retention.
    Committee Bill. Subsection (h) of section 101 of the 
Committee bill would amend section 7451(c)(2) of title 38, so 
as to adjust the pay cap for registered nurses and others in 
covered positions from Level V to Level IV. Level IV is 
currently set at $153,200. By raising the cap on nurse basic 
pay, the Committee intends to provide VA with additional 
flexibility to compete in local labor markets. Based on 
testimony presented at Committee hearings, and on oversight 
activities, the Committee believes that additional pay would 
improve VA's ability to recruit and retain qualified nurses.
    This provision was supported by VA in testimony submitted 
to the Committee for its April 22, 2009, hearing. Also, in 
testimony before the Committee on May 21, 2008, Cecilia McVey, 
MHA, RN, Former President of the Nurses Organization of 
Veterans Affairs, called for the increase in the cap on RN pay 
proposed by the Committee bill.
            Subsection 101(i)--Exemption for certified registered nurse 
                    anesthetists from limitation on authorized 
                    competitive pay.
    Subsection (i) of section 101 of the Committee bill would 
allow pay for certified registered nurse anesthetists (CRNAs) 
to exceed the pay caps established for RNs employed by the 
Department.
    Background. As discussed above, under subsection 101(h), 
current law limits pay for CRNAs at level V of the Executive 
Schedule, currently $143,500. Additional compensation may be 
provided to CRNAs in the form of recruitment and/or retention 
bonuses. As is currently the case with RNs, the level V cap 
often prevents CRNAs from receiving locality pay.
    In December 2007, the Government Accountability Office 
(``GAO'') released a report on CRNA retention, titled 
``Department of Veterans Affairs (VA) medical facilities have 
challenges in recruiting and retaining VA CRNAs for their 
workforce'' (GAO-08-56). GAO found that about three-fourths of 
all VA medical facility chief anesthesiologists responding to 
the survey reported that they had difficulty recruiting CRNAs. 
Overall, 54 percent of VA medical facility chief 
anesthesiologists reported temporarily closing some operating 
rooms and 72 percent reported delaying some elective surgeries 
due to difficulty fully staffing CRNAs. GAO projected that 26 
percent of VA's CRNAs will either retire from or leave VA by 
2012. VA medical facility officials reported that the 
recruitment and retention challenges are caused primarily by 
the low level of VA CRNA salaries when compared with CRNA 
salaries in local market areas.
    In testimony before the Committee on April 9, 2008, Ms. 
Cullen and Steven P. Kleinglass, Director of the Minneapolis VA 
Medical Center, both discussed the challenges created by the 
current limit on CRNA pay. Mr. Kleinglass noted that at the 
Minneapolis VAMC, the VA pay scale falls behind the local 
medical community as a whole, and that ``therefore, in theory, 
we should have most of our employees on a retention bonus.'' 
Ms. Cullen, in San Francisco, is prevented from offering 
locality pay due to the statutory limit, even though the local 
median salary for CRNAs is $171,334. As a result, she has had 
to implement the 25 percent retention incentive extensively. At 
the same hearing, Ms. O'Meara echoed these concerns. 
``Facilities around the country are finding it increasingly 
difficult to recruit CRNAs.''
    Committee Bill. Subsection (i) of section 101 of the 
Committee bill would further amend section 7451(c)(2) of title 
38, as amended by subsection 101(h) of the Committee bill, to 
allow pay for CRNAs to exceed the pay caps established for RNs 
employed by the Department.
    This proposed exemption would provide VA with greater 
flexibility to offer additional pay to CRNAs, a necessary tool 
when CRNA positions prove difficult to fill due to insufficient 
compensation.
    This proposed amendment was endorsed in testimony before 
the Committee on May 21, 2008, by Carl Blake, National 
Legislative Director, Paralyzed Veterans of America and J. 
David Cox, RN, National Secretary-Treasurer, American 
Federation of Government Employees. In addition, VA supported 
this provision in testimony submitted for the Committee's April 
22, 2009, hearing.
            Subsection 101(j)--Increased limitation on special pay for 
                    nurse executives.
    This provision would amend section 7452(g)(2) to increase 
the limitation on special pay for nurse executives from $25,000 
to $100,000.
    Background. Under current law, the Secretary may provide 
between $10,000 and $25,000 in special pay to nurse executives 
at each Department health care facility and at the VA Central 
Office. The amount is determined based on the grade of the 
nurse executive position, the scope and complexity of the nurse 
executive position, the personal qualifications of the nurse 
executive, the characteristics of the health care facility 
concerned, the nature and number of specialty care units at the 
health care facility concerned, demonstrated difficulties in 
recruitment and retention of nurse executives at the health 
care facility concerned, and such other factors as the 
Secretary considers appropriate.
    Given the limits on nurse pay, most nurse executives are 
already paid at or near the top of their grade. As such, VA 
lacks the ability to provide additional financial incentive to 
individuals who take on the increased responsibility of 
executive positions. Given the systemic shortage of nurses as 
described previously, the Committee believes that an additional 
financial incentive is warranted to attract highly qualified 
nurses to executive positions.
    Committee Bill. Subsection (j) of section 101 of the 
Committee bill would amend section 7452(g)(2) of title 38 so as 
to increase the authorized limit on special pay for nurse 
executives from $25,000 to $100,000. In testimony before the 
Committee on May 21, 2008, Mr. Blake expressed PVA's support 
for this provision of the Committee bill.
            Subsection 101(k)--Locality pay scale computation.
    Subsection 101(k) of the Committee bill would amend section 
7451 of title 38 so as to improve implementation and 
transparency of VA's locality pay system for nurses and others 
in covered positions.
    Background. Section 7451(d) of title 38 currently 
authorizes a locality pay system (LPS) to address 
geographically-related pay issues, and to strengthen 
recruitment and retention of nurses and others in covered 
positions. That section mandates that pay for personnel in 
covered positions at each facility be adjusted periodically to 
reflect changing pay rates in local labor markets. The director 
of each facility is charged with using data from the Bureau of 
Labor Statistics (BLS) to determine prevalent pay rates, and to 
make necessary adjustments to the pay of nurses and others in 
covered positions employed by the facility in question. When 
BLS data are not available, the director is required to use 
data provided by a third party. If no third party data are 
available, the director is required to conduct a locality pay 
survey to determine prevalent pay rates. Each locality pay 
schedule, of which there are nearly 800, is required to be 
reviewed and approved by the Under Secretary for Health.
    In the report titled ``Many Medical Facilities Have 
Challenges Recruiting and Retaining Nurse Anesthetists'' (GAO-
08-56, December 2007), GAO found that, in 2005 and in 2006, 
over half of VA medical facilities used the LPS to determine 
whether to adjust VA CRNA salaries. However, in the eight VA 
medical facilities visited, GAO found that the majority of the 
facilities did not correctly follow VA's LPS policy. Officials 
at these facilities did not always know or were not aware of 
certain aspects of the LPS policy, and VA has not provided 
training on the LPS to VA medical facility officials since the 
policy was changed in 2001. As a result, GAO found that VA 
medical facility officials cannot ensure that VA CRNA salaries 
have been adjusted as needed to be competitive. While the 
report dealt only with CRNAs, the conclusions regarding faulty 
implementation of the LPS are likely applicable to others in 
covered positions, based on Committee oversight activities.
    The failure to properly implement the LPS runs the risk of 
negatively affecting recruitment and retention, and 
inappropriately limits the pay of nurses and others who 
continue their employment at VA. Further, due to a lack of 
transparency of the LPS process, employees do not have 
reasonable access to the surveys that determine locality pay.
    Committee Bill. Subsection (k)(1) of section 101 of the 
Committee bill would add a new subparagraph (F) to section 
7451(d)(3) of title 38. Proposed new subsection (F) would 
require the Under Secretary for Health to provide appropriate 
education, training, and support to directors of Department 
health care facilities in the conduct and use of LPS surveys. 
The Committee intends for this change to address the inadequate 
training found by GAO.
    In testimony before the Committee on April 9, 2008, Ms. 
O'Meara emphasized the need for adequate training in the use 
and implementation of the LPS. At the Committee hearing on May 
21, 2008, Mr. Cox stated that ``management training on the 
nurse locality pay process will increase compliance with the 
2000 nurse locality pay law (The Veterans Benefits and Health 
Care Improvement Act of 2000, Pub. L. 106-419) that Congress 
enacted to address recruitment and retention.''
    In testimony submitted for the Committee hearing on April 
9, 2008, the Department stated that development of web-based 
training to assist in the conduct of surveys was expected to be 
available by late summer 2008, and that additional training 
events are planned. The Committee believes these are important 
improvements in education on the LPS, but believes that 
additional measures may be required.
    Subsection (k)(2) of section 101 of the Committee bill 
would add a new subparagraph (D) to section 7451(e)(4) of title 
38. Under this proposed new subparagraph (D), a facility 
director would be required to publicize information on the 
methodology used in making an adjustment to rates of pay based 
on the LPS. This is intended to improve transparency in the 
LPS.
    Subsection (k)(3) of section 101 of the Committee bill 
would further amend section 7451(e) by adding a new paragraph 
(6). Under current law, each facility director is required to 
report to the Secretary on wage-related staffing issues. 
Proposed new paragraph (6) would require such reports to be 
made available to any individual in a position included in such 
report, or, upon the authorization of such individual, to the 
representative of the labor organization representing that 
individual. Taken together, the Committee believes that the 
changes proposed by subsections (k)(2) and (3) of section 101 
of the Committee bill will improve transparency of the LPS.
    These amendments address concerns raised in testimony 
before the Committee on May 21, 2008, by Mr. Cox, and on April 
9, 2008, by Ms. O'Meara. According to Mr. Cox, ``greater 
employee access to pay survey data will add accountability to 
the locality pay process to ensure that surveys are done 
properly and that needed pay adjustments are made.''
    The Committee is aware that in some facilities, access to 
LPS survey data is unnecessarily challenging for many 
employees. As Ms. O'Meara said in her testimony on April 9, 
2008, ``[l]ocality pay should be provided based on local labor 
market conditions, and be paid according to consistent rules, 
not on how hard employees fight for it or whether a particular 
manager decides to pay it.''
    Concerns have been raised that the Committee bill places 
inordinate emphasis on the conduct of LPS surveys, rather than 
the use of BLS or third party data, which the Department 
prefers. The Committee recognizes the value of BLS and third 
party data and does not intend that facility directors conduct 
their own surveys when such information is available. The 
Committee believes that, implemented effectively and according 
to statute, the LPS can effectively address geographically-
related pay issues, and can strengthen recruitment and 
retention.
            Subsection 101(l)--Eligibility of part-time nurses for 
                    additional nurse pay.
    Subsection (l) of section 101 of the Committee bill would 
expand eligibility for additional premium pay to part-time 
nurses.
    Background. Additional pay for nurses is authorized by 
section 7453 of title 38. In general, nurses are eligible for 
overtime pay when they work over forty hours in a week or 8 
hours in a day. Further additional pay is mandated for nurses 
who work on weekends, at night, and on holidays. Other than 
overtime pay, eligibility for additional pay is limited to 
nurses working on specified tours of duty that meet the 
requirements of each type of additional pay. Those nurses not 
assigned to a specific tour are not eligible for the additional 
pay associated with such tour, even if their period of service 
includes hours which fall within the eligible time periods. 
This limit affects the pay of both full- and part-time nurses, 
as well as nurses who are on call and not assigned to tours of 
duty.
    Based on testimony presented at Committee hearings, and 
information gathered during Committee oversight activity, the 
Committee concludes that in many facilities VA is challenged to 
fill nurse staff positions and some nursing tours are difficult 
to cover. The Committee believes that the current eligibility 
criteria for additional pay are too restrictive to create 
effective financial incentives to encourage nurses to work 
those tours.
    Further, the current additional pay statute creates 
unacceptable inequities between part-time and full-time nurses. 
In testimony before the Committee on April 9, 2008, Ms. O'Meara 
cited chronic problems with implementation of additional pay 
requirements. She urged ``the Committee to take steps to ensure 
that premium pay is available to all RNs who perform services 
on weekends or off shifts, work overtime on a voluntary or 
mandatory basis, or work during on call duty.'' By not 
providing part-time nurses additional pay on the same basis as 
full-time nurses, there is a disincentive for part-time and on-
call nurses to serve during times of the day and week that are 
harder to staff. This is contrary to the intent of the 
additional pay authorities.
    In addition, excluding part-time and on-call nurses from 
eligibility for additional pay, and denying additional pay for 
nurses not assigned to a specific eligible tour, creates 
further disparity between VA and non-VA compensation, and 
contributes to recruitment and retention challenges.
    Committee Bill. Subsection (l) of section 101 of the 
Committee bill would amend section 7453 of title 38 so as to 
expand eligibility for additional premium pay to part-time 
nurses.
    An amendment to subsection (a) of section 7453 would 
provide that part-time nurses would be generally eligible for 
additional pay when they meet the criteria in other subsections 
of section 7453. Amendments to subsections (b) (concerning 
evening pay), (c) (concerning weekend pay), and (d) (concerning 
overtime pay), would replace ``tour of duty'' with ``period of 
service.'' These changes would make any service performed 
during evenings or weekends, or as overtime, eligible for 
additional pay.
    It is the Committee's intent to change the basis for 
additional pay from the tour to the nurse's period of service 
and the timing of such service. This reflects original 
Congressional intent that additional pay is intended to create 
incentives for nurses to work at times that would otherwise be 
difficult to staff. The changes proposed by the Committee bill 
would not eliminate the utility of established tours nor would 
they reduce additional pay for such tours. Rather, the changes 
would encourage a greater number of nurses to work during such 
times, and would equitably reward all nurses who do so. In 
testimony before the Committee on May 21, 2008, Mr. Blake 
expressed the support of Paralyzed Veterans of America for 
eligibility of part-time nurses for additional pay.
    Subsection (l)(1)(D)(i) of section 101 of the Committee 
bill would address an inequity in eligibility for additional 
pay for overtime under section 7453(e) of title 38. Under 
current law, nurses who perform continuous service in excess of 
8 hours but on two different calendar days are not eligible for 
additional pay for overtime service. This section of the 
Committee bill would amend section 7453(e) to add service 
performed in excess of eight consecutive hours to the list of 
service eligible for additional overtime pay. In testimony 
before the Committee on April 9, 2008, Ms. O'Meara emphasized 
the urgency of this legislative change.
            Subsection 101(m)--Exemption of additional nurse positions 
                    from limitation on increase in rates of basic pay.
    Subsection (m) of section 101 of the Committee bill would 
make additional health care occupations exempt from limitations 
on increases in rates of basic pay.
    Background. Under current law, rates of basic pay for 
nurses and other health care providers may be increased under 
section 7455 of title 38. Under that section, the Secretary may 
determine that salary increases are necessary for the purposes 
of recruitment and retention, and to compete with pay for 
similar positions in non-Federal facilities in the same labor 
market.
    Under subsection (c)(1) of section 7455, the amount of 
increase in the maximum pay rate generally is limited to two 
times the amount by which the original maximum exceeds the 
minimum, and the maximum rate as so increased may not exceed 
the pay rate of the Assistant Under Secretary for Health. Nurse 
anesthetists, pharmacists, and licensed physical therapists are 
exempted from this limit, based on the challenges VA faces in 
recruiting and retaining employees in these occupations, as 
discussed earlier in this report.
    Committee Bill. Subsection (m) of section 101 of the 
Committee bill would amend section 7455(c)(1) so as to make 
additional occupations exempt from limitations on increases in 
rates of basic pay. Specifically, this provision would add 
licensed practical nurses, licensed vocational nurses, and 
nursing positions otherwise covered by title 5 to the list of 
positions exempted from the limits imposed by section 
7455(c)(1). Also, this subsection would amend the current law 
limitation on the permissible increase by utilizing the same 
formula that is applied to the cap on title 5 special rates. 
This change would give VA the greatest flexibility in 
establishing maximum rates for title 38 employees. This 
provision, combined with subsection (h) of section 101 of the 
Committee bill, should ensure that VA has the pay flexibility 
to compete with other employers for qualified health care 
providers. In testimony before the Committee on April 9 and May 
21, 2008, respectively, Ms. O'Meara and Mr. Cox emphasized the 
need for additional pay flexibility to strengthen VA's ability 
to compete with other employers.

Section 102. Limitations on overtime duty, weekend duty, and 
        alternative work schedules for nurses.

    Section 102 of the Committee bill, which is derived from 
S.252 as introduced, would amend various provisions of title 38 
so as to establish special rules for nurse staff overtime 
service, modify rules relating to leave during weekend duty, 
and change the underlying authority for alternative work 
schedules for nurses.
            Subsection 102(a)--Overtime duty.
    Background. Under current law, the Secretary may require 
nurses to perform mandatory overtime in emergency situations. 
The Committee recognizes that this authority is essential to 
ensuring adequate staffing to provide patient care. However, 
based on oversight activities, and as discussed at the 
Committee hearing on April 9, 2008, it appears that, at some 
facilities, the use of emergency mandatory overtime is 
excessive and even abusive.
    At the Committee hearing on April 9, 2008, Ms. O'Meara 
testified that ``facility directors continue to invoke the 
emergency exception when staffing shortages are the result of 
easily anticipated scheduling and hiring problems.'' At that 
same hearing, testimony on this issue was received from two VA 
medical center directors, Steven P. Kleinglass, of the 
Minneapolis VA Medical Center, and Sheila M. Cullen, of the San 
Francisco VA Medical Center. These two facilities illustrate 
two different approaches to the use of the emergency mandatory 
overtime authority. According to Mr. Kleinglass, in Minneapolis 
mandatory overtime is used to respond to a number of 
situations, including unplanned leave, sick leave, emergency 
annual leave, absenteeism, and tardiness for duty by nursing 
staff. At the San Francisco medical center, on the other hand, 
mandatory overtime has been used only once in the past three 
years, an event implemented in cooperation with local 
bargaining union.
    The Committee is concerned that VA lacks a clear definition 
of ``emergency'' for the purposes of implementing mandatory 
overtime and that VA facility directors appear to have 
unbridled discretion on the interpretation and implementation 
of this authority. Without a clear definition of what 
constitutes allowable situations, the use of emergency 
authority can lead to inconsistent implementation and abuse.
    Research has highlighted the danger of excessive overtime 
service by nurses, as well as other health care providers. In 
the report Keeping Patients Safe: Transforming the Work 
Environment of Nurses (2004), the Institute of Medicine 
recommended that ``to reduce error-producing fatigue, state 
regulatory bodies should prohibit nursing staff from providing 
patient care in any combination of scheduled shifts, mandatory 
overtime, or voluntary overtime in excess of 12 hours in any 
given 24-hour period and in excess of 60 hours per 7-day 
period.''
    At least nine states have enacted legislation restricting 
the use of emergency mandatory overtime. In the interest of 
patient and employee safety and appropriate labor standards, 
these states limit the number of hours a nurse can be required 
to work, except in certain defined emergency situations.
    Committee Bill. Subsection (a) of section 102 of the 
Committee bill would add a new section 7459 to subchapter IV of 
chapter 74 of title 38. This new section would limit nursing 
staff--including RNs, licensed practical or vocational nurses, 
nurse assistants appointed under title 38 or title 5 of United 
States Code, or any other nurse position designated by the 
Secretary--to no more than 40 hours of work per administrative 
work week (or 24 hours if such staff is covered by section 7456 
of title 38), and not more than eight consecutive hours (or 12 
hours if such staff is covered by sections 7456 or 7456A of 
title 38). Nursing staff may exceed these limits voluntarily or 
in emergency situations, as defined by the Committee bill.
    The definition of ``emergency circumstances'' would be set 
out in subsection (c) of the proposed new section 7459. Under 
this subsection, the Secretary would be authorized to require 
mandatory overtime otherwise prohibited if the following 
conditions were met: (1) the work is a consequence of an 
emergency that could not have been reasonably anticipated; (2) 
the emergency is non-recurring and is not caused by or 
aggravated by the inattention of the Secretary or lack of 
reasonable contingency planning by the Secretary; (3) the 
Secretary has exhausted all good faith, reasonable attempts to 
obtain voluntary workers; (4) the nurse staff have critical 
skills and expertise that are required for the work; and (5) 
the work involves work for which the standard of care for a 
patient assignment requires continuity of care through 
completion of a case, treatment, or procedure. Nursing staff 
would not be required to work hours after the requirement for a 
direct role by the staff in responding to medical needs 
resulting from the emergency ends.
    The Committee is concerned that undue reliance on mandatory 
overtime is not desirable and believes that, with reasonable 
contingency planning, including consultation with nurse staff, 
all VA facilities have the capacity to eliminate unnecessary 
use of emergency mandatory overtime. It is clear that many VA 
facilities already avoid unnecessary use of emergency mandatory 
overtime through effective planning for adequate nurse 
staffing.
    Subsection (b)(2) of the proposed new section 7459 would 
prohibit discrimination or adverse personnel action against 
nursing staff if such staff were to refuse to work hours 
prohibited by such section. This protection has proven 
necessary in the many of the states which have legislatively 
limited mandatory overtime, including Connecticut, Maryland, 
Minnesota, New Jersey, and Washington. In written testimony 
before the Committee on April 22, 2009, Ammie Hilsabeck 
expressed AFGE's support for this provision of the Committee 
bill.
            Subsection 102(b)--Weekend duty.
    Subsection (b) of section 102 of the Committee bill would 
amend section 7456 of title 38, which authorizes VA to pay 
nurses who perform two regularly schedule 12 hour tours on the 
weekend for 40 hours. According to VA, this plan is typically 
used only when a facility has significant difficulties in 
securing adequate nurse staffing for the weekends.
    Committee Bill. The Committee bill would repeal subsection 
(c) of section 7456 which charges nurses 5 hours of leave for 3 
hours of absence during a 12 hour tour of duty. In written 
testimony before the Committee on April 22, 2009, AFGE 
indicated its support for this provision.
            Subsection 102(c)--Alternative work schedules.
    Subsection (c) of section 102 of the Committee bill would 
modify an existing alternative work schedule available to VA 
nurses.
    Background. Section 7456A of title 38 authorizes the 
Secretary to provide alternative work schedules to RNs working 
for the Department. These schedules, known as ``36/40'' 
schedules, allow VA nurses to work three regularly scheduled 
12-hour tours of duty within a work week and to have that 
service considered for all purposes as a full 40-hour basic 
work week. These alternative work schedules are authorized ``in 
order to obtain or retain the services of registered nurses.''
    Alternative work schedules were authorized in December 2004 
by the Department of Veterans Affairs Health Care Personnel 
Enhancement Act of 2004, Public Law 108-445. According to the 
Senate report accompanying the legislation that resulted in the 
new law, S. Rpt. 108-375, this new authority was a response to 
an 
August 2003 request by the Department so as to ``enhance its 
ability to recruit and retain high quality nurses.'' In that 
report, the Committee noted that, based on a survey conducted 
in 2000 by the American Organization of Nurse Executives, 
inflexible scheduling was a major cause of nurse 
dissatisfaction. The original intent of Congress in authorizing 
alternative work schedules was that such schedules be widely 
available so as to enhance the Department's ability to improve 
employee satisfaction and therefore be better able to recruit 
and retain nurses in competition with other employers.
    Since the passage of Public Law 108-445, the implementation 
of 36/40 alternative work schedules has varied throughout the 
VA health care system. In testimony for the Committee hearing 
on April 9, 2008, VA indicated that it ``encourages facility 
managers to use alternate work schedules for all eligible 
employees whenever feasible,'' and noted that the use of these 
schedules ``increases VA's visibility as the employer of 
choice.''
    Some facilities, such as the San Francisco VA Medical 
Center, have made effective use of alternative schedules to 
reduce vacancy rates in nursing positions, and to improve nurse 
satisfaction. In testimony before the Committee on April 9, 
2008, the San Francisco VAMC Director, Ms. Cullen, stated that 
``most new hires are highly interested in an alternative work 
schedule. We believe that offering an alternative work schedule 
improves recruitment, retention and employee satisfaction.'' 
Mr. Kleinglass, the Director of the Minneapolis VAMC, in 
testimony before the Committee on April 9, 2008, noted that the 
use of alternative schedules at the Minneapolis VA Medical 
Center allows staff to ``find balance between their work and 
home lives as they feel best suits their individual needs.''
    Unfortunately, based on Committee oversight work, many VA 
facilities have failed to make 36/40 alternative work schedules 
widely available. While facility directors have discretion on 
the implementation of these schedules, Congress intended that 
their use be throughout the VA health care system. In testimony 
before the Committee on April 9, 2008, Ms. O'Meara stated:

        As a result of delay and resistance by the VA at the 
        national and local levels, [alternative work schedules] 
        have failed to meet their potential for addressing VA 
        nurse recruitment and retention problems. It seems as 
        if the law was never passed.

    Committee Bill. Subsection (c) of section 102 of the 
Committee bill would amend section 7456A of title 38 so as to 
modify the 36/40 alternative work schedule authorized by that 
section. Specifically, this section of the Committee bill would 
amend section 7456A(b)(1)(A) to modify the scheduling 
requirement for the 36/40 alternative work schedule. Currently, 
the 36/40 alternative work schedule is defined as ``three 
regularly scheduled 12-hour tours of duty within a work week.'' 
The Committee bill would redefine the schedule as six regularly 
scheduled 12-hour periods of service within an 80-hour pay 
period.
    The intent of this provision is to facilitate easier 
implementation of the alternative work schedule. In testimony 
for the Committee hearing on May 21, 2008, the Department noted 
that because a work week is defined as Sunday through Saturday, 
it is often difficult schedule three 12-hour tours in their 
entirety within one work week. The Department expressed support 
for these provisions of the Committee bill, as they would 
provide greater flexibility to scheduling.
    By providing greater flexibility in the scheduling of the 
alternative work schedule, the Committee intends to facilitate 
and encourage wider use of such schedules. Based on hearing 
testimony and oversight activities, the Committee believes that 
by unnecessarily limiting the use of the current 36/40 
alternative work schedules, VA facilities forego a valuable 
recruitment and retention tool, and fail to keep pace with the 
health care industry.
    Section 103. Improvements to Certain Educational Assistance 
Programs.
    Section 103 of the Committee bill would amend two existing 
VA Education Assistance Programs and provide the Secretary of 
Veterans Affairs with new authority to make repayment of 
educational loans for certain health professionals.
    Background. Chapter 76 of title 38 contains numerous 
authorities that are designed to enhance VA's ability to 
attract and retain health professions. Among these authorities 
are the Health Professional Scholarship Program (hereinafter 
``HPSP''), in Subchapter II, and the Education Debt Reduction 
Program, in Subchapter VII.
    The authorization for the programs needs to be extended in 
order to continue to give VA this authority, as the private 
sector has made recruiting health care professionals 
increasingly competitive. Title VII of Public Law 105-368 and 
Public Law 107-135 made amendments to these programs. VA 
currently awards Employee Incentive Scholarship Program 
scholarships to qualifying and current employees to help VHA 
meet the health care staffing requirements set forth in Section 
7401 of title 38, U.S.C., in which the difficulties surrounding 
recruitment and retention of VA health care employees is 
specifically addressed.
    Committee Bill. Subsection (a) of section 103 of the 
Committee bill would amend section 7618 of title 38 so as to 
reinstate HPSP through the end of 2013. The Committee believes 
that renewing HPSP, which expired in 1998, will help reduce the 
nursing shortage in VA by enabling VA to provide scholarships 
to nursing personnel who, on completion of their education, 
will be obligated to work a year for every year of education, 
with a minimum obligation of two years, at a VA health care 
facility. This subsection would also expand eligibility for the 
scholarship program to all VA health personnel appointed to 
positions described under paragraphs (1) and (3) of section 
7401 of title 38, which includes all title 38 health care 
employees as well as all hybrid occupations. It also expands 
the use of the program to any eligible employee, not just to 
those recently appointed. The Committee expects that this 
expansion of those eligible for the scholarship program will be 
helpful in VA's efforts to recruit and retain employees in a 
number of difficult-to-fill health care occupations.
    Subsection (b) of section 103 would amend two provisions in 
subchapter VII of chapter 76, relating to VA's Education Debt 
Reduction Program.
    Paragraph (1) of subsection (b) would amend section 
7681(a)(2) so as to add retention, along with recruitment, as a 
purpose of the debt reduction program.
    Paragraph (2) would amend subsection (a)(1) of section 7682 
and would strike subsection (c) of that section so as to make 
the debt reduction program available to ``an'' employee, not 
just to a ``recently appointed'' employee as in current law. 
The Committee's intent is that this program should be available 
beginning from the first date of a qualified applicant's 
employment. In addition, the Department had interpreted 
``recently appointed'' to exclude any employee who had worked 
for VA for longer than 6 months. The new language makes it 
clear that eligibility for the program will not be subject to 
this 6 month time limit.
    Subsection (c) of section 103 would authorize the Secretary 
of VA, in consultation with the Secretary of Health and Human 
Services, to use the authorities in section 487E of the Public 
Health Service Loan Repayment Program for the repayment of 
educational loans of health professionals from disadvantaged 
backgrounds in order to secure clinical research expertise in 
VA from such individuals. This loan repayment program is 
currently not available to Federal employees other than those 
working for the National Institutes of Health. By extending 
this authority to VA, clinicians with medical specialization 
and research interests may be more likely to join VHA. Funding 
for the repayment of educational loans under this program would 
have to come from VA medical care funding.
    Section 104. Standards for Appointment and Practice of 
Physicians in Department of Veterans Affairs Medical 
Facilities.
    Section 104, which was originally derived from S.2377 in 
the 110th Congress prior to being incorporated in S.2969, would 
establish a new section in title 38 setting out procedures for 
appointing new physicians in VA, and the requisite 
qualifications of such physicians.
    Background. Current section 7402 of title 38 sets forth the 
requirements that must be met in order for a person to be 
appointed as a physician with VA. Included in these 
requirements are that the applicant holds the degree of doctor 
of medicine, or doctor of osteopathy, from a university 
approved by the Secretary; that the applicant has completed an 
internship approved by the Secretary; and that the applicant is 
licensed to practice medicine, surgery, or osteopathy in a 
State.
    Under subsection (f) of section 7402, any applicant who has 
or has had multiple licenses or certifications and has had one 
or more of them suspended, revoked, or surrendered for cause, 
is subject to employment restrictions.
    VA also requires extensive disclosures from applicants, 
including the status of their credentials, and is permitted to 
deny appointment or terminate employment if that information is 
not disclosed. This information must be resubmitted every two 
years. A VA policy that took effect on November 14, 2008, 
requires applicants to submit extensive information regarding 
previous malpractice claims, and authorizations to their State 
licensing boards to permit those boards to release records to 
VA.
    Current law does not require physicians to be board 
certified in the area in which they will practice in order to 
be eligible for employment with VA. VA permits facility 
directors and chiefs of staff to determine that an applicant is 
qualified based on other factors. VA believes its current 
requirements are in keeping with medical standards.
    Physicians elsewhere in Federal service are not required to 
be licensed in the State in which they practice, but simply to 
be licensed in any State. VA makes use of telemedicine, and 
exchanges physicians or allows physicians to collaborate with 
others in the Federal system in different States. This also 
occurs during certain emergency situations. Additionally, some 
States have licensing procedures that take more than 1 year to 
complete.
    Committee Bill. Section 104 of the Committee bill would 
establish a new section in title 38--section 7402A Appointment 
and practice of physicians: standards--which would set forth 
the procedures for appointing new physicians in VA, and the 
requisite or desired qualifications to practice as a VA 
physician. This provision would take effect immediately upon 
enactment, except for subsection (f) as that section pertains 
to physicians already employed by VA, which would go into 
effect 60 days after enactment, and subsection (g), relating to 
performance contracts with VISN directors, which would go into 
effect upon the start of the first cycle, beginning after the 
date of enactment, of performance contracts for VISN directors.
    Subsection (a) of the proposed new section would require 
the Secretary, through the Under Secretary for Health, to 
develop and promulgate minimum standards a physician must meet 
in order to be appointed to that position in the VHA, or to be 
permitted to practice in the VA medical facilities. The 
standards developed would be required to include the 
requirements outlined in the new section 7402A.
    Subsection (b) of the proposed new section would require 
any individual seeking to be appointed as a physician within 
the VHA to provide the following information: a full and 
complete explanation of any lawsuit for medical malpractice or 
negligence that is pending or was brought against the 
applicant; any settlements agreed to as a result of a lawsuit 
for malpractice or negligence; and any investigation or 
disciplinary action against the applicant that relates to the 
applicant's work as a physician. The applicant must also 
provide authorization to the licensing board of any state where 
the applicant holds or has ever held a license to practice 
medicine, to disclose to the Secretary any records pertaining 
to: any lawsuit for malpractice or negligence brought against 
the applicant, and the details any settlements agreed to as a 
result; any court or administrative agency's judgment against 
the applicant; any disciplinary action brought against the 
applicant by any State body or administrative agency; any 
change in the status of the applicant's license to practice 
medicine, whether voluntary or involuntary; any open 
investigation of, or outstanding allegation against, the 
applicant; and any written notification from the State to the 
applicant pertaining to the potential termination of the 
applicant's license.
    Subsection (c) of the proposed new section would require 
any physician appointed to practice in the VHA, after the 
enactment of the Committee bill, to disclose to the Secretary, 
within 30 days of occurrence: a judgment against the physician 
for medical malpractice or negligence; a payment made as part 
of a settlement for a lawsuit or action, previously disclosed 
prior to appointment, or any disposition or change in status of 
any issue disclosed prior to appointment. Additionally, this 
subsection would require any physician practicing in VHA at the 
time of the enactment of the Committee bill to provide, within 
60 days after the date of enactment, to the Secretary with an 
authorization for state medical boards to release any 
information regarding pending or completed disciplinary actions 
or claims against a license to practice medicine. A physician 
currently practicing in VHA would be required, as a condition 
of employment, to agree to disclose, within 30 days of 
occurrence, any future claim or judgment against the physician 
or payment as part of a settlement arising from a lawsuit 
alleging malpractice or negligence, or the disposition or 
change in status of any matter disclosed pursuant to the 
authorization for disclosure the physician would be required to 
give to a State licensing board.
    Subsection (d) of the proposed new section would require 
the director of the VISN in which an applicant seeks employment 
as a VA physician to conduct an investigation into the 
information disclosed by the applicant as required by new 
subsection (b). The appropriate VISN director also would be 
required to perform a similar investigation of any material 
disclosed by a VA physician employed as of the date of 
enactment of the Committee bill, or a physician appointed after 
that date who discloses information while employed by VA, as 
required by new subsection (c). The results of all such 
investigations would be required to be fully documented.
    Subsection (e) of the proposed new section would require an 
applicant seeking to be employed as a VA physician to receive 
the approval of the appropriate VISN director, unless a full 
investigation by the medical center director failed to disclose 
any actions described in new subsections (b),(c), and (d). In 
this event, the VISN Director's approval would not be required.
    If an applicant has disclosed information as required by 
new subsection (b), the VISN director, if the director chooses 
to approve the applicant, would be required to certify in 
writing that the investigation of each issue required by new 
subsection (d) was completed, and the director would be 
required to provide a written explanation as to why any 
identified issue did not disqualify the applicant.
    Subsection (f) of the proposed new section would require 
each VA medical facility that employs physicians who are 
extended the privileges of practice at that facility to enroll 
each physician in the Proactive Disclosure Service of the 
National Practitioners Data base.
    Subsection (g) of the proposed new section would require 
the Secretary to include in each performance contract with a 
VISN director, a provision that encourages the director to hire 
physicians who are board certified or eligible for such 
certification in the field in which they will be practicing 
when employed by VA. The Secretary would be authorized to 
determine the nature of this provision in the performance 
contracts.
    The Committee believes that the requirements that would be 
put in place by the proposed new section 7402A are necessary to 
strengthen qualification standards for hiring physicians at VA 
and for monitoring their performance once they are working for 
VA. Despite the measures VA has in place regarding review of 
qualifications, history, and credentials, there have been 
incidents of physicians practicing in VA with suspended 
licenses and other problems with their qualifications. One of 
the more recent incidents of such a situation occurred at the 
Marion, Illinois, VA Medical Center, and that lack of 
appropriate review resulted in several patient deaths. The fact 
that VA's existing policy failed to prevent this result 
illustrates that additional measures to prevent under-qualified 
physicians from practicing medicine are needed and that it is 
justified to give VA's hiring practices the force of law.

                     TITLE II--HEALTH CARE MATTERS

Section 201. Repeal of certain annual reporting requirements.

    Section 201, which was initially derived from S.2984, by 
request legislation introduced in the 110th Congress, would 
repeal the requirement for VA to submit to Congress two annual 
reports, one relating to pay adjustments for registered nurses, 
and one relating to VA's long-range health planning.
    Background. Public Law 101-366, The Department of Veterans 
Affairs Nurse Pay Act of 1990, established a reporting 
requirement relating to pay adjustments for registered nurses 
because, at that time, annual General Schedule (GS) 
comparability increases were extended to VA nurses at the 
discretion of the facility Director. However, with the 
subsequent enactment of Public Law 106-419, the Veterans 
Benefits and Health Care Improvement Act of 2000, GS 
comparability increases must be given to VA nurses and other 
health care personnel described in section 7451.
    With respect to VA's long-range health care planning, VA's 
annual budget documents contain information on the Veterans 
Health Administration's tactical and strategic goals, 
performance measures, and supporting activities; current and 
anticipated methods for serving VA's special populations; and 
other priorities, resource requirements and distribution 
methodologies. With the advent of VA's 5-Year Strategic Plan in 
2004, VA's budget submission also includes the top 20 
priorities for medical construction projects.
    Committee Bill. Subsection (a) of section 201 of the 
Committee bill would repeal the requirement to report annually 
on any pay adjustments made to the basic pay of VA nurses and 
other health care personnel described in section 7451 of title 
38. In light of the fact that covered staff receive, at a 
minimum, the annual increases in pay provided under the GS 
schedule, the Committee views this annual report as 
unnecessary.
    Subsection (b) of this section of the Committee bill would 
repeal the requirement for the Secretary to annually report on 
the Department's long-range health planning, including 
operation and construction plans for medical facilities. The 
Committee is satisfied that this report contains information 
that is already submitted in other reports and plans, 
particularly those prepared annually in connection with the 
Department's budget request.

Section 202. Modifications to annual Gulf War research report.

    Section 202, which is also derived from S.2984 from the 
110th Congress, would make changes to VA's annual report on 
Gulf War research.
    Background. Under current law, section 707 of the Persian 
Gulf War Veterans' Health Status Act, Public Law 102-585, the 
executive branch, through a designated head of an appropriate 
department or agency, is required to report to the Committees 
on Veterans' Affairs of the Senate and the House of 
Representatives on the status and results of all research 
undertaken in the area of Gulf War Illnesses and the research 
priorities identified during the previous year. Since the 
requirement was enacted in 1992, the Secretary of Veterans 
Affairs has been the official responsible for compiling and 
submitting this report. This report is due by March 1 of each 
year. Under current law, this report is a continuing 
obligation.
    Committee Bill. Section 202 of the Committee bill would 
change the due date of this annual report to Congress on the 
research on the health effects of service during the Persian 
Gulf War from March 1 to July 1 of each year, and also 
establish a sunset date for this reporting requirement of July 
2013.
    VA has testified that it is difficult if not impossible to 
submit the report by the current March 1 statutory deadline and 
it is the Committee's view that a July 1 deadline is more 
attainable. Imposition of a sunset date is intended to afford 
Congress sufficient opportunity to assess, in 5 year's time, 
whether there exists a continued need for this formal reporting 
requirement.

Section 203. Payment for care furnished to CHAMPVA beneficiaries.

    Section 203, which is also derived from S.2984 as 
introduced in the 110th Congress, would clarify the status of 
payment made by VA to health care providers on behalf of 
beneficiaries under the Civilian Health and Medical Program of 
the Department of Veterans Affairs (hereinafter, ``CHAMPVA'') 
program.
    Background. CHAMPVA is a health care program under which VA 
shares the cost of covered health care services and supplies 
with eligible beneficiaries. The program is administered by the 
Veterans Health Administration. To be eligible for CHAMPVA, a 
person must be in one of these categories: (1) the spouse or 
child of a veteran who has been rated permanently and totally 
disabled for a service-connected disability by VA; (2) the 
surviving spouse or child of a veteran who died from a VA-rated 
service-connected disability; (3) the surviving spouse or child 
of a veteran who was at the time death rated permanently and 
totally disabled from a service-connected disability; or (4) 
the surviving spouse or child of a servicemember who died in 
the line of duty, of a cause other than willful misconduct. 
Most of these cases, these family members are eligible for the 
Department of Defense's health care program known as TRICARE.
    While VA's regulations for the CHAMPVA program, in section 
17.55 of title 38 CFR, provide for VA payments to providers 
under the CHAMPVA program to constitute payment in full, VA's 
enforcement of this regulation has been hampered by a lack of 
statutory authority. VA has indicated that some providers still 
attempt to bill beneficiaries for the difference between the 
billed amount and the amount payable under the CHAMPVA program.
    Committee Bill. Section 203 of the Committee bill would 
amend section 1781 of title 38 to provide that payments made by 
the Secretary to providers who furnish medical care to a 
beneficiary covered under CHAMPVA shall constitute full 
payment, removing any liability for the beneficiary to the 
provider.

Section 204. Disclosures from certain medical records.

    Section 204, which is also derived from S.2984 from the 
110th Congress, would permit VA health care practitioners to 
disclose the relevant portions of certain VA records to 
surrogate decisionmakers who are authorized to make decisions 
on behalf of patients who lack decisionmaking capacity.
    Background. Section 7332 of title 38 authorizes VA to 
disclose treatment information for drug abuse, alcoholism and 
alcohol abuse, human immunodeficiency virus (HIV) infection, 
and sickle cell anemia only for certain purposes which are set 
out in the section. Disclosure to surrogate decisionmakers for 
the purpose of making informed decisions regarding the 
treatment of patients who lack decisionmaking capacity, but to 
whom the patients had not specifically authorized release of 
section 7332-protected information prior to losing 
decisionmaking capacity, is not one of the specified purposes.
    Committee Bill. Section 204 of the Committee bill would 
amend section 7332 of title 38 to permit VA health care 
practitioners to disclose the relevant portions of VA records 
of the treatment of drug abuse, alcoholism and alcohol abuse, 
HIV infection, and sickle cell anemia to surrogate 
decisionmakers who are authorized to make decisions on behalf 
of patients who lack decisionmaking capacity, but to whom the 
patient has not specifically authorized release of section 
7332-protected information prior to losing decisionmaking 
capacity. This change would allow for such disclosure only 
under the circumstances where the information is clinically 
relevant to the decision that the surrogate is being asked to 
make. The term ``representative'' means the individual, 
organization, or other body authorized under section 7331 of 
title 38 and the regulations implementing that provision, to 
give informed consent on behalf of a patient who lacks 
decisionmaking capacity.

Section 205. Disclosure to secretary of health-plan contract 
        information and social security number of certain veterans 
        receiving care.

    Section 205, which is also derived from S.2984 of the 110th 
Congress, would authorize VA to require that those seeking or 
receiving VA health care provide certain information in 
connection with such care.
    Background. Although VA has authority under section 1729 of 
title 38, U.S.C., to recover from health insurance carriers the 
reasonable charges for treatment of a veteran's nonservice-
connected disability, there is no express statutory authority 
that requires an applicant for, or a recipient of, VA medical 
care to provide information concerning health insurance 
coverage.
    Under Section 7 of the Privacy Act, VA cannot deny to an 
individual any right, benefit, or privilege provided by law 
because of such individual's refusal to disclose his or her 
social security number. However, this prohibition does not 
apply with respect to any disclosure that is required by 
Federal statute.
    VHA must match veterans' income data with the Internal 
Revenue Service and the Social Security Administration to carry 
out its income verification responsibility under section 5317 
of title 38. Such matching requires the use of verified social 
security numbers. According to VHA, officials have obtained 
verified social security numbers for approximately 97 percent 
of its enrolled veterans and 86 percent of the spouses for whom 
income is reported. While this suggests that the voluntary 
reporting process is working, VHA estimates that they still 
have more than 1 million veterans enrolled for whom no social 
security number has been provided. Further, VHA notes that the 
Department has been unable to match income for more than 
675,000 spouses because the social security numbers have not 
been provided.
    Committee Bill. Section 205 would amend title 38 by adding 
a new section--section 1709. Disclosure to Secretary of health-
plan contract information and social security number of certain 
veterans receiving care--which would authorize the Secretary of 
Veterans Affairs to require that applicants for, and recipients 
of, VA medical care and services provide their health-plan 
contact information and social security numbers to the 
Secretary upon request.
    Subsection (a) of the new section would require specific 
information on any health-plan contract which provides 
coverage. Information that may be required regarding health-
plan coverage would include the name of the health-plan 
contract, the name of the veteran's spouse, if coverage is 
under the spouse's health-plan contract, the plan number, and 
the plan's group code. This authority will ensure that VA is 
able to obtain contract information for a particular health 
plan.
    Subsection (b) of the new section would provide that the 
Secretary may require applicants for, or recipients of, VA 
medical care or services to provide their social security 
numbers and those of dependents or VA beneficiaries upon whom 
the applicant or the recipient's eligibility is based. This 
subsection, in conjunction with subsection (c), discussed 
below, affords the Secretary the statutory authority to require 
applicants for and recipients of VA health care benefits to 
disclose social security numbers.
    Subsection (c) of the new section would provide that the 
Secretary shall deny the application for, or terminate an 
individual's enrollment in, VA's patient enrollment system of 
individuals who fail to provide information requested pursuant 
to subsection (b). The subsection further provides that the 
Secretary may reconsider the application for or reinstate the 
provision of care or services once the information requested 
pursuant to subsection (b) has been provided.
    Subsection (d) of the new section would provide that this 
section may not be construed as authority to deny medical care 
and treatment to an individual in a medical emergency.
    VA strongly supported this provision in testimony provided 
to the Committee for its April 22, 2009, hearing. Because 
eligibility for medical care and services is conditioned on the 
applicant or recipient's provision of health-plan contract 
information or social security numbers, the Administration 
believes that the applicant or recipient will have an incentive 
to provide the requested information. The Committee expects VA 
to provide a high degree of confidentiality for beneficiaries' 
health plan information and social security numbers.

Section 206. Enhancement of quality management.

    Section 206 of the Committee bill, which was originally 
derived from S.2377 as introduced in the 110th Congress, would 
require actions to enhance VA's quality management efforts.
    Background. Under current law, section 7311 of title 38, VA 
operates a quality management system to monitor and evaluate 
the quality of VA health care. That system is headed by the 
Chief Quality and Performance Management Officer of the 
National Quality and Performance Office. While a number of 
other entities have a role in VA quality management efforts, 
including the Office of the Inspector General, the Office of 
the Medical Inspector, the National Patient Safety Office, and 
the Office of Compliance and Business Integrity, none has a 
permanent oversight capacity at every VA medical center.
    VA's quality management program, including the National 
Surgical Quality Improvement Program (NSQIP), has proven 
effective in certain situations. However, in a report titled 
``Quality of Care Issues, VA Medical Center, Marion, Illinois'' 
(January 2008), the VA Office of the Inspector General (OIG) 
found that the quality management process was ineffective in 
many respects. The peer review process, the tracking of 
performance data on providers, and mortality assessments as 
carried out at the Marion, Illinois VA Medical Center were all 
found to be deficient. The OIG concluded that:

        [T]he oversight reporting structure for quality 
        management reviews at the Marion VAMC was fragmented 
        and inconsistent, making it extremely difficult to 
        determine the extent of oversight of patient quality or 
        corrective actions taken to improve patient care. This 
        occurred partially because quality management 
        responsibilities were split between multiple groups at 
        the facility with little or no management oversight.

    The OIG further concluded that the Marion VAMC Surgery 
Service leadership was ineffective, and that communication 
between the nurse responsible for NSQIP at the facility, 
surgical providers, and the Chief of Surgery was highly 
ineffective, allowing multiple quality management processes to 
fail.
    Based on information related to the Marion, IL experience 
and other oversight activity, the Committee believes that the 
Department's internal processes can ensure quality in some 
circumstances, but that significant improvements are necessary. 
Continuous and attentive monitoring is not fully in place, and 
facility leadership across the VA system must prioritize 
quality management.
    Committee Bill. Section 206 of the Committee bill would add 
a new section 7311A to chapter 73 of title 38. This new section 
would require the Under Secretary for Health (``USH'') to 
appoint a National Quality Management Officer, reporting 
directly to the Under Secretary, who would develop requirements 
and standards for a national quality management program, and 
prescribe regulations for its implementation. The National 
Quality Management Officer would be responsible for developing 
ways of measuring quality at individual VA facilities, and 
ensuring that those measures were routinely monitored and 
analyzed.
    The Committee believes that such a position would help 
ensure the thorough and uniform discharge of quality management 
requirements under such programs and activities throughout VA 
facilities. The USH would also be required to designate quality 
management officers for each VISN. Such officers would direct 
the quality management effort of each network and coordinate, 
monitor, and oversee the quality management programs and 
activities of the medical facilities in the Network.
    Additionally, section 206 of the Committee bill would 
require each VA Medical Center Director to appoint a quality 
management officer for that facility. The Director would be 
required to ensure that other clinical or administrative duties 
of the person appointed as the quality management officer are 
reduced so as to not interfere with the person's quality 
management duties. The quality management officer would report 
to the Director of the facility and to the quality management 
officer of the VISN of which that facility is a part.
    Section 206 would also require the USH to put in place a 
system through which VHA employees might submit reports, on a 
confidential basis, on quality of care matters to the quality 
management officer at the employee's facility. Such a system 
would provide a safe channel through which employees might 
report their concerns about care being furnished at the 
facility. Such a system should make it possible for any such 
reports to receive appropriate attention and review.
    This section of the Committee bill also would require the 
Secretary of Veterans Affairs to submit a report to Congress on 
all policies and protocols of VA that pertain to maintenance of 
health care quality and protection of patient safety at VA 
medical facilities. This report would be required to include an 
assessment of the NSQIP, with special emphasis on the 
effectiveness of the design and structure of the program's data 
collection, evaluation, and assessment structure, and the 
sufficiency of resources allocated to that program.
    In testimony before the Committee on May 21, 2008, Dr. 
Gerald M. Cross, Principal Deputy Under Secretary for Health, 
expressed VA's support for the provisions of this section of 
the Committee bill that require a comprehensive review and 
report on health care quality and patient safety policies 
across the VA health care system. In written testimony 
submitted for the Committee's April 22, 2009, VA stated that 
the Department supported the intent of these provisions.

Section 207. Reports on improvements to Department health care quality 
        management.

    Section 207, which is also derived from S.2377 from the 
110th Congress, would require the Secretary to report on VA 
efforts to implement the provisions of the Committee bill 
concerning quality management.
    Background. There are currently no regular requirements for 
VA to report to Congress on VHA quality management efforts. 
This lack of effective reporting mechanisms can contribute to 
ineffective quality oversight. While the Inspector General 
performs oversight of individual facilities and specific 
events, the Committee believes a comprehensive annual reporting 
requirement would more effectively ensure oversight and 
accountability by the Committee and the Congress.
    Committee Bill. Section 207 would require the Secretary to 
submit a report to the Committees on Veterans' Affairs and 
Appropriations of the Senate and the Committees on Veterans' 
Affairs and Appropriations of the House of Representatives by 
December 15, 2009, and annually thereafter, through 2012. This 
report would detail VA efforts, over the preceding fiscal year, 
to implement the provisions of sections 104 (relating to 
standards for appointment and practice of VHA physicians) and 
206 (relating to quality management officers) of the Committee 
bill, along with any recommendations the Secretary may have to 
improve the implementation of these sections or to otherwise 
improve the quality of VA health care. The Committee expects 
that this reporting requirement will lead to increased 
oversight of the Department's efforts to improve quality 
management efforts and activities.

Section 208. Pilot program on use of community-based organizations and 
        local and state government entities to ensure that veterans 
        receive care and benefits for which they are eligible.

    Section 208 of the Committee bill, which is also derived 
from S.2796 from the 110th Congress, would require VA to carry 
out a pilot program to study the use of community-based 
organizations, and local and State government entities, to help 
ensure that veterans receive needed care and benefits.
    Background. Dr. Stanley Luke, PhD, Vice President for 
Programs of Helping Hands Hawaii, one of Hawaii's largest 
social service nonprofits and a provider of direct services to 
Hawaii veterans, testified before the Committee on May 21, 
2008, expressing support for the pilot program contemplated by 
this section of the Committee bill. According to Dr. Luke, as a 
consequence of cultural or other factors in certain locations, 
VA personnel may sometimes not be the most appropriate to reach 
out to veterans and that, in such instances, local 
organizations, with local cultural skills, may be better able 
to relate to and interact with veterans and their families in 
specific locations.
    Helping Hands Hawaii has attempted to assist veterans 
through outreach, explaining eligibility and available benefits 
and services, and providing mental health care. The pilot 
program provided for under this section of the Committee bill 
would have VA focus more intently on this approach and study 
whether these efforts can be effectively replicated.
    Committee Bill. Section 208 of the Committee bill would 
require the Secretary to establish and implement a pilot 
program to study the use of community-based organizations, and 
local and State government entities, in the provision of care 
and benefits to veterans. This program would specifically seek 
to improve coordination between community, State, and Federal 
providers of health care and benefits to veterans who are 
transitioning from military to civilian life; to make medical 
care and mental health care more available to veterans who are 
transitioning; to provide assistance to families of 
transitioning veterans; and to provide greater outreach to 
veterans and their families, and to inform them about their 
eligibility for, and the availability of, benefits and care.
    The pilot program would continue for a period of two years 
after enactment of the Committee bill, and be carried out at 
five locations that the Secretary would select. In selecting 
the program locations, the Secretary would be required to place 
special emphasis on rural areas, areas with high proportions of 
minority groups, areas with high proportions of individuals who 
have limited access to health care, and areas that are not in 
close proximity to an active duty military station.
    The Secretary would award grants to organizations and 
entities for them to use in providing services under the pilot 
program. Any organization or entity wishing to participate in 
the program would be required to submit an application to the 
Secretary containing a description of how the program was 
developed in consultation with VA and a plan for the 
organization to coordinate activities with local, State, and 
Federal Government agencies that provide services so as to 
avoid duplication of services.
    The Secretary would be required to promulgate regulations 
governing the appropriate use of grant funds by organizations. 
The Secretary would also be required to submit a report on the 
pilot program within 180 days after the program's end. The 
report would include findings and conclusions, an assessment of 
the benefits that were provided, and any recommendations from 
the Secretary regarding whether to continue the pilot program.

Section 209. Specialized residential care and rehabilitation for 
        certain veterans.

    Section 209, which was originally derived from S.2889, by 
request legislation in the 110th Congress, would authorize VA 
to contract for specialized residential care and rehabilitation 
services for certain veterans of Operation Enduring Freedom and 
Operation Iraqi Freedom (hereinafter (``OEF'' and ``OIF,'' 
respectively).
    Background. Some veterans with TBI or other serious 
disabilities and conditions have significant long-term care 
needs. These veterans may not need nursing home care, but they 
do not always have the resources needed to remain at home and 
live independently. This presents a challenge both for the 
veteran and the health care system.
    Committee Bill. Section 209 of the Committee bill would 
amend title 38 section 1720 of title 38 by adding a new 
subsection (g) that would authorize the Secretary of Veterans 
Affairs, in carrying out a community residential care program, 
to contract for specialized residential care and rehabilitation 
services for eligible veterans. Veterans covered by this 
provision would be veterans of OIF/OEF who: (1) suffer from 
TBI, (2) have an accumulation of deficits in activities of 
daily living and instrumental activities of daily living that 
affects their ability to care for themselves, and (3) would 
otherwise receive their care and rehabilitation in a nursing 
home, which would exceed their needs.
    It is the intent of the Committee that VA should have 
authority to provide veterans with significant long-term needs 
with a much more appropriate treatment setting for long-term 
rehabilitation services. VA supported this provision in its 
testimony submitted for the April 22, 2009, hearing.

Section 210. Expanded study on the health impact of Project Shipboard 
        Hazard and Defense.

    Section 210 of the Committee bill would require VA to 
contract with the Institute of Medicine of the National 
Academies (IOM) for an expanded study on the health impact of 
Project Shipboard Hazard and Defense.
    Background. During the period 1962-1974, the Department of 
Defense conducted a series of tests of chemical and biological 
materials in water-borne settings. The tests, known as Project 
Shipboard Hazard and Defense (hereinafter ``Project SHAD'') 
exposed hundreds of veterans to VX nerve gas, E. Coli, and 
other substances.
    The SHAD tests were intended to show the vulnerability of 
Navy ships to chemical and biological warfare agents. By 
learning how those agents would disperse, military planners 
hoped to be able to improve procedures to protect crewmembers 
and decontaminate ships.
    Beginning in 2002, VA contracted with IoM to conduct a 
study of the health effects on veterans who participated in 
Project SHAD. While there are many known medical problems 
associated with repeated chemical and biological weapons 
exposure, the Committee is concerned that the study is 
incomplete because it omits a number of Project SHAD veterans 
who were known to the Department of Defense and to VA.
    Committee Bill. Section 210 of the Committee bill would 
require the Secretary to enter into a contract with IOM, within 
90 days after the enactment of this Act, for the purposes of 
IoM conducting a study of the health impacts of Project SHAD on 
servicemembers participating in the tests. The Committee bill 
would require that this study include all servicemembers 
involved in the tests, insofar as is practicable and consistent 
with the requirements of conducting sound research. The 
Committee Bill would authorize the utilization of the results 
from the study ``Long-Term Health Effects of Participation in 
Project SHAD'' conducted by IoM.
    Congress has previously approved unrestricted, VA-provided 
care for veterans who participated in Project SHAD. While the 
Committee remains committed to these veterans receiving care, 
the Committee also believes there is value in examining the 
impact of the testing on participants in order to better 
understand the potential effects of other such testing.
    The Committee also notes that there is value in continued 
research into the areas of chemical and biological weapons 
exposure and that VA and DOD should make every effort to 
identify and contact all former servicemembers who participated 
in Project SHAD as well as testing that occurred during the 
same time period at Edgewood Arsenal, Dugway Proving Grounds, 
Ft. McClellan, and Ft. Detrick.

Section 211. Use of non-Department facilities for rehabilitation of 
        individuals with Traumatic Brain Injury.

    Section 211 of the Committee bill would specify the 
circumstances under which non-VA facilities would be utilized 
as part of the rehabilitation and community reintegration plans 
for veterans and members of the Armed Forces who are receiving 
care from VA for TBI.
    Background. VA has done much in recent years to develop its 
capability to treat TBI. However, VA has limited experience in 
treating younger veterans with debilitating injuries such as 
TBI. In 2007, Congress passed a series of VA-related provisions 
in the National Defense Authorization Act, the bulk of which 
sought to expand and enhance TBI care at VA facilities. As part 
of those provisions, Congress gave VA the ability to enter into 
cooperative agreements with public or private entities to send 
certain veterans suffering with TBI to non-Department 
facilities for rehabilitative care. In some circumstances, VA 
may find the service of a non-VA facility to be better suited 
to providing the care required by some veterans with TBI. In 
the Senate-passed version of the NDAA, specific criteria for 
eligibility and standards of care were set out, but those 
provisions were dropped in the final compromise.
    Committee Bill. Section 211 of the Committee bill would 
amend section 1710E of title 38 so as to add two new 
subsections that were included in the Senate-passed version of 
the NDAA 2007. Proposed new subsection (b) would specify that 
non-VA facilities would be used when the Secretary cannot 
provide treatment or services at the frequency or for the 
duration required by the individual plan of veteran or 
servicemember suffering from TBI or when the Secretary 
determines that it is optimal for the veteran or 
servicemember's recovery and rehabilitation. Proposed new 
subsection (d) would establish standards for the selection of a 
non-Department facility, requiring that the facility itself 
maintains care standards that have been established by an 
independent, peer-reviewed organization that accredits 
specialized rehabilitation programs for adults with TBI.
    The Committee notes that VA provides services for veterans 
with TBI currently through a variety of different mechanisms 
and that the authority in this section is limited to those 
situations in which the Secretary determines that the treatment 
or services offered are optimal for the recovery and 
rehabilitation of the individual, and where the Secretary is 
unable to otherwise provide such treatment or services at the 
frequency or for the duration prescribed. The Brain Injury 
Association of America supports this section, ``as it sets 
forth a pivotal mechanism for enhancing cooperation between the 
private sector and the VA health care system. Such cooperation 
is vitally necessary in order to provide access to, and choice 
within, the full continuum of care that returning 
servicemembers with TBI need and deserve.''

Section 212. Inclusion of Federally-recognized tribal organizations in 
        certain programs for State veterans' homes.

    Section 212 of the Committee bill would include tribal 
organizations in certain authorities relating to State 
veterans' homes. The health facilities of tribal organizations 
would be eligible to be treated as veterans homes for funding 
purposes, and tribal organizations would be eligible to apply 
for veteran State home construction grants.
    Background. State veterans homes are homes established by 
the States for disabled veterans in need of long-term care. 
They provide nursing home care, domiciliary care and adult day 
care. VA partners with the States in two ways to assist in 
funding the homes. Under Sections 1741-1743 of title 38, VA has 
the authority to carry out a per diem payment program under 
which it provides a portion of the daily cost of care for each 
veteran residing in a home. Under Sections 8131-8137 of title 
38, VA has the authority to conduct a construction grant 
program, in which it can provide up to 65 percent of the total 
cost of building a home, with the States required to contribute 
35 percent. Under current law, tribal organizations are not 
considered States for the purposes of eligibility for either of 
these programs.
    Based on the 2000 U.S. Census, the Department of Veterans 
Affairs projected in a September 2006 report that during the 
time period from 2005 to 2020, the number of older veterans 
overall will decline by 10 percent. During that same time, VA 
projected a nearly 60 percent increase in the number of older 
American Indian and Alaska Native veterans. The expected 
decline in the overall number of older veterans is attributed 
largely to the World War II and Korean War-era veteran 
populations, which are declining largely for age-related 
reasons. In contrast, American Indian veterans are much less 
likely to be World War II or Korean War-era, and more likely to 
be Vietnam-era than the overall veteran population.
    As early as the 1990s, Native Americans identified a 
pressing need for improved long term care in Native 
communities. In 1995, the National Indian Council on Aging 
described long-term care as the most pressing issue facing 
American Indian elders. According to a survey reported in the 
2002 American Indian and Alaska Native Roundtable on Long-Term 
Care, only 17 percent of tribes report having nursing homes 
available on the reservation or in the tribal community. 
Nineteen percent reported that their tribe was planning to 
create or expand long-term care services. Despite recognition 
of the need for long term care, as well as interest among 
tribes in developing such care, Native American communities are 
constrained by limited Federal funding and the abject poverty 
that characterizes much of Indian Country.
    Committee Bill. Subsection (a) of section 212 of the 
Committee bill would amend section 8138 of title 38 so as to 
allow for the treatment of health facilities of tribal 
organizations, or beds within such facilities, as State 
veterans' homes. As a result of this amendment, tribal 
organization health facilities would be treated in the same 
manner as other health facilities (or beds), except that newly 
designated subsection (f) of section 8138, which sets September 
30, 2009, as the expiration date for the treatment of new 
health facilities as State homes, would not apply to the health 
facilities of tribal organizations.
    Subsection (b) of section 212 of the Committee bill would 
amend title 38 in a number of ways so as to give the Secretary 
the authority to award construction grants to tribal 
organizations for the construction of State veterans' homes as 
set forth in subchapter III of chapter 81 of title 38.
    Subsection (b)(1)(A) would provide that, for the purposes 
of the subchapter, `tribal organization' would have the meaning 
given to the term in section 3765 of title 38.
    Subsection (b)(1)(B) would amend section 8132 of title 38, 
the declaration of purpose for the subchapter, to include 
tribal organizations along with the ``several states'' as the 
entities to be assisted in creating State veterans' homes.
    Subsection (b)(1)(C) would amend title 38 by adding a new 
section--Section 8133A. Tribal organizations--that would give 
the Secretary express authority to award construction grants to 
tribal organizations. This new section would provide that 
grants to tribal organizations shall be awarded in the same 
manner as States, with certain exceptions. One such exception 
is that, for the purpose of assigning priority under subsection 
(c)(2) of section 8135 of title 38, if a tribal organization is 
located within a State that has previously applied for a 
construction grant, the tribal organization shall be treated as 
if it previously applied as well. Other exceptions may be 
prescribed by the Secretary to take into account the unique 
circumstances of tribal organizations. By recognizing the 
limited long-term care options in Native American communities, 
as well as the sovereign status of federally-recognized tribes, 
section 212 would enable the Secretary to award State veterans 
home grants directly to tribal organizations.
    As reported by the Harvard Project on American Indian 
Economic Development: ``Where tribes make their own decisions 
about what approaches to take and what resources to develop, 
they consistently out-perform outside decisionmakers.'' The 
Committee expects that, by including tribal organizations among 
those eligible to apply for State veteran homes grants, these 
organizations will be able to provide more effective long-term 
care for the veterans in their communities.

Section 213. Pilot program on provision of dental insurance plans to 
        veterans and survivors and dependents of veterans.

    Section 213 of the Committee bill would direct the 
Secretary of Veterans Affairs to carry out a pilot program to 
assess the feasibility of providing a dental insurance plan to 
eligible veterans, survivors, and dependents of veterans.
    Background. The Department of Veterans Affairs provides a 
full range of dental services at its facilities. However, under 
section 1712 of title 38, dental services are only offered to 
certain veterans or to veterans under special circumstances. 
For example, veterans who have a service-connected compensable 
dental condition, are former prisoners of war, or who have 100 
percent service-connected disabilities are eligible for any 
needed dental care. Other veterans are eligible only for dental 
care necessary to resolve problems arising in certain narrowly 
defined situations, such as a veteran whose dental condition is 
aggravating a service-related condition or who requires dental 
care to continue participation in a vocational rehabilitation 
program. In addition, CHAMPVA does not provide dental coverage 
for survivors and dependents of veterans receiving care under 
that program except under very limited circumstances. CHAMPVA, 
established by Public Law 93-82, is primarily a fee-for-service 
program that provides reimbursement for most medical care for 
certain eligible dependents and survivors of veterans rated 
permanently and totally disabled from a service-connected 
condition. The program reimburses providers and facilities a 
fixed amount for treatment given, less any co-pay from 
beneficiaries.
    The Department of Defense administers a health care system 
for active duty servicemembers, military retirees, certain 
Reserve and National Guard members, and eligible family members 
under the TRICARE program. Through TRICARE, dental benefits may 
be provided to select beneficiaries at military treatment 
facilities; for others, voluntary dental insurance coverage is 
available through a Department of Defense contract with private 
insurers. Section 703 of Public Law 104-201, the National 
Defense Authorization Act for Fiscal Year 2007, established the 
TRICARE Retiree Dental Program (TRDP) through which military 
retirees and their eligible family members are given the option 
to purchase dental coverage under a contract managed by the 
Department of Defense. Over one million eligible participants 
have some level of dental coverage under TRDP. TRDP enrollees 
have access to a network of about 112,000 dental plan providers 
across the Nation. Premiums currently range from $14 to $48 per 
month for an individual policy, depending on the region and 
type of dental plan selected.
    Committee Bill. Section 213 of the Committee bill, in a 
freestanding provision with subsection (a) through (k), would 
require the Secretary to carry out a pilot program on the 
provision of dental insurance plans to veterans and survivors 
and dependents of veterans.
    Subsection (a) would require the Secretary to carry out the 
pilot program so as to assess the feasibility and advisability 
of providing dental insurance.
    Subsection (b) would define the participants in the pilot 
program as veterans enrolled in VA's medical care system and 
survivors and dependents of veterans eligible for medical care 
under CHAMPVA.
    Subsections (c) and (d) would specify that the pilot 
program would be carried out for a period of three years in not 
less than two and no more than four VISNs.
    Subsection (e) would specify that the Secretary is to 
contract with a dental insurer to administer the dental plan.
    Subsection (f) would require the dental plan under the 
pilot program to provide benefits considered appropriate by the 
Secretary, including diagnostic, preventative, endodontic, 
surgical, and emergency services.
    Subsection (g) would provide that enrollment in the dental 
insurance plan would be voluntary and would be for such minimum 
period of enrollment as the Secretary prescribes.
    Subsection (h) would require the Secretary to set premiums 
for dental plan coverage on an annual basis and would specify 
that the premiums would be paid entirely by plan enrollees.
    Subsection (i) would permit the voluntary disenrollment 
from a dental plan if the disenrollment occurs within 30 days 
of the beginning of the enrollment period or, under certain 
allowable circumstances, such as a relocation to a jurisdiction 
outside a plan area or a serious medical condition preventing 
use of plan benefits, if the disenrollment does not jeopardize 
the fiscal integrity of the dental plan.
    Subsection (j) would specify that nothing regarding the 
pilot program will affect VA's responsibility to provide dental 
care under section 1712 of title 38 nor would an individual's 
participation in an insurance plan under the pilot program 
affect the individual's entitlement to dental services under 
that section.
    Subsection (k) would specify that the dental insurance plan 
under the pilot program is to be administered pursuant to 
regulations prescribed by VA.
    The Committee is interested in testing within the VA 
healthcare system the TRDP concept of supplementing dental 
benefits provided at government facilities with more 
comprehensive, voluntary dental insurance coverage financed 
through enrollee premiums. This concept is not meant to 
minimize VA's obligation to provide high quality dental 
services under existing requirements of law.

             TITLE III--WOMEN VETERANS HEALTH CARE MATTERS

Section 301. Report on barriers to receipt of health care for women 
        veterans.

    Section 301 of the Committee bill, which was originally 
derived from S.2799 of the 110th Congress, would require the 
Secretary to submit a report to Congress, no later than June 1, 
2010, on the barriers to women veterans' access to VA health 
care.
    Background. Under current law, VA is authorized to provide 
care to all veterans, including women veterans. While there has 
been some specific legislative action on certain areas of care 
for women veterans, such as for homeless reintegration 
services, the Committee believes that much more can be done. 
Although this approach has yielded some clear successes, there 
are concerns that there may be insufficient attention to 
ensuring uniform access to gender-specific services across the 
VA health care system. According to DOD, women represent 
approximately 17 percent of all deployed servicemembers, and 
therefore are a growing portion of the veteran population.
    Committee Bill. Section 301 of the Committee bill, in a 
freestanding provision, would require VA to submit a report to 
Congress, not later than June 1, 2010, that would be required 
to include, among other elements, information on an 
identification and assessment of any stigma associated with 
women veterans seeking mental health care, access to care for 
women veterans described in terms of distance to VA facilities, 
availability of child care, the comfort and personal safety 
perception of women veteran patients, the sensitivity of VA 
health care providers to issues affecting women veterans, and 
the effectiveness of outreach to women veterans.
    The Committee seeks to ensure that appropriate attention 
and resources are directed to the needs of women veterans. For 
that to happen, those needs must be properly identified and 
described. That is the goal of this mandated study.
    VA testified at the Committee's May 21, 2008, hearing on 
pending legislation that it was already in the process of 
conducting an assessment of barriers to care for women 
veterans. The results of that effort can either be provided to 
the Committee as soon as the results are available or can be 
made a part of the report mandated by this section of the 
Committee bill.

Section 302. Plan to improve provision of health care services to women 
        veterans.

    Section 302 of the Committee bill, which is also derived 
from S.2799 of the 110th Congress, would require VA to develop 
a plan to improve the provision of health care services to 
women veterans, and to submit this plan to Congress no later 
than 18 months after enactment of the Committee bill.
    Background. Public Law 102-585, enacted in 1992, authorized 
new and expanded services for women veterans, including 
counseling for sexual trauma on a priority basis, specific 
health services for women, such as Pap smears, mammography, and 
general reproductive health care (including birth control and 
treatment of menopause) at many VA medical facilities.
    Public Law 104-262, enacted in 1996, expanded services 
further to include maternity and infertility benefits. In 
fiscal year 1997, the Under Secretary for Health appointed the 
first full-time Director for the Women Veterans Health Program. 
The program oversees a system of medical and psychosocial 
services for women.
    As discussed above, in connection with section 301 of the 
Committee bill, the Committee is concerned that these benefits 
are not being furnished evenly across the VA system.
    The 2008 Report of the Advisory Committee on Women Veterans 
found that:

        The new and complex needs of today's women veterans, 
        particularly those who served in Operations Enduring 
        and Iraqi Freedom, require that VA assess the 
        effectiveness of its existing gender specific programs 
        and initiate new ones that strategically address the 
        many needs of this cohort in a way that is inviting, 
        compassionate, and demonstrate a driven yield toward 
        the best outcomes.

    The burgeoning demand for care from women veterans requires 
that VA be fully prepared to deal with their health care needs. 
The estimated population of women veterans as of 2001 was 1.6 
million, or about 7.2 percent of the total veteran population. 
Currently, women make up 14.8 percent of the active duty 
military force and approximately 22.8 percent of the reserve 
force. By 2010, they are expected to represent over 14 percent 
of the total veteran population. Fifty-six percent of women 
veterans who use VA are less than 45 years of age.
    Committee Bill. Section 302 of the Committee bill, in a 
freestanding provision, would require VA to develop a plan on 
the provision of health care services to women veterans. The 
plan would include how VA intends to improve current services 
to women veterans, as well as how to appropriately provide for 
the future needs of women currently serving in Operations Iraqi 
and Enduring Freedom. As part of this plan, the Secretary would 
be required to identify the types of health care services that 
will be available to women veterans at each VA medical center, 
as well as what personnel would be required to provide such 
services. This plan would have to be submitted to the two 
Veterans' Affairs Committees not later than 18 months after the 
date of enactment of the Committee bill.
    It is the Committee's view that requiring VA to develop a 
plan is a first step toward ensuring that the needs of women 
veterans are met, now and into the future.

Section 303. Independent study on health consequences of women veterans 
        of military service in Operation Iraqi Freedom and Operation 
        Enduring Freedom.

    Section 303, which is also derived from S.2799 of the 110th 
Congress, would require the Secretary to enter into an 
agreement with a non-Department entity to conduct an 
independent study on the health consequences of service for 
women veterans of service on active duty in the Armed Forces in 
deployment in OIF/OEF.
    Background. Public Law 98-160, enacted in 1983, established 
the Advisory Committee on Women Veterans (hereinafter, 
``Advisory Committee''). In addition, Public Law 103-446, 
enacted in 1994, created the Center for Women Veterans 
(hereinafter, ``Center''). Both entities play invaluable roles 
in helping to shape VA's responses to the needs and concerns of 
women veterans.
    The Advisory Committee evaluates existing VA programs and 
makes recommendations for the enhancement of programs and 
services for women veterans while the Center oversees all VA 
programs for women veterans. However, neither entity is 
specifically charged to focus on the possible health 
consequences for women veterans who have served on activity 
duty in the Armed Forces in deployment in OIF/OEF.
    More than 160,000 female U.S. servicemembers have served in 
Iraq, Afghanistan, and the Middle East since 2003. From March 
19, 2003 through June 6, 2009, 624 women were wounded in action 
in OIF or OEF. Statistics were not kept by gender for wars 
prior to the Iraq and Afghanistan conflicts.
    Another consequence of the increased number of women 
serving in the U.S. military is an increase in the occurrence 
of rape and sexual assault by male servicemembers. Connie Lee 
Best, PhD, a Clinical Psychologist and Professor in the 
Department of Psychiatry and Behavioral Sciences at the Medical 
University of South Carolina testified before the Committee on 
April 25, 2007, noting that:

        Numerous research studies have documented rates of rape 
        ranging from lows of 6 percent for active duty to rates 
        that are significantly higher. One study found that 23% 
        of female users of VA health care reported experiencing 
        at least one sexual assault while in the military.

    Given the extensive service of women in OIF/OEF, the 
Committee is of the view that VA must fully assess the health 
consequences of their service. Only then will VA know how best 
to meet their specific needs.
    Committee Bill. Section 303 of the Committee bill, in a 
freestanding provision, would require the Secretary of Veterans 
Affairs to enter into an agreement with a non-Department 
entity, such as the IOM, to conduct an independent study on the 
health consequences of service in OIF/OEF for women veterans. 
The study would be required to include an examination of any 
and all possible environmental and occupational exposures and 
their effects on the general, mental, and reproductive health 
of women veterans who served in OIF/OEF. It would also be 
required to include an analysis of all published literature on 
such exposures to women while serving in the Armed Forces, 
including combat trauma and military sexual trauma. The entity 
conducting the study would be required to complete and submit a 
report of the study to Congress no later than 18 months after 
entering into the agreement for the study, and the Secretary 
would be required to submit a response to the report of the 
study no later than 90 days following the receipt of the 
report.

Section 304. Training and certification for mental health care 
        providers on care for veterans suffering from sexual trauma.

    Section 304 of the Committee bill, which is also derived 
from S.2799 of the 110th Congress, would require VA to 
implement a program for education, training, certification and 
continuing medical education for VA mental health care 
providers on care and counseling services for veterans 
suffering from military sexual trauma.
    Background. Public Law 102-585, enacted in 1999, authorized 
VA to include outreach and counseling services for women 
veterans who experienced incidents of sexual trauma while 
serving on active duty in the military. The law was later 
amended by Public Law 103-452 so as to authorize VA to provide 
counseling related to sexual trauma to men, as well as to 
women. Public Law 108-422, enacted in 2004, extended VA's 
authority permanently to provide military sexual trauma 
(``MST'') counseling and treatment to active duty 
servicemembers or those serving on active duty for training.
    VA has a number of strong programs geared toward mental 
health needs generally. However, MST is a discrete phenomenon 
and must be addressed as such. In addition, given the high 
numbers of women subjected to MST, as discussed above in 
connection with Section 303 of the Committee bill, the 
Committee believes that a more targeted approach is necessary.
    Dr. Connie Best testified before the Committee in 2007 
that:

        * * * the VA is staffed by some of the best mental 
        health providers and by some with exceptional expertise 
        in MST. However, I believe the one of the problems 
        facing the VA in their responsibility to meet the needs 
        of today's veterans who have experienced MST is one of 
        sheer numbers * * *. That means more qualified and 
        appropriately trained providers must be available. 
        Those providers must be able to provide specialized 
        sexual assault services and understand the interaction 
        of sexual trauma with combat-related trauma.

    Dr. Best suggested that VA should add specialized training 
programs for providers in the treatment of MST.
    Committee Bill. Section 304 of the Committee bill would 
amend section 1720D of title 38 so as to add two new 
subsections.
    Proposed new subsection (d) would require VA to implement a 
program for education, training, certification and continuing 
medical education for VA mental health care providers on care 
and counseling services for veterans suffering from MST. The 
new subsection would require that the training be carried out 
in a consistent manner and that it include principles of 
evidence-based treatment and care for sexual trauma. VA would 
also be required to determine the minimum qualifications 
necessary for mental health professionals certified under the 
program to provide evidence-based care and therapy to veterans 
for MST.
    Proposed new subsection (e) would require VA to report to 
Congress annually on the care, counseling and services provided 
to veterans under section 1720D. Specifically, VA would be 
required to provide information on the number of mental health 
professionals and primary care providers who have been 
certified under the program; the amount and nature of 
continuing medical education provided under such program to 
professionals and providers who have been so certified; the 
number of women veterans who received counseling, care and 
services from professionals and providers who have been trained 
or certified under the program; the number of training, 
certification, and continuing medical education programs 
operating under subsection (d); and the number of trained full-
time equivalent employees required in each facility of the 
Department to meet the needs of veterans requiring treatment 
and care for sexual trauma.
    Finally, subsection (b) of section 304 of the Committee 
bill, in a freestanding provision, would require the Secretary 
to establish education, training, certification and staffing 
standards for VA health care facilities for full-time 
equivalent employees who are trained to provide sexual trauma 
treatment and care.

Section 305. Pilot program on counseling in retreat settings for women 
        veterans newly separated from service in the armed forces.

    Section 305 of the Committee bill, which is also derived 
from S.2799 of the 110th Congress, would require VA to carry 
out a pilot program to evaluate the feasibility and 
advisability of providing reintegration and readjustment 
services in group retreat settings to certain women veterans.
    Background. VA operates a program of readjustment 
counseling which is provided through community-based facilities 
known as Vet Centers. Currently, there are 232 Vet Centers, 
located in all fifty states, the District of Columbia, Guam, 
Puerto Rico and the US Virgin Islands. Each provides assistance 
to veterans in need to readjustment counseling. The Vet Centers 
are managed by the Readjustment Counseling Service located in 
the Veterans Health Administration.
    VA appears to appreciate the value of retreats for its 
employees, especially those involved in mental health issues. 
Recent retreats include one on the implementation of the VA's 
Mental Health Strategic Plan and another for those advocating 
recovery models of care in VISN 3. The Committee believes that 
there is merit to evaluating the impact of providing 
reintegration assistance in retreat settings to woman veterans 
returning from a prolonged deployment.
    Committee Bill. Section 305 of the Committee bill, in a 
freestanding provision, would require VA to establish, not 
later than 180 days after the date of enactment of the 
Committee bill, a pilot program designed to evaluate the 
feasibility of providing reintegration and readjustment 
services in group retreat settings to women veterans who are 
recently separated from service in the Armed Forces after a 
prolonged deployment. This pilot program would be required to 
be carried out for two years, beginning on the date the program 
begins, in no fewer than five locations selected by the 
Secretary.
    Participation in the pilot program would be strictly 
voluntary. Services provided under the program would include 
information and assistance on reintegration into family, 
employment, and community; financial and occupational 
counseling; information and counseling on stress reduction and 
conflict resolution; and any other counseling the Secretary 
considers appropriate to assist the participants in 
reintegrating into their families and communities.
    The Committee bill would authorize the appropriation of $2 
million annually in fiscal years 2010 and 2011 to carry out the 
pilot program. VA would be required to report to Congress on 
the pilot program no later than 180 days after completion of 
the program.

Section 306. Report on full-time women veterans program managers at 
        medical centers.

    Section 306 of the Committee bill, which is also derived 
from S.2799 of the 110th Congress, would require the Secretary 
to submit to Congress a report on the employment of program 
managers solely for the management and oversight of women 
veterans' health care needs. This report would include whether 
or not each facility employs at least one such full-time 
employee.
    Background. Women Veterans Program Managers are generally 
available at each VA facility, although not all are full-time 
positions. These coordinators ensure that women veterans are 
afforded equal access to all services. They work to ensure that 
women veterans receive high quality comprehensive medical care 
in an environment that is sensitive to the privacy needs of 
women. Women Veterans Program Managers also advocate for 
gender-specific issues and needs. The Committee recognizes the 
valuable contributions of the Women Veterans Program Managers 
and believes that it is essential that every VA Medical Center 
have sufficient resources to ensure that these positions are 
full-time.
    Committee Bill. Section 306 of the Committee bill, in a 
freestanding provision, would require the Secretary, acting 
through the Under Secretary for Health, to submit a one-time 
report on Women Veterans Program Managers, so as to determine 
how many of these positions are filled on a full-time basis.

Section 307. Service on certain advisory committees of women recently 
        separated from service in the Armed Forces.

    Section 307 of the Committee bill, which is also derived 
from S.2799 of the 110th Congress, would require the Secretary 
to appoint women veterans who are recently separated from the 
Armed Forces, to the Department's Advisory Committee on Women 
Veterans and to the Advisory Committee on Minority Veterans.
    Background. Public Law 98-160, enacted in 1983, established 
the Advisory Committee on Women Veterans and set forth specific 
criteria for membership on the Committee, including those with 
service-connected disabilities, those who represent women 
veterans, and others. There is no specific requirement that any 
member of the Advisory Committee be a woman veteran who has 
recently separated from service in the Armed Forces.
    Public Law 103-446, enacted in 1994, established the 
Advisory Committee on Minority Veterans and set forth specific 
criteria for membership on the Committee including 
representatives of veterans who are minority group members, 
individuals who are recognized authorities in fields pertinent 
to the needs of veterans who are minority group members, 
veterans who are minority group members and who have experience 
in a military theater of operations, and others. There is no 
specific requirement that any member of this Advisory Committee 
be a woman veteran, who is also a member of a minority group 
and who is recently separated from service in the Armed Forces.
    Committee Bill. Subsection (a) of section 307 of the 
Committee bill would amend section 542(a)(2)(A) of title 38so 
as to require the Secretary to appoint women veterans who are 
recently separated from the Armed Forces, to the VA Advisory 
Committee on Women Veterans.
    Subsection (b) of section 307 of the Committee bill would 
amend section 544(a)(2)(A) so as to require the Secretary to 
appoint women veterans who are also members of a minority group 
and recently separated from the Armed Forces to serve on the 
Advisory Committee on Minority Veterans.
    Subsection (c) of section 307 of the Committee bill would 
provide that the amendments made by this section shall apply 
with appointments made to the two advisory committees on or 
after the date of enactment of the Committee bill.

Section 308. Pilot program on subsidies for child care for certain 
        veterans receiving health care.

    Section 308 of the Committee bill, which is also derived 
from S.2799 of the 110th Congress, would require the Secretary 
to implement a pilot program to assess the feasibility and 
advisability of providing subsidies to certain veterans in 
order to allow them to purchase child care services to 
facilitate better access to health care from VA.
    Background. There is currently no authority for VA to 
reimburse veterans for child care expenses incurred while 
receiving VA medical care. The Committee recognizes that some 
veterans face significant barriers to receiving health care 
from VA and that the absence of adequate child care for those 
veterans who are primary caretakers of children is one such 
impediment. This problem can be even more daunting for veterans 
in that situation who are in need of intensive health care 
services, such as care for PTSD, mental health, and other 
therapeutic programs.
    In order to address the issue of the need for child care 
for its own employees, VA created the VA Child Care Subsidy 
Program, as authorized by Public Law 107-67, the Treasury and 
General Government Appropriations Act for Fiscal Year 2002. 
That law authorized the use of appropriated funds by executive 
agencies in order to provide child care services for Federal 
civilian employees. The VA program is needs based, with the 
amount of reimbursement available to an employee depending on 
total family income and the amount paid for child care. In 
order to qualify for reimbursement, children must be placed in 
a licensed day care, home care or before/after school program, 
and beneficiaries must complete and submit an application form.
    The Committee believes that this existing VA program 
provides an excellent model for VA to emulate as it moves 
forward with the child care subsidies for veterans, which would 
be authorized by this section of the Committee bill.
    Committee Bill. Section 308 of the Committee bill, in a 
freestanding provision, would require VA to carry out a pilot 
program to examine what effect subsidies for child care for 
certain veterans receiving VA health care would have on 
improving access to health care services. The pilot program 
would be authorized for two years, beginning on the date the 
program begins, and would be required to be carried out in no 
fewer than three VISNs.
    Subsidies for child care would only be available during the 
time period that a veteran is actually receiving specified 
health care services at a VA medical facility, and during the 
time required by the veteran to travel to and from the site of 
treatment. Veterans eligible for subsidies would be those who 
are the primary caretaker of a child or children and who are 
receiving regular or intensive mental health care, or other 
intensive health care services determined by the Secretary as 
ones for which access would be improved by payment of a subsidy 
for child care.
    The pilot program would be required to be modeled, insofar 
as practicable, on the VA Child Care Subsidy Program and would 
use the same income eligibility and payment structure as used 
in that program. The Secretary would be required to report on 
the program to Congress within six months of the conclusion of 
the program on the Secretary's findings and conclusions about 
the program, along with any recommendations the Secretary 
considers appropriate. The Committee bill would authorize the 
appropriation of $1.5 million annually for fiscal year 2010 and 
2011 for the purposes of the pilot program.

Section 309. Care for newborn children of women veterans receiving 
        maternity care.

    Section 309 of the Committee bill, which is also derived 
from S.2799 of the 110th Congress, would authorize the 
Secretary to provide health care services, for not more than 
seven days after birth, to a newborn child of a woman veteran 
who is receiving maternity care from VA.
    Background. Under current law, VA is authorized to provide 
maternity and infertility benefits to women veterans who enroll 
for VA care. Obstetrical care, excluding care for the newborn, 
is provided under contract.
    While a veteran's care extends to maternity, prenatal, and 
postnatal care for female veterans, there is no authority for 
the provision of, or payment for, any care for the newborn 
child of a female veteran patient. This statutory scheme 
results in a significant gap in care for the increasing number 
of women veterans enrolled with VA.
    The current women veteran population is predominantly of 
child bearing age. Therefore, it is a disservice to the growing 
female veteran population and an inequity to not provide some 
newborn care.
    According to various studies, the average hospital stay for 
low-birth weight infants (a common reason for prolonged 
neonatal hospital stays) ranges from 6.2 to 68.1 days, whereas 
the average hospital stay for average-sized infants was 2.3 
days. Seven days of coverage would assist the mothers of 
newborns in need of simple, routine care, as well as many in 
need of more complex hospitalization.
    Committee Bill. Section 309 of the Committee bill would add 
a new section--section 1786, entitled ``Care for newborn 
children of women veterans receiving maternity care''--to 
Subchapter VIII of chapter 17 of title 38. This new section 
would authorize the Secretary to provide health care services, 
for not more than seven days after birth, to a newborn child of 
a woman veteran who is receiving maternity care from VA, if the 
mother gave birth in a VA medical facility, or in an outside 
facility pursuant to a contract between that facility and the 
Department. These services would include all post-delivery 
care, including routine care, required by a newborn.
    It is the Committee's belief that this limited but 
important step will help to ensure that the needs of women 
veterans enrolling for VA care are met in a more complete 
manner.

                      TITLE IV--MENTAL HEALTH CARE

Section 401. Eligibility of members of the Armed Forces who serve in 
        Operation Iraqi Freedom or Operation Enduring Freedom for 
        counseling and services through Readjustment Counseling 
        Service.

    Section 401 would allow members of the Armed Forces, 
including members of National Guard or Reserves, who serve in 
OIF/OEF to receive services through VA's Readjustment 
Counseling Service.
    Background. Adrian Atizado representing the Disabled 
American Veterans, testified before the Committee on April 22, 
2009:

        According to VA, as of August 2008, over 945,000 OEF/
        OIF servicemembers have separated from military 
        service. Of those, over 400,000 OEF/OIF veterans have 
        sought VA health care since 2002, and over 178,483 have 
        received a diagnosis of a possible mental health 
        disorder. Within that group, 105,465 have been given a 
        probable diagnosis of Post Traumatic Stress Disorder 
        (PTSD).

    While recently separated OIF/OIF veterans and members of 
the National Guard or Reserves who were mobilized for service 
in OIF/OEF who served their period of mobilization, are 
eligible for readjustment counseling services from VA under 
section 1712A of title 38, members of the Armed Forces still on 
active duty are not eligible for these services.
    Committee Bill. Section 401 of the Committee bill, in a 
freestanding provision consisting of four subsections, would 
establish eligibility for readjustment counseling services for 
any member of the Armed Forces who serves on active duty in 
OIF/OEF, including a member of the National Guard or Reserves.
    Subsection (a) would set forth the basic eligibility for 
this population of servicemembers for readjustment counseling 
and related mental health services under section 1712A of title 
38. These services would be provided through VA's Vet Centers.
    Subsection (b) would specify that there is no requirement 
that a servicemember be currently on active duty to be eligible 
for these services.
    Subsection (c) would condition the eligibility for these 
services on regulations prescribed jointly by the Secretaries 
of Defense and VA.
    Subsection (d) would limit the availability of services 
under this section to the availability of appropriations for 
the provision of these services, to ensure that new veterans 
entering the Vet Center system will not be a detriment to those 
the Vet Centers are currently serving.
    The Committee recognizes that among many in the active duty 
and reserve Armed Forces, there is a stigma associated with 
seeking assistance in connection with mental health concerns. 
In light of the clear indication that many who serve in combat 
may experience psychological impact from such service--as shown 
by a 2008 Rand Corporation Study on mental health in OIF/OEF 
veterans, (Tanielian and Jaycox (Eds.), ``Invisible Wounds of 
War: Psychological and Congitive Injuries, Their Consequences, 
and Services to Assist Recovery,'' Santa Monica, CA: RAND 
Corporation, 2008.)--there appears to be significant value in 
allowing servicemembers still on active duty to come to VA's 
Vet Centers for help in dealing with such concerns.
    At the same time, the Committee is concerned about placing 
an undue burden upon the Vet Centers, given their current 
responsibility to not only provide readjustment counseling to 
currently eligible veterans, but also to provide outreach to 
returning servicemembers and newly discharged veterans.

Section 402. Restoration of authority of Readjustment Counseling 
        Service to provide referral and other assistance upon request 
        to former members of the Armed Forces not authorized 
        counseling.

    Section 402 of the Committee bill would restore the 
authority of VA's Readjustment Counseling Service to provide 
referral and other assistance, upon request, to former members 
of the Armed Forces who have been discharged or released from 
active duty but who are not otherwise eligible for such 
counseling and services.
    Background. VA was first authorized to furnish readjustment 
counseling services to Vietnam-era veterans in 1979 in Public 
Law 96-22. Included in that original authority was a provision 
that required VA to provide referral services and other 
assistance to veterans who sought readjustment counseling but 
who were not eligible to receive those services because of the 
nature of their discharge from the military or for other 
reasons. This authority was repealed in 1996 in Public Law 104-
262, the Veterans Health Care Eligibility Reform Act of 1996.
    Committee Bill. Section 402 of the Committee bill would 
amend section 1712A of title 38 by adding a subsection (c) 
which would restore the provisions which require VA to provide 
referral services and other assistance to veterans who request 
readjustment counseling but who are not eligible for such 
services.
    It is the Committee's intent that those who have been 
discharged under conditions other than honorable still be 
afforded assistance in acquiring mental health services and 
also in gaining review of their discharges. The Committee 
believes that VA should be available to provide some assistance 
to those who have served and are in need of readjustment 
assistance, even if they are not eligible for the full array of 
VA benefits.

Section 403. Study on suicides among veterans.

    Section 403 of the Committee bill would require VA to 
conduct a study on suicides among veterans since January 1, 
1999, and report to Congress on the findings.
    Background. Numerous reports have illustrated that the rate 
of suicide among veterans is steadily increasing. One such 
report was the RAND study noted above which reported that 1 in 
5 veterans of the wars in Iraq and Afghanistan are returning 
and suffering with stress or mental health disorders, but that 
only half of those veterans are actually receiving treatment 
for these conditions.
    VA's Office of Mental Health reported that the number of 
suicides attempted at VA facilities increased from 492 in 2000 
to 790 in 2007. The Army reported seven confirmed and 17 
suspected suicides in January 2009. This number of suicides 
would surpass the number of troops killed in combat for the 
same month in Iraq and Afghanistan combined. Between 1995 and 
2007, there have been over 2,200 suicides among active-duty 
servicemembers. Despite these increases, there remains no 
centralized database of veteran suicides and attempts.
    Committee Bill. Section 403 of the Committee bill, in a 
freestanding provision consisting of four subsections, would 
require VA to conduct a study to determine the number of 
veterans who died by suicide between January 1, 1999, and the 
date of enactment of the Committee bill.
    Subsection (a) would set forth the basic requirement for 
the study.
    Subsection (b) would require VA, in carrying out this 
study, to coordinate with the DOD, Veterans Service 
Organizations, the Centers for Disease Control and Prevention, 
and state public health offices and veterans agencies.
    Subsection (c) would require VA to submit a report to the 
Committees on Veterans' Affairs of the Senate and the House of 
Representatives on the findings of the study.
    Subsection (d) would authorize the appropriation of such 
sums as may be necessary to carry out the study.
    Because the data shows that the incidence of suicide among 
veterans is at record levels, the Committee believes a need 
exists to have more comprehensive and accurate information so 
this problem can be more successfully addressed.

Section 404. Transfer of funds to Secretary of Health and Human 
        Services for Graduate Psychology Education program.

    Section 404 would mandate the transfer of $5 million from 
VHA accounts to the Secretary of Health and Human Services 
(HHS) for the Graduate Psychology Education program.
    Background. The Graduate Psychology Education program was 
established under section 755(b)(1)(J) of the Public Health 
Services Act. This program is the only Federal program solely 
dedicated to training post-doctoral psychologists.
    Recent studies have projected continuing high demand for 
psychological treatment of PTSD, TBI, and other combat-related 
stress disorders. Reports issued by GAO, the DOD Mental Health 
Task Force, the Presidential Task Force on Returning Global War 
on Terror Heroes, the Institute of Medicine, and the 
President's Commission on Care For America's Returning Wounded 
Warriors, have identified shortages of trained mental health 
providers, detailed problems in the training pipeline, and 
provided recommendations concerning the workforce needed to 
deal with what is projected to be an increased demand for 
mental health care among servicemembers and veterans.
    VA faces immediate challenges in recruiting mental health 
professionals with focused specialty training in combat-related 
stress disorders and post-deployment readjustment.
    Committee Bill. Section 404 of the Committee bill would, in 
a freestanding provision consisting of three subsections, 
mandate the transfer of funds from VA to the Department of 
Health and Human Services (HHS) for the Graduate Psychology 
Education program and delineate the use of the funds and the 
preferences for VA health care facilities.
    Subsection (a) would require VA, no later than the 
September 30, 2010, to transfer $5,000,000 from accounts of VHA 
to HHS for the Graduate Psychology Education program.
    Subsection (b) would specify that the funds transferred by 
VA to HHS be used to make grants that would support the 
training of psychologists in the treatment of PTSD, TBI, and 
other combat-related disorders.
    Subsection (c) would establish a preference in the awarding 
of grants under this provision to VA health care facilities and 
to graduate educational programs affiliated with VA facilities.
    The Committee expects that establishing a collaborative VA-
HHS training pipeline should help ensure a steady flow of 
specially-trained psychologists to serve the veteran 
population. Graduates of these training programs will continue 
to practice their specialty and will also be candidates for 
hire by VA or civilian practices that serve veteran patient 
populations. Many of the positions may be in rural communities 
where veterans, especially those from National Guard and 
Reserve units, often return to find VA facilities distant or 
community-based outpatient clinics lacking mental health 
professionals.
    The Committee intends for the grantee training programs 
receiving support through this effort to be involved with VA 
clinicians and facilities as training sites, thus ensuring that 
the substantial services provided in the course of training 
will go to veterans. Ensuring an adequate supply of well-
trained psychologists--specializing in combat stress 
disorders--is in the strong interest of the Nation, VA, and 
individual veterans.

                       TITLE V--HOMELESS VETERANS

    Veterans remain one of the more disproportionately 
represented groups among the overall homeless population. It 
has been estimated that one in every three homeless persons is 
a veteran.
    Dean Stoline, testifying for The American Legion before the 
Committee on January 28, 2009, spoke of the substantial needs 
of this population:

        * * * there are approximately 154,000 homeless veterans 
        on the street each night. This number, compounded with 
        300,000 servicemembers entering the private sector each 
        year since 2001 with at least a third of them 
        potentially suffering from mental illness, requires 
        that intensive and numerous programs to prevent and 
        assist homeless veterans are available.

    Many of these homeless veterans are returning from the 
conflicts in Iraq and Afghanistan. VA reported that almost 3000 
OIF/OEF homeless veterans were treated at VA medical centers 
over that past four years.
    VA administers a number of programs aimed at combating and 
preventing homelessness among veterans. These programs include 
the provision of residential domiciliary-based care (including 
mental health care and substance abuse disorder treatment), a 
grant and per diem program to assist community-based entities 
that serve homeless veterans, employment and job training 
assistance, and supported permanent housing.
    The Committee has worked cooperatively with VA to expand 
and enhance its authority to serve this particular population. 
Title V of the Committee bill includes a number of provisions, 
some proposed by VA, some suggested by advocates, some from 
legislation, all of which are designed to enhance and improve 
VA efforts to address the overall problem and to provide 
assistance to homeless veterans

Section 501. Pilot program on financial support for entities that 
        coordinate the provision of supportive services to formerly 
        homeless veterans residing on certain military property.

    Section 501 of the Committee bill would authorize the 
Secretary to create and implement a pilot program to carry out, 
and evaluate the impact of, providing grants to certain 
organizations that will assist formerly homeless veterans 
living on certain government property.
    Background. The National Coalition for Homeless Veterans 
(NCHV), in testimony before the Committee on May 21, 2008, 
cited VA's 2006 Community Homelessness Assessment and Local 
Education Networking Groups report, ``The lack of affordable 
permanent housing is cited as the No. 1 unmet need of America's 
veterans.'' This need is listed as the second highest unmet 
need in the 2007 report.
    Currently, veterans can utilize services from organizations 
that are sponsored by the VA Grant and Per Diem program, but 
organizations sponsored by this program can only provide 
services to a veteran for up to two years. Domiciliary Care for 
Homeless Veterans provides treatment and rehabilitation to 
homeless veterans, but the average length of stay is only four 
months. VA's Compensated Work Therapy/Transitional Residence 
program provides both a residence and employment in conjunction 
with work-skills training and other rehabilitation. The average 
stay in this program is only 174 days. VA's Supported Housing 
program allows VA staff to assist in locating permanent housing 
for veterans, but does not provide any funding or vouchers to 
allow VA to provide that housing.
    A new VA pilot program provides loan guarantees for 
transitional family housing, but not permanent long-term 
housing. All of these programs are beneficial steps, but many 
veterans are still not ready for transition to independent 
living at the end of these programs. NCHV points out that 
despite these programs, ``many formerly homeless veterans still 
cannot afford fair market rents, nor will most of them qualify 
for mortgages even with the VA home loan guarantee. They are, 
essentially, still at risk of homelessness.'' Gerald M. Cross, 
M.D., Principal Deputy Under Secretary for Health at VA, 
testified at the Committee's May 21, 2008, hearing that 
military facilities that have been recently closed or had a 
major mission change could potentially be prime locations to 
house already homeless veterans or those in danger of becoming 
homeless.
    Committee Bill. Section 501 of the Committee bill, in a 
freestanding provision consisting of six subsections, would 
authorize the Secretary, subject to the availability of 
appropriations, to carry out, and evaluate the impact of, a 
pilot program which would provide grants to entities that 
coordinate the provision of supportive services for very low 
income formerly homeless veterans.
    Subsection (a) authorizes the Secretary to award grants to 
public and nonprofit organizations to coordinate supportive 
services to low-income formerly homeless veterans residing in 
permanent housing that is located on qualifying properties as 
part of a pilot program.
    Subsection (b) defines qualifying property as property that 
had been a military installation closed as part of the 2005 
round of defense base closure and realignment under the Defense 
Base Closure and Realignment Act of 1990, or under subchapter 
III of chapter 5 of title 40, U.S.C. The Secretary of Defense 
must determine, after reviewing any local authority's 
redevelopment plans for the property, that the property can be 
used to assist the homeless in accordance with any such 
redevelopment plan.
    Subsection (c) requires the Secretary to prescribe criteria 
and requirements for grants under this section and to publish 
such criteria and requirements in the Federal Register.
    Subsection (d) limits the duration of the pilot program to 
five years after the date of the commencement of the program.
    Subsection (e) defines ``very low income'' to have the same 
meaning as that used by the Department of Housing and Urban 
Development.
    Subsection (f) authorizes the appropriation of not more 
than $3,000,000 in each fiscal year from 2010 through 2014 to 
carry out the pilot program.
    The Committee agrees with VA's position that military 
facilities that have been recently closed or have had a major 
mission change could serve as excellent locations to house 
homeless veterans, or those in danger of becoming homeless. In 
developing economic revitalization and community development 
plans, local authorities could utilize grants under the program 
that would be established by this provision so as to aid in 
financing the conversion of such properties. The Committee 
believes that veterans with certain applicable skills--
including but not limited to such occupations as carpentry, 
plumbing, and landscaping--could be employed in the property 
conversion process, or in other aspects of a community's 
redevelopment plan, a process that could further aid very low-
income veterans. It is the Committee's belief that this 
combination of available housing and employment under local 
revitalization plans or in areas of the local economy could 
enable participating veterans to become self supporting.

Section 502. Pilot program on financial support of entities that 
        coordinate the provision of supportive services to formerly 
        homeless veterans residing in permanent housing.

    Section 502 of the Committee bill would authorize the 
Secretary to implement a similar pilot program providing 
supportive services to homeless veterans residing in permanent 
housing on properties not qualifying under Section 501's pilot 
program.
    Background. Currently, there are a number of community-
based and/or non-profit organizations that can and do provide a 
variety of services to assist formerly homeless veterans with 
their reintegration into society. These groups, coupled with 
VA's current efforts to provide supportive services, seek to 
prevent homelessness from recurring, an approach consistent 
with the overall direction that efforts against homelessness 
are moving in. The focus among both VA providers and community 
groups is shifting to prevention rather than reaction to 
homelessness occurring. In VA's case, this is done largely 
through intensive case management and collaboration with 
veterans service organizations to find permanent housing for 
formerly homeless veterans.
    Committee Bill. Section 502 of the Committee bill 
authorizes the Secretary to carry out a pilot program to make 
grants to public and nonprofit organizations to coordinate 
supportive services for veterans residing in permanent housing.
    Subsection (a) would authorize the Secretary, subject to 
the availability of appropriations, to award up to 10 grants to 
public and nonprofit organizations to coordinate the provision 
of supportive services to veterans residing in permanent 
housing on qualifying properties.
    Subsection (b) defines qualifying properties under this 
subsection as properties in the United States on which 
permanent housing is provided to formerly homeless veterans, as 
determined by the Secretary.
    Subsection (c) requires the Secretary to prescribe criteria 
and requirements for grants under this section and to publish 
such criteria and requirements in the Federal Register.
    Subsection (d) limits the duration of the pilot program to 
five years after the date of the commencement of the program.
    Subsection (e) identifies the definition of ``very low 
income'' to be that found in the Resident Characteristics 
Report issued annually by the Department of Housing and Urban 
Development.
    Subsection (f) authorizes appropriations of not more than 
$3,000,000 in each of the fiscal years 2010 through 2014 to 
carry out the purposes of this section.
    This effort, in ten communities across the Nation, would 
further assist veterans in reintegrating into the community and 
becoming self sufficient. The Committee expects that the ten 
locations selected for the pilot program under section 502(a) 
of the Committee bill will all be different from the locations 
selected for the pilot program under section 501, described 
above.
    Joseph L. Wilson, Deputy Director of the Veterans Affairs 
and Rehabilitation Commission of The American Legion, described 
the need for the type of pilot program authorize in this 
section of the Committee bill and in the prior section, in his 
May 21, 2008, testimony before the Committee, saying ``[w]hile 
permanent housing provides a stable base for veterans and their 
families the need for resources to improve their way of life is 
just as important * * *.These funded pilot programs will extend 
more opportunities for formerly homeless veterans, which in 
turn allow them to achieve and maintain a quality existence, 
deserving of their service to our country.''

Section 503. Pilot program on financial support of entities that 
        provide outreach to inform certain veterans about pension 
        benefits.

    Section 503 of the Committee bill would authorize the 
Secretary to implement a pilot program to carry out, and 
evaluate the impact of, providing grants to certain 
organizations to inform certain veterans and their spouses 
about VA pension benefits.
    Background. A recent study, (Greg Greenberg, Joyce H. Chen, 
Robert A. Rosenheck, Wesley J. Kasprow. ``Receipt of Disability 
through an Outreach Program for Homeless Veterans.'' Military 
Medicine 172, no. 5 (May 1, 2007): 461-5.), concluded that 
there is an acute need for outreach to low-income and elderly 
veterans, and their spouses, to inform them of their potential 
eligibility for need-based pension benefits from VA. Some of 
these veterans and their spouses live in areas that are far 
from VA facilities, and hence are underserved in outreach from 
VA. Pension benefits are given by VA to wartime veterans who 
have limited income, and are either 65 years of age, or older, 
or who are permanently and totally disabled.
    Committee Bill. Section 503 of the Committee bill would 
authorize the Secretary to carry out and evaluate the impact of 
a pilot program informing certain veterans and their spouses 
about VA pension benefits.
    Subsection (a) authorizes the Secretary to carry out a 
pilot program which would provide grants to nonprofit or public 
organizations, including faith-based organizations, to provide 
outreach and information to low-income and elderly veterans and 
their spouses who live in rural areas, of VA pension benefits 
and services for which they may qualify for under chapter 15 of 
title 38, U.S.C.
    Subsection (b) requires the Secretary to prescribe criteria 
and requirements for grants under this section and to publish 
such criteria and requirements in the Federal Register.
    Subsection (c) limits the duration of the pilot program to 
five years after the date of the commencement of the program.
    Subsection (d) authorizes appropriations of not more than 
$1,275,000 in each of the fiscal years 2010 through 2014 to 
carry out the purposes of this section.
    The Committee believes that utilizing local organizations 
and their existing networks would be an effective way of 
disseminating key information to veterans and their spouses 
about the VA pension program.

Section 504. Assessment of pilot programs.

    Section 504 of the Committee bill would require the 
Secretary to submit a report to Congress on each of the pilot 
programs detailed in sections 501-503 of the Committee bill at 
least 1 year before the end of each program's authorization. 
Each report would be required to contain the lessons learned by 
the Secretary which can be applied to other similar programs, 
any recommendations from the Secretary as to whether to 
continue the pilot program, the number of veterans and 
dependents served by the pilot program, an assessment of the 
quality of service provided by the program, the amount of funds 
provided to grant recipients under the program, and the names 
of all organizations that have received grants.

        TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS

    Title VI of the Committee bill includes a number of 
provisions that would amend subchapter IV of chapter 73 
relating to NPCs.
    NPCs were first authorized in 1988 in Public Law 100-322. 
Prior to 1988, it was difficult for VA to accept private or 
non-VA public funding for its research program. The methods in 
place, such as the General Post Fund, were not well-suited to 
this task. The General Post Fund was primarily designed to 
accept and administer veterans' bequests, the regulations of 
which made it difficult to flexibly disburse funds. 
Additionally, university partners who could administer funds 
for VA frequently had high overhead costs, reducing the amount 
of funding available for actual research. NPCs were designed to 
be a mechanism that could flexibly administer such funds, be 
regulated and overseen by the Federal Government, and remain 
affiliated with, but not part of, VA.
    While NPCs were originally designed to support only VA 
research, Congress has since expanded their role to include 
support of education and training. Since that initial authority 
was provided, the number of NPCs that have been established has 
ranged from 96 to 84, with prior year revenues totaling more 
than $240 million reported in June 2008. NPCs play a central 
role in VA research, making up 18 percent of VA's total 
research funding. Through NPCs, VA researchers access funding 
from, and collaborate with, the Department of Defense and the 
National Institutes of Health of the Department of Health and 
Human Services. NPCs also give VA researchers access to 
research support from foundations, corporations, and private 
organizations.
    NPCs were originally intended to support the research 
programs of individual medical centers. This facility-specific 
approach effectively supports individual programs, and NPCs are 
essential components of many facilities' research efforts. 
However, in the twenty years since the inception of NPCs, the 
character of VA research has changed and the standards applied 
to nonprofit corporation governance and management have become 
more rigorous. Some facility research programs may simply be 
too small to generate a revenue stream sufficient to support 
the infrastructure and governance necessary to meet these 
standards, but the facilities would nonetheless benefit from 
having ready access to the benefits NPCs provide.
    In general, the provisions of Title VI of the Committee 
bill would alter the existing law to allow for multi-medical 
center non-profit research corporations. Traditional NPCs are 
chartered in the state in which they are physically located and 
affiliated with one VA facility. In order to combine resources, 
NPCs affiliated with nearby medical centers, possibly in 
different states, need the ability to form higher-revenue 
corporations, known as multi-medical center research 
corporations, without unduly imposing on VA a requirement for 
multiple personnel from multiple facilities to serve on an NPC 
board of directors.
    The Committee bill would grant authority to the Secretary 
to establish multi-medical center research corporations, to 
approve the conversion of single-facility NPCs to multi-medical 
center research corporations. It also details the composition 
of the board of directors for such corporations. The bill also 
would make permanent the authority of the Secretary to 
establish NPCs, clarify the powers of such corporations to 
allow them to more flexibly disburse their funds, and clarify 
the purposes of NPCs to remove ambiguity about their role in 
supporting education and training. Finally, this title would 
improve the oversight of NPCs, and make a clerical amendment.

Section 601. General authorities on establishment of corporations.

    Section 601 of the Committee bill would expand 
authorizations for the establishment of NPCs, and clarify the 
definition and purpose of such corporations.
    Background. Current law relating to the authority to 
establish NPCs, section 7361 of title 38, allows NPCs to be 
established at one VA medical center, and in one state. As 
discussed above, NPCs were originally intended to support the 
research programs of individual medical centers but that model 
is no longer optimal. Current law requires that NPCs be tax 
exempt organizations but does not specify the specific terms of 
that status, which has led to some confusion about the tax and 
regulatory status of NPCs in some states and among some 
stakeholders.
    Committee Bill. Section 601 of the Committee bill would 
amend section 7361 of title 38 in a number of ways, with the 
principal focus on authorizing the creation of multi-medical 
center research corporations.
    Subsection (a)(1) of section 601 would amend section 7361 
so as to insert a new subsection (b) that would expressly 
authorize the establishment of ``multi-medical center research 
corporations.'' The board of directors of a multi-medical 
center research corporation would have to include the director 
of each VA medical center involved in the corporation. A multi-
medical center research corporation would be authorized to 
manage finances relating to research or education or both 
performed at the VA medical centers involved.
    Additionally, single-facility NPCs and multi-medical center 
research corporations would retain unchanged their current 
ability to administer funds for research programs conducted at 
multiple facilities, regardless of whether those facilities are 
served by a multi-medical center research corporation. NPCs 
could also serve as pass-through entities for programs 
performed at multiple facilities.
    Subsection (a)(2) of section 601 would add a new subsection 
(f) to section 7361 that would authorize an existing NPC to 
become a multi-medical center research corporation if its board 
of directors approves such an expansion and it is also approved 
by the Secretary. Ms. Donna McCartney, Chair of the National 
Association of Veterans' Research and Education Foundations 
(NAVREF) and Executive Director of the Palo Alto Institute for 
Research and Education, testified before the Committee on May 
21, 2008, that this provision is necessary because:

        ``* * * it will allow interested VA facilities with 
        small research programs to join with larger ones. Or 
        several smaller facilities may pool their resources to 
        support management of one NPC with funds and staffing 
        adequate to ensure an appropriate level of internal 
        controls, including segregation of financial duties.''

    Subsection (b) of section 601 would further amend section 
7361 by adding a new subsection (c) which would consist of the 
provisions of current section 7365, relating to the 
applicability of State law to NPCs, modified so as to specify 
that multi-medical center corporations operating in different 
states would be created under and subject to the laws of one of 
the States in which the corporation operates.
    Subsection (c) of section 601 would further amend section 
7361 by recasting as a new subsection (d)(1) a provision in 
subsection (a) of current section 7361 relating to the 
obligation of NPCs to comply only with those Federal laws, 
regulations, and executive orders and directives that apply to 
private non-profit corporations generally and by adding a new 
paragraph (2) to subsection (d) which would expressly provide 
that NPCs are not owned or controlled by, or are not an agency 
or instrumentality of, the United States.
    Subsection (d) of section 601 would further amend section 
7361 by restoring the requirement that all NPCs must operate as 
501(c)(3) tax exempt organizations. This amendment is designed 
to eliminate confusion in some states and among some 
stakeholders over the tax status of NPCs.
    In testimony, for the record of the Committee's April 22, 
2009, hearing, VA expressed support for section 601 and 
specifically for permitting the formation of multi-medical 
center research corporations.

Section 602. Clarification of purposes of corporations.

    Section 602 of the Committee bill, which is derived from 
S.2926 in the 110th Congress, would clarify the purpose of NPCs 
to include specific reference to their role as funding 
mechanisms for approved research and education, in addition to 
their role in facilitating research and education.
    Background. Current law is not specific with respect to the 
role of NPCs in supporting research and education, and does not 
include multi-medical center corporations. Further, the statute 
currently contains provisions that appear to allow NPCs to 
offer residencies and similar programs, possibly in conflict 
with the prohibition against nonprofit corporations conferring 
personal benefits on individuals.
    Committee Bill. Section 602 of the Committee bill would 
amend section 7362 of title 38 in a number of ways, with the 
principal focus on providing that, in addition to supporting 
the conduct and administration of VA research projects and 
education activities, NPCs may support functions more generally 
related to VA research and education.
    Subsection (a) of section 602 would amend subsection (a) of 
section 7362 so as to clarify that NPCs are intended to provide 
``a flexible funding mechanism'' for both the conduct of 
approved research and education at one or more VA medical 
centers and to fund ``functions'' relating to research and 
education. These functions would include, but not be limited 
to, travel to scientific conferences, recruitment of clinician 
investigators, improvements in laboratories, procurement of 
general use research equipment, and support for the 
institutional review board, the animal laboratory and the 
facility human protections program. Under current law, support 
for such functions often cannot be tied to specific research 
projects and, as such, may not be permitted.
    Ms. McCartney's testimony noted that there have been 
differences in interpretation regarding the permissibility of 
NPC expenditures supporting VA research and education 
generally, instead of being tied directly to an approved 
project. This section of the Committee bill would clarify that 
issue.
    Subsection (b) of section 602 would amend subsection (b) of 
section 7362 so as to make a technical modification to a 
defined term relating to education and training.
    Subsection (c) of section 602 would further amend 
subsection (b) of section 7362 so as to strike a provision that 
allows NPCs to include, under the education function of a 
corporation, the employment of individuals as part of a 
residency or similar program. By removing this language 
relating to residencies and similar programs, it is not the 
Committee's intent that this change diminish the authority of 
NPCs to support elements of education and training activities 
for VA trainees, such as VA residents, but simply to clarify 
that NPCs cannot be chief sponsors of residencies, as they are 
neither hospitals nor academic institutions and that function 
may conflict with regulations governing 501(c)(3) 
organizations. NPCs would still be able to support education 
and training activities for VA trainees, and, for purposes of 
this section, employees of the Veterans Health Administration 
include VA trainees.
    Subsection (d) of section 602 would further amend 
subsection (b) of section 7362 so as to clarify that NPCs are 
authorized to provide education and training to patients as 
well as families of patients. The Committee recognizes that 
patients' families often play a central role in the care and 
recovery of veteran patients. As such, education for family 
members directly supports the care and recovery of these 
veterans. The return of wounded servicemembers from Iraq and 
Afghanistan, many with severe TBI or debilitating multiple 
traumas, is placing growing demands on family caregivers. 
Clarifying that NPCs can provide such education would be an 
important form of support for family caregivers.

Section 603. Modification of requirements for boards of directors of 
        corporations.

    Section 603 of the Committee bill would address the 
requirements for the composition of NPC boards of directors.
    Background. Under current section 7363, certain non-VA 
personnel who serve on the board of an NPC must be familiar 
with issues involving medical and scientific research or 
education. This limits the composition of boards of directors, 
and prevents potential board members from serving who may have 
valuable business, legal, or financial expertise.
    In addition, subsection (c) of section 7363 requires that 
members of NPC boards have no ``financial relationship'' with 
any entity that is a source of funding for VA, with the 
exception of governmental and non-profit entities. This phrase 
has been interpreted by VA as an absolute prohibition on any 
financial relationship on the part of a board member with a 
precluded entity, either in the past or present. That 
prohibition was included in the original NPC authorizing 
legislation, Public Law 100-322, in 1988. Subsequently, the 
Office of Government Ethics (hereinafter ``OGE'') promulgated 
governmentwide conflict of interest regulations in 5 CFR Part 
2635, and the waiver regulations required by section 208 of 
title 18, U.S.C., in 5 CFR Part 2640 in August 1992, and 
December 1996, respectively. In light of those actions by OGE, 
the requirements placed on NPC board members have become more 
onerous than those applied to many government and non-profit 
employees.
    Further, the financial conflict of interest requirements of 
current subsection (c) of section 7363(c) go beyond the 
requirements in paragraph (1) of subsection (c) of section 
7366, which state that NPC board members ``shall be subject to 
Federal laws and regulations applicable to Federal employees 
with respect to conflicts of interest in the performance of 
official functions.'' Under that paragraph, NPC board members 
are governed by the statutory criminal code, section 208 of 
title 18, U.S.C., and conflict of interest regulations, 5 CFR 
Sec. Sec. 2635.401-2635.403. Those regulations, in addition to 
guidance from the Internal Revenue Service and the Office of 
Government Ethics, provide for the permissibility of de minimus 
affiliations, and for the ability to recuse oneself when 
necessary to avoid conflicts of interest.
    Committee Bill. The Committee bill would amend section 7363 
of title 38 in a number of ways so as to describe membership in 
boards of multi-medical center research corporations, allow 
non-VA individuals with diverse backgrounds to serve on NPC 
boards, and to modify the provisions relating to conflicts of 
interest.
    Subsection (a) of section 603 would amend paragraph (1) of 
subsection (a) of section 7363 so as to restructure the current 
law without changing the intent or effect except to provide 
that the directors of each medical center affiliated with a 
multi-medical center research corporation are to be members of 
that corporation's board of directors.
    Subsection (b) of section 603 would amend paragraph (2) of 
subsection (a) of section 7363 so as to require that not less 
than two non-VA personnel be members of the board, and, in 
addition to those with medical or scientific expertise, would 
permit individuals to be on an NPC board who have backgrounds 
or business, legal, or financial expertise that would benefit a 
board.
    Ms. McCartney testified that this provision of the 
Committee bill would substantially aid NPCs in acquiring the 
expertise needed to efficiently run research corporations, 
including legal and financial management expertise.
    Subsection (c) of section 603 would amend subsection (c) of 
section 7363 so as to eliminate the requirement in current law 
that members of NPC boards have no financial relationship with 
any entity that is a source of funding for research or 
education by VA, with the exception of governmental and non-
profit entities. By eliminating the restrictions in current 
law, this section of the Committee bill would bring NPCs into 
conformity with other 501(c)(3) entities and Federal conflict 
of interest regulations.
    Ms. McCartney emphasized the importance of this change and 
the Committee concurs with her view that there is no reason to 
hold board members of NPCs to a higher standard than what 
applies to similar organizations or to government employees.

Section 604. Clarification of powers of corporations.

    Section 604 of the Committee bill would restate NPCs' 
authorities so as to clarify that they may accept, administer, 
and transfer funds for various purposes.
    Background. Section 7364 of title 38, entitled ``General 
powers,'' sets forth the core authorities of NPCs. Over the 
years, the incompleteness and imprecision of some of these 
provisions have created obstacles to the conduct of NPC 
business. In addition, current law is unclear and potentially 
contradictory on some financial and personnel issues.
    Current section 7364 does not fully address the financial 
authorities necessary to NPCs. While the provision specifies 
that NPCs may accept gifts and grants, it does not mention 
other sources of funding common to NPCs, such as fees, 
reimbursements, and bequests. In some situations, VA has 
interpreted existing law to mean that NPCs may only accept the 
types of income explicitly specified in current section 7364. 
In addition, the authority of NPCs to utilize funds is poorly 
defined, as it leaves out the administration, retention, and 
spending of such funds.
    Under current law, NPCs do not have the authority to charge 
non-VA attendees fees for educational or training programs nor 
do they have authority to retain such fees. While NPCs are 
tasked with facilitating education and training, and to accept 
funds in support of such activities, section 8154 of title 38 
provides that only the Secretary has authority to conduct VA 
educational programs, and to charge non-VA attendees fees for 
such programs. That provision also specifies that the fees 
collected be credited to the applicable VA medical 
appropriation. As a result, even when non-VA attendees are 
willing to pay fees to contribute to the costs of educational 
or training events, NPCs do not have explicit authority to 
charge or retain such funds, a result which presents a 
significant obstacle to the conduct of such events.
    Cooperative Research and Development Agreements (CRADAs) 
are agreements mandated by VA to establish the terms and 
conditions for certain industry-sponsored studies performed at 
VA medical centers and administered by NPCs. Each CRADA must be 
reviewed and approved by a VA attorney. Although NPCs generally 
handle the preliminary negotiations relating to the development 
of CRADAs, VA attorney review is often extensive, and can take 
a number of hours, incurring significant costs. While NPCs 
frequently have funds available to reimburse the Office of 
General Counsel (OGC) for these costs, OGC does not have 
authority to accept or retain reimbursement for its services.
    Current section 7364 does not specifically address the 
transfer of funds between VA and NPCs for costs associated with 
personnel assignments under the Intergovernmental Personnel Act 
(IPA), under subchapter VI of chapter 33 of title 5, U.S.C. IPA 
assignments between VA medical centers and NPCs have been 
common since the inception of NPCs. The assignment of NPC 
employees to VA has proven to be of significant benefit to VA 
research. In a May 2008 report titled ``Audit of Veterans 
Health Administration's Oversight of Nonprofit Research and 
Education Corporations,'' the VA Office of the Inspector 
General (hereinafter, ``OIG'') found that under current law, 
reimbursements from VA to NPCs, pursuant to the IPA, constitute 
transfers of funds appropriated to VA prohibited by subsection 
7362(a) of title 38. This finding jeopardizes an important 
element of the partnership between VA and NPCs.
    Current section 7364 authorizes NPCs to spend funds only on 
research projects that have been approved by the VA facility 
Research and Development Committee. Requiring approval prior to 
any expenditure of funds unduly hinders operations and planning 
necessary to the application or preparation for research 
projects, such as the costs of hiring a grant writer or study 
coordinator to prepare a grant proposal.
    Committee Bill. Section 604 of the Committee bill would 
amend section 7364 of title 38, by striking the current 
sections (a) through (c) and inserting new subsections (a) 
through (e) which, collectively, would set forth the general 
powers of NPCs and clarify the relationship between VA and 
NPCs.
    Proposed paragraph (1)(A) of new subsection (a) of section 
7364 would allow NPCs to accept, administer, retain, and spend 
funds derived from gifts, contributions, grants, fees, 
reimbursements, and bequests from individuals and public and 
private entities. New paragraph (1)(B) would authorize NPCs to 
enter into contracts and agreements with individuals and public 
and private entities. These changes make explicit the financial 
authorities of NPCs, which the Committee views as consistent 
with the intent of the original authorizing legislation.
    Proposed new paragraph (C) of new subsection (a)(1) would 
authorize NPCs to charge registration fees for education and 
training programs they administer, and to retain such funds.
    Proposed paragraph (2) subsection (a) would prohibit the 
use of funds appropriated to VA to pay fees charged by NPCs. 
Taken together, these provisions would enable NPCs, and the 
research programs served by NPCs, to gain financial support for 
their educational and training programs.
    Proposed paragraph (D) of new subsection (a)(1) would 
authorize NPCs to reimburse OGC for certain expenses of 
providing legal services attributable to NPC research and 
education agreements. With financial assistance from NPCs, OGC 
would be better able to staff Regional Counsel offices and the 
VA Central Office so as to meet the demand to review the 
growing number of CRADAs. Proposed new paragraph (3) of 
subsection (a) would further mandate that funds reimbursed to 
OGC by NPCs are to be used only for staff and training, and 
related travel, for the provision of legal services related to 
review of research agreements such as CRADAs.
    Proposed paragraph (E) of new subsection (a)(1) is a 
renumbering of the text of subsection (a)(2) of current section 
7364. Proposed paragraph (1) of new subsection (b) is a 
renumbering of the text of the second sentence of subsection 
(a) of current section 7362. The language would be moved to new 
section 7364 in order to group it with other provisions 
addressing NPC funding issues.
    Proposed new paragraph (2) of subsection (b) would 
authorize VA to reimburse an NPC for all or a portion of the 
pay or benefits, or both, of an NPC employee assigned to VA 
under the Interagency Personnel Agreement. The Committee 
believes that this authorization will remove any uncertainty 
about the appropriateness of using VA funds to reimburse NPCs 
for personnel appointed to VA pursuant to the IPA in the past 
and going forward.
    Proposed new subsection (c) of section 7364 would grant 
powers to NPCs allowing them to disburse limited funds for 
essential activities that must be accomplished prior to 
research project approval. Such activities would include grant 
proposal writing, development, and review. Currently, NPCs are 
not permitted to disburse any funds in support of a research 
program until that program has been approved by VA. The 
Committee believes that this restriction is impractically 
rigid, and hinders NPC ability to appropriately prepare for 
project proposals.
    Proposed new subsection (d) of section 7364 would grant 
powers to NPCs allowing them to disburse limited funds for 
essential activities that must be accomplished prior to 
education and training activity approval. Such essential 
activities would include grant request writing, strategy 
development, creating presentations and briefings and perhaps 
even making deposits to reserve meeting space. Currently, NPCs 
are not permitted to disburse any funds in support of an 
education activity until that program has been approved. The 
Committee believes that this restriction is impractically 
rigid, and hinders NPCs' ability to appropriately prepare for 
education activities.
    Proposed new subsection (e) of section 7364 would permit 
the Under Secretary for Health to establish policies and 
procedures for the spending of funds by NPCs. These policies 
and procedures would be required to not only comply with 
applicable regulations, but also to be designed to facilitate 
the mission of NPCs as flexible funding mechanisms
    Ms. McCartney voiced strong support for these provisions in 
her testimony before the Committee on May 21, 2008. VA also 
supported this provision in its testimony for the record of the 
Committee's April 22, 2009 hearing.

Section 605. Redesignation of Section 7364A of title 38, U.S.C.

    Section 605 of the Committee bill, would redesignate 
section 7364A as section 7365, as a conforming amendment to the 
provision in section (b)(2) of section 601 of the Committee 
bill, which struck current section 7365 after moving the 
contents of that section to new subsection (c) of section 7361.
    Section 606. Improved accountability and oversight of 
corporations.
    Section 606 of the Committee bill would strengthen VA 
oversight of NPCs.
    Background. VA is responsible for oversight of the NPCs, 
and a number of bodies carry out that duty. The Secretary 
established the VA Nonprofit Corporation Oversight Board in 
2004 to review the activities of VA NPCs for consistency with 
VA policy and interests. Earlier, in 2003, VHA established the 
Nonprofit Research and Education Corporation Program Office 
(hereinafter, ``NPPO'') to provide oversight of NPC activities. 
The NPPO is responsible for providing oversight and guidance 
affecting operations and financial management, performing 
substantive reviews of the annual reports submitted by each 
NPC, compiling the information for VA's annual submission to 
Congress, improving accountability, and ensuring deficiencies 
are corrected. In accordance with the CFO Act of 1990 (Public 
Law 101-576) and a 1994 General Counsel opinion, VHA's CFO also 
has financial oversight responsibility for NPCs.
    The May 2008 OIG report discussed earlier found a number of 
problems with VA oversight of NPCs. The OIG found that ``NPCs 
did not implement adequate controls to properly manage funds'' 
and that VA failed to adequately implement ``effective 
oversight procedures,'' or require ``minimum control 
requirements for NPC activities.'' While the OIG did not find 
significant problems resulting from ineffective oversight, the 
report concluded that ``VHA cannot be reasonably assured that 
the NPCs are fully complying with applicable laws or 
regulations or effectively managing research and education 
funds.''
    Committee Bill. Subsection (a) of section 606 of the 
Committee bill would amend subsection (b) of section 7366 of 
title 38 so as to require NPCs to include the corporation's 
most recent IRS Form 990 `Return of Organization Exempt from 
Income Tax' or equivalent documents, and the applicable 
schedules, in an NPC's annual report to the Secretary. The 
information in Form 990 is extensive, and would be valuable to 
the Secretary in the conduct of thorough oversight.
    Subsection (b) of section 606 would amend subsection (c) of 
section 7366 so as to make the laws and regulations governing 
conflicts of interest within NPCs conform to laws governing 
similar entities, and to those governing conflicts of interest 
among Federal employees, as discussed above under section 603 
of the Committee bill.
    Subsection (c) of section 606 would amend subsection 
(d)(3)(c) of section 7366 so as to raise the threshold for 
reporting identifying information for payees from $35,000 to 
$50,000. Current law requires the Secretary, in annual reports 
to Congress, to provide identifying information on every payee 
paid more than $35,000. The proposed increase would make the 
statute governing NPC practices consistent with IRS standards 
for scrutinizing compensation for higher paid employees. The 
Committee believes that the original intent of this reporting 
requirement was to scrutinize large payments and compensation 
of higher paid employees, and that rising salaries over time 
have simply overtaken the current statute.

Section 607. Repeal of sunset.

    This provision repeals Section 7368, which prohibited the 
creation of NPCs after December 31, 2008. This is necessary to 
permit the formation of multicenter NPCs as otherwise 
authorized within Title VI of the Committee bill.

                  TITLE VII--MISCELLANEOUS PROVISIONS

Section 701. Expansion of authority for Department of Veterans Affairs 
        police officers.

    Section 701 of the Committee bill would expand certain 
authorities set out in title 38 relating to VA police officers 
so as to better reflect the current scope of their duties and 
responsibilities.
    Background. When originally enacted, section 902 of title 
38 was formulated in a manner that suited a health care system 
that delivered the majority of its services in centralized 
campus environments. As a result, VA police officers rarely had 
official business off VA property. Today, however, VA medical 
facilities now include large campuses, urban hospitals, 
Community Based Outpatient Clinics, and storefront Vet Centers. 
VA's increasingly decentralized delivery points for care 
necessitates that VA police officers travel frequently among VA 
facilities and off-campus sites. This includes travel off 
Department property to conduct administrative portions of 
investigations, such as interviewing witnesses or crime 
victims. It also includes travel off-campus to bring about the 
safe return of high-risk patients who have eloped and are a 
danger to themselves or others. The responsibilities of VA 
police officers also extend to responding to emergencies and 
disasters at the local, regional, and national levels.
    Because the jurisdiction of VA police officers is limited 
by current law to Department property, VA police officers are 
not able to carry their Department-issued weapons off property 
when conducting official business or on official travel.
    Committee Bill. Subsection (a)(1) of section 701 of the 
Committee bill would amend section 902(a) of title 38 so as to 
permit VA police officers to: (1) carry VA-issued weapons, 
including firearms, while off Department property in an 
official capacity or while in official travel status; (2) 
conduct investigations, on and off Department property, of 
offenses that may have been committed on Department property, 
consistent with agreements with affected local, state, or 
Federal law enforcement agencies; and (3) carry out, as needed 
and appropriate, any of the duties described in section 
902(a)(1), as revised, when engaged in such duties pursuant to 
other Federal statutes and (4) execute any arrest warrant 
issued by a competent judicial authority.
    Subsection (a)(2) of section 701 would further amend 
section 902 of title 38 to specify that the powers granted to 
VA police officers be exercised in accordance with guidelines 
approved by the Secretary and the Attorney General of the 
United States.
    Under current law, a VA officer who observes criminal 
activity beyond Department property cannot legally respond when 
a VA patient or provider is the victim. It is the Committee's 
view that this limitation unduly restricts the ability of VA 
police to fully carry out their assigned responsibilities. 
Extending these authorities would be consistent with powers 
Congress has granted to other Federal law enforcement officers, 
such as those in the Federal Protective Service, the Department 
of Homeland Security, the Pentagon Force Protection Agency, and 
the United States Capitol Police. The Fraternal Order of Police 
expressed support for this provision in a letter to Chairman 
Akaka and Ranking Member Burr. The Committee requested input 
from the Department of Justice on this provision, which was not 
provided by the date of this report.

Section 702. Uniform allowance for Department of Veterans Affairs 
        police officers.

    Section 702 of the Committee bill as incorporated into 
S.252, would amend title 38 so as to modify the authority of VA 
to pay an allowance to VA police officers for the purchase of 
uniforms.
    Background. VA employs approximately 2,600 uniformed police 
officers. VA uniformed police officers are generally paid 
approximately $40,000 per year. Under current law, which was 
enacted in 1991, VA may pay no more than $200 per fiscal year, 
with authority to increase the amount to $400 in one fiscal 
year. Because there has been no increase since 1991, VA 
uniformed police officers have to pay out of their own funds to 
supplement their initial uniform purchases and maintain their 
uniforms. OPM has published new regulations to increase the 
authorized uniform allowance for other, non-VA Federal police 
officers to $800 for initial and annual purchases.
    Committee Bill. Section 702 of the Committee bill would 
amend section 903(b) of title 38, which governs the uniform 
allowance for VA police officers, to limit the allowable amount 
to the lesser of: (1) the amount prescribed by the OPM; or (2) 
the estimated or actual costs as determined by periodic surveys 
conducted by VA. The provision would also amend section 903(c) 
of title 38 to provide that the allowance established under 
subsection (b) of section 902 of title 38, as modified by the 
Committee bill, shall be paid at the beginning of an officer's 
appointment for those appointed on or after October 1, 2008, 
and for other officers at the request of the officer, subject 
to the fiscal year limitations established in subsection (b), 
as modified by the Committee bill.
    The Committee believes that in order to compete for good 
candidates to become VA police officers and to retain those 
already employed by VA, there is a need to increase the uniform 
allowance and for VA to ensure that the annual allowance 
remains at an appropriate level. VA supported this provision in 
testimony for the Committee's April 22, 2009 hearing.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the CBO, estimates that enactment of 
the Committee bill would, relative to current law, increase 
discretionary spending by almost $900 million over the 2010-
2014 period, assuming appropriation of the necessary amounts. 
The Committee bill would not increase direct spending, based on 
information supplied by the CBO. Enactment of the Committee 
bill would not affect receipts, and would not affect the budget 
of state, local or tribal governments.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                                Congressional Budget Office
                                     Washington, DC, July 16, 2009.
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.252, the Veterans 
Health Care Authorization Act of 2009.
    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.252, Veterans Health Care Authorization Act of 2009

    Summary: S.252 would make several changes to existing 
veterans' health care programs and create a number of new 
health care programs for veterans. In total, CBO estimates that 
implementing the bill would cost almost $900 million over the 
2010-2014 period, assuming appropriation of the specified and 
estimated amounts. Enacting the bill would affect direct 
spending and revenues, but CBO estimates that impact would not 
be significant.
    S.252 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S.252 is shown in the following table. The 
costs of this legislation fall within budget function 700 
(veterans benefits and services).


----------------------------------------------------------------------------------------------------------------
                                                                 By fiscal year, in millions of dollars--
                                                        --------------------------------------------------------
                                                           2010     2011     2012     2013     2014   2010-22014
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATIONa

          Pilot Program for Dental Insurance:
    Estimated Authorization Level......................       10       65       85       85       85        330
    Estimated Outlays..................................        9       59       82       84       85        319
            Health Care for Female Veterans:
    Estimated Authorization Level......................       37       34       30       31       34        166
    Estimated Outlays..................................       34       33       30       31       34        162
                 Education Assistance:
    Estimated Authorization Level......................       11       27       39       43       48        168
    Estimated Outlays..................................       10       25       37       42       47        161
                   Medical Personnel:
    Estimated Authorization Level......................       18       18       19       19       20         94
    Estimated Outlays..................................       16       18       19       19       20         92
                  Quality Management:
    Authorization Level................................       25       25        0        0        0         50
    Estimated Outlays..................................       23       25        2        0        0         50
                    Pilot Programs:
    Estimated Authorization Level......................       10       10        7        7        7         41
    Estimated Outlays..................................       10       10        7        7        7         41
         Expanded Eligibility for Vet Centers:
    Authorization Level................................       10        9        6        6        6         37
    Estimated Outlays..................................        9        9        6        6        6         36
    Specialized Residential and Rehabilitation Care:
    Authorization Level................................        2        3        5        6        8         24
    Estimated Outlays..................................        2        3        5        6        8         24
                        Studies:
    Authorization Level................................        3        0        0        0        0          3
    Estimated Outlays..................................        3        *        0        0        0          3
              Uniforms for Police Offices:
    Authorization Level................................        1        1        1        1        1          5
    Estimated Outlays..................................        1        1        1        1        1          5
                   Other Provisions:
    Authorization Level................................        1        1        1        1        1          5
    Estimated Outlays..................................        1        1        1        1        1          5
----------------------------------------------------------------------------------------------------------------
      Total Changes:
          Estimated Authorization Level................      128      193      193      199      210        923
          Estimated Outlays............................      118      184      190      197      209        898
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000; numbers may not sum to totals because of rounding.
aIn addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
  enacting S.252 would increase direct spending and revenues by less than $500,000 a year.

    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted near the start of fiscal year 2010, 
that the authorized and estimated amounts will be appropriated 
each year, and that outlays will follow historical spending 
patterns for similar programs.

Spending subject to appropriation

    CBO estimates that implementing S.252 would cost $898 
million over the 2010-2014 period, assuming appropriation of 
the specified and estimated amounts.
    Pilot Program for Dental Insurance. Section 214 would 
require the Department of Veterans Affairs (VA) to implement a 
pilot program to provide dental insurance to all enrolled 
veterans and their survivors and dependents. VA would be 
directed to carry out the 3-year program in at least two but no 
more than four Veterans Integrated Services Networks (VISNs; 
regional networks of medical facilities). CBO estimates that 
implementing this provision would cost about $320 million over 
the 2010-2014 period, assuming appropriation of the estimated 
amounts.
    The bill would require VA to contract with a dental insurer 
who would administer the program. Veterans would be required to 
pay premiums and copayments. However, the bill would grant VA 
wide discretion in designing several critical parameters of the 
program, such as the covered benefits, requirements for 
enrollment and disenrollment, and premiums. For purposes of 
this estimate, CBO assumes that the pilot program would be 
carried out at three VISNs and that the program would be 
similar to the TRICARE Dental Program, which is available to 
reservists, their family members, and active-duty 
servicemembers.
    CBO estimates that the program would begin accepting 
enrollees around the middle of fiscal year 2010, and based on 
the participation rates for the TRICARE program, that about 
12,000 veterans, survivors, and dependents would join that 
year. We estimate that enrollment would rise to 78,000 in 2011 
and 97,000 in 2012 before stabilizing at a level of about 
90,000 a year.
    The TRICARE program pays up to $1,200 a year for 
nonorthodontic services, and many diagnostic and preventive 
services do not count toward the cap. Based on costs for the 
TRICARE program and for dental care provided by VA to a limited 
number of veterans, CBO estimates that in 2010 VA would pay 
about $800 per enrollee under the pilot program. After 
adjusting for inflation, CBO estimates that the pilot program 
would have initial costs of $9 million in 2010, rising to $59 
million in 2011, before stabilizing at slightly more than $80 
million a year thereafter.
    Health Care for Female Veterans. Title III of the bill 
would authorize several programs targeted to women veterans. 
CBO estimates that implementing that title would cost $162 
million over the 2010-2014 period, assuming appropriation of 
the authorized and estimated amounts.
    Care for Newborns. Section 309 would authorize VA to 
provide care for up to seven days to the newborn children of 
female veterans who receive maternity care through the 
department. Based on data from VA, CBO estimates that about 
6,600 babies would become eligible for such care in 2010 at an 
average cost of $2,770 per baby. After adjusting for inflation 
and population growth--the number of female veterans of child-
bearing age is expected to rise in future years--CBO estimates 
that implementing this provision would cost $102 million over 
the 2010-2014 period.
    Training for Mental Health Providers. Section 304 would 
require VA to educate, train, and certify mental health 
professionals who specialize in treating sexual trauma. Based 
on information from VA's Office of Mental Health Services, CBO 
estimates that VA would need 66 employees a year to provide 
training at a cost of $46 million over the 2010-2014 period.
    Report and Study on Female Veterans. Section 301 would 
require the Secretary to conduct a study of the barriers faced 
by women veterans in receiving VA health care. Based on 
information from VA, CBO estimates that implementing this 
provision would cost $3 million over the 2010-2014 period.
    Section 303 would require VA to contract with an outside 
entity to conduct a study on the health consequences facing 
female veterans of Operation Iraqi Freedom and Operation 
Enduring Freedom (OIF/OEF) as a result of their service. Based 
on information from VA, CBO estimates that implementing this 
provision would cost $4 million over the 2010-2014 period.
    Counseling for Female Veterans. Section 305 would require 
VA to implement a pilot program to provide counseling in group 
retreat settings to female veterans who have recently separated 
after lengthy deployments, and would authorize the 
appropriation of $2 million per year for 2010 and 2011 for that 
purpose. CBO estimates that this pilot program would cost $4 
million over the 2010-2014 period.
    Child Care. Section 308 would require VA to implement a 
pilot program to provide child care for certain female veterans 
who use VA medical facilities, and would authorize the 
appropriation of $1.5 million per year for 2010 and 2011 for 
that purpose. CBO estimates that this pilot program would cost 
$3 million over the 2010-2014 period.
    Education Assistance. Three separate provisions in section 
103 would authorize VA to provide scholarships and assistance 
with education loans to certain employees. In total, CBO 
estimates that enacting those provisions would cost $161 
million over the 2010-2014 period, assuming appropriation of 
the estimated amounts.
    Health Professionals Scholarship Program. Section 103(a) 
would reinstate a scholarship program for health professionals 
that expired in 1998. The provision would give VA the authority 
to provide funds to cover tuition, fees, and other costs 
related to their education. In exchange for financial 
assistance, recipients would be obligated to work at VA for a 
specified period of time.
    Based on information from VA, CBO estimates that after a 
six-month period to establish the program, VA would grant about 
100 awards in 2010 with an average award of $46,000. In the 
following years, CBO estimates VA would grant 200 new awards a 
year. Based on information from VA, CBO expects that 
scholarships would last an average of two years. After 
adjusting for an estimated 5.5 percent annual increase in 
tuition and other costs, CBO estimates that implementing this 
provision would cost $5 million in 2010 and $82 million over 
the 2010-2014 period, assuming appropriation of the estimated 
amounts.
    Debt Reduction. Two other provisions of section 103 would 
allow VA to help employees repay education loans. Subsection 
(b) would expand eligibility for the Education Debt Reduction 
Program from those recently appointed to all employees involved 
in direct patient care. In 2008, about 6,500 employees received 
an average annual benefit of $5,800 under this program, which 
reimburses employees over a five-year period. Based on 
information from VA, CBO estimates that 450 additional 
employees each year would become eligible. After adjusting for 
inflation, CBO estimates that implementing this provision would 
cost $44 million over the 2010-2014 period, assuming 
appropriation of the estimated amounts.
    The second provision, subsection 103(c), would allow 
certain clinical researchers at VA who have disadvantaged 
backgrounds to use a National Institutes of Health (NIH) 
program for repayment of education loans. The NIH program 
provides an annual benefit of up to $35,000 per employee. Based 
on information from VA, CBO estimates that 100 new employees 
each year would receive an average amount of $30,000 a year 
over three years. Assuming appropriation of the estimated 
amounts, CBO estimates that implementing this provision would 
cost $35 million over the 2010-2014 period.
    Medical Personnel. Section 101 contains several provisions 
that would affect compensation for medical personnel. In total, 
CBO estimates that implementing those provisions would cost $92 
million over the 2010-2014 period, assuming appropriation of 
the necessary amounts.
    Overtime Pay. Section 101(l) would loosen certain pay 
restrictions, thereby allowing nurses, physician assistants, 
and certain other employees to earn additional pay for evening 
or weekend work. Under current law, employees can earn 
additional pay for working evenings or weekends only on their 
regular tour of duty. The bill would allow such pay for any 
evening or weekend hours worked, even if they were occasional 
or ad-hoc. In 2008, such employees worked roughly 1.8 million 
hours of overtime at an average overtime rate of about $55 an 
hour. CBO estimates that under current law VA does not pay 
night or weekend differentials for 75 percent of those hours 
(1.4 million hours). After adjusting for inflation, CBO 
estimates that under the bill VA would pay additional night 
differentials of $6 per hour for about 485,000 hours and 
weekend differentials of $15 per hour for 385,000 hours, for a 
total cost of $46 million over the 2010-2014 period, assuming 
appropriation of the estimated amounts.
    Higher Pay for Nurses. Subsections 101(h) and 101(i) would 
increase the pay caps for registered nurses and certified 
registered nurse anesthetists. Based on information from VA, 
CBO estimates that the department would pay an average 
additional amount of $10,000 a year to about 560 nurses at a 
cost of $6 million a year. Subsection (j) would increase the 
maximum special pay for nurse executives from $25,000 to 
$100,000. Based on information from VA, CBO estimates that the 
department would pay an average additional amount of $10,000 to 
about 135 nurse executives at a cost of about $1 million a 
year. In total, CBO estimates that implementing those three 
provisions would increase pay for nurses by $7 million a year.
    Incentive Pay for Pharmacist Executives. Section 101(f) 
would allow VA to pay additional compensation of up to $40,000 
a year to pharmacist executives as a recruitment and retention 
tool. Based on information from VA, CBO estimates that the 
department would pay an additional $40,000 a year to 40 people 
for a total cost of $8 million over the 2010-2014 period.
    Increased Pay Scale for Appointees. Section 101(e) would 
allow VA to pay certain appointees using a higher pay scale. 
Based on information from VA, CBO estimates that the department 
would pay an average additional amount of $14,000 to about 40 
people, for a total cost of $3 million over the 2010-2014 
period.
    Quality Management. Section 206 would require VA to 
designate a quality management officer (QMO) for each of its 
135 medical facilities and VISNs as well as a principal QMO who 
would report directly to the Undersecretary for Health. VA 
already has QMOs serving at all levels specified in the bill. 
This section also would authorize the appropriation of $25 
million each year in 2010 and 2011 for assessing the 
reliability of existing measures of the quality of VA care and 
developing a new aggregate metric. CBO estimates that 
implementing this provision would cost $50 million over the 
2010-2014 period, assuming appropriation of the authorized 
amounts.
    Pilot Programs. Several sections of S.252 would require VA 
to carry out pilot programs to provide or pay for health care 
and related benefits. In total, CBO estimates that enacting 
those provisions (not including the dental pilot program, which 
is discussed above) would cost $41 million over the 2010-2014 
period, assuming appropriation of the specified and estimated 
amounts.
    Homeless Veterans. Title V would require VA to carry out 
three separate pilot programs to provide outreach and various 
services to homeless veterans and would authorize the 
appropriation of $36 million over the 2010-2014 period for 
those purposes. CBO estimates that implementing those pilot 
programs would cost $35 million over the 2010-2014 period.
    Transition Assistance. Section 208 would require VA to 
implement a pilot program to provide grants to community-based 
organizations and state and local entities that provide 
assistance to veterans transitioning to civilian life. The 
program would operate in five locations for a period of two 
years. VA currently provides similar assistance through Vet 
Centers. Vet Centers are community-based counseling centers 
that provide free mental health services to combat veterans and 
their families. Based on information from VA regarding spending 
on Vet Centers, CBO estimates that implementing that program 
would cost $6 million over the 2010-2014 period.
    Expanded Eligibility for Vet Centers. Section 401 would 
allow members of the Armed Forces, including reservists, who 
served in OIF/OEF to receive readjustment counseling and 
related services through VA's Vet Centers. According to VA 
data, there are currently 232 centers nationwide, and they 
served roughly 167,000 veterans in 2008. In 2009, Vet Centers 
received $185 million in appropriated funds.
    Data from the Department of Defense (DOD) on OIF/OEF 
deployments indicate that roughly 1.1 million servicemembers 
are currently or have previously been deployed and are 
nonveterans (that is, they are still on active duty or in the 
reserves). After adjusting for expected separations (OIF/OEF 
veterans are eligible under current law) and smaller expected 
deployments starting in 2011, CBO estimates that of those 
remaining, about a third would seek mental health services. 
However, DOD indicates that servicemembers are already offered 
free counseling similar to that provided through Vet Centers. 
Therefore, CBO estimates that about 18,500 servicemembers (5 
percent of those seeking mental health services) would use Vet 
Centers in 2010 and that the number of users would decline to 
about 9,000 in 2014. Using a per person cost of $550 in 2010 
(about half the expected cost for veterans, because 
servicemembers also have access to free DOD counseling) and 
adjusting for annual inflation, CBO estimates that implementing 
this provision would cost $36 million over the 2010-2014 
period, assuming appropriation of the necessary amounts.
    Specialized Residential and Rehabilitation Care. Section 
209 would require VA to contract with appropriate entities to 
provide specialized care to OIF/OEF veterans whose Traumatic 
Brain Injuries (TBI) are so severe that they cannot live 
independently and would otherwise require nursing home care. 
According to VA, some veterans with TBI but without sufficient 
family support or financial means to afford private residential 
care often end up in nursing homes that do not provide 
appropriate care. Under the bill, VA would place such veterans 
in specialized programs that would provide appropriate 
residential and rehabilitation care.
    Based on information from VA regarding the number of such 
veterans and the cost of their care, CBO estimates that in 
2010, VA would initially care for 20 veterans with TBI at a 
cost of roughly $84,000 per person. After adjusting for 
inflation, CBO estimates that over the 2010-2014 period, VA 
would pay for care provided to about 50 veterans a year at an 
average annual cost of $5 million, and that implementing this 
provision would cost $24 million over that period, assuming 
appropriation of the necessary amounts.
    Studies. Section 211 would require an expanded study on the 
health impact of chemical and biological testing conducted by 
DOD in the 1960s and 1970s. Based on information from VA 
regarding a similar ongoing study, CBO estimates that 
implementing this provision would cost about $2 million over 
the 2010-2014 period, assuming appropriation of the necessary 
amounts.
    Section 403 would require VA to conduct a study and report 
to the Congress on the number of veterans who died by suicide 
between 1997 and the date of enactment of the bill. VA would be 
required to coordinate with DOD, veterans service 
organizations, the Centers for Disease Control and Prevention, 
and state public health offices and veterans agencies. Based on 
information from VA, CBO estimates that implementing this 
provision would cost $1 million in 2010 and less than $500,000 
in 2011, assuming availability of appropriated funds.
    Together, CBO estimates that those two studies would cost 
$3 million over the 2010-2014 period, assuming appropriation of 
the necessary amounts.
    Uniforms for Police Officers. Section 702 would double the 
uniform allowances payable to about 2,600 department police 
officers from $400 for initial purchases and $200 for recurring 
purchases to $800 and $400, respectively. CBO estimates that 
implementing this provision would cost about $1 million a year 
over the 2010-2014 period, assuming availability of 
appropriated funds.
    Other Provisions. Several sections of the bill, when taken 
individually, would have no significant impact on spending 
subject to appropriation (most would have costs, but a few 
would have savings). Taken together, CBO estimates that 
implementing the following provisions would have a net cost of 
$1 million a year, assuming availability of appropriated funds:

     Sections 201 would repeal a reporting requirement 
pertaining to nurses' pay.
     Section 202 would modify a reporting requirement 
pertaining to Gulf War veterans.
     Section 205 would require veterans receiving care 
through the department to provide their Social Security number 
as well as pertinent information about their coverage through 
other health plans. Based on information from VA, CBO estimates 
that under the bill the department would be able to better 
match patient records with those of the Internal Revenue 
Service and the Social Security Administration, and would 
collect an additional $100 each from roughly 36,500 veterans. 
Those additional collections of $4 million a year would be 
retained by the department and spent on medical care and 
services.
     Section 207 would require annual reports on the 
quality of the department's physicians and health care.
     Section 210 would allow VA to disclose the names 
and addresses of veterans and servicemembers who use VA care to 
third-party insurers, so that VA can recover the costs of such 
care. Based on a VA field survey, CBO estimates that under the 
bill the department would collect an additional $9 million a 
year. Those amounts would be retained by the department and 
spent on medical care and services.
     Section 212 would modify authority granted to VA 
under Public Law 110-181 to pay for care provided to veterans 
with TBI to conform to how VA is implementing the program under 
current law.
     Section 306 would require a report on managers of 
programs for female veterans.
     Section 404 would require VA to transfer $5 
million to the Secretary of Health and Human Services for an 
education program in psychology.

Direct spending and revenues

    Section 701 would enhance the law enforcement authorities 
of VA police officers. Because those prosecuted and convicted 
under the bill could be subject to criminal fines, the Federal 
Government might collect additional fines if the legislation is 
enacted. Criminal fines are recorded as revenues, then 
deposited in the Crime Victims Fund, and later spent. CBO 
expects that any additional revenues and direct spending would 
not be significant because of the relatively small number of 
cases likely to be affected.
    In addition, section 603 would authorize certain VA 
research and education facilities to charge fees for education 
and training programs. Those fees would be retained and spent 
by the facilities, and CBO estimates that enacting this 
provision would have no net significant effect on direct 
spending.
    Intergovernmental and private-sector impact: S.252 contains 
no intergovernmental or private-sector mandates as defined in 
UMRA. State, local, and tribal governments that provide 
assistance to veterans would benefit from grants and other 
programs authorized in the bill.
    Previous CBO estimate: On June 16, 2009, CBO transmitted a 
cost estimate for H.R. 1211, the Women Veterans Health Care 
Improvement Act, as ordered reported by the House Committee on 
Veterans' Affairs on June 10, 2009. Sections 101, 201, 202, and 
203 of H.R. 1211 are similar to sections 301, 309, 304, and 308 
of S.252 respectively, as are their estimated costs.
    Estimate prepared by: Federal Costs: 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 May 21, 2009, meeting. On that date, 
the Committee ordered S.252 reported favorably to the Senate by 
roll call vote, without dissent. The Committee bill was agreed 
to by a 14 to 0 vote.


----------------------------------------------------------------------------------------------------------------
                Yeas                                 Senator                                 Nays
----------------------------------------------------------------------------------------------------------------
                      X (by proxy)   Mr. Rockefeller
                                 X   Mrs. Murray
                      X (by proxy)   Mr. Sanders
                                 X   Mr. Brown
                                 X   Mr. Webb
                                 X   Mr. Tester
                                 X   Mr. Begich
                                 X   Mr. Burris
                      X (by proxy)   Mr. Specter
                                 X   Mr. Burr
                                 X   Mr. Isakson
                      X (by proxy)   Mr. Wicker
                                 X   Mr. Johanns
                                     Mr. Graham
                                 X   Mr. Akaka, Chairman
----------------------------------------------------------------------------------------------------------------
                                14   TALLY                                                                    0
----------------------------------------------------------------------------------------------------------------


                             Agency Report

    On April 22, 2009, Gerald M. Cross, M.D., Principal Deputy 
Under Secretary for Health, Department of Veterans Affairs, 
appeared before the Committee and submitted testimony on the 
Committee bill. Excerpts of the testimony are reprinted below:

 PREPARED STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY 
       UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

    Good Afternoon Mr. Chairman and Members of the Committee: 
Thank you for inviting me here today to present the 
Administration's views on a number of bills that would affect 
Department of Veterans Affairs (VA) programs of benefits and 
services. With me today are Walter A. Hall, Assistant General 
Counsel and Joleen Clark, Chief Workforce Management and 
Consulting Officer for VHA.

           *       *       *       *       *       *       *


        S.252 ``VETERANS HEALTH CARE AUTHORIZATION ACT OF 2009''

    S.252 contains seven separate titles addressing a wide 
range of issues including personnel matters, homeless veterans, 
nonprofit research and education corporations and many health 
care matters including provisions specific to mental health and 
women veterans health care. Title I contains several provisions 
intended to enhance VA's ability to recruit and retain nurses 
and other health-care professionals and set certain standards 
for appointment and practice of physicians. These provisions 
are virtually identical to those reported in S.2969 from the 
110th Congress. We appreciated the opportunity to work with 
Committee staff on the prior bill and to provide technical 
comments and operational observations. We note that the 
reported bill and now Title I of S.252 address many of our 
concerns and comments. However, there are several provisions we 
cannot support.
    Section 101 contains provisions for the enhancement of 
authorities for retention of medical professionals.
    Secretarial Authority to Extend Hybrid Status to Additional 
Occupations Subsection (a) would provide the Secretary 
authority to extend hybrid status to additional occupations. It 
would add ``nurse assistants'' to the list of so-called hybrid 
occupations for which the Secretary is authorized to appoint 
and to determine qualifications and rates of pay under title 
38. In addition, it would authorize the Secretary to extend 
hybrid status to ``such other classes of health care 
occupations as the Secretary considers necessary for the 
recruitment and retention needs of the Department'' subject to 
a requirement to provide 45 days' advance notice to the 
Veterans' Affairs Committees and OMB. Before providing such 
notice, VA would be required to solicit comments from unions 
representing employees in such occupations.
    VA favors such a provision. Nursing Assistants are critical 
to the Veterans Health Administration's (VHA) ability to 
provide care for a growing population of older veterans, who 
are high-acuity patients and/or frail elderly requiring 24-hour 
nursing care. Turnover data, 11.1 percent for 2007 and 10.96 
percent for 2008, illustrate the great difficulty VA 
experiences in retaining this occupation. It is increasingly 
critical for VHA to be able to quickly and easily employ these 
nurse extenders. The same holds true for other hard-to-recruit 
health care occupations. This bill would give the Secretary the 
ability to react quickly when it is determined that these 
authorities would be useful to help recruit and retain a 
critical occupation without seeking additional legislative 
authority. However, the bill language should be modified to 
specifically apply to occupations that clearly involve the 
delivery of health care. In addition, because this authority 
involves the conversion of title 5 occupations to title 38 
hybrids, the 45-day notice requirement should be modified to 
add OPM. Thus, we recommend modifying subsection 2(a) of the 
bill to read:

        (a) Secretarial Authority to Extend Title 38 Status to 
        Additional Positions.
        (1) In general.--Paragraph (3) of section 7401 of title 
        38, United States Code, is amended by striking ``and 
        blind rehabilitation outpatient specialists.'' and 
        inserting in its place the following: ``blind 
        rehabilitation outpatient specialists, and such other 
        classes of health care occupations who
        (A) are employed in the Administration (other than 
        administrative, clerical, and physical plant 
        maintenance and protective services employees);
        (B) are paid under the General Schedule pursuant to 
        section 5332 of title 5;
        (C) are determined by the Secretary to be providing 
        either direct patient care services or services 
        incident to direct patient-care services; and
        (D) would not otherwise be available to provide medical 
        care and treatment for veterans;
        (E) as the Secretary considers necessary for the 
        recruitment and retention needs of the Department.
        (2) Notwithstanding chapter 71 of title 5, United 
        States Code, the Secretary's authority provided in 
        paragraph (1) is subject to the following requirements:
        ``(A) Not later than 45 days before the Secretary 
        appoints any personnel for a class of health care 
        occupations that is not specifically listed in this 
        paragraph, the Secretary shall submit to the Committee 
        on Veterans' Affairs of the Senate, the Committee on 
        Veterans' Affairs of the House of Representatives, the 
        Office of Personnel Management, and the Office of 
        Management and Budget notice of such appointment.
        ``(B) Before submitting notice under subparagraph (A), 
        the Secretary shall solicit comments from any labor 
        organization representing employees in such class and 
        include such comments in such notice.''
Probationary Periods for Part-Time Nurses
    Subsection (b) provides for probationary periods for part-
time (PT) Registered Nurses (RN) and revises the probationary 
period for RNs, both fulltime (FT) and PT, from 2 years to a 
maximum of its equivalency in hours, 4180. It also provides 
that a PT appointee who previously served on a FT basis in a 
``pure'' title 38 position (7401(1)), and completed a 
probationary period in the FT position, would not have to serve 
a probationary period in the PT ``pure'' title 38 position. VA 
opposes this provision. We believe this provision is 
technically flawed and would not be helpful.
    Part-time title 38 employees, including RNs, do not serve 
probationary periods. Probationary periods apply to full-time, 
permanent employees. We see no benefit to creating a 
probationary period for part-time nurses as these positions are 
temporary.
Prohibition on Temporary Part-Time Nurse Appointments In Excess of 
        4,180 Hours
    Subsection (c) would add a new section 7405(g) that would 
provide that part-time appointments of RNs are no longer 
temporary after no more than 4180 hours. After completion of 
the 4180 hours, the RN in essence would be converted to a 
permanent employee under section 7403(a) who has completed the 
probationary period. VA opposes this provision because it would 
impair our ability to adapt to changing demands in patient need 
and resource allocations. VA currently has the authority to 
create temporary appointments for up to three years. If this 
proposal is enacted, VA would lose this valuable flexibility. 
VA uses this flexibility to manage positions during periods of 
changing patient care needs and budgets. Without this current 
flexibility, VA's ability to make adjustments in the size of 
our temporary workforce would be limited. VA and its employees 
would be put into an untenable dilemma of either preemptively 
dismissing employees just prior to the expiration of the their 
probationary periods when patient demand justifies their 
continued employment or allowing a nurse to convert and retain 
employment, even if patient demand no longer justifies that 
position. In either scenario, patient care would be placed in 
competition with organizational flexibility, while the current 
system allows VA to achieve and maintain both.
Reemployed Annuitant Offset Waiver
    Subsection (d) generally provides that annuitants may be 
temporarily reemployed in a title 38 position without being 
subject to having their salary offset by the amount of their 
annuity. VA opposes this provision as 5 U.S.C. 8344 and 8468 
provide the agency access to retired title 38 health care 
providers.
Rate of Basic Pay for Section 7306 Appointees Set to Rate of Basic Pay 
        for SES
    Subsection (e) would amend section 7404(a) to add a 
provision setting the basic pay of non-physician/dentist 
section 7306 employees in accordance with the rate of basic pay 
for the Senior Executive Service (SES). This amendment would be 
effective the first pay period that is 180 days after 
enactment.
    VA supports the principle of pay equity with SES rates for 
its section 7306 nonphysician/dentist executives as a tool 
needed to meet the challenge of recruitment and retention. 
Equity in pay for executive level managers and consultants is 
essential to attracting and retaining candidates for key 
positions. The pay schedule for 38 U.S.C. Sec. 7306 appointees 
is capped at the pay rate for Level V of the Executive Schedule 
(currently $143,500). Locality pay is paid up to the rate for 
Level III (currently $162,900).
    Individuals appointed under 38 U.S.C. Sec. 7306 serve in 
executive level positions that are equivalent in scope and 
responsibility to positions in the SES. By comparison, 
employees in the SES receive a significantly higher rate of 
basic pay. The maximum SES pay limitation is the rate for Level 
II (currently $177,200) pending OPM certification that the 
agency meets all regulatory criteria for certified performance 
appraisal systems, including that the employing agency makes 
meaningful distinctions based on performance. We estimate the 
costs of this provision to be $343,917 in FY 2010 and 
$3,765,786 over a 10-year period.
    As noted, the SES pay system conditions pay up to EX Level 
II on OPM certification that an agency's SES rating system 
meets all regulatory criteria for certified performance 
appraisal systems. In this regard we note that VHA uses the 
same rating system for its section 7306 executives as it uses 
for its SES members. OPM has certified this system in the past, 
and just last year recertified VA through July 2010. For 
consistency, we recommend that the bill be modified to require 
that the Secretary make the same certification for the rating 
system covering section 7306 employees. Thus, we suggest that 
section 101(e)(3) be modified to read as follows:

        (3) Positions to which an Executive order applies under 
        paragraph (1) and are not described by paragraph (2) 
        shall be paid basic rates of pay in accordance with 
        section 5382 of title 5 for Senior Executive Service 
        positions and not greater than the rate of basic pay 
        payable for level III of the Executive Schedule; or if 
        the Secretary certifies that the employees are covered 
        by a performance appraisal system meeting the 
        certification criteria established by regulation under 
        section 5307(d), level II of the Executive Schedule.
Comparability Pay Program for Section 7306 and SES Appointees
    Subsection (f) would amend section 7410 to add a new 
subsection to establish ``comparability pay'' for VHA non-
physician/dentist section 7306 employees and SES employees of 
not more than $100,000 per employee in order to achieve annual 
pay levels comparable to the private sector. Similar to 
provisions for RN Executive Pay in section 7452(g), it would 
provide that ``comparability pay'' would be in addition to 
other pay, awards and bonuses; would be considered base pay for 
retirement purposes; would not be base pay for adverse action 
purposes; and could not result in aggregate pay exceeding the 
annual pay of the President.
    VA supports the concept of comparability pay for its non-
physician/dentist executives. However, we recommend that the 
new administration be given an opportunity to review this 
matter. Public sector executive pay is dramatically below the 
private sector for comparable positions, particularly in the 
health care sector. This proposal would allow VA executives to 
receive salaries far exceeding executives in other agencies 
which also must compete with the private sector. It would be a 
potentially precedent-setting departure from the unitary 
approach to governmentwide SES pay.
Special Incentive Pay for Department Pharmacist Executives
    Subsection (g) would further amend section 7410 to 
authorize recruitment and retention special incentive pay for 
pharmacist executives of up to $40,000. VA's determination of 
whether to provide and the amount of such incentive pay would 
be based on: grade and step, scope and complexity of the 
position, personal qualifications, characteristics of the labor 
market concerned, and such other factors as the Secretary 
considers appropriate. As with RN Executive Pay and 
comparability pay proposed by subsection (f), this subsection 
would provide that ``comparability pay'' would be in addition 
to other pay, awards and bonuses; would be considered base pay 
for retirement purposes; would not be base pay for adverse 
action purposes; and could not result in aggregate pay 
exceeding the annual pay of the President.
    This provision will provide a retention incentive to about 
40 positions: pharmacy benefit managers (PBM), consolidated 
mail outpatient pharmacy (CMOP) directors and VISN formulary 
leaders (VFL). VA supports this provision. Long-standing, 
severe and worsening pay compression exists within the ranks of 
senior pharmacy program managers in VHA. A national survey 
performed yearly by the American Society of Health System 
Pharmacists provides evidence that a similar trend exists in 
the private sector. Currently VHA has had extreme difficulty in 
recruiting pharmacists for leadership positions. Some examples 
include: the VA Medical Center in Bay Pines has not had a 
permanent Pharmacy Manager for two years; the VA Medical 
Center, Portland, Oregon position has been vacant for one year; 
the VA Medical Center, Asheville, NC has been vacant over one 
year; and numerous other facilities are experiencing the same 
recruiting difficulties. Several other facilities with extended 
vacancies that were recently been filled include: the VA 
Medical Center, Omaha, NE for two years; VA Medical Center 
Dayton, OH for two years; and VA Medical Center, Las Vegas, NV 
vacant for one year. The current pay rate that we are able to 
pay executives varies minimally from staff pharmacist positions 
and therefore is not an incentive to recruit pharmacy 
executive/those in leadership roles to VA. This provision will 
provide a mechanism to alleviate this compression. VA is still 
developing costs for this proposal and will submit them for the 
record when they are available.
Physician/Dentist Pay
    Subsection (h) concerns physician/dentist pay. VA supports 
this provision. Paragraph (1) would provide that the title 5 
non-foreign cost of living adjustment allowance for physicians 
and dentists would be determined as a percentage of base pay 
only. This would clarify the application of the title 5 non-
foreign cost of living adjustment allowance to VHA physicians 
and dentists. The VA physician/dentist pay statute, 38 U.S.C. 
Sec.  7431, does not address how the allowance is determined 
for physicians and dentists. We recommend that this provision 
be amended to clarify that it is applicable only to these 
physicians and dentists employed at Department facilities in 
Alaska, Guam, Hawaii, and Puerto Rico. These are the only 
Department facilities to which the title 5 non-foreign cost of 
living adjustment allowance is applicable.
    Paragraph (2) would amend section 7431 (c)(4)(B)(i) to 
exempt physicians and dentists in administrative or executive 
leadership provisions from the panel process in determining the 
amount of market pay and pay tiers for such physicians and 
dentists. In situations where physicians or dentists occupy 
these leadership positions as chief officers, network 
directors, and medical center directors, the consultation of a 
panel has some limitations. The small number of physicians and 
dentists who would qualify as peers for these leaders results 
in their serving on each other's compensation panels and, in 
some cases, on their supervisor's panel. Providing the 
Secretary with discretion to identify administrative or 
executive physician/dentist positions that may be excluded from 
the panel process would resolve these issues.
    Paragraph (3) would provide an exception to the prohibition 
on the reduction of market pay for changes in board 
certification or reduction of privileges correcting an 
oversight in the recent revision of the physician/dentist pay 
statute. This modification would allow VA to address situations 
where there is a loss of board certification or an adverse 
reduction in clinical privileges. No costs are associated with 
this provision.
RN and CRNA Pay
    Subsections (i) and (j) relate to RN and Certified 
Registered Nurse Anesthetist (CRNA) Pay. Subsection (i) would 
amend the current cap for registered nurse from EL V to EL IV. 
VA supports this provision. This would increase the cap from 
level V to level IV for both RNs and CRNAs, consistent with the 
pay cap that applies to the GS locality pay system. We note 
that subsection (i) would obviate the need for subsection (j) 
as the two pay scales affected are already tied to each other. 
We estimate the cost of this provision to be $6.16 million for 
FY 2010 and $72.31 million over a 10-year period.
    Subsection (k) would make amendments to the RN locality pay 
system (LPS). These provisions are not helpful and are 
unnecessary. No costs are associated with this provision.
    Paragraph (1) would require the Under Secretary for Health 
to provide education, training, and support to VAMC directors 
in the ``conduct and use'' of LPS surveys, including third 
party surveys. Paragraph (2) would require the annual report 
VAMCs must provide to VA Central Office to include the 
methodology for every schedule adjustment. These reports form 
the basis for the annual VA report to Congress. We are 
concerned that this provision, especially in conjunction with 
proposed paragraph 3, could result in the inappropriate 
disclosure of confidential salary survey data, contrary to 
current section 7451 (d)(5). It also would impose an onerous 
burden inasmuch as VHA has nearly 800 nurse locality pay 
schedules. We do note that VA policy does provide for how these 
surveys are to be obtained or conducted. Paragraph (3) would 
require the most recent VAMC report on nurse staffing to be 
provided to any covered employee or employee's union 
representative upon request. This provision should be modified 
to specify at what point the report must be provided. It would 
not be appropriate to provide an individual a copy of the VAMC 
report before Congress receives the VA report.
    Subsection (I) would increase the maximum payable for nurse 
executive special pay to $100,000. This provision would make 
the amount of nurse executive pay consistent with the Executive 
Comparability Pay proposed in section 2(f) of this bill. 
However, special pay of this amount would allow VA nurse 
executives to receive salaries far exceeding executives in 
other agencies that also must compete with the private section 
and there is no evidence that such levels of pay are necessary. 
Thus, VA opposes this provision.
    The caption for subsection (m) suggests it provides for 
eligibility of part-time nurses for certain nurse premium pay. 
However, many of the substantive amendments are not limited to 
part-time nurses, or to all registered nurses.
    VA opposes subsection (m) as it has serious technical 
flaws, is unnecessary, and is costly.
    Subparagraph (1)(A) would amend section 7453 (a) to make 
part-time nurses eligible for premium pay under that section. 
However, part-time nurses already are eligible for section 7453 
premium pay where they meet the criteria for such pay.
    Subparagraphs (1)(B) and (1)(C) would require evening tour 
differential to be paid to all nurses performing any service 
between 6 pm and 6 am, and any service on a weekend, instead of 
just those performing service on a tour of duty established for 
those times to meet on-going patient care needs. Under current 
law, these differentials are limited to the RN's normal tour of 
duty and any additional time worked on an established tour.
    The ``tour of duty'' requirement in the current law is 
intended to ensure adequate professional care and treatment to 
patients during off and undesirable tours. The limitation of 
tour differential and weekend pay only for service on a ``tour 
of duty'' rewards those employees who are subject to regular 
and recurring night and weekend work requirements. If that is 
changed to ``period of service'', any employees performing 
night or weekend work on an occasional or ad-hoc basis would 
also be entitled to this premium pay in addition to overtime 
pay, providing an inappropriate windfall for performing 
occasional work.
    Subparagraph (2) would authorize title 5 VHA employees to 
receive 25 percent premium pay for performing weekend work on 
Saturday and Sunday. We understand the purpose of this 
provision is to limit the expansion of weekend premium pay to 
non-tour hours to registered nurses. However, it does not fully 
achieve that purpose. Pursuant to section 7454(a) and (b)(2), 
physician assistants, expanded-function dental auxiliaries, and 
hybrids are also entitled to weekend pay under section 7453. 
The expansion of weekend pay proposed in this subparagraph 
would apply to them as well. In addition, because physician 
assistants and expanded-function dental auxiliaries are 
entitled to all forms of registered nurse premium pay under 
section 7453, the expansion of the night differential premium 
pay also would apply to them. Furthermore, where VA has 
authorized section 7453 night differential for hybrids, the 
expansion of the night differential premium pay would apply to 
them as well.
    Subsection (n) would add additional occupations to the 
exemption to the 28th step cap on title 38 special salary 
rates: LPNs, LVNs, and unspecified ``other nursing positions 
otherwise covered by title 5''. Notwithstanding the exemption, 
under current statute, title 38 special salary rates cannot 
exceed the rate for EL V. It is not clear what positions 
``nursing positions otherwise covered by title 5'' would 
include. RNs are appointed under title 38, LPNs/LVNs are 
hybrids, and section 101(a)(2) of the bill would convert 
nursing assistants to hybrid. Moreover, it is not apparent why 
only these positions and not all positions authorized title 38 
special rates would be exempted. Using the same formula for the 
cap on title 5 special rates would afford VA the most 
flexibility in establishing maximum rates for title 38 special 
rates. We also note that adopting the title 5 fixed-percentage 
formula would render unnecessary the section 7455(c)(2) report 
for exceeding 94 percent of the grade maximum and, so, propose 
deleting it.
    Thus we recommend amending section 7455 to read as follows:

        (a)(1) Subject to subsections (b), (c), and (d), when 
        the Secretary determines it to be necessary in order to 
        obtain or retain the services of persons described in 
        paragraph (2), the Secretary may increase the minimum 
        rates of basic pay authorized under applicable statutes 
        and regulations, and may make corresponding increases 
        in all rates of the pay range for each grade. Any 
        increase in such rates of basic pay----

           *       *       *       *       *       *       *

        (c) The amount of any increase under subsection (a) in 
        the minimum rate for any grade may not exceed the 
        maximum rate of basic pay (excluding any locality-based 
        comparability payment under section 5304 of title 5 or 
        similar provision of law) for the grade or level by 
        more than 30 percent, and no rate may be established 
        under this section in excess of the rate of basic pay 
        payable for level IV of the Executive Schedule.

    VA's concerns that pay setting authorized by this provision 
may be subject to collective bargaining are discussed in 
conjunction with S.362.
    Section 102(a)(1) would add new section 7459, imposing 
restrictions on nurse overtime. Section 7459 generally would 
prohibit mandatory overtime for nurses (RNs, LPNs, LVNs, 
nursing assistants, and any other nurse position designated by 
the Secretary). It would permit mandatory overtime by nurses 
under certain conditions: an emergency that could not have been 
reasonably anticipated; the emergency is non-recurring and not 
due to inattention or lack of reasonable contingency planning; 
VA exhausted all good faith, reasonable attempts to obtain 
voluntary workers; the affected nurses have critical skills and 
expertise; and the patient work requires continuity of care 
through completion of a case, treatment, or procedure. VA could 
not penalize nurses for refusing to work prohibited mandatory 
overtime. Section 7459 provides that nurses may work overtime 
hours on a voluntary basis.
    VA favors this mandatory overtime restriction with the 
caveat that first and foremost, VA needs to be able to mandate 
overtime where issues of patient safety are identified by 
facility leadership. We note VAMCs currently have policies 
preventing RNs from working more than 12 consecutive hours and 
60 hours in a 7-day period pursuant to section 4(b) of Pub. L. 
108-445.
    Section 102(b) would amend 38 U.S.C. 7456 (the ``Baylor 
Plan''), which authorizes VA to allow nurses who perform two 
12-hour regularly scheduled tours of duty on a weekend to be 
paid for 40 hours. This work-scheduling practice typically 
would be used when facilities encounter significant staffing 
difficulties caused by similar work scheduling practices in the 
local community. It would delete current section 7456(c), the 
current Baylor Plan requirement, which provides for a 5-hour 
leave charge for each 3 hours of absence that reflects the 
relative value of the truncated Baylor tour, in effect 
increasing the value of leave for affected employees. 
Currently, VA has only one employee working on the Baylor Plan. 
VA opposes this provision as providing an unwarranted windfall.
    Section 102(c) would amend section 7456A to change the 36/
40 alternate work schedule to a 72/80 alternate work schedule, 
so that under the schedule six 12-hour ``periods of service'' 
anytime in a pay period would substitute for three ``12-hour 
tours of duty'' in each week of the pay period. Similar changes 
would be made to section 7456A's overtime, premium pay and 
leave provisions.
    VA is experiencing planning problems with the use of the 
current 36/40 schedule. The problem stems from the 36/40 
language requiring three 12-hour tours in a work week and 
because VA defines ``work week'' as Sunday to Saturday. The 
problem occurs because the work week requirement prevents 
scheduling one of the 12-hour tours over two different weeks, 
e.g., 6PM Saturday to 6AM Sunday. Changing ``work week'' to 
``pay period'' only makes the problem occur every 2 weeks 
instead of every week, so we do not view that as helpful. We do 
support changing the 36/40 alternate work schedule to a 72/80 
alternate work schedule, so that the six 12-hour tours can 
occur anytime in a pay period, providing more work scheduling/
planning flexibility. We would be glad to provide appropriate 
bill language.
    Section 103 would make amendments to VA's Education 
Assistance Programs. VA supports these proposals. Section 
103(a) would amend section 7618 to reinstate the Health 
Professionals Educational Assistance Scholarship Program 
through the end of 2014. The program expired in 1998. The 
Health Professional Scholarship Program would help reduce the 
nursing shortage in VA by obligating scholarship recipients to 
work for 2 years at a VA health care facility after graduation 
and licensure. This proposal would also expand eligibility for 
the scholarship program to all hybrid occupations. This would 
be helpful in recruiting and retaining employees in the several 
hard-to-fill hybrid occupations. We are still determining costs 
for this provision and will forward them to the Committee as 
soon as they are available.
    Section 103(b) would make certain amendments to the 
Education Debt Reduction Program. It would amend section 
7681(a)(2) to add retention as a purpose of the program and 
amend section 7682(a)(1) to make it available to ``an'' 
employee, in lieu of ``recently appointed.'' It would also 
increase the authorized statutory amounts in section 7683 to 
$60,000 and $12,000, respectively.
    The ``recently appointed'' requirement limits eligibility 
to employees who have been appointed within six months. VA's 
experience has been that this is not a sufficient period. In 
several instances, employees applying just missed the six-month 
deadline. In many cases it takes more than six months for 
employees to become aware of this very helpful recruitment and 
retention program. This proposal offers greater flexibility to 
VA in applying the program. VA also supports the increased 
amounts in light of increased education costs since the program 
was enacted. We note this program can be implemented in a cost-
neutral fashion.
    Section 103(c) would authorize VA researchers from 
``disadvantaged backgrounds'' to participate in a loan 
repayment program that the VA may establish using the Public 
Health Service Act authorities for the NIH Loan Repayment 
Program. We agree that loan repayment incentives would be 
helpful to clinicians with medical specialization and research 
interests who might consider career clinical care or clinical 
research opportunities relating to the work of VHA.
    Section 104 is nearly identical to S.246, Section 2(a), 
which I have previously discussed.
    Section 201 would eliminate two reporting requirements: the 
Nurse Pay Report and the Long-Term Planning Report. VA supports 
this provision. There would be no discernible cost savings 
associated with this provision. Similarly, VA supports Section 
202 to amend the Persian Gulf War Veterans' Health Status Act 
to change the due date of the annual report to Congress from 
March 1 to July 1. This change would have no impact on cost.
    VA also supports Section 203. Section 203 will provide 
clarification of the legal authority beyond the existing 
regulations that will prevent providers from collecting from 
the beneficiary any amounts in excess of the CHAMPVA determined 
allowable amount. VA favors this provision. There would be no 
significant cost to VA.
    Section 204, relating to payer provisions for care 
furnished to certain children of Vietnam Veterans, has been 
made moot by the passage of Pub. L. 110-387, Section 408, 
``Spina Bifida Comprehensive Health Care.''
    VA strongly supports Section 205 of S.252, which would 
permit VA health care practitioners to disclose the relevant 
portions of VA records of the treatment of drug abuse, 
alcoholism and alcohol abuse, infection with the human 
immunodeficiency virus, and sickle cell anemia to surrogate 
decisionmakers who are authorized to make decisions on behalf 
of patients who lack decisionmaking capacity, but to whom the 
patient had not specifically authorized release of that legally 
protected information prior to losing decisionmaking capacity. 
This provision would only permit such a disclosure when the 
practitioner deems the content necessary for the representative 
to make an informed decision regarding the patient's treatment. 
This provision is critical to ensure that a patient's surrogate 
has all the clinically relevant information needed to provide 
full and informed consent with respect to the treatment 
decisions that the surrogate is being asked to make.
    Section 206 would authorize VA to require that applicants 
for, and recipients of, VA medical care and services provide 
their health-plan contract information and social security 
numbers to the Secretary upon request. It would also authorize 
VA to require applicants for, or recipients of, VA medical care 
or services to provide their social security numbers and those 
of dependents or VA beneficiaries upon whom the applicant or 
recipient's eligibility is based. Recognizing that some 
individuals do not have social security numbers, the provision 
would not require an applicant or recipient to furnish the 
social security number of an individual for whom a social 
security number has not been issued. Under this provision, VA 
would deny the application for medical care or services, or 
terminate the provision of, medical care or services, to 
individuals who fail to provide the information requested under 
this section. However, the legislation authorizes the Secretary 
to reconsider the application for, or reinstate the provision 
of, care or services once the information requested under this 
section has been provided. Of note, this provision makes clear 
that its terms may not be construed to deny medical care and 
treatment to an individual in a medical emergency.
    Given the significant privacy concerns related to this 
provision, we defer views until further analysis can be made 
and the new administration is given an opportunity to review 
this matter.
    Section 207 addresses quality management in VA facilities 
and establishes quality management officer positions at the 
national, VISN and facility level. Section 207 is similar to 
S.246, Section 3, although the position established is termed 
``Quality Management Officer'' (QMO), and there is no 
stipulation that the position be filled by a board-certified 
physician. Section 207 would require the QMO to be responsible 
for and undertake specific actions to carry out VHA's quality 
management program. Section 207 additionally would require the 
National QMO to assess quality of care by developing an 
aggregate quality metric from existing data sources, monitoring 
and analyzing existing measures of quality, and encouraging 
research and development in the area of quality metrics. 
Section 207 would authorize appropriations necessary to carry 
out the quality management program, including $25,000,000 for 
the quality metric provisions during the 2 fiscal year period 
following enactment. Mr. Chairman, we support the intent of 
these provisions, that is enhancing VA's quality management 
programs, and have already undertaken actions to achieve many 
of the same goals. We would welcome the opportunity to meet 
with the Committee to discuss recent actions we have undertaken 
to improve the quality of care across the system, including 
program oversight related measures.
    Section 208 requires submission of an annual report to 
Congress describing progress toward implementing provisions of 
Sections 104 and 207. VA has no objection to this requirement 
and, in fact, supports the concept of transparency in health 
care. We note that a comprehensive Hospital Quality Report was 
prepared by the Department in 2008 and is updated annually.
    We estimate that the requirement that the VISN Director 
review all information needed for physician appointment would 
require an additional FTEE (GS 14) at the VISN level. We also 
estimate that the appointment of a board-certified physician to 
serve as QAO at the facility and network levels would require 
162 physicians for 141 medical staffs and 21 networks. We 
estimate salary and benefits costs for each QAO to be 
approximately $200,000 (actual will vary according to 
specialty, time commitment, and local market factors). We 
estimate total costs for a FTE MD QAO and FTE VISN coordinator 
to be $35.10 million in the first year, $188.05 million over 
five years, and approximately $413.22 million over 10 years. We 
estimate that salaries plus benefits for the new positions will 
include a 4% increase in costs for each subsequent year.
    Section 209 would require the Secretary to conduct a pilot 
program, in collaboration with the Secretary of Defense, to 
assess the feasibility of training and certifying family 
caregivers to be personal care attendants for veterans and 
members of the of the Armed Forces suffering from TBI. The 
pilot program would be conducted at three VA medical centers 
and, if determined appropriate, at one DOD medical center. VA 
would be required to determine the eligibility of a family 
member to participate in the pilot programs, and such a 
determination would have to be based on the needs of the 
veteran or servicemember as determined by the patient's 
physician. The training curricula would be developed by VA and 
include applicable standards and protocols used by 
certification programs of national brain injury care specialist 
organizations and best practices recognized by caregiver 
organizations. Training costs would be borne by VA, with DOD 
required to reimburse VA for the costs of training family 
members of servicemembers. Family caregivers certified under 
this program would be eligible for VA compensation and may 
receive assessments of their needs in the role of caregiver and 
referrals to community resources to obtain needed services.
    VA does not support section 209. Currently, we are able to 
contract for caregiver services with home health and similar 
public and private agencies. The contractor trains and pays 
them, affords them liability protection, and oversees the 
quality of their care. This remains the preferable arrangement 
as it does not divert VA from its primary mission of treating 
veterans and training clinicians. Moreover, it does not put VA 
in the position of having to tell family members how, at the 
risk of losing their caregiver compensation, they have to care 
for their loved ones. If enacted, we estimate the cost of the 
three-year pilot to be $178.4 million.
    Section 210 would require VA, in collaboration with DOD, to 
carry out a pilot program to assess the feasibility of 
providing respite care to family caregivers of servicemembers 
and veterans diagnosed with TBI, through the use of students 
enrolled in graduate education programs in the fields of mental 
health or rehabilitation. Students participating in the program 
would provide respite relief to the servicemember's or 
veteran's family caregiver, while also providing socialization 
and cognitive skill development to the servicemember or 
veteran. VA would be required to recruit these students, train 
them in the provision of respite care, and work with the heads 
of their graduate programs to determine the amount of training 
and experience needed to participate in the pilot program.
    VA does not support section 210. Individuals providing 
respite care do not require advanced degrees, only appropriate 
training. Respite care does not require specialized skills, and 
its functions are not applicable to curricula objectives in the 
graduate degree programs related to mental health or 
rehabilitation that we are aware of. Further, section 210 would 
require VA to use graduate students in roles that are not 
permissible under academic affiliation agreements, and we have 
serious doubts this proposal would be acceptable to graduate 
schools.
    Moreover, VA has a comprehensive respite care program. We 
also have specialized initiatives underway for TBI patients to 
reduce the strain on their caregivers, which overlap with this 
bill. We also provide respite care by placing the veteran in a 
local VA facility for the duration of the respite period. 
Veterans may receive up to 30 days of respite care per year. We 
estimate the costs of conducting the pilot program to be $3.5 
million in the first year and approximately $11.4 million over 
five years.
    Section 211 would require the Secretary to carry out a two-
year pilot grant program (at five locations selected by the 
Secretary) to assess the feasibility of using community-based 
organizations and local and State government entities to 
increase the coordination of VA benefits and services to 
veterans transitioning from military service to civilian life, 
to increase the availability of medical services available to 
these veterans, and to provide their families with their own 
readjustment services. Grantees could use grant funds for 
purposes prescribed by the Secretary.
    VA opposes section 211 because it is duplicative of the 
Department's on-going efforts. Vet Centers are already 
providing many of the services contemplated by this provision. 
Additionally, VA case managers and Federal recovery 
coordinators already coordinate the delivery of health care and 
other VA services available to veterans transitioning from 
military service to civilian life, including supportive 
services for their families. VA is committing ever increasing 
resources to these ends. The duplicated efforts required by the 
bill would likely create significant confusion for the 
beneficiary.
    To the extent the Secretary determines external resources 
are necessary to provide the services described in the bill, VA 
already has the necessary authority to contract for them. We 
favor using contracts instead of grants, as the former allow VA 
to respond to changing local needs and assure the quality of 
services provided. That approach also gives us an accurate way 
to project the cost of the services. This provision, on the 
other hand, would not. It would also not be cost-effective as 
it is likely that a grant awarded under the program would be 
for an amount significantly less than the cost VA incurs in 
administering the grant. We also note the bill would not 
include authority for VA to recapture unused grant funds in the 
event a grantee fails to provide the services described in the 
grant.
    Although the proposed pilot project is limited to five 
locations, the bill does not specify the number and amount of 
the grants to be awarded. We are unable to estimate the cost of 
this provision due to the lack of specificity.
    Section 212 would authorize VA to contract for specialized 
residential care and rehabilitation services for veterans of 
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/
OIF) who: (1) suffer from Traumatic Brain Injury, (2) have an 
accumulation of deficits in activities of daily living and 
instrumental activities of daily living that affects their 
ability to care for themselves, and (3) would otherwise receive 
their care and rehabilitation in a nursing home. These veterans 
do not require nursing home care, but they generally lack the 
resources to remain at home and live independently; this 
represents an extremely small subset of the OEF/OIF population. 
In fact, for FY 2010, VA estimates only 10 veterans would 
qualify and participate in this program. Age appropriate day 
health and other community programs, VA's home based primary 
care, and medical foster homes will be expanded to provide 
these Veterans with long-term specialized rehabilitation 
services. VA supports this legislation as it would enable us to 
provide these veterans with long-term rehabilitation services 
in a far more appropriate treatment setting than we are 
currently authorized to provide. VA estimates the discretionary 
cost of section 212 to be $923,000 for the first year, $12.2 
million over five years, and $76.8 over ten years.
    Section 213 would amend sections 5701 and 7332 of title 38, 
United States Code. The amendments would authorize VA to 
disclose individually-identifiable patient medical information 
without the prior written consent of a patient to a third-party 
health plan to collect reasonable charges under VA collections 
authority for care or services provided for a non-service-
connected disability. The section 5701 amendment would 
specifically authorize disclosure of a patient's name and 
address information for this purpose. The section 7332 
amendment would authorize disclosure of both individual 
identifier information and medical information for purposes of 
carrying out the Department's collection responsibilities.
    Given the significant privacy concerns related to this 
provision, we defer views on this section until further 
analysis can be made and the new administration is given an 
opportunity to review this matter.
    Section 214 would require VA to enter into a contract with 
the Institute of Medicine of the National Academies to conduct 
an expanded study on the health impact of Project Shipboard 
Hazard and Defense (Project SHAD). VA opposes this proposal. 
The 2007 four-year, $3.8 million, VA-sponsored study by the 
National Academies of Sciences (NAS) ``Long-Term Health Effects 
of Participation in Project SHAD'' represented an exhaustive 
effort to locate and evaluate the health of every living or 
deceased SHAD veteran. That study found little or no long-term 
health effects linked to SHAD participation, and spending 
additional resources with the hope that possibly tracking down 
a small number of additional SHAD veterans might significantly 
change those results is unrealistic. We have been assured by 
the NAS group who conducted the original study that they have 
spared no effort in tracking down every SHAD participant as 
part of their study. We estimate that such a study would cost 
$2.5 million.
    When VA is providing inpatient or outpatient care for a 
patient with Traumatic Brain Injury, VA is required to develop 
an individual plan for the veteran or servicemember. In 
implementing such plans, 38 U.S.C. Sec.  1710E authorizes the 
Secretary to provide hospital care and medical services through 
cooperative agreements with appropriate public or private 
entities that have established long-term neurobehavioral 
rehabilitation and recovery programs. Section 215 would amend 
this authority by defining covered individuals as 
servicemembers or veterans receiving inpatient or outpatient 
rehabilitative hospital care or medical services for Traumatic 
Brain Injury to whom the Secretary is unable to provide 
treatment or services at the frequency or for the duration 
described in the plan, or for whom the Secretary determines 
such care is optimal. This provision would also require that 
facilities participating in such cooperative agreements 
maintain standards for the provision of treatment or services 
that have been established by an independent, peer-reviewed 
organization that accredits specialized rehabilitation programs 
for adults with Traumatic Brain Injury.
    VA supports this provision but recommends that the plan 
referenced in this provision be described as the VA 
Individualized Rehabilitation and Reintegration Plan developed 
in accordance with section 1710C. Further, the bill as 
currently drafted states that the Secretary may not provide 
treatment or services at the non-VA facility unless the 
facility ``maintains standards for the provision of such 
treatment or services established by an independent, peer-
reviewed organization that accredits specialized rehabilitation 
programs for adults with Traumatic Brain Injury.''
    Section 216 would include federally recognized tribal 
organizations in certain State home programs. Specifically, 
section 216(a) would authorize VA to treat a health facility or 
certain beds in a health facility of a tribal organization as a 
State nursing home for veterans. This would allow VA to pay per 
diem to the organization for the nursing home care of veterans 
in the home. The home would be required to meet the existing 
standards for State homes and such other standards as VA 
requires. In addition, the organization would have to 
demonstrate that, but for treatment in the home, a substantial 
number of veterans residing in the area would not have access 
to nursing home care, and the Secretary would have to determine 
that treatment of the facility or beds as a State home would 
best meet the needs of veterans for nursing home care in the 
area. Finally, tribal organizations would be subject to 
limitations on the number of beds that could receive per diem 
under this provision.
    VA opposes Section 216(a). It would be very difficult to 
maintain a critical mass of staff with expertise in the care of 
frail, elderly patients in such a setting. Moreover, this would 
duplicate the function of the existing Community Nursing Home 
Program under which VA can pay for the care of Veterans placed 
in nursing homes in the private sector. VA contracts with more 
than 4,500 community nursing homes nationally and can add more 
as needed to assure Veterans' access to care.
    Section 216(b) would authorize VA to award grants to tribal 
organizations for the construction or acquisition of state 
homes in the same manner and under the same conditions as 
grants awarded to States subject to exceptions prescribed by VA 
to take into account the unique circumstances of tribal 
organizations. This provision would require VA to give priority 
to grant applications from tribal organizations that had not 
previously applied for a grant even if the State in which the 
tribal organization was located had previously applied for (or 
received) a grant.
    VA also opposes Section 216(b). The proposal would 
disenfranchise the states for which the construction grant 
program was expressly established since priority for awarding 
of grants is prescribed in statute and regulation. The first 
priority is for renovations necessary to protect the lives and 
safety of Veterans residing in the home. The second priority is 
for grants to states, or under this provision, tribal entities, 
that have never previously received a grant from this program. 
Since every state has received a grant and no tribal entity 
ever has, all construction and renovation applications from 
tribes would take precedence over all applications from states, 
except for life safety grants, until all tribal entities that 
wished to submit applications had done so. Since there are more 
500 recognized tribal entities, it could be years before states 
are again able to receive grants other than life safety grants, 
and even then they would have to compete with more than 500 
eligible applicants instead of the 50 states and a few 
territories now eligible for the grants. The radical change 
being proposed would be detrimental to the states for which 
this program was specifically established.
    VA estimates the cost of Section 216 to be $2.6 million for 
the first year, $14.2 million over five years, and $31.5 
million over ten years.
    Section 217 would require the Secretary to carry out a 
pilot program to assess the feasibility and advisability of 
providing a dental insurance plan to veterans enrolled for VA 
health care pursuant to section 1705 of title 38 and survivors 
or dependants enrolled for care under section 1781 of title 38 
(CHAMPVA). Under this plan, VA would manage and administer a 
group dental plan. VA opposes section 217 as this provision 
would establish an entirely new and dramatically different role 
for VA.
    Section 301 of this bill corresponds to section 101 of 
S.597, another bill on today's agenda. This section would 
require VA to contract with a qualified independent entity or 
organization to carry out a comprehensive assessment of the 
barriers encountered by women veterans seeking comprehensive 
health care from VA, building on the VA's own ``National Survey 
of Women Veterans in Fiscal Year 2007-2008'' (National Survey). 
Many requirements related to sample size and the scope of the 
survey would apply to the conduct of the assessment. Section 
301 would also require the contractor-entity to conduct 
research on the effects of the following concerns on the study 
participants:

     The perceived stigma associated with seeking 
mental health care services.
     The effect of driving distance or availability of 
other forms of transportation to the nearest appropriate VA 
facility on access to care.
     The availability of child care.
     The acceptability of integrated primary care, or 
with women's health clinics, or both.
     The comprehension of eligibility requirements for, 
and the scope of services available under, such health care.
     The perception of personal safety and comfort of 
women veterans in inpatient, outpatient, and behavioral health 
facilities of the Department.
     The gender sensitivity of health care providers 
and staff to issues that particularly affect women.
     The effectiveness of outreach for health care 
services available to women veterans.
     The location and operating hours of health care 
facilities that provide services to women veterans.
     Such other significant barriers identified by the 
Secretary.

    Additionally, section 301 would require the Secretary to 
ensure that the heads of the Center for Women Veterans and the 
Advisory Committee on Women Veterans review the results of the 
comprehensive assessment and submit their own findings with 
respect to it to the Under Secretary for Health and other VA 
offices that administer health care benefits to women veterans.
    The results of our National Survey will not be available 
until later in the fiscal year. Consequently, we do not think 
it feasible to enter into a contract for the mandated 
assessment and research until we have first had a chance to 
complete and fully analyze the results of the National Survey. 
Only in this way can the assessment and research adequately 
build on the National Survey and reliably augment, rather than 
duplicate, VA's efforts in this area. We estimate the cost of 
section 101 to be $3.5 million.
    The next section, section 302, corresponds to section 201 
of S.597 and requires VA to develop a plan to improve the 
provision of health care services to women veterans. VA fully 
supports the evaluation and enhancement of care to women 
veterans and initiated a planning and implementation program in 
September 2008. Consequently, this provision is unnecessary as 
the initiative is already underway.
    Section 303 of S.252 corresponds to section 102 of S.597. 
This section would require VA to enter into a contract with an 
entity or organization to conduct a very detailed and 
comprehensive assessment of all VA health care services and 
programs provided to women veterans at each VA facility. The 
assessment would have to include VA's specialized programs for 
women with PTSD, homeless women, women requiring care for 
substance abuse or mental illnesses, and those requiring 
obstetric and gynecologic care. It would also need to address 
whether effective health care programs (including health 
promotion and disease prevention programs) are readily 
available to, and easily accessed by, women veterans based on a 
number of specified factors.
    After the assessment is performed, the bill would require 
VA to develop an extremely detailed plan to improve the 
provision of health care services to women veterans, taking 
into account, among other things, projected health care needs 
of women veterans in the future and the types of services 
available for women veterans at each VA medical center. VA 
would then be required to report to Congress on the assessment 
and plan, including any administrative or legislative 
recommendations VA deems appropriate. What is unclear in the 
bill is whether the contractor-entity conducting the assessment 
would also be required to develop the follow-up ``plan,'' as 
the terms of section 303 refer to the contractor's conduct of 
``studies and research'' required by that section. VA supports 
section 303 only if the development of the mandated plan would 
be conducted by a contractor-entity. We estimate the total 
costs of this section to be $4,354,000 during the period of 
Fiscal Year 2010 through Fiscal Year 2012.
    Section 304 corresponds to section 202 of S.597. This 
provision would require the Secretary to establish a program 
for education, training, certification and continuing medical 
education for VA mental health professionals furnishing care 
and counseling services for military sexual trauma (MST). VA 
would also be required to determine the minimum qualifications 
necessary for mental health professionals certified under the 
program to provide evidence-based treatment. The provision 
would establish extremely detailed reporting requirements. VA 
would also have to establish education, training, 
certification, and staffing standards for VA health care 
facilities for full-time equivalent employees who are trained 
to provide MST services.
    We do not support the training-related requirements of 
section 304 because they are duplicative of existing programs. 
In FY 2007, VA funded a Military Sexual Trauma Support Team, 
whose mission is, in part, to enhance and expand MST-related 
training and education opportunities nationwide. VA also hosts 
an annual four-day long training session for 30 clinicians in 
conjunction with the National Center for PTSD, which focuses on 
treatment of the after-effects of MST. VA also conducts 
training through monthly teleconferences that attract 130 to 
170 attendees each month. VA has recently unveiled the MST 
Resource Homepage, a webpage that serves as a clearinghouse for 
MST-related resources such as patient education materials, 
sample power point trainings, provider educational 
opportunities, reports of MST screening rates by facility, and 
descriptions of VA policies and benefits related to MST. It 
also hosts discussion forums for providers. In addition, VA 
primary care providers screen their veteran-patients, 
particularly recently returning veterans, for MST, using a 
screening tool developed by the Department. We are currently 
revising our training program to further underscore the 
importance of effective screening by primary care providers who 
provide clinical care for MST within primary care settings.
    We object strongly to section 304's requirement for 
staffing standards. Staffing-related determinations must be 
made at the local level based on the identified needs of the 
facility's patient population, workload, staffing, and other 
capacity issues. Retaining this flexibility is essential to 
permit VA and individual facilities to respond to changing 
needs and available resources. Imposition of national staffing 
standards would be an inefficient and ineffective way to manage 
a health care system that is dynamic and experiences continual 
changes in workload, utilization rates, etc.
    Section 305 would require VA, not later than six months 
after the date of enactment, to conduct a pilot program to 
evaluate the feasibility of providing reintegration and 
readjustment services in a group retreat setting to women 
veterans recently separated from service after a prolonged 
deployment. Participation in the pilot would be at the election 
of the veteran. Services provided under the pilot would 
include, for instance, traditional VA readjustment counseling 
services, financial counseling, information on stress 
reduction, and information and counseling on conflict 
resolution.
    We are unclear as to the purpose of and need for this 
provision. The term ``group retreat setting'' is not defined, 
but we assume it could not include VA medical facilities or Vet 
Centers, as we could not limit Vet Center access to any one 
group of veterans. Moreover, it is important to note that many 
Vet Centers are already well designed to meet the individual 
and group needs of women veterans. We estimate that the cost of 
the pilot would be around $300,000.
    Section 306 mandates a report to Congress to ensure that 
health care needs of women are met and to assess whether there 
is at least one full-time Women Veterans Program Manager 
employed at each VAMC. This section is substantially similar to 
section 103 of S.597. The report shall include an assessment of 
whether there is at least one full-time employee at each VA 
medical center who is a full-time women veterans program 
manager. VA does not oppose this provision but we believe it is 
unnecessary. VA is already reporting regularly on the 
employment of Women Veteran Program Managers. To date, 137 of 
the 144 positions have been filled as full-time employees. No 
additional funds would be required to submit this report.
    Next, section 307 (and the corresponding provision in 
S.597, section 204) would require the Department's Advisory 
Committee on Women Veterans, created by statute, to include 
women veterans who are recently separated veterans. It would 
also require the Department's Advisory Committee on Minority 
Veterans to include recently separated veterans who are 
minority group members. These requirements would apply to 
committee appointments made on or after the bill's enactment. 
We fully support section 307. These amendments would help both 
Committees to better identify and address the needs of their 
respective veteran-populations.
    Section 308 would require the Secretary, commencing not 
later than six months after the date of enactment, to carry out 
a two-year pilot program, at no fewer than three VISN sites, to 
pay veterans the costs of childcare they incur to travel to and 
from VA facilities for regular mental health services, 
intensive mental health services, or other intensive health 
care services specified by the Secretary. The provision is 
gender-neutral. Any veteran who is a child's primary caretaker 
and who is receiving covered health care services would be 
eligible to participate in the pilot program. The corresponding 
provision is in section 205 of S.597.
    VA is very cognizant of the veterans' needs for convenient 
access to health care; however, we oppose section 308 as this 
expansion would divert resources from direct medical care.
    We support section 309, which would authorize VA to furnish 
health care services up to seven days after birth to a newborn 
child of a female veteran who is receiving maternity care 
furnished by VA if the veteran delivered the child in a VA 
facility or in another facility pursuant to contract for 
service related to such delivery. This provision corresponds to 
section 206 of S.597. We estimate that the cost would be $55.3 
million the first year, $293.6 million over five years, and 
approximately $589.4 over ten years.
    VA supports Section 401, which would make members of the 
Armed Forces who serve in Operation Enduring Freedom or 
Operation Iraqi Freedom eligible for counseling and services 
through Readjustment Counseling Service, but we are concerned 
with the precedent that would be established by providing 
disparate eligibility to veterans of different conflicts. Under 
this provision active duty combat veterans of OEF/OIF would 
have access to Vet Centers for counseling and related mental 
health services and behavioral health services, including 
substance abuse assessment, counseling, and referral. Active 
duty veterans of the Persian Gulf War or other prior or 
subsequent combat would not have access to those services. 
Providing these services to active duty OEF/OIF personnel would 
cost approximately $3.7 million in the first year, $19.8 over 
five years, and $44.1 million over ten years. DOD has 
reimbursed VA for services provided to active duty members; 
however, we have not yet discussed the funding of this 
provision or possible reimbursement rates with DOD for 
readjustment counseling services.
    Until 1996, VA had specific statutory authority to refer 
ineligible veterans to non-VA resources and to advise such 
individuals of the right to apply for review of the 
individual's discharge or release. VA supports Section 402, 
which would reinstate these provisions. Reinstatement of these 
provisions would give the Vet Centers the latitude to help 
Veterans with problematic discharges with problems deemed by 
Vet Center staff to be related to war trauma, through referral 
to services outside the VA and/or referral for assistance with 
discharge upgrades when appropriate. The total number of 
Veterans this provision would affect is assumed to be small so 
the costs of this provision would be negligible.
    VA opposes Section 403, requiring VA to conduct a study to 
determine the number of Veterans who have committed suicide 
between January 1, 1997, and the date of the bill's enactment. 
VA opposes conducting the study because other information, more 
valuable in guiding VA's strategy for suicide prevention, is 
already available and is continually being refined through 
other research and data collection efforts. Moreover, we do not 
believe that the new requirement would yield any additional 
information of significant value.
    Rates and counts of deaths from suicide are available from 
2000 onward for Veterans who utilized the VHA Health Care 
System. In addition, they are available on specific cohorts of 
Veterans including those who served in OEF/OIF and in the first 
Persian Gulf War, whether or not they utilize VHA health care 
services. Finally, they are available on all individuals 
identified at the times of their deaths as Veterans by their 
families in the sixteen states that participate in the Centers 
for Disease Control and Prevention's National Violent Death 
Reporting System. VA estimates that the overall cost for 
conducting such a study would be $2,356,000 in FY 2010 and 
$7,224,000 over five years.
    VA is opposed to Section 404, which would transfer $5 
million from VA to the Department of Health and Human Services 
(HHS) by the end of FY 2010 for a graduate psychology education 
(GPE) program. This transfer of funds to the GPE Program would 
reduce funding available for VA programs or services without 
any clear benefit to VA in exchange for those services. VA much 
prefers to target these funds to increasing internship and 
post-doctoral training positions within VA facilities. VA 
already supports 435 Psychology internship positions in 90 
different programs and 200 postdoctoral fellowship programs in 
54 programs. Thus we already provide the ``training of 
psychologists in the treatment of Veterans with Post Traumatic 
Stress Disorder, Traumatic Brain Injury, and other combat-
related disorders'' that this legislation aims to achieve. 
Assuming that this $5 million would become a recurring transfer 
of funds, the estimate over ten years is $50 million.
    Sections 501 and 502 of S.252 would authorize VA to conduct 
two five-year pilot grant programs under which public and non-
profit organizations (including faith-based and community 
organizations) would receive funds for coordinating the 
provision of local supportive services for very low income, 
formerly homeless veterans who reside in permanent housing. 
Under one of the pilot programs, VA would provide grants to 
organizations assisting veterans residing in permanent housing 
located on military property that the Secretary of Defense 
closed or slated for closure as part of the 2005 Base 
Realignment and Closure program and ultimately designated for 
use in assisting the homeless. The other pilot program would 
provide grants to organizations assisting veterans residing in 
permanent housing on any property across the country. Both 
pilot programs would require the Secretary to promulgate 
regulations establishing criteria for receiving grants and the 
scope of supportive services covered by the grant program.
    The 2005 Base Realignment and Closure process has been 
completed and local plans have already been developed. 
Therefore the new authority as proposed in section 501 would be 
ineffective. Further, the Veterans Mental Health and Other Care 
Improvement Act of 2008, Public Law 110-387, Title VI, Section 
604 provided authorization for VA to facilitate the provision 
of supportive services for very low income veterans for veteran 
families in permanent housing. VA is in the process of writing 
regulations and hopes to offer funding later this year. Section 
604 allows VA to effectively aid veterans better than either of 
the two pilots. We respectfully suggest that the two pilots are 
no longer needed and believe that the supportive services 
grants under Pub. L. 110-387 which this Committee approved last 
year to be a more effective way to assist veterans.
    Section 503 of S.252 would require that VA establish a 
pilot program for financial support of entities that provide 
outreach to inform certain veterans about pension benefits. To 
this end, the bill would provide VA with additional authority 
to make grants to public and non-profit organizations 
(including faith-based and community organizations) for 
purposes of providing outreach to inform low-income and elderly 
veterans and their spouses residing in rural areas about 
potential eligibility for VA pension. The bill authorized the 
expenditure of $1,275,000 from General Operating Expenses (GOE) 
in each of fiscal years 2010 through 2014. Although VA supports 
the intent of Section 503 of S.252, we oppose the bill because 
it duplicates ongoing outreach efforts by VBA to conduct 
outreach to low income and elderly veterans and their spouses 
and dependents. If this legislation is enacted, VA would need 
additional GOE to administer the pilot program and to train the 
public and non-profit organizations to accurately discuss VA 
benefit programs.
    VA's outreach efforts to elderly veterans and their 
survivors include several approaches. We have provided the 
Social Security Administration with our pamphlet ``Federal 
Benefits for Veterans and Dependents.'' Additionally, we have 
participated and will continue to participate in the annual 
conference of the American Association of Retired Persons 
(AARP). This year VA will participate in the National 
Convention of the Association of Directors of Assisted Living 
Facilities. From January 2008 to January 2009 the number of 
veterans receiving disability pension declined about two 
percent or less than 7,000 veterans. That decline can be almost 
entirely accounted for by the decline in the number of World 
War II veterans receiving pension. The decline in this 
population accounted for 85 percent of the decline. The Vietnam 
Era veteran population is only now reaching age 65 where 
entitlement exists based on age. We expect their participation 
in the pension program to rise. With respect to survivor 
pension, the number of widow(ers) on the rules has increased 
5,924 or 7.2 percent over the same January to January period. 
In light of the significantly lower allowable income limits for 
survivors, this rise is primarily attributable to entitlement 
being established as a result of high medical expenses. The 
rise is reflective of our work with social security and AARP 
and soon with the assisted living organizations.
    Section 504 of the bill would authorize a 3-year pilot 
program to assess the feasibility of providing grants to public 
or nonprofit organizations as a means of providing expanded 
services to veterans participating in vocational rehabilitation 
programs under chapter 31 of title 38, United States Code. 
Under this program, VA would provide financial assistance 
through grants to public or nonprofit organizations that would 
then establish new programs or activities, or expand or modify 
existing programs or activities, to provide assistance to 
veterans participating in vocational rehabilitation programs 
under chapter 31. The type of assistance to be provided 
includes transportation, childcare, and clothing to facilitate 
participation in a vocational rehabilitation program or related 
activity. The pilot program would be used to assess the 
feasibility of providing such expanded services to veterans 
through these types of grants.
    VA supports efforts to facilitate successful completion of 
vocational rehabilitation programs under chapter 31. However, 
VA does not support the use of grant programs to achieve this 
objective. The administrative burden associated with creating 
and administering such a grant program would be prohibitive, 
particularly since VA must continue to monitor grantee's 
activities to ensure alignment with VA program objectives and 
each program participant's individual rehabilitation plan. VA 
personnel already use existing systems to process direct 
reimbursements to veterans for authorized, necessary costs 
associated with participation in their specific vocational 
rehabilitation programs. VA believes that, subject to the 
availability of funding for the purpose, any incentive programs 
to facilitate completion of vocational rehabilitation programs 
should be built onto existing VA reimbursement authorities.
    The Department would be authorized $5 million from the 
amounts available in VA's GOE account in each of fiscal years 
2010 through 2012 to carry out section 504 of this bill.
    Section 505 would require that not less than one year 
before the expiration of the authority to carry out the pilot 
programs established under section 501 through 504, VA would 
submit a report to Congress including the following: lessons 
learned, recommendations on whether to continue such pilot 
program, the number of veterans and dependents served by such 
pilot program, an assessment of the quality of service provided 
to veterans and dependents, the amount of funds provided to 
grant recipients, and the names of organizations that have 
received grants.
    VA supports sections 601 to section 606 of Title VI, which 
would update and clarify provisions of Public Law 100-322 
authorizing VA-affiliated Nonprofit Research Corporations 
(NPCs). Title VI promulgates revisions that will allow the NPCs 
to better serve VA research and education programs while 
maintaining the high degree of oversight applied to these 
nonprofits. There are no added costs associated with Title VI. 
VA supports Title VI.
    Subsection (a)(1) of section 701 of the bill would amend 
section 902(a) of title 38, U.S.C., so as to permit VA police 
officers to: (1) carry VA-issued weapons, including firearms, 
while off VA property in an official capacity or while in 
official travel status; (2) conduct investigations, on and off 
VA property, of offenses that may have been committed on VA 
property, consistent with agreements with affected local, 
state, or Federal law enforcement agencies; (3) carry out, as 
needed and appropriate, any of the duties described in section 
902(a)(1), as revised, when engaged in such duties pursuant to 
other Federal statutes; and (4) execute any arrest warrant 
issued by a competent judicial authority. Subsection (a)(2) of 
section 701 would further amend section 902 of title 38 to 
specify that the powers granted to VA police officers be 
exercised in accordance with guidelines approved by the 
Secretary and the Attorney General of the United States. VA 
will work with the Department Justice to formulate our views on 
this proposed legislation. We will submit our views at a later 
date.
    Section 702 of the Committee bill would amend section 
903(b) of title 38, U.S.C., which governs the uniform allowance 
for VA police officers, to limit the allowable amount to the 
lesser of: (1) the amount prescribed by the OPM; or (2) the 
estimated or actual costs as determined by periodic surveys 
conducted by VA. The provision would also amend section 903(c) 
of title 38 to provide that the allowance established under 
subsection (b) of section 902 of title 38, as modified by the 
Committee bill, shall be paid at the beginning of an officer's 
appointment for those appointed on or after October 1, 2008, 
and for other officers at the request of the officer, subject 
to the fiscal year limitations established in subsection (b), 
as modified by the Committee bill.
    VA supports these provisions. Under current section 903, 
uniformed Department of Veteran Affairs Police are paid $400 
for an initial uniform allowance, and then $200 annually 
throughout their careers. This is a marginal amount and does 
not cover the actual costs of uniforms and equipment required 
by the Department for our officers. VA Police officer uniforms 
are required by the Department and purchased by the officers 
using the statutorily authorized allowance. These amounts were 
last updated in 1991. Our Police Officers generally have to 
reach into their own pockets to supplement both the initial 
purchases and annual upkeep.
    The Office of Personnel Management (OPM) published new 
regulations in the Federal Register that increase the 
authorized uniform allowance amount up to $800 initially and 
$800 annually. Section 702 would allow the Department to 
occasionally review and increase initial allowances up to the 
OPM-authorized maximum, if that is necessary.
    The Department requires that all VA police officers present 
an image of professionalism and authority. Authorizing an 
updated uniform allowance will help to achieve that. We also 
note that uniform allowances are a recruiting tool. We estimate 
costs at $1.58 million for one year, $6.5 million for five 
years, and $16.82 million for ten years.

           *       *       *       *       *       *       *


                        Changes in Existing Law

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

                      TITLE 38. VETERANS' BENEFITS

PART I. GENERAL PROVISIONS

           *       *       *       *       *       *       *


CHAPTER 5. AUTHORITY AND DUTIES OF THE SECRETARY

           *       *       *       *       *       *       *



Subchapter III. Advisory Committees

           *       *       *       *       *       *       *



SEC. 542. ADVISORY COMMITTEE ON WOMEN VETERANS

    (a)(1) * * *
    (2)(A) * * *
          (i) * * *
          (ii) individuals who are recognized authorities in 
        fields pertinent to the needs of women veterans, 
        including the gender-specific health-care needs of 
        women; [and]
          (iii) representatives of both female and male 
        veterans with service-connected disabilities, including 
        at least one female veteran with a service-connected 
        disability and at least one male veteran with a 
        service-connected disability[.] ; and
          (iv) women veterans who are recently separated from 
        service in the Armed Forces.

           *       *       *       *       *       *       *


SEC. 544. ADVISORY COMMITTEE ON MINORITY VETERANS

    (a)(1) * * *
    (2)(A) * * *
          (i) * * *
          (ii) * * *
          (iii) veterans who are minority group members and who 
        have experience in a military theater of operations; 
        [and]
          (iv) veterans who are minority group members and who 
        do not have such experience[.] ; and
          (v) women veterans who are minority group members and 
        are recently separated from service in the Armed 
        Forces.

           *       *       *       *       *       *       *


     CHAPTER 9. SECURITY AND LAW ENFORCEMENT ON PROPERTY UNDER THE 
JURISDICTION OF THE DEPARTMENT

           *       *       *       *       *       *       *



SEC. 902. ENFORCEMENT AND ARREST AUTHORITY OF DEPARTMENT POLICE 
                    OFFICERS

    (a)(1) Employees of the Department who are Department 
police officers shall, with respect to acts occurring on 
Department property[, enforce]--
          (A) enforce Federal laws;
          (B) enforce the rules prescribed under section 901 of 
        this title; [and]
          (C) [subject to paragraph (2), traffic and motor 
        vehicle laws of a State or local government within the 
        jurisdiction of which such Department property is 
        located.] enforce traffic and motor vehicle laws of a 
        State or local government (by issuance of a citation 
        for violation of such laws) within the jurisdiction of 
        which such Department property is located as authorized 
        by an express grant of authority under applicable State 
        or local law;
          (D) carry the appropriate Department-issued weapons, 
        including firearms, while off Department property in an 
        official capacity or while in an official travel 
        status;
          (E) conduct investigations, on and off Department 
        property, of offenses that may have been committed on 
        property under the original jurisdiction of Department, 
        consistent with agreements or other consultation with 
        affected local, State, or Federal law enforcement 
        agencies; and
          (F) carry out, as needed and appropriate, the duties 
        described in subparagraphs (A) through (E) of this 
        paragraph when engaged in duties authorized by other 
        Federal statutes.
    [(2) A law described in subparagraph (C) of paragraph (1) 
may be enforced under such subparagraph only as authorized by 
an express grant of authority under applicable State or local 
law. Any such enforcement shall be by the issuance of a 
citation for violation of such law.]
    (2) [(3)] Subject to regulations prescribed under 
subsection (b), a Department police officer may make arrests on 
Department property for a violation of a Federal law or any 
rule prescribed under section 901(a) of this title, and on any 
arrest warrant issued by competent judicial authority.
    (b) * * *
    (c) [The Secretary shall consult with the Attorney General 
before prescribing regulations under paragraph (1) of 
subsection (b).] The powers granted to Department police 
officers designated under this section shall be exercised in 
accordance with guidelines approved by the Secretary and the 
Attorney General.
    (d) * * *

SEC. 903. UNIFORM ALLOWANCE

    (a) * * *
    [(b) The amount of the allowance that the Secretary may pay 
under this section--
          [(1) may be based on estimated average costs or 
        actual costs;
          [(2) may vary by geographic regions; and
          [(3) except as provided in subsection (c), may not 
        exceed $200 in a fiscal year for any police officer.]
    (b)(1) The amount of the allowance that the Secretary may 
pay under this section is the lesser of--
          (A) the amount currently allowed as prescribed by the 
        Office of Personnel Management; or
          (B) estimated costs or actual costs as determined by 
        periodic surveys conducted by the Department.
    (2) During any fiscal year no officer shall receive more 
for the purchase of a uniform described in subsection (a) than 
the amount established under this subsection.
    (c) [The amount of an allowance under this section may be 
increased to an amount up to $400 for not more than one fiscal 
year in the case of any Department police officer. In the case 
of a person who is appointed as a Department police officer on 
or after January 1, 1990, an allowance in an amount established 
under this subsection shall be paid at the beginning of such 
person's employment as such an officer. In the case of any 
other Department police officer, an allowance in an amount 
established under this subsection shall be paid upon the 
request of the officer.] The allowance established under 
subsection (b) shall be paid at the beginning of a Department 
police officer's employment for those appointed on or after 
October 1, 2008. In the case of any other Department police 
officer, an allowance in the amount established under 
subsection (b) shall be paid upon the request of the officer.

PART II. GENERAL BENEFITS

           *       *       *       *       *       *       *


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

                         SUBCHAPTER I. GENERAL

SEC.

1701. DEFINITIONS.

           *       *       *       *       *       *       *


1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION AND 
                    SOCIAL SECURITY NUMBER OF CERTAIN VETERANS 
                    RECEIVING CARE.

           *       *       *       *       *       *       *


SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS

           *       *       *       *       *       *       *


1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING MATERNITY 
                    CARE.

Subchapter I. General

           *       *       *       *       *       *       *


SEC. 1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION 
                    AND SOCIAL SECURITY NUMBER OF CERTAIN VETERANS 
                    RECEIVING CARE

    (a) Required Disclosure of Health-Plan Contracts.--(1) Any 
individual who applies for or is in receipt of care described 
in paragraph (2) shall, at the time of such application, or 
otherwise when requested by the Secretary, submit to the 
Secretary such current information as the Secretary may require 
to identify any health-plan contract (as defined in section 
1729(i) of this title) under which such individual is covered, 
to include, as applicable--
          (A) the name, address, and telephone number of such 
        health-plan contract;
          (B) the name of the individual's spouse, if the 
        individual's coverage is under the spouse's health-plan 
        contract;
          (C) the plan number; and
          (D) the plan's group code.
    (2) The care described in this paragraph is--
          (A) hospital, nursing home, or domiciliary care;
          (B) medical, rehabilitative, or preventive health 
        services; or
          (C) other medical care under laws administered by the 
        Secretary.
    (b) Required Disclosure of Social Security Number.--(1) Any 
individual who applies for or is in receipt of care described 
in paragraph (2) shall, at the time of such application, or 
otherwise when requested by the Secretary, submit to the 
Secretary--
          (A) the individual's social security number; and
          (B) the social security number of any dependent or 
        Department beneficiary on whose behalf, or based upon 
        whom, such individual applies for or is in receipt of 
        such care.
    (2) The care described in this paragraph is--
          (A) hospital, nursing home, or domiciliary care;
          (B) medical, rehabilitative, or preventive health 
        services; or
          (C) other medical care under laws administered by the 
        Secretary.
    (3) This subsection does not require an individual to 
furnish the Secretary with a social security number for any 
individual to whom a social security number has not been 
assigned.
    (c) Failure to Disclose Social Security Number.--(1) The 
Secretary shall deny an individual's application for, or may 
terminate an individual's enrollment in, the system of patient 
enrollment established by the Secretary under section 1705 of 
this title, if such individual does not provide the social 
security number required or requested to be submitted pursuant 
to subsection (b).
    (2) Following a denial or termination under paragraph (1) 
with respect to an individual, the Secretary may, upon receipt 
of the information required or requested under subsection (b), 
approve such individual's application or reinstate such 
individual's enrollment (if otherwise in order), for such 
medical care and services provided on and after the date of 
such receipt of information.
    (d) Construction.--Nothing in this section shall be 
construed as authority to deny medical care and treatment to an 
individual in a medical emergency.

               Subchapter II. Hospital, Nursing Home, or 
Domiciliary Care and Medical Treatment

           *       *       *       *       *       *       *


SEC. 1710E. TRAUMATIC BRAIN INJURY: USE OF NON-DEPARTMENT FACILITIES 
                    FOR REHABILITATION

    (a) Cooperative agreements.-- * * *
    (b) Covered Individuals.--The care and services provided 
under subsection (a) shall be made available to an individual--
          (1) who is described in section 1710C(a) of this 
        title; and
          (2)(A) to whom the Secretary is unable to provide 
        such treatment or services at the frequency or for the 
        duration prescribed in such plan; or
          (B) for whom the Secretary determines that it is 
        optimal with respect to the recovery and rehabilitation 
        for such individual.''
    (c) [(b)] Authorities of State protection and advocacy 
systems.-- * * *
    (d) Standards.--The Secretary may not provide treatment or 
services as described in subsection (a) at a non-Department 
facility under such subsection unless such facility maintains 
standards for the provision of such treatment or services 
established by an independent, peer-reviewed organization that 
accredits specialized rehabilitation programs for adults with 
traumatic brain injury.

SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL 
                    HEALTH SERVICES.

           *       *       *       *       *       *       *


    (c) Upon receipt of a request for counseling under this 
section from any individual who has been discharged or released 
from active military, naval, or air service but who is not 
otherwise eligible for such counseling, the Secretary shall--
          (1) provide referral services to assist such 
        individual, to the maximum extent practicable, in 
        obtaining mental health care and services from sources 
        outside the Department; and
          (2) if pertinent, advise such individual of such 
        individual's rights to apply to the appropriate 
        military, naval, or air service, and to the Department, 
        for review of such individual's discharge or release 
        from such service.
    (d) [(c)] The Under Secretary for Health may provide for 
such training of professional, paraprofessional, and lay 
personnel as is necessary to carry out this section 
effectively, and, in carrying out this section, may utilize the 
services of paraprofessionals, individuals who are volunteers 
working without compensation, and individuals who are veteran-
students (as described in section 3485 of this title) in 
initial intake and screening activities.
    (e) [(d)](1) In furnishing counseling and related mental 
health services under subsections (a) and (b) of this section, 
the Secretary shall have available the same authority to enter 
into contracts with private facilities that is available to the 
Secretary (under sections 1703(a)(2) and 1710(a)(1)(B) of this 
title) in furnishing medical services to veterans suffering 
from total service-connected disabilities.

           *       *       *       *       *       *       *

    (f) [(e)] The Secretary, in cooperation with the Secretary 
of Defense, shall take such action as the Secretary considers 
appropriate to notify veterans who may be eligible for 
assistance under this section of such potential eligibility.
    (g) [(f)] For the purposes of this section:
          (1) * * *

           *       *       *       *       *       *       *


SEC. 1720. TRANSFERS FOR NURSING HOME CARE; ADULT DAY HEALTH CARE

           *       *       *       *       *       *       *


    (g) The Secretary may contract with appropriate entities to 
provide specialized residential care and rehabilitation 
services to a veteran of Operation Enduring Freedom or 
Operation Iraqi Freedom who the Secretary determines suffers 
from a traumatic brain injury, has an accumulation of deficits 
in activities of daily living and instrumental activities of 
daily living, and because of these deficits, would otherwise 
require admission to a nursing home even though such care would 
generally exceed the veteran's nursing needs.

           *       *       *       *       *       *       *


SEC. 1720D. COUNSELING AND TREATMENT FOR SEXUAL TRAUMA

           *       *       *       *       *       *       *


    (d)(1) The Secretary shall implement a program for 
education, training, certification, and continuing medical 
education for mental health professionals to specialize in the 
provision of counseling and care to veterans eligible for 
services under subsection (a). In carrying out the program, the 
Secretary shall ensure that all such mental health 
professionals have been trained in a consistent manner and that 
such training includes principles of evidence-based treatment 
and care for sexual trauma.
    (2) The Secretary shall determine the minimum 
qualifications necessary for mental health professionals 
certified by the program under paragraph (1) to provide 
evidence-based treatment and therapy to veterans eligible for 
services under subsection (a) in facilities of the Department.
    (e) The Secretary shall submit to Congress each year a 
report on the counseling and care and services provided to 
veterans under this section. Each report shall include data for 
the preceding year with respect to the following:
          (1) The number of mental health professionals and 
        primary care providers who have been certified under 
        the program under subsection (d), and the amount and 
        nature of continuing medical education provided under 
        such program to professionals and providers who have 
        been so certified.
          (2) The number of women veterans who received 
        counseling and care and services under subsection (a) 
        from professionals and providers who have been trained 
        or certified under the program under subsection (d).
          (3) The number of training, certification, and 
        continuing medical education programs operating under 
        subsection (d).
          (4) The number of trained full-time equivalent 
        employees required in each facility of the Department 
        to meet the needs of veterans requiring treatment and 
        care for sexual trauma.
          (5) Such other information as the Secretary considers 
        appropriate.
    (f) [(d)] In this section, the term ``sexual harassment'' 
means repeated, unsolicited verbal or physical contact of a 
sexual nature which is threatening in character.

           *       *       *       *       *       *       *


                Subchapter VIII. Health Care of Persons 
                          Other Than Veterans

SEC. 1781. MEDICAL CARE FOR SURVIVORS AND DEPENDENTS OF CERTAIN 
                    VETERANS

    (a) * * *

           *       *       *       *       *       *       *

    (e) Payment by the Secretary under this section on behalf 
of a covered beneficiary for medical care shall constitute 
payment in full and extinguish any liability on the part of the 
beneficiary for that care.

           *       *       *       *       *       *       *


SEC. 1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING 
                    MATERNITY CARE

    (a) In General.--The Secretary may furnish health care 
services described in subsection (b) to a newborn child of a 
woman veteran who is receiving maternity care furnished by the 
Department for not more than 7 days after the birth of the 
child if the veteran delivered the child in--
          (1) a facility of the Department; or
          (2) another facility pursuant to a Department 
        contract for services relating to such delivery.
    (b) Covered Health Care Services.--Health care services 
described in this subsection are all post-delivery care 
services, including routine care services, that a newborn 
requires.

           *       *       *       *       *       *       *


             PART V. BOARDS, ADMINISTRATIONS, AND SERVICES

CHAPTER 73. VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS

           *       *       *       *       *       *       *


          SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION

SEC.

7311. QUALITY ASSURANCE.

7311A. QUALITY MANAGEMENT OFFICERS.

           *       *       *       *       *       *       *


SUBCHAPTER IV. RESEARCH CORPORATIONS

           *       *       *       *       *       *       *


7365. COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT CLAIMS LAWS.

[7364A. COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT CLAIMS LAWS.]

[7365. APPLICABLE STATE LAW.]

           *       *       *       *       *       *       *


          Subchapter II. General Authority and Administration

SEC. 7311. QUALITY ASSURANCE

           *       *       *       *       *       *       *


    (b)(1) * * *

           *       *       *       *       *       *       *

    (4) As part of the quality management program, the Under 
Secretary for Health shall establish mechanisms through which 
employees of Veterans Health Administration facilities may 
submit reports, on a confidential basis, on matters relating to 
quality of care in Veterans Health Administration facilities to 
the quality management officers of such facilities under 
section 7311A(b) of this title. The mechanisms shall provide 
for the prompt and thorough review of any reports so submitted 
by the receiving officials.

           *       *       *       *       *       *       *


SEC. 7311A. QUALITY MANAGEMENT OFFICERS

    (a) National Quality Management Officer.--(1) The Under 
Secretary for Health shall designate an official of the 
Veterans Health Administration to act as the principal quality 
management officer for the quality management program required 
by section 7311 of this title. The official so designated may 
be known as the ``National Quality Management Officer of the 
Veterans Health Administration'' (in this section referred to 
as the ``National Quality Management Officer'').
    (2) The National Quality Management Officer shall report 
directly to the Under Secretary for Health in the discharge of 
responsibilities and duties of the Officer under this section.
    (3) The National Quality Management Officer shall be the 
official within the Veterans Health Administration who is 
principally responsible for the quality management program 
referred to in paragraph (1). In carrying out that 
responsibility, the Officer shall be responsible for the 
following:
          (A) Establishing and enforcing the requirements of 
        the program referred to in paragraph (1).
          (B) Developing an aggregate quality metric from 
        existing data sources, such as the Inpatient Evaluation 
        Center of the Department, the National Surgical Quality 
        Improvement Program, and the External Peer Review 
        Program of the Veterans Health Administration, that 
        could be used to assess reliably the quality of care 
        provided at individual Department medical centers and 
        associated community based outpatient clinics.
          (C) Ensuring that existing measures of quality, 
        including measures from the Inpatient Evaluation 
        Center, the National Surgical Quality Improvement 
        Program, System-Wide Ongoing Assessment and Review 
        reports of the Department, and Combined Assessment 
        Program reviews of the Office of Inspector General of 
        the Department, are monitored routinely and analyzed in 
        a manner that ensures the timely detection of quality 
        of care issues.
          (D) Encouraging research and development in the area 
        of quality metrics for the purposes of improving how 
        the Department measures quality in individual 
        facilities.
          (E) Carrying out such other responsibilities and 
        duties relating to quality management in the Veterans 
        Health Administration as the Under Secretary for Health 
        shall specify.
    (4) The requirements under paragraph (3) shall include 
requirements regarding the following:
          (A) A confidential system for the submittal of 
        reports by Veterans Health Administration personnel 
        regarding quality management at Department facilities.
          (B) Mechanisms for the peer review of the actions of 
        individuals appointed in the Veterans Health 
        Administration in the position of physician.
    (b) Quality Management Officers for VISNs.--(1) The 
Regional Director of each Veterans Integrated Services Network 
(VISN) shall appoint an official of the Network to act as the 
quality management officer of the Network.
    (2) The quality management officer for a Veterans 
Integrated Services Network shall report to the Regional 
Director of the Veterans Integrated Services Network, and to 
the National Quality Management Officer, regarding the 
discharge of the responsibilities and duties of the officer 
under this section.
    (3) The quality management officer for a Veterans 
Integrated Services Network shall--
          (A) direct the quality management office in the 
        Network; and
          (B) coordinate, monitor, and oversee the quality 
        management programs and activities of the 
        Administration medical facilities in the Network in 
        order to ensure the thorough and uniform discharge of 
        quality management requirements under such programs and 
        activities throughout such facilities.
    (c) Quality Management Officers for Medical Facilities.--
(1) The director of each Veterans Health Administration medical 
facility shall appoint a quality management officer for that 
facility.
    (2) The quality management officer for a facility shall 
report directly to the director of the facility, and to the 
quality management officer of the Veterans Integrated Services 
Network in which the facility is located, regarding the 
discharge of the responsibilities and duties of the quality 
management officer under this section.
    (3) The quality management officer for a facility shall be 
responsible for designing, disseminating, and implementing 
quality management programs and activities for the facility 
that meet the requirements established by the National Quality 
Management Officer under subsection (a).
    (d) Authorization of Appropriations.--(1) Except as 
provided in paragraph (2), there are authorized to be 
appropriated such sums as may be necessary to carry out this 
section.
    (2) There are authorized to be appropriated to carry out 
the provisions of subparagraphs (B), (C), and (D) of subsection 
(a)(3), $25,000,000 for the two-year period of fiscal years 
beginning after the date of the enactment of this section.

           *       *       *       *       *       *       *


              Subchapter III. Protection of Patient Rights

SEC. 7332. CONFIDENTIALITY OF CERTAIN MEDICAL RECORDS

           *       *       *       *       *       *       *


    (b)(2) * * *
          (A) * * *

           *       *       *       *       *       *       *

          (F)(i) To a representative of a patient who lacks 
        decision-making capacity, when a practitioner deems the 
        content of the given record necessary for that 
        representative to make an informed decision regarding 
        the patient's treatment.
          (ii) In this subparagraph, the term 
        ``representative'' means an individual, organization, 
        or other body authorized under section 7331 of this 
        title and its implementing regulations to give informed 
        consent on behalf of a patient who lacks decision-
        making capacity.

           *       *       *       *       *       *       *


                  Subchapter IV. Research Corporations

SEC. 7361. AUTHORITY TO ESTABLISH; STATUS

    (a) The Secretary may authorize the establishment at any 
Department medical center of a nonprofit corporation to provide 
a flexible funding mechanism for the conduct of approved 
research and education at the medical center. [Except as 
otherwise required in this subchapter or under regulations 
prescribed by the Secretary, any such corporation, and its 
directors and employees, shall be required to comply only with 
those Federal laws, regulations, and executive orders and 
directives which apply generally to private nonprofit 
corporations.] Such a corporation may be established to 
facilitate either research or education or both research and 
education.
    (b)(1) Subject to paragraph (2), a corporation established 
under this subchapter may facilitate the conduct of research, 
education, or both at more than one medical center. Such a 
corporation shall be known as a ``multi-medical center research 
corporation''.
    (2) The board of directors of a multi-medical center 
research corporation under this subsection shall include the 
official at each Department medical center concerned who is, or 
who carries out the responsibilities of, the medical center 
director of such center as specified in section 
7363(a)(1)(A)(i) of this title.
    (3) In facilitating the conduct of research, education, or 
both at more than one Department medical center under this 
subchapter, a multi-medical center research corporation may 
administer receipts and expenditures relating to such research, 
education, or both, as applicable, performed at the Department 
medical centers concerned.
    (c) Any corporation established under this subchapter shall 
be established in accordance with the nonprofit corporation 
laws of the State in which the applicable Department medical 
center is located and shall, to the extent not inconsistent 
with any Federal law, be subject to the laws of such State. In 
the case of any multi-medical center research corporation that 
facilitates the conduct of research, education, or both at 
Department medical centers located in different States, the 
corporation shall be established in accordance with the 
nonprofit corporation laws of the State in which one of such 
Department medical centers is located.
    (d)(1) Except as otherwise provided in this subchapter or 
under regulations prescribed by the Secretary, any corporation 
established under this subchapter, and its officers, directors, 
and employees, shall be required to comply only with those 
Federal laws, regulations, and executive orders and directives 
that apply generally to private nonprofit corporations.
    (2) A corporation under this subchapter is not--
          (A) owned or controlled by the United States; or
          (B) an agency or instrumentality of the United 
        States.
    (e) [(b)] If by the end of the four-year period beginning 
on the date of the establishment of a corporation under this 
subchapter the corporation is not recognized as an entity the 
income of which is exempt from taxation under section 501(c)(3) 
of the Internal Revenue Code of 1986, the Secretary shall 
dissolve the corporation.
    (f) A corporation established under this subchapter may act 
as a multi-medical center research corporation under this 
subchapter in accordance with subsection (b) if--
          (1) the board of directors of the corporation 
        approves a resolution permitting facilitation by the 
        corporation of the conduct of research, education, or 
        both at the other Department medical center or medical 
        centers concerned; and
          (2) the Secretary approves the resolution of the 
        corporation under paragraph (1).

SEC. 7362. PURPOSE OF CORPORATIONS

    (a) [Any corporation established under this subchapter 
shall be established solely to facilitate] A corporation 
established under this subchapter shall be established to 
provide a flexible funding mechanism for the conduct of 
approved research and education at one or more Department 
medical centers and to facilitate functions related to the 
conduct of research as described in section 7303(a) of this 
title and education and training as described in sections 7302, 
7471, 8154, and 1701(6)(B) of this title in conjunction with 
the applicable Department medical center or centers. [Any funds 
received by the Secretary for the conduct of research or 
education at the medical center other than funds appropriated 
to the Department may be transferred to and administered by the 
corporation for these purposes.]
    (b) For purposes of this section, [the term ``education and 
training''] the term ``education'' includes education and 
training and means the following:
          (1) In the case of employees of the Veterans Health 
        Administration, such term means work-related 
        instruction or other learning experiences to--
                  (A) improve performance of current duties;
                  (B) assist employees in maintaining or 
                gaining specialized proficiencies; and
                  (C) expand understanding of advances and 
                changes in patient care, technology, and health 
                care administration.
          [Such term includes (in the case of such employees) 
        education and training conducted as part of a residency 
        or other program designed to prepare an individual for 
        an occupation or profession.]
          (2) In the case of veterans under the care of the 
        Veterans Health Administration, such term means 
        instruction or other learning experiences related to 
        improving and maintaining the health of veterans [to 
        patients and to the families] and includes education 
        and training for patients and families and guardians of 
        patients.

SEC. 7363. BOARD OF DIRECTORS; EXECUTIVE DIRECTOR

    (a) The Secretary shall provide for the appointment of a 
board of directors for any corporation established under this 
subchapter. The board shall include--
          (1) [the director of the medical center, the chief of 
        staff of the medical center, and as appropriate, the 
        assistant chief of staff for research for the medical 
        center and the assistant chief of staff for education 
        for the medical center, or, in the case of a facility 
        at which such positions do not exist, those officials 
        who are responsible for carrying out the 
        responsibilities of the medical center director, chief 
        of staff, and, as appropriate, the assistant chief of 
        staff for research and the assistant chief of staff for 
        education; and] with respect to the Department medical 
        center--
                  (A)(i) the director (or directors of each 
                Department medical center, in the case of a 
                multi-medical center research corporation);
                  (ii) the chief of staff; and
                  (iii) as appropriate for the activities of 
                such corporation, the associate chief of staff 
                for research and the associate chief of staff 
                for education; or
                  (B) in the case of a Department medical 
                center at which one or more of the positions 
                referred to in subparagraph (A) do not exist, 
                the official or officials who are responsible 
                for carrying out the responsibilities of such 
                position or positions at the Department medical 
                center; and
          (2) subject to subsection (c), not less than two 
        members who are not officers or employees of the 
        Federal Government [and who are familiar with issues 
        involving medical and scientific research or education, 
        as appropriate.] and who have backgrounds, or business, 
        legal, financial, medical, or scientific expertise, of 
        benefit to the operations of the corporation.
    (b) * * *
    (c) An individual appointed under subsection (a)(2) to the 
board of directors of a corporation established under this 
subchapter may not be affiliated with[, employed by, or have 
any other financial relationship with] or employed by any 
entity that is a source of funding for research or education by 
the Department unless that source of funding is a governmental 
entity or an entity the income of which is exempt from taxation 
under the Internal Revenue Code of 1986.

SEC. 7364. GENERAL POWERS

    [(a) A corporation established under this subchapter may--
          [(1) accept gifts and grants from, and enter into 
        contracts with, individuals and public and private 
        entities solely to carry out the purposes of this 
        subchapter; and
          [(2) employ such employees as it considers necessary 
        for such purposes and fix the compensation of such 
        employees.
    [(b) A corporation established under this subchapter may 
not spend funds for a research project unless the project is 
approved in accordance with procedures prescribed by the Under 
Secretary for Health for research carried out with Department 
funds. Such procedures shall include a peer review process.
    [(c)(1) A corporation established under this subchapter may 
not spend funds for an education activity unless the activity 
is approved in accordance with procedures prescribed by the 
Under Secretary for Health.
    [(2) The Under Secretary for Health shall prescribe 
policies and procedures to guide the expenditure of funds by 
corporations under paragraph (1) consistent with the purpose of 
such corporations as flexible funding mechanisms.]
    (a) In General.--(1) A corporation established under this 
subchapter may, solely to carry out the purposes of this 
subchapter--
          (A) accept, administer, retain, and spend funds 
        derived from gifts, contributions, grants, fees, 
        reimbursements, and bequests from individuals and 
        public and private entities;
          (B) enter into contracts and agreements with 
        individuals and public and private entities;
          (C) subject to paragraph (2), set fees for education 
        and training facilitated under section 7362 of this 
        title, and receive, retain, administer, and spend funds 
        in furtherance of such education and training;
          (D) reimburse amounts to the applicable appropriation 
        account of the Department for the Office of General 
        Counsel for any expenses of that Office in providing 
        legal services attributable to research and education 
        agreements under this subchapter; and
          (E) employ such employees as the corporation 
        considers necessary for such purposes and fix the 
        compensation of such employees.
    (2) Fees charged under paragraph (1)(C) for education and 
training described in that paragraph to individuals who are 
officers or employees of the Department may not be paid for by 
any funds appropriated to the Department.
    (3) Amounts reimbursed to the Office of General Counsel 
under paragraph (1)(D) shall be available for use by the Office 
of the General Counsel only for staff and training, and related 
travel, for the provision of legal services described in that 
paragraph and shall remain available for such use without 
fiscal year limitation.
    (b) Transfer and Administration of Funds.--(1) Except as 
provided in paragraph (2), any funds received by the Secretary 
for the conduct of research or education at a Department 
medical center or centers, other than funds appropriated to the 
Department, may be transferred to and administered by a 
corporation established under this subchapter for such 
purposes.
    (2) A Department medical center may reimburse the 
corporation for all or a portion of the pay, benefits, or both 
of an employee of the corporation who is assigned to the 
Department medical center if the assignment is carried out 
pursuant to subchapter VI of chapter 33 of title 5.
    (3) A Department medical center may retain and use funds 
provided to it by a corporation established under this 
subchapter. Such funds shall be credited to the applicable 
appropriation account of the Department and shall be available, 
without fiscal year limitation, for the purposes of that 
account.
    (c) Research Projects.--Except for reasonable and usual 
preliminary costs for project planning before its approval, a 
corporation established under this subchapter may not spend 
funds for a research project unless the project is approved in 
accordance with procedures prescribed by the Under Secretary 
for Health for research carried out with Department funds. Such 
procedures shall include a scientific review process.
    (d) Education Activities.--Except for reasonable and usual 
preliminary costs for activity planning before its approval, a 
corporation established under this subchapter may not spend 
funds for an education activity unless the activity is approved 
in accordance with procedures prescribed by the Under Secretary 
for Health.
    (e) Policies and Procedures.--The Under Secretary for 
Health may prescribe policies and procedures to guide the 
spending of funds by corporations established under this 
subchapter that are consistent with the purpose of such 
corporations as flexible funding mechanisms and with Federal 
and State laws and regulations, and executive orders, 
circulars, and directives that apply generally to the receipt 
and expenditure of funds by nonprofit organizations exempt from 
taxation under section 501(c)(3) of the Internal Revenue Code 
of 1986.

SEC. 7365. [7364A.] COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT 
                    CLAIMS LAWS

           *       *       *       *       *       *       *


[SEC. 7365. APPLICABLE STATE LAW

    [Any corporation established under this subchapter shall be 
established in accordance with the nonprofit corporation laws 
of the State in which the applicable medical center is located 
and shall, to the extent not inconsistent with any Federal law, 
be subject to the laws of such State.]

SEC. 7366. ACCOUNTABILITY AND OVERSIGHT

    (a) * * *
    [(b) Each such corporation shall submit to the Secretary an 
annual report providing a detailed statement of its operations, 
activities, and accomplishments during that year. A corporation 
with revenues in excess of $300,000 for any year shall obtain 
an audit of the corporation for that year. A corporation with 
annual revenues between $10,000 and $300,000 shall obtain an 
independent audit of the corporation at least once every three 
years. Any audit under the preceding sentences shall be 
performed by an independent auditor. The corporation shall 
include the most recent such audit in the corporation's report 
to the Secretary for that year.]
    (b)(1) Each corporation shall submit to the Secretary each 
year a report providing a detailed statement of the operations, 
activities, and accomplishments of the corporation during that 
year.
    (2)(A) A corporation with revenues in excess of $300,000 
for any year shall obtain an audit of the corporation for that 
year.
    (B) A corporation with annual revenues between $10,000 and 
$300,000 shall obtain an audit of the corporation at least once 
every three years.
    (C) Any audit under this paragraph shall be performed by an 
independent auditor.
    (3) The corporation shall include in each report to the 
Secretary under paragraph (1) the following:
          (A) The most recent audit of the corporation under 
        paragraph (2).
          (B) The most recent Internal Revenue Service Form 990 
        ``Return of Organization Exempt from Income Tax'' or 
        equivalent and the applicable schedules under such 
        form.
    (c)(1) Each member of the board of directors of a 
corporation established under this subchapter, each officer and 
each employee of such a corporation[, and each employee of the 
Department who is involved in the functions of the corporation 
during any year] shall be subject to Federal [laws and] 
regulations applicable to Federal employees with respect to 
conflicts of interest in the performance of official functions.
    (2) Each corporation established under this subchapter 
shall each year submit to the Secretary a statement signed by 
the executive director of the corporation verifying that each 
director, officer, and employee has certified awareness of the 
laws and regulations referred to in paragraph (1) and of the 
consequences of violations of those [laws and] regulations [in 
the same manner as Federal employees are required to so 
certify].
    (d) * * *

           *       *       *       *       *       *       *

          (3) * * *

           *       *       *       *       *       *       *

                  (C) if the amount expended with respect to 
                any payee exceeded [$35,000] $50,000, 
                information that identifies the payee.

           *       *       *       *       *       *       *


         CHAPTER 74. VETERANS HEALTH ADMINISTRATION--PERSONNEL

                       SUBCHAPTER I. APPOINTMENTS

SEC.

7401. * * *

7402. * * *

7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS.

           *       *       *       *       *       *       *


SUBCHAPTER IV. PAY FOR NURSES AND OTHER HEALTH-CARE PERSONNEL

           *       *       *       *       *       *       *


7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY.

           *       *       *       *       *       *       *


Subchapter I. Appointments

           *       *       *       *       *       *       *


SEC. 7401. APPOINTMENTS IN VETERANS HEALTH ADMINISTRATION

           *       *       *       *       *       *       *


          (3) Audiologists, speech pathologists, and 
        audiologist-speech pathologists, biomedical engineers, 
        certified or registered respiratory therapists, 
        dietitians, licensed physical therapists, licensed 
        practical or vocational nurses, nurse assistants, 
        medical instrument technicians, medical records 
        administrators or specialists, medical records 
        technicians, medical technologists, dental hygienists, 
        dental assistants, nuclear medicine technologists, 
        occupational therapists, occupational therapy 
        assistants, kinesiotherapists, orthotist-prosthetists, 
        pharmacists, pharmacy technicians, physical therapy 
        assistants, prosthetic representatives, psychologists, 
        diagnostic radiologic technologists, therapeutic 
        radiologic technologists, social workers, marriage and 
        family therapists, licensed professional mental health 
        counselors, blind rehabilitation specialists, [and 
        blind rehabilitation outpatient specialists.] blind 
        rehabilitation outpatient specialists, and such other 
        classes of health care occupations as the Secretary 
        considers necessary for the recruitment and retention 
        needs of the Department subject to the following 
        requirements:
                  (A) Such other classes of health care 
                occupations--
                          (i) are not occupations relating to 
                        administrative, clerical, or physical 
                        plant maintenance and protective 
                        services;
                          (ii) that would otherwise receive 
                        basic pay in accordance with the 
                        General Schedule under section 5332 of 
                        title 5;
                          (iii) provide, as determined by the 
                        Secretary, direct patient care services 
                        or services incident to direct patient 
                        services; and
                          (iv) would not otherwise be available 
                        to provide medical care or treatment 
                        for veterans.
                  (B) Not later than 45 days before the 
                Secretary appoints any personnel for a class of 
                health care occupations that is not 
                specifically listed in this paragraph, the 
                Secretary shall submit to the Committee on 
                Veterans' Affairs of the Senate, the Committee 
                on Veterans' Affairs of the House of 
                Representatives, and the Office of Management 
                and Budget notice of such appointment.
                  (C) Before submitting notice under 
                subparagraph (B), the Secretary shall solicit 
                comments from any labor organization 
                representing employees in such class and 
                include such comments in such notice.

           *       *       *       *       *       *       *


SEC. 7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS

    (a) In General.--The Secretary shall, acting through the 
Under Secretary for Health, prescribe standards to be met by 
individuals in order to qualify for appointment in the Veterans 
Health Administration in the position of physician and to 
practice as a physician in medical facilities of the 
Administration. The standards shall incorporate the 
requirements of this section.
    (b) Disclosure of Certain Information Before Appointment.--
Each individual seeking appointment in the Veterans Health 
Administration in the position of physician shall do the 
following:
          (1) Provide the Secretary a full and complete 
        explanation of the following:
                  (A) Each lawsuit, civil action, or other 
                claim (whether open or closed) brought against 
                the individual for medical malpractice or 
                negligence.
                  (B) Each payment made by or on behalf of the 
                individual to settle any lawsuit, action, or 
                claim covered by subparagraph (A).
                  (C) Each investigation or disciplinary action 
                taken against the individual relating to the 
                individual's performance as a physician.
          (2) Provide the Secretary a written authorization 
        that permits the State licensing board of each State in 
        which the individual holds or has held a license to 
        practice medicine to disclose to the Secretary any 
        information in the records of such State on the 
        following:
                  (A) Each lawsuit, civil action, or other 
                claim brought against the individual for 
                medical malpractice or negligence covered by 
                paragraph (1)(A) that occurred in such State.
                  (B) Each payment made by or on behalf of the 
                individual to settle any lawsuit, action, or 
                claim covered by subparagraph (A).
                  (C) Each medical malpractice judgment against 
                the individual by the courts or administrative 
                agencies or bodies of such State.
                  (D) Each disciplinary action taken or under 
                consideration against the individual by an 
                administrative agency or body of such State.
                  (E) Any change in the status of the license 
                to practice medicine issued the individual by 
                such State, including any voluntary or 
                nondisciplinary surrendering of such license by 
                the individual.
                  (F) Any open investigation of the individual 
                by an administrative agency or body of such 
                State, or any outstanding allegation against 
                the individual before such an administrative 
                agency or body.
                  (G) Any written notification by the State to 
                the individual of potential termination of a 
                license for cause or otherwise.
    (c) Disclosure of Certain Information Following 
Appointment.--(1) Each individual appointed in the Veterans 
Health Administration in the position of physician after the 
date of the enactment of this section shall, as a condition of 
service under the appointment, disclose to the Secretary, not 
later than 30 days after the occurrence of such event, the 
following:
          (A) A judgment against the individual for medical 
        malpractice or negligence.
          (B) A payment made by or on behalf of the individual 
        to settle any lawsuit, action, or claim disclosed under 
        paragraph (1) or (2) of subsection (b).
          (C) Any disposition of or material change in a matter 
        disclosed under paragraph (1) or (2) of subsection (b).
          (D) Any lawsuit, disciplinary action, or claim filed 
        or undertaken after the date of the disclosures under 
        subsection (b).
    (2) Each individual appointed in the Veterans Health 
Administration in the position of physician as of the date of 
the enactment of this section shall do the following:
          (A) Not later than the end of the 60-day period 
        beginning on the date of the enactment of this section 
        and as a condition of service under the appointment 
        after the end of that period, submit the request and 
        authorization described in subsection (b)(2).
          (B) Agree, as a condition of service under the 
        appointment, to disclose to the Secretary, not later 
        than 30 days after the occurrence of such event, the 
        following:
                  (i) A judgment against the individual for 
                medical malpractice or negligence.
                  (ii) A payment made by or on behalf of the 
                individual to settle any lawsuit, action, or 
                claim disclosed pursuant to subparagraph (A) or 
                under this subparagraph.
                  (iii) Any disposition of or material change 
                in a matter disclosed pursuant to subparagraph 
                (A) or under this subparagraph.
    (3) Each individual appointed in the Veterans Health 
Administration in the position of physician shall, as part of 
the biennial review of the performance of the physician under 
the appointment, submit the request and authorization described 
in subsection (b)(2). The requirement of this paragraph is in 
addition to the requirements of paragraph (1) or (2), as 
applicable.
    (d) Investigation of Disclosed Matters.--(1) The Director 
of the Veterans Integrated Services Network (VISN) in which an 
individual is seeking appointment in the Veterans Health 
Administration in the position of physician shall perform an 
investigation (in such manner as the standards required by this 
section shall specify) of each matter disclosed under 
subsection (b) with respect to the individual.
    (2) The Director of the Veterans Integrated Services 
Network in which an individual is appointed in the Veterans 
Health Administration in the position of physician shall 
perform an investigation (in a manner so specified) of each 
matter disclosed under subsection (c) with respect to the 
individual.
    (3) The results of each investigation performed under this 
subsection shall be fully documented.
    (e) Approval of Appointments by Directors of VISNs.--(1) An 
individual may not be appointed in the Veterans Health 
Administration in the position of physician without the 
approval of the Director of the Veterans Integrated Services 
Network in which the individual will first serve under the 
appointment, unless the medical center director and 
credentialing and privileging manager of the facility hiring 
the physician certify in writing that--
          (A) a full investigation was carried out in 
        compliance with section 104 of this title; and
          (B) an investigation did not disclose any actions 
        described in subsections (b), (c), and (d) of such 
        section.
    (2) In approving the appointment under this subsection of 
an individual for whom any matters have been disclosed under 
subsection (b), a Director shall--
          (A) certify in writing the completion of the 
        performance of the investigation under subsection 
        (d)(1) of each such matter, including the results of 
        such investigation; and
          (B) provide a written justification why any matters 
        raised in the course of such investigation do not 
        disqualify the individual from appointment.
    (f) Enrollment of Physicians With Practice Privileges in 
Proactive Disclosure Service.--Each medical facility of the 
Department at which physicians are extended the privileges of 
practice shall enroll each physician extended such privileges 
in the Proactive Disclosure Service of the National 
Practitioner Data Bank.
    (g) Encouraging Hiring of Physicians With Board 
Certification.--(1) The Secretary shall, for each performance 
contract with a Director of a Veterans Integrated Services 
Network (VISN), include in such contract a provision that 
encourages such director to hire physicians who are board 
eligible or board certified in the specialty in which the 
physicians will practice.
    (2) The Secretary may determine the nature and manner of 
the provision described in paragraph (1).

SEC. 7403. PERIOD OF APPOINTMENTS; PROMOTIONS

           *       *       *       *       *       *       *


    (b)(1) [Appointments] Except as otherwise provided in this 
subsection, appointments described in subsection (a) shall be 
for a probationary period of two years.
    (2) With respect to the appointment of a registered nurse 
under this chapter, paragraph (1) shall apply with respect to 
such appointment regardless of whether such appointment is on a 
full-time basis or a part-time basis.
    (3) An appointment described in subsection (a) on a part-
time basis of a person who has previously served on a full-time 
basis for the probationary period for the position concerned 
shall be without a probationary period.
    (4) [(2)] The record of each person serving under such an 
appointment in the Medical, Dental, and Nursing Services shall 
be reviewed from time to time by a board, appointed in 
accordance with regulations of the Secretary. If such a board 
finds that such person is not fully qualified and satisfactory, 
such person shall be separated from the service.

           *       *       *       *       *       *       *


SEC. 7404. GRADES AND PAY SCALES

    (a)(1) The annual [The annual] rates or ranges of rates of 
basic pay for positions provided in section 7306 of this title 
shall be prescribed from time to time by Executive order as 
authorized by chapter 53 of title 5 or as otherwise authorized 
by law.
    (2) The pay [The pay] of physicians and dentists serving in 
positions to which an Executive order applies [under the 
preceding sentence] under paragraph (1) shall be determined 
under subchapter III of this chapter instead of such Executive 
order.
    (3)(A) The rate of basic pay for a position to which an 
Executive order applies under paragraph (1) and is not 
described by paragraph (2) shall be set in accordance with 
section 5382 of title 5 as if such position were a Senior 
Executive Service position (as such term is defined in section 
3132(a) of title 5).
    (B) A rate of basic pay for a position may not be set under 
subparagraph (A) in excess of--
          (i) in the case the position is not described in 
        clause (ii), the rate of basic pay payable for level 
        III of the Executive Schedule; or
          (ii) in the case that the position is covered by a 
        performance appraisal system that meets the 
        certification criteria established by regulation under 
        section 5307(d) of title 5, the rate of basic pay 
        payable for level II of the Executive Schedule.
    (C) Notwithstanding the provisions of subsection (d) of 
section 5307 of title 5, the Secretary may make any 
certification under that subsection instead of the Office of 
Personnel Management and without concurrence of the Office of 
Management and Budget.

           *       *       *       *       *       *       *


SEC. 7405. TEMPORARY FULL-TIME APPOINTMENTS, PART-TIME APPOINTMENTS, 
                    AND WITHOUT-COMPENSATION APPOINTMENTS

           *       *       *       *       *       *       *


    (g)(1) Except as provided in paragraph (3), employment of a 
registered nurse on a temporary part-time basis under 
subsection (a)(1) shall be for a probationary period of two 
years.
    (2) Except as provided in paragraph (3), upon completion by 
a registered nurse of the probationary period described in 
paragraph (1)--
          (A) the employment of such nurse shall--
                  (i) no longer be considered temporary; and
                  (ii) be considered an appointment described 
                in section 7403(a) of this title; and
          (B) the nurse shall be considered to have served the 
        probationary period required by section 7403(b).
    (3) This subsection shall not apply to appointments made on 
a term limited basis of less than or equal to three years of--
          (A) nurses with a part-time appointment resulting 
        from an academic affiliation or teaching position in a 
        nursing academy of the Department;
          (B) nurses appointed as a result of a specific 
        research proposal or grant; or
          (C) nurses who are not citizens of the United States 
        and appointed under section 7407(a) of this title.
    (h)(1) The Secretary may waive the application of sections 
8344 and 8468 of title 5 (relating to annuities and pay on 
reemployment) or any other similar provision of law under a 
Government retirement system on a case-by-case basis for an 
annuitant reemployed on a temporary basis under the authority 
of subsection (a) in a position described under paragraph (1) 
of that subsection.
    (2) An annuitant to whom a waiver under paragraph (1) is in 
effect shall not be considered an employee for purposes of any 
Government retirement system.
    (3) An annuitant to whom a waiver under paragraph (1) is in 
effect shall be subject to the provisions of chapter 71 of 
title 5 (including all labor authority and labor representative 
collective bargaining agreements) applicable to the position to 
which appointed.
    (4) In this subsection:
          (A) The term ``annuitant'' means an annuitant under a 
        Government retirement system.
          (B) The term ``employee'' has the meaning under 
        section 2105 of title 5.
          (C) The term ``Government retirement system'' means a 
        retirement system established by law for employees of 
        the Government of the United States.

           *       *       *       *       *       *       *


SEC. 7410. ADDITIONAL PAY AUTHORITIES

    (a) In General.--The Secretary may [The Secretary may] 
authorize the Under Secretary for Health to pay advance 
payments, recruitment or relocation bonuses, and retention 
allowances to the personnel described in paragraph (1) of 
section 7401 of this title, or interview expenses to candidates 
for appointment as such personnel, in the same manner, and 
subject to the same limitations, as in the case of the 
authority provided under sections 5524a, 5706b, 5753, and 5754 
of title 5.
    (b) Special Incentive Pay for Department Pharmacist 
Executives.--(1) In order to recruit and retain highly 
qualified Department pharmacist executives, the Secretary may 
authorize the Under Secretary for Health to pay special 
incentive pay of not more than $40,000 per year to an 
individual of the Veterans Health Administration who is a 
pharmacist executive.
    (2) In determining whether and how much special pay to 
provide to such individual, the Under Secretary shall consider 
the following:
          (A) The grade and step of the position of the 
        individual.
          (B) The scope and complexity of the position of the 
        individual.
          (C) The personal qualifications of the individual.
          (D) The characteristics of the labor market 
        concerned.
          (E) Such other factors as the Secretary considers 
        appropriate.
    (3) Special incentive pay under paragraph (1) for an 
individual is in addition to all other pay (including basic 
pay) and allowances to which the individual is entitled.
    (4) Except as provided in paragraph (5), special incentive 
pay under paragraph (1) for an individual shall be considered 
basic pay for all purposes, including retirement benefits under 
chapters 83 and 84 of title 5, and other benefits.
    (5) Special incentive pay under paragraph (1) for an 
individual shall not be considered basic pay for purposes of 
adverse actions under subchapter V of this chapter.
    (6) Special incentive pay under paragraph (1) may not be 
awarded to an individual in an amount that would result in an 
aggregate amount of pay (including bonuses and awards) received 
by such individual in a year under this title that is greater 
than the annual pay of the President.

           *       *       *       *       *       *       *


            Subchapter III. Pay for Physicians and Dentists

SEC. 7431. PAY

           *       *       *       *       *       *       *


    (b) * * *

           *       *       *       *       *       *       *

          (5) The non-foreign cost of living adjustment 
        allowance authorized under section 5941 of title 5 for 
        physicians and dentists whose pay is set under this 
        section shall be determined as a percentage of base pay 
        only.

           *       *       *       *       *       *       *

    (c) * * *

           *       *       *       *       *       *       *

          (4)(A) * * *
          (B)(i) In determining the amount of the market pay 
        for a particular physician or dentist under this 
        subsection, and in determining a tier (if any) to apply 
        to a physician or dentist under subsection (e)(1)(B), 
        the Secretary shall consult with and consider the 
        recommendations of an appropriate panel or board 
        composed of physicians or dentists (as applicable). The 
        Secretary may exempt physicians and dentists occupying 
        administrative or executive leadership positions from 
        the requirements of the previous sentence.

           *       *       *       *       *       *       *

          (7) No adjustment of the amount of market pay of a 
        physician or dentist under paragraph (6) may result in 
        a reduction of the amount of market pay of the 
        physician or dentist while in the same position or 
        assignment at the medical facility of the Department 
        [concerned.] concerned, unless there is a change in 
        board certification or reduction of privileges.

           *       *       *       *       *       *       *


                Subchapter IV. Pay for Nurses and Other 
                         Health-Care Personnel

SEC. 7451. NURSES AND OTHER HEALTH-CARE PERSONNEL: COMPETITIVE PAY

           *       *       *       *       *       *       *


    (c)(1) * * *
    (2) The maximum rate of basic pay for any grade for a 
covered position may not exceed the maximum rate of basic pay 
established for positions in [level V] level IV of the 
Executive Schedule under section 5316 of title 5. The maximum 
rate of basic pay for a grade for the position of certified 
registered nurse anesthetist pursuant to an adjustment under 
subsection (d) may exceed the maximum rate otherwise provided 
in the preceding sentence.

           *       *       *       *       *       *       *

    (d)(3)(A) * * *

           *       *       *       *       *       *       *

    (F) The Under Secretary for Health shall provide 
appropriate education, training, and support to directors of 
Department health care facilities in the conduct and use of 
surveys, including the use of third-party surveys, under this 
paragraph.

           *       *       *       *       *       *       *

    (e)(4) * * *

           *       *       *       *       *       *       *

          (D) In any case in which the director conducts such a 
        wage survey during the period covered by the report and 
        makes adjustment in rates of basic pay applicable to 
        one or more covered positions at the facility, 
        information on the methodology used in making such 
        adjustment or adjustments.
          (E) [(D)] In any case in which the director, after 
        finding that there is, or is likely to be, in 
        accordance with criteria established by the Secretary, 
        a significant pay-related staffing problem at that 
        facility for any covered position, determines not to 
        conduct a wage survey with respect to that position, a 
        statement of the reasons why the director did not 
        conduct such a survey.

           *       *       *       *       *       *       *

    (e)(5) * * *
    (6)(A) Upon the request of an individual described in 
subparagraph (B) for a report provided under paragraph (4) with 
respect to a Department health-care facility, the Under 
Secretary for Health or the director of such facility shall 
provide to the individual the most current report for such 
facility provided under such paragraph.
    (B) An individual described in this subparagraph is--
          (i) an individual in a covered position at a 
        Department health-care facility; or
          (ii) a representative of the labor organization 
        representing that individual who is designated by that 
        individual to make the request.

           *       *       *       *       *       *       *

    [(f) Not later than March 1 of each year, the Secretary 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report regarding any pay 
adjustments under the authority of subsection (d) effective 
during the 12 months preceding the submission of the report. 
Each such report shall set forth, by health-care facility, the 
percentage of such increases and, in any case in which no 
increase was made, the basis for not providing an increase.]
    (f) [(g)] For the purposes of this section, the term 
``health-care facility'' means a medical center, an independent 
outpatient clinic, or an independent domiciliary facility.

SEC. 7452. NURSES AND OTHER HEALTH-CARE PERSONNEL: ADMINISTRATION OF 
                    PAY

           *       *       *       *       *       *       *


    (g)(1) * * *
    (2) The amount of special pay paid to a nurse executive 
under paragraph (1) shall be not less than $10,000 or more than 
[$25,000] $100,000.

           *       *       *       *       *       *       *


SEC. 7453. NURSES: ADDITIONAL PAY

    (a) In addition to the rate of basic pay provided for 
nurses, [a nurse] a full-time nurse or part-time nurse shall 
receive additional pay as provided by this section.
    (b) A nurse performing service [on a tour of duty], any 
part of which is within the period commencing at 6 postmeridian 
and ending at 6 antemeridian, shall receive additional pay for 
each hour of [service on such tour] such service at a rate 
equal to 10 percent of the nurse's hourly rate of basic pay if 
at least four hours [of such tour] of such service fall between 
6 postmeridian and 6 antemeridian. When less than four hours 
[of such tour] of such service fall between 6 postmeridian and 
6 antemeridian, the nurse shall be paid the differential for 
each hour of service performed between those hours.
    (c) A nurse performing service [on a tour of duty], any 
part of which is within the period commencing at midnight 
Friday and ending at midnight Sunday, shall receive additional 
pay for each hour of [service on such tour] such service at a 
rate equal to 25 percent of such nurse's hourly rate of basic 
pay.
    (d) * * *
    (e)(1) A nurse performing officially ordered or approved 
hours of service in excess of 40 hours in an administrative 
workweek, or in excess of [eight hours in a day] eight 
consecutive hours, shall receive overtime pay for each hour of 
such additional service. The overtime rates shall be one and 
one-half times such nurse's hourly rate of basic pay.

           *       *       *       *       *       *       *

    (5) * * *
          (A) such travel occurs during such nurse's [tour of 
        duty] period of service; or

           *       *       *       *       *       *       *


SEC. 7454. PHYSICIAN ASSISTANTS AND OTHER HEALTH CARE PROFESSIONALS: 
                    ADDITIONAL PAY

    (b)(1) * * *

           *       *       *       *       *       *       *

    [(3) Employees appointed under section 7408 of this title 
shall be entitled to additional pay on the same basis as 
provided for nurses in section 7453(c) of this title.]
    (3) Employees appointed under section 7408 of this title 
performing service on a tour of duty, any part of which is 
within the period commencing at midnight Friday and ending at 
midnight Sunday, shall receive additional pay in addition to 
the rate of basic pay provided such employees for each hour of 
service on such tour at a rate equal to 25 percent of such 
employee's hourly rate of basic pay.
    (c) * * *

SEC. 7455. INCREASES IN RATES OF BASIC PAY

           *       *       *       *       *       *       *


    [(c)(1) The amount of any increase under subsection (a) in 
the maximum rate for any grade may not (except in the case of 
nurse anesthetists, pharmacists, and licensed physical 
therapists) exceed by two times the amount by which the maximum 
for such grade (under applicable provisions of law other than 
this subsection) exceeds the minimum for such grade (under 
applicable provisions of law other than this subsection), and 
the maximum rate as so increased may not exceed the rate paid 
for individuals serving as Assistant Under Secretary for 
Health.
    [(2) Whenever the amount of an increase under subsection 
(a) results in a rate of basic pay for a position being equal 
to or greater than the amount that is 94 percent of the maximum 
amount permitted under paragraph (1), the Secretary shall 
promptly notify the Committees on Veterans' Affairs of the 
Senate and House of Representatives of the increase and the 
amount thereof.]
    (c)(1) Subject to paragraph (2), the amount of any increase 
under subsection (a) in the minimum rate for any grade may not 
exceed the maximum rate of basic pay (excluding any locality-
based comparability payment under section 5304 of title 5 or 
similar provision of law) for the grade or level by more than 
30 percent.
    (2) No rate may be established under this section in excess 
of the rate of basic pay payable for level IV of the Executive 
Schedule.

           *       *       *       *       *       *       *


SEC. 7456. NURSES: SPECIAL RULES FOR WEEKEND DUTY

           *       *       *       *       *       *       *


    [(c) A nurse described in subsection (b)(1) who is absent 
on approved sick leave or annual leave during a regularly 
scheduled 12-hour tour of duty shall be charged for such leave 
at a rate of five hours of leave for three hours of absence.]
    (c) [(d)] The Secretary shall prescribe regulations for the 
implementation of this section.

SEC. 7456A. NURSES: ALTERNATE WORK SCHEDULES

    (a) * * *
    (b) [36/40] 72/80 work schedule.
          (1)(A) Subject to paragraph (2), if the Secretary 
        determines it to be necessary in order to obtain or 
        retain the services of registered nurses at any 
        Department health-care facility, the Secretary may 
        provide, in the case of nurses employed at such 
        facility, that such nurses who work [three regularly 
        scheduled 12-hour tours of duty within a work week 
        shall be considered for all purposes to have worked a 
        full 40-hour basic work week.] six regularly scheduled 
        12-hour tours of duty within a 14-day period shall be 
        considered for all purposes to have worked a full 80-
        hour pay period.
          (B) A nurse who works under the authority in 
        subparagraph (A) shall be considered a 0.90 full-time 
        equivalent employee in computing full-time equivalent 
        employees for the purposes of determining compliance 
        with personnel ceilings.
          (2)(A) Basic and additional pay for a nurse who is 
        considered under paragraph (1) to have worked a full 
        [40-hour basic work week] 80-hour pay period shall be 
        subject to subparagraphs (B) and (C).
          (B) The hourly rate of basic pay for a nurse covered 
        by this paragraph for service performed as part of a 
        [regularly scheduled 36-hour tour of duty within the 
        work week] scheduled 72-hour tour of duty within the 
        bi-weekly pay period shall be derived by dividing the 
        nurse's annual rate of basic pay by 1,872.
          (C) The Secretary shall pay overtime pay to a nurse 
        covered by this paragraph who--
                  (i) performs a period of service in excess of 
                such nurse's [regularly scheduled 36-hour tour 
                of duty within an administrative work week] 
                scheduled 72-hour tour of duty within an 
                administrative pay period;
                  (ii) for officially ordered or approved 
                service, performs a period of service in excess 
                of 8 hours on a day other than a day on which 
                such nurse's [regularly] scheduled 12-hour tour 
                of duty falls;
                  (iii) performs a period of service in excess 
                of 12 hours for any day included in the 
                [regularly scheduled 36-hour tour of duty work 
                week] scheduled 72-hour tour of duty pay 
                period; or
                  (iv) performs a period of service in excess 
                of 40 hours during an administrative work week.
          (D) The Secretary may provide a nurse to whom this 
        subsection applies with additional pay under section 
        7453 of this title for any period included in a 
        [regularly] scheduled 12-hour tour of duty.
          (3) A nurse who works a work schedule described in 
        this subsection who is absent on approved sick leave or 
        annual leave during a [regularly] scheduled 12-hour 
        tour of duty shall be charged for such leave at a rate 
        of ten hours of leave for every nine hours of absence.

SEC. 7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY

    (a) Limitation.--Except as provided in subsection (c), the 
Secretary may not require nursing staff to work more than 40 
hours (or 24 hours if such staff is covered under section 7456 
of this title) in an administrative work week or more than 
eight consecutive hours (or 12 hours if such staff is covered 
under section 7456 or 7456A of this title).
    (b) Voluntary Overtime.--(1) Nursing staff may on a 
voluntary basis elect to work hours otherwise prohibited by 
subsection (a).
    (2) The refusal of nursing staff to work hours prohibited 
by subsection (a) shall not be grounds to discriminate (within 
the meaning of section 704(a) of the Civil Rights Act of 1964 
(42 U.S.C. 2000e-3(a))) against the staff, dismissal or 
discharge of the staff, or any other adverse personnel action 
against the staff.
    (c) Overtime Under Emergency Circumstances.--(1) Subject to 
paragraph (2), the Secretary may require nursing staff to work 
hours otherwise prohibited by subsection (a) if--
          (A) the work is a consequence of an emergency that 
        could not have been reasonably anticipated;
          (B) the emergency is non-recurring and is not caused 
        by or aggravated by the inattention of the Secretary or 
        lack of reasonable contingency planning by the 
        Secretary;
          (C) the Secretary has exhausted all good faith, 
        reasonable attempts to obtain voluntary workers;
          (D) the nurse staff have critical skills and 
        expertise that are required for the work; and
          (E) the work involves work for which the standard of 
        care for a patient assignment requires continuity of 
        care through completion of a case, treatment, or 
        procedure.
    (2) Nursing staff may not be required to work hours under 
this subsection after the requirement for a direct role by the 
staff in responding to medical needs resulting from the 
emergency ends.
    (d) Nursing Staff Defined.--In this section, the term 
`nursing staff' includes the following;
          (1) A registered nurse.
          (2) A licensed practical or vocational nurse.
          (3) A nurse assistant appointed under this chapter or 
        title 5.
          (4) Any other nurse position designated by the 
        Secretary for purposes of this section.

           *       *       *       *       *       *       *


CHAPTER 76. HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM

           *       *       *       *       *       *       *


Subchapter II. Scholarship Program

           *       *       *       *       *       *       *


SEC. 7612. ELIGIBILITY; APPLICATION; AGREEMENT

           *       *       *       *       *       *       *


    (b)(1) * * *
    (2) A qualifying field of education or training for 
purposes of this subchapter is education or training leading to 
employment as an appointee under paragraph (1) or (3) of 
section 7401 of this title. [(under section 7401 of this title) 
as any of the following:]
          [(A) A physician, dentist, podiatrist, optometrist, 
        nurse, physician assistant, or expanded function dental 
        auxiliary.
          [(B) A psychologist described in section 7401(3) of 
        this title or a certified or registered respiratory 
        therapist, licensed physical therapist, or licensed 
        practical or vocational nurse.]

           *       *       *       *       *       *       *


SEC. 7618. EXPIRATION OF PROGRAM

    The Secretary may not furnish scholarships to new 
participants in the Scholarship Program after [December 31, 
1998] December 31, 2014.

           *       *       *       *       *       *       *


            Subchapter VII. Education Debt Reduction Program

SEC. 7681. AUTHORITY FOR PROGRAM

    (a) In general.--
          (1) * * *
          (2) The purpose of the Education Debt Reduction 
        Program is to assist in the recruitment and retention 
        of qualified health care professionals for positions in 
        the Veterans Health Administration for which 
        recruitment or retention of an adequate supply of 
        qualified personnel is difficult.
    (b) * * *

SEC. 7682. ELIGIBILITY

    (a) Eligibility.--An individual is eligible to participate 
in the Education Debt Reduction Program if the individual--
          (1) is [a recently appointed] an employee in the 
        Veterans Health Administration serving in a position 
        (as determined by the Secretary) providing direct-
        patient care services or services incident to direct-
        patient care services for which recruitment or 
        retention of qualified health-care personnel (as so 
        determined) is difficult; and

           *       *       *       *       *       *       *

    [(c) Recently appointed individuals.--For purposes of 
subsection (a), an individual shall be considered to be 
recently appointed to a position if the individual has held 
that position for less than 6 months.]

           *       *       *       *       *       *       *


            PART VI. ACQUISITION AND DISPOSITION OF PROPERTY

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

     SUBCHAPTER I. ACQUISITION AND OPERATION OF MEDICAL FACILITIES

SEC.

           *       *       *       *       *       *       *


[8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES.]

           *       *       *       *       *       *       *


   SUBCHAPTER III. STATE HOME FACILITIES FOR FURNISHING DOMICILIARY, 
NURSING HOME, AND HOSPITAL CARE

           *       *       *       *       *       *       *


8133A. TRIBAL ORGANIZATIONS.

           *       *       *       *       *       *       *


              Subchapter I. Acquisition and Operation of 
Medical Facilities

           *       *       *       *       *       *       *


[SEC. 8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES

    [(a) In order to promote effective planning for the 
efficient provision of care to eligible veterans, the 
Secretary, based on the analysis and recommendations of the 
Under Secretary for Health, shall submit to each committee an 
annual report regarding long-range health planning of the 
Department. The report shall be submitted each year not later 
than the date on which the budget for the next fiscal year is 
submitted to the Congress under section 1105 of title 31.
    [(b) Each report under subsection (a) shall include the 
following:
          [(1) A five-year strategic plan for the provision of 
        care under chapter 17 of this title to eligible 
        veterans through coordinated networks of medical 
        facilities operating within prescribed geographic 
        service-delivery areas, such plan to include provision 
        of services for the specialized treatment and 
        rehabilitative needs of disabled veterans (including 
        veterans with spinal cord dysfunction, blindness, 
        amputations, and mental illness) through distinct 
        programs or facilities of the Department dedicated to 
        the specialized needs of those veterans.
          [(2) A description of how planning for the networks 
        will be coordinated.
    [(c) The Secretary shall submit to each committee not later 
than January 31 of each year a report showing the location, 
space, cost, and status of each medical facility (1) the 
construction, alteration, lease, or other acquisition of which 
has been approved under section 8104(a) of this title, and (2) 
which was uncompleted as of the date of the last preceding 
report made under this subsection.
    [(d)(1) The Secretary shall submit to each committee, not 
later than January 31 of each year, a report showing the 
current priorities of the Department for proposed major medical 
construction projects. Each such report shall identify the 20 
projects, from within all the projects in the Department's 
inventory of proposed projects, that have the highest priority 
and, for those 20 projects, the relative priority and rank 
scoring of each such project and the projected cost of such 
project (including the projected operating costs, including 
both recurring and nonrecurring costs). The 20 projects shall 
be compiled, and their relative rankings shall be shown, by 
category of project (including the categories of ambulatory 
care projects, nursing home care projects, and such other 
categories as the Secretary determines).
    [(2) The Secretary shall include in each report, for each 
project listed, a description of the specific factors that 
account for the relative ranking of that project in relation to 
other projects within the same category.
    [(3) In a case in which the relative ranking of a proposed 
project has changed since the last report under this subsection 
was submitted, the Secretary shall also include in the report a 
description of the reasons for the change in the ranking, 
including an explanation of any change in the scoring of the 
project under the Department's scoring system for proposed 
major medical construction projects.]

           *       *       *       *       *       *       *


   Subchapter III. State Home Facilities for Furnishing Domiciliary, 
Nursing Home, and Hospital Care

           *       *       *       *       *       *       *


SEC. 8131. DEFINITIONS

           *       *       *       *       *       *       *


          (5) The term ``tribal organization'' has the meaning 
        given such term in section 3765 of this title.

SEC. 8132. DECLARATION OF PURPOSE

    The purpose of this subchapter is to assist the several 
States and tribal organizations to construct State home 
facilities (or to acquire facilities to be used as State home 
facilities) for furnishing domiciliary or nursing home care to 
veterans, and to expand, remodel, or alter existing buildings 
for furnishing domiciliary, nursing home, adult day health, or 
hospital care to veterans in State homes.

SEC. 8133. AUTHORIZATION OF APPROPRIATIONS

           *       *       *       *       *       *       *


SEC. 8133A. TRIBAL ORGANIZATIONS

    (a) Authority To Award Grants.--The Secretary may award a 
grant to a tribal organization under this subchapter in order 
to carry out the purposes of this subchapter.
    (b) Manner and Condition of Grant Awards.--(1) Grants to 
tribal organizations under this section shall be awarded in the 
same manner, and under the same conditions, as grants awarded 
to the several States under the provisions of this subchapter, 
subject to such exceptions as the Secretary shall prescribe for 
purposes of this subchapter to take into account the unique 
circumstances of tribal organizations.
    (2) For purposes of according priority under subsection 
(c)(2) of section 8135 of this title to an application 
submitted under subsection (a) of such section, an application 
submitted under such subsection (a) by a tribal organization of 
a State that has previously applied for award of a grant under 
this subchapter for construction or acquisition of a State 
nursing home shall be considered under subparagraph (C) of such 
subsection (c)(2) an application from a tribal organization 
that has previously applied for such a grant.

           *       *       *       *       *       *       *


SEC. 8138. TREATMENT OF CERTAIN HEALTH FACILITIES AS STATE HOMES

           *       *       *       *       *       *       *


    (d) * * *
    (e)(1) A health facility (or certain beds in a health 
facility) of a tribal organization is treatable as a State home 
under subsection (a) in accordance with the provisions of that 
subsection.
    (2) Except as provided in paragraph (3), the provisions of 
this section shall apply to a health facility (or certain beds 
in such facility) treated as a State home under subsection (a) 
by reason of this subsection to the same extent as health 
facilities (or beds) treated as a State home under subsection 
(a).
    (3) Subsection (f) shall not apply to the treatment of 
health facilities (or certain beds in such facilities) of 
tribal organizations as a State home under subsection (a).
    (f) [(e)] The Secretary may not treat any new health 
facilities (or any new certain beds in a health facility) as a 
State home under subsection (a) after September 30, 2009.

           *       *       *       *       *       *       *


              PERSIAN GULF WAR VETERANS' HEALTH STATUS ACT

(Public Law 102-585; 106 Stat. 4943; 38 U.S.C. 527 Note)

           *       *       *       *       *       *       *


TITLE VII. PERSIAN GULF WAR VETERANS' HEALTH STATUS

           *       *       *       *       *       *       *


SEC. 707. COORDINATION OF HEALTH-RELATED GOVERNMENT ACTIVITIES ON THE 
                    PERSIAN GULF WAR

           *       *       *       *       *       *       *


    (c) Reports.--
          (1) [Not later than March 1 of each year] Not later 
        than July 1, 2010, and July 1 of each of the five 
        following years, the head of the department or agency 
        designated under subsection (a) shall submit to the 
        Committees on Veterans' Affairs of the Senate and House 
        of Representatives a report on--
                  (A) the status and results of all such 
                research activities undertaken by the executive 
                branch during the previous year; and
                  (B) research priorities identified during 
                that year.

           *       *       *       *       *       *       *

  

                                  
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