[Senate Report 111-80]
[From the U.S. Government Publishing Office]


                                                       Calendar No. 167
111th Congress                                                   Report
                                 SENATE
 1st Session                                                     111-80

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



 
              CAREGIVER AND VETERANS HEALTH SERVICES ACT 
                                OF 2009

                                _______
                                

               September 25, 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. 801]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (S. 801), to amend 
title 38, United States Code, to waive charges for humanitarian 
care provided by the Department of Veterans Affairs 
(hereinafter, ``VA'' or ``the Department'') to family members 
accompanying veterans severely injured after September 11, 
2001, as they receive medical care from the Department, and to 
provide assistance to family caregivers, and for other 
purposes, reports favorably thereon with an amendment, and 
recommends that the bill, (as amended) do pass.

                              Introduction

    On April 2, 2009, Chairman Akaka introduced S. 801, the 
proposed ``Family Caregiver Program Act of 2009.'' S. 801, as 
introduced, would create a national program for the caregivers 
of seriously injured veterans to provide them with education, 
grants, counseling, and other support.
    Earlier, on February 10, 2009, Senator Akaka introduced 
S. 404, the proposed ``Veterans'' Emergency Care Fairness Act 
of 2009.'' S. 404 would expand veteran eligibility for 
reimbursement by the Secretary of Veterans Affairs for 
emergency treatment furnished in a non-Department facility.
    On March 6, 2009, Senator Durbin introduced S. 543, the 
proposed ``Veteran and Servicemember Caregiver Support Act of 
2009.'' S. 543 would require a pilot program on training, 
certification, and support for family caregivers of seriously 
disabled veterans.
    On March 19, 2009, Senator Tester introduced S. 658, the 
proposed ``Rural Veterans Improvement Act of 2009.'' S. 658 
would, among other things, improve health care for veterans who 
live in rural areas.
    On March 30, 2009, Senator Akaka introduced S. 734, the 
proposed ``Rural Veterans Health Care Access and Quality Act of 
2009.'' This bill would improve the capacity of the Department 
of Veterans Affairs to recruit and retain physicians in 
underserved areas known as Health Professional Shortage Areas 
(hereinafter, ``HPSAs'') and improve the provision of health 
care to veterans in rural areas.
    On April 2, 2009, Senator Brown introduced S. 793, the 
proposed ``Department of Veterans Affairs Vision Scholars Act 
of 2009.'' S. 793 would direct the Secretary of Veterans 
Affairs to establish a scholarship program for students seeking 
a degree or certificate in the areas of visual impairment and 
orientation and mobility.
    On February 26, 2009, the Committee held a hearing on 
caring for veterans in rural areas. Testimony was offered by: 
Kara Hawthorne, Director, Office of Rural Health, Veterans 
Health Administration; Adam W. Darkins, M.D., Chief Consultant 
for Care Coordination, Veterans Health Administration; Reverend 
Ricardo Flippin, Project Coordinator, West Virginia Council of 
Churches, CARE-NET: Caring Beyond the Yellow Ribbon; H. Alan 
Watson, Chief Executive Officer, St. Mary's Medical Center of 
Campbell County, Lafollette, Tennessee; Tom Loftus, Commander, 
The American Legion, Post 45, Clarksville, Virginia; and Matt 
Kuntz, Executive Director, National Alliance for the Mentally 
Ill, Montana Chapter.
    On April 22, 2009, the Committee held a hearing on pending 
health care legislation. Testimony was offered by: Gerald M. 
Cross, M.D., Principal Deputy Under Secretary for Health, 
Department of Veterans Affairs, accompanied by Walter A. Hall, 
Assistant General Counsel, and 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, representing the American 
Federation of Government Employees; and Blake Ortner, Senior 
Associate Legislative Director, Paralyzed Veterans of America.

                           Committee Meeting

    After carefully reviewing the testimony from the foregoing 
hearings, the Committee met in open session on May 21, 2009, to 
consider, among other legislation, an amended version of 
S. 801, consisting of provisions from S. 801 as introduced, and 
other legislation noted above, as well as several freestanding 
provisions. The Committee voted unanimously to report favorably 
S. 801, as amended.

                     Summary of S. 801 as Reported

    S. 801, as reported, would amend the title of the original 
bill (hereinafter, ``the Committee bill'' or ``this Act''), and 
would provide for a program of support for caregivers of 
seriously injured veterans, improve health care provided to 
veterans residing in rural areas, and make other enhancements 
and expansions to VA health care.

                       TITLE I--CAREGIVER SUPPORT

    Section 101 would authorize VA to waive the cost of 
furnishing hospital care or medical services for caregivers of 
veterans in emergency cases.
    Section 102 would create a comprehensive program to provide 
assistance to the caregivers of severely injured veterans.
    Section 103 would authorize the Secretary to pay for the 
caregivers' lodging and subsistence as well as the expenses of 
travel for the period consisting of travel to and from a 
treatment facility and the duration of a treatment episode at 
that facility.
    Section 104 would require VA to collaborate with the 
Department of Defense (hereinafter, ``DOD'') to conduct, and 
thereafter submit to Congress, a national survey of family 
caregivers.

                  TITLE II--RURAL HEALTH IMPROVEMENTS

    Section 201 would authorize the Secretary to include 
education loan repayment in offers of employment in an amount 
equal to the potential employee's total indebtedness.
    Section 202 would create a new visual impairment, 
orientation and mobility professionals' education assistance 
program.
    Section 203 would require VA to transfer funds to the 
Department of Health and Human Services for the purpose of 
listing VA facilities on the National Health Service Corps 
list.
    Section 204 would mandate the expansion of telehealth 
services, promote the training of health care personnel in 
telemedicine technologies, and require appropriate 
reimbursement to facilities offering those services.
    Section 205 would authorize rural health demonstration 
projects which may include partnering with other agencies or 
community entities.
    Section 206 would authorize VA to contract-out mental 
health services for Operation Iraqi Freedom (hereinafter, 
``OIF'') and Operation Enduring Freedom (hereinafter, ``OEF'') 
veterans in rural areas.
    Section 207 would promote improved partnership and 
collaboration between VA and the Indian Health Service 
(hereinafter, ``IHS'') to enhance care for Indian veterans.
    Section 208 would require VA to reimburse certain veterans 
requiring air travel transportation for treatment at VA 
facilities.
    Section 209 would require the VA Office of Rural Health to 
develop a 5-year strategic plan for improving access to quality 
health care for veterans who live in rural areas.
    Section 210 would provide incentives for providers paid by 
VA through contracts or on a fee-for-service basis to implement 
certain quality improvement measures.
    Section 211 would authorize VA to use volunteers and other 
individuals to provide readjustment counseling, and to expedite 
the credentialing and privileging of licensed independent 
health care providers working on a volunteer basis in 
readjustment counseling centers.
    Section 212 would require VA to establish rural health 
Centers of Excellence.
    Section 213 would authorize a pilot program that 
incentivizes physicians to assume inpatient responsibilities at 
community hospitals in health professional shortage areas.
    Section 214 would require reports on the implementation of 
sections 209 through 213 of the Committee bill and a report on 
VA fee-basis health care and outreach programs.
    Section 215 would authorize grants to veterans service 
organizations for the purposes of providing certain 
transportation services to veterans.

                  TITLE III--OTHER HEALTH CARE MATTERS

    Section 301 would authorize VA to reimburse certain 
veterans for emergency treatment received at a non-VA medical 
facility, without regard to insurance coverage.
    Section 302 would exempt veterans who are catastrophically 
disabled from copayment requirements for the receipt of 
hospital care or medical services.

               TITLE IV--CONSTRUCTION AND NAMING MATTERS

    Section 401 would authorize funds for design and 
construction at the VA Medical Center, Walla Walla, Washington.
    Section 402 would designate the VA outpatient clinic in 
Havre, Montana as the ``Merril Lundman Department of Veterans 
Affairs Outpatient Clinic.''

                       Background and Discussion


                       TITLE I--CAREGIVER SUPPORT

    Title I of the Committee bill contains a number of 
provisions that are designed to help caregivers of veterans.
    Many veterans returning from the conflicts in Iraq and 
Afghanistan sustained severe injuries and need substantial 
care. According to VA, as of January 2009, 981,834 OEF/OIF 
servicemembers had left active duty, and 425,538 (or 43 
percent) had accessed VA health care.
    Congress has recognized the need for VA to provide 
assistance to caregivers of severely injured veterans. Public 
Law 109-461, Section 214 authorized $5,000,000 for each of the 
fiscal years (FY) 2007 and 2008 for VA to carry out pilot 
caregiver assistance programs. VA began eight caregiver 
assistance pilot programs in October 2007. A 1-year extension 
of the authority for these pilot programs was approved in 
Public Law 110-329, the ``Consolidated Security, Disaster 
Assistance, and Continuing Appropriations Act, 2009.''
    These pilot programs offer such services as caregiver 
education, training, improved care coordination, and peer 
networking. They do not provide health care, mental health 
counseling, or financial assistance to caregivers. Based on the 
comprehensive needs of caregivers, Ralph Ibson, Health Policy 
Senior Fellow of the Wounded Warrior Project (hereinafter, 
``WWP'') testified before the Committee at its April 22, 2009, 
health legislation hearing that ``the time for pilot programs 
is past.''
    Fully supporting caregiving activities is also cost 
effective, as the cost of providing care in an institutional 
setting can be much greater than the cost of providing care in 
the home. According to a survey conducted in 2005 by MetLife's 
Mature Market Institute, the average cost of a private room in 
a nursing home in the United States was $74,095 per year. VA is 
obligated to provide nursing home care for veterans who need 
such care, and who meet one of the following criteria: a 
service-connected disability rating of 70 percent or more; a 
need for nursing home care for a service-connected disability; 
or a rating of 60 percent when a veteran is either unemployable 
or permanently and totally disabled. In its 2009 budget 
submission, VA projected that the average daily census in its 
institutional care settings, including community living 
centers, community nursing homes, and state veterans homes, 
would reach 90,654 in 2010, an increase of 25.3 percent over 
2009 levels.
    Many veterans, however, prefer care in the home, especially 
younger veterans such as those now returning from the conflicts 
in Afghanistan and Iraq. As the WWP witness, Ralph Ibson, 
testified before the Committee at its April 22, 2009, health 
legislation hearing:

        These individuals usually want to return to, or remain 
        in, their homes, and strongly resist being 
        institutionalized * * *. Most warriors want to be cared 
        for by their loved ones, if possible, rather than 
        agency personnel. Most families want the same for their 
        wounded warrior. But the extraordinary demands of 
        caregiving invariably takes a toll on family 
        caregivers--physically, psychologically, emotionally, 
        and financially.

At the same hearing, the witness representing the American 
Federation of Government Employees (hereinafter, ``AFGE''), 
Ammie Hilsabeck, also called the contributions of today's 
caregivers ``invaluable economically as they obviate the rising 
costs of traditional institutional care.''
    The financial toll on caregivers can be substantial, 
however. The 2006 MetLife Caregiving Cost Study estimated that 
15 to 20 percent of the nation's workforce as a whole is 
engaged in caregiving at any one time. According to CNA's April 
2009 report Economic Impact on Caregivers of the Seriously 
Wounded, Ill, and Injured, 84 percent of veteran caregivers 
were either working or in school prior to becoming a caregiver. 
MetLife's cost study estimated that employer costs for working 
caregivers totaled up to $33.6 billion in lost productivity. In 
addition, an employed caregiver lost an average of about 
$659,000 in wages, pension, and Social Security benefits over a 
``career'' of caregiving.
    These financial burdens may impact the ability of 
caregivers to obtain health insurance. According to a 2001 
Kaiser Family Foundation study, half of all caregivers have an 
annual household income of less than $35,000. In the Family 
Caregiver Alliance's September 2003 policy brief, authors 
reported that 25 percent of women caregivers had difficulty 
obtaining medical insurance compared to 16 percent of non-
caregiving women.
    Mental health concerns are often prevalent in this 
population as well. Caregivers report unmet needs in the areas 
of finding time for themselves (35 percent) and of managing 
emotional and/or physical stress (29 percent). In one study, 30 
to 59 percent of caregivers reported depressive disorders or 
symptoms.\1\ Testifying before the Committee at its April 22, 
2009, health legislation hearing, the WWP witness said:
---------------------------------------------------------------------------
    \1\Cohen, D., Luchins, D., Eisdorfer, C., Paveza, G., Ashford, J., 
Gorelick, P., et al. (1990). Caring for relatives with Alzheimer's 
Disease: The mental health risks to spouses, adult children, and other 
family caregivers. Behavior, Health and Aging, 1, 171-182.

        Highlighting the need for access to counseling and 
        other health care services, the studies also show that 
        family caregivers experience an increased likelihood of 
        stress, depression, and mortality compared to their 
        non-caregiving peers * * *. Caregivers report poorer 
        levels of perceived health, more chronic illnesses, and 
        poorer immune responses to viral challenges.

Sec. 101. Waiver of Charges for Humanitarian Care.

    Section 101, which is derived from S. 801 as introduced, 
would modify VA's authority to furnish humanitarian care so 
that caregivers who accompany veterans would be exempt from 
charges for emergency medical services.
    Background. Non-veterans may receive medical care from VA 
in emergency cases under current law, but VA charges them for 
such services. Charging caregivers who accompany veterans to VA 
facilities, and subsequently need emergency care, adds to the 
economic impact of caregiving on veterans' families.
    Committee Bill. Section 101 of the Committee bill would 
revise section 1784 of title 38, to amend existing law which 
authorizes VA to furnish and charge for hospital care or 
medical services in emergencies, so as to authorize VA to 
furnish such services, without charge, in emergency cases to 
attendants accompanying certain veterans when the veterans are 
receiving care from or through VA.
    Subsections (a) and (b) of revised section 1784 are a 
restatement of current law which authorizes VA to furnish and 
charge for care in emergencies. New subsection (c) of section 
1784 would require VA to waive charges for such services if 
those services are provided to an ``attendant of a covered 
veteran'' while the attendant is accompanying such a veteran 
receiving care at a VA facility, or at a non-VA facility that 
is under contract with the Department or which is providing 
care on a fee-for-service basis to the veteran. For purposes of 
this section, an attendant is defined as a family member of the 
veteran; an individual eligible to receive ongoing family 
caregiver assistance under other provisions of this title; or 
any other individual the Secretary determines to have a 
relationship with the veteran sufficient to demonstrate a close 
affinity with the veteran and who provides a significant 
portion of the veteran's care.
    This new subsection would also authorize VA to bill third 
parties for health care provided should an attendant be 
entitled to care or services under a health plan contract or 
have other legal recourse against a third party that would 
extinguish some or all liability associated with the charges.
    New subsection (d) of section 1784 would define a covered 
veteran as any veteran with a severe injury incurred or 
aggravated in the line of duty in the active military, naval or 
air service on or after September 11, 2001. ``Severe injury'' 
would be defined as any physiological, psychological or 
neurological condition that renders a veteran unable to live 
independently.
    The WWP testified in support of these provisions before the 
Committee at its April 22, 2009, health legislation hearing, 
noting the economic impact of caregiving on the family.

Sec. 102. Family Caregiver Assistance.

    Section 102 of the Committee bill, which is derived from 
S. 801 as introduced, contains a number of provisions that 
would require VA to provide training, medical care, a financial 
stipend and other support for caregivers of veterans sustaining 
or aggravating a severe injury after September 11, 2001, while 
on active duty.
    Background. While family caregivers may currently receive 
certification and training through home health agencies, and 
become employees of those agencies, according to a recent 
survey conducted by VHA, only 233 family caregivers received 
such training and certification through existing home health 
agencies in FY 2008. The study also found that in FY 2009, VA 
referred only 168 family caregivers to home care agencies for 
training and certification. This suggests that the population 
of caregivers who would be eligible for stipends under this 
section would be very small.
    A report from the Principal Deputy Assistant Secretary of 
the Air Force for Manpower and Reserve Affairs found that there 
was a greater need for caregiving services. The Assistant 
Secretary was tasked by the Joint Department of Defense and 
Department of Veterans Affairs Wounded, Ill, and Injured Senior 
Oversight Committee (hereinafter, ``SOC'') to evaluate issues 
of personnel, pay, and financial support, including the 
economic impact borne by caregivers of the seriously wounded, 
ill, and injured. This review, conducted by the Center for 
Naval Analyses (hereinafter, ``CNA''), a non-partisan non-
profit research organization, found that 37 percent of 
caregivers had unmet financial obligations, and that three out 
of every four caregivers had quit, or taken time off from work 
or school. CNA estimated that approximately 720 seriously 
wounded, ill, or injured veterans annually would need the 
services of a caregiver. Further, these servicemembers were 
expected to require the services of a caregiver for an average 
of 19 months.
    The WWP witness testified before the Committee at its April 
22, 2009, hearing on health legislation that proper caregiver 
training and health care reduces the chances of injury to both 
the caregiver and the recipient of the care. Current law limits 
VA's ability to provide those services. Under section 1782 of 
title 38, VA is authorized to provide counseling, training, and 
mental health services to members of the veteran's immediate 
family, the veteran's legal guardian, and to the individual in 
whose household the veteran certifies an intention to live. 
These services, however, are only available for: (1) veterans 
receiving treatment for a service-connected disability if the 
services are necessary in connection with that treatment; and 
(2) veterans receiving treatment for other than a service-
connected disability if the services are necessary in 
connection with the treatment, the services were initiated 
during the veteran's hospitalization, and the continued 
provision of the services on an outpatient basis is essential 
to permit the discharge of the veteran from the hospital. There 
is no requirement to provide these services if care can be 
provided by individuals other than the family caregiver, or if 
the caregiver does not live with the veteran.
    In a letter to the Committee, Shawn Moon, General Manager 
for Government and Education Services of Franklin Covey, a 
national organization with specific expertise in the design of 
training programs, said the following:

        A family caregiver assistance program that emphasizes 
        awareness; prevention and wellness; early intervention 
        and treatment; and proactive health risk, condition or 
        disease management is a prudent federal investment. 
        Over the long term, the benefits of this approach will 
        be realized in improved care and outcomes for wounded 
        warriors, better health and quality of life for family 
        caregivers, reduced health care utilization, and 
        increased cost savings.

    Committee Bill. Section 102 of the Committee bill would 
create a comprehensive program to provide assistance to the 
caregivers of severely injured veterans.
    Subsection (a)(1) of this section of the Committee bill 
would amend subchapter II of chapter 17 by adding a new 
section, section 1717A, entitled ``Family caregiver 
assistance.''
    New section 1717A would consist of eleven subsections, (a) 
through (k), as follows:

    Subsection (a) of new section 1717A would require the 
Secretary to provide caregiver assistance as part of home 
health services authorized by Section 1717, so as to reduce the 
number of veterans who are receiving, or in need of, 
institutional care. Such assistance would be furnished upon the 
joint application of an eligible veteran and a family member or 
other individual designated by the veteran. The Secretary would 
be permitted to furnish such assistance only if it is in the 
best interest of the veteran to furnish this assistance.
    Subsection (b) of new section 1717A would define which 
veterans would be eligible to receive caregiver assistance. An 
eligible veteran would be either a veteran or a member of the 
Armed Forces undergoing medical discharge who has a serious 
injury incurred or aggravated in the line of duty in the active 
military, naval, or air service on or after September 11, 2001, 
and who is determined to be in need of personal care services 
because of being unable to perform one or more independent 
activities of daily living; or of needing supervision or 
protection as a result of neurological or other impairment; or 
because of other matters specified by VA. The Secretary would 
have discretion to extend the program to other veterans after 
the first 2 years.
    Subsection (c) of new section 1717A would require the 
Secretary to evaluate each eligible veteran applying for 
caregiver services to identify the personal care services 
required by the veteran, and to determine whether the 
requirements could be significantly or substantially satisfied 
by the individual designated by the veteran. This evaluation 
would be carried out at a VA facility or a non-VA facility 
determined appropriate by VA. The Secretary would also be 
required to evaluate each family member or other designee of an 
eligible veteran who makes a joint application to determine the 
amount of basic instruction, preparation, and training 
necessary for the individual to provide the personal care 
services required by the veteran, as well as additional 
instruction, preparation, and training required to be the 
primary personal care attendant for the veteran.
    Subsection (d) of new section 1717A would provide for the 
training and approval of personal care attendants. The 
Secretary would be required to provide the basic instruction, 
preparation and training determined necessary to enable the 
individual to provide personal care services. The Secretary 
would be authorized to provide additional instruction, 
preparation, and training determined to be required if the 
caregiver is approved as the personal care attendant of the 
veteran, and requests, with concurrence of the veteran, such 
additional instruction.
    Subsection (d) would require the Secretary to approve the 
caregiver as a personal care attendant for the veteran 
following completion of basic instruction, preparation and 
training. If the Secretary determines that a personal care 
attendant, once designated, is in need of additional training, 
VA must provide that training.
    Subsection (d) would require VA to provide for necessary 
travel, lodging and per diem expenses incurred by the caregiver 
of an eligible veteran in undergoing training under this 
section.
    Subsection (d) would require VA to provide respite care to 
veterans whose caregivers are undergoing training if the 
participation of the caregiver in this training would interfere 
with the provision of personal care services to the veteran.
    Subsection (e) of new section 1717A would provide for the 
designation of one family member or designee as the primary 
personal care attendant for such eligible veteran with at least 
one eligible caregiver. Eligible caregivers would have to be 
approved, would have to have completed all instruction, 
preparation and training, would have to elect to provide 
personal care services to the veteran, would have to have the 
veteran's consent to be the primary provider, and would have to 
be considered competent to provide such services to the 
veteran.
    Subsection (e) would allow a veteran to revoke consent with 
respect to a caregiver at any time and would require the 
Secretary to immediately revoke an individual's designation as 
the primary personal care attendant if the individual fails to 
meet the specified requirements. In such a case, the Secretary, 
in consultation with the veteran or the veteran's surrogate, 
would be authorized to designate a new primary personal care 
attendant. In the case of a revocation, the Secretary would be 
required to ensure that the revocation would not interfere with 
the provision of personal care services required by a veteran.
    Subsection (f) of new section 1717A would provide for any 
ongoing family caregiver assistance including direct technical 
support, counseling, and access to an interactive Web site on 
caregiver services to all individuals meeting the 
qualifications for personal care attendant. In addition, the 
primary personal care attendant of each veteran would be 
provided with that same assistance, as well as mental health 
services, respite care of not less than 30 days annually, 
medical care unless the individual is entitled to care or 
services under a health plan contract U.S.C. 1725(f), and a 
monthly caregiver stipend.
    Respite care would be provided either through appropriate 
VA facilities or through existing respite care contracts or, if 
neither approach is appropriate, through other facilities or 
arrangements that are medically and age appropriate.
    Subsection (f) would allow VA to contract for insurance, 
medical services, or health plans if VA determines that the 
Department lacks the capacity to furnish medical care to 
primary personal care attendants.
    Subsection (f) would require VA to provide monthly personal 
caregiver stipends in accordance with a schedule determined by 
the Secretary and based on the amount and degree of personal 
care services provided. To the extent practicable, the amount 
of the personal caregiver stipend would not be less than the 
amount a commercial home health entity would pay an individual 
in the geographic area of the veteran to provide equivalent 
personal care services. If personal care services are not 
available from a commercial provider in the geographic area of 
an eligible veteran, the Secretary would be allowed to consider 
the costs of commercial providers of personal care services in 
other geographic areas with similar costs of living.
    Subsection (f) would require termination of caregiver 
assistance if the veteran no longer requires personal care 
services.
    Subsection (g) of new section 1717A would grant the 
Secretary the authority to appoint a surrogate for the veteran 
if an eligible veteran lacks the capacity to submit 
applications, provide consent, make a request, or concur with a 
request under section 1717A.
    Subsection (h) of new section 1717A would provide oversight 
of the caregiver assistance program through contracts with 
appropriate entities. Each veteran receiving personal care 
services from a personal care attendant would be visited in his 
or her home by such oversight entity no less often than once 
every 6 months. An oversight entity visiting an eligible 
veteran would be required to submit findings for each visit, 
including whether the veteran is receiving the care the veteran 
requires.
    If an oversight entity finds that a veteran has not 
received required care, the Secretary would be authorized to 
take appropriate actions, including revoking a caregiver's 
approval and designation as a primary personal care attendant.
    If the Secretary were to terminate ongoing family caregiver 
assistance under subsection (f) because of the findings of an 
oversight entity, the Secretary would not be authorized to 
provide compensation to such entity for the provision of 
personal care services to such veteran, unless the Secretary 
determines that it is in the best interests of the veteran to 
do so.
    Subsection (i) of new 1717A would provide for a program of 
outreach to inform eligible veterans and their family members 
of the availability and nature of family caregiver assistance 
under section 1717A.
    Subsection (j) of new section 1717A would specify that a 
decision by the Secretary affecting the furnishing of caregiver 
assistance shall be considered a medical determination, and 
that nothing in section 1717A shall be construed to create 
either an employment relationship between VA and someone 
receiving family caregiver assistance, or any entitlements to 
any service or stipend.
    Subsection (k) of new section 1717A would define family 
caregiver assistance, family member, and personal care services 
for purposes of section 1717A.
    Subsection (a)(2) of this section of the Committee bill 
would provide for a clerical amendment.
    Subsection (a)(3) of this section of the Committee bill 
would amend section 1781(a) of title 38 so as to authorize 
health care for primary personal care attendants designated 
under new section 1717A who are not entitled to care or 
services under some other health plan contract.
    Subsection (a)(4) of this section of the Committee bill 
would specify, in a freestanding provision, that any family 
caregiver assistance furnished under new section 1717A would be 
in addition to any family caregiver assistance furnished under 
VA programs.
    Subsection (a)(5) of this section of the Committee bill 
provides that the amendments made by subsection (a) would take 
effect 270 days after the date of the enactment of this Act.
    The Disabled Veterans of America, the Paralyzed Veterans of 
America, and the Wounded Warrior Project testified at the 
Committee's April 22, 2009, hearing on health care legislation 
in support of the need for the services that would be provided 
under new section 1717A. AFGE provided written testimony 
supporting the bill as a whole.
    Subsection (b)(1) of section 102 of the Committee bill 
would mandate the development of a plan for the implementation 
of new section 1717A and require VA to submit a report on such 
plan to the Veterans' Affairs Committees of the House of 
Representatives and Senate not later than 180 days after the 
date of the enactment of this Act.
    Subsection (b)(2) of this section of the Committee bill 
would require VA, in developing the plan in the implementation 
of new section 1717A, to consult with veterans eligible for 
family caregiver assistance; family members of veterans who 
provide personal services to such veterans; veterans service 
organizations; national organizations that specialize in the 
provision of assistance to individuals with the types of 
disabilities that personal care attendants will encounter while 
providing personal care services; such other organizations with 
an interest in the provision of care to veterans as the 
Secretary considers appropriate; and the Secretary of Defense 
with respect to matters concerning personal care services for 
members of the Armed Forces undergoing medical discharge from 
the Armed Forces who would be eligible to benefit from family 
caregiver assistance that would be furnished under new section 
1717A.
    The report would be required to contain the plan; a 
description of the veterans, caregivers and organizations 
consulted by the Secretary; a description of such 
consultations; recommendations of such individuals and 
organizations that were not incorporated into the plan; and the 
reasons the Secretary did not incorporate such recommendations 
into the plan.
    Subsection (c)(1) of section 102 of the Committee bill 
would require VA, no later than 2 years after the effective 
date of this Act and annually thereafter, to submit a 
comprehensive report on the implementation of new section 1717A 
of title 38 to the Veterans' Affairs Committees of the House of 
Representatives and the Senate. This report would be required 
to contain the number of individuals that received caregiver 
assistance under section 1717A; a description of the outreach 
activities carried out by the Secretary in accordance with 
subsection (i) of new section 1717A; information on the 
resources expended by the Secretary under 1717A; an assessment 
of the manner in which resources are expended by the Secretary 
under section 1717A, particularly with respect to the provision 
of monthly personal caregiver stipends; a description of the 
outcomes achieved by, and any measurable benefits of, carrying 
out the requirements of section 1717A; a justification of any 
determination to extend the time period under which veterans 
would be eligible for family caregiver assistance; an 
assessment of the effectiveness and efficiency of the 
implementation of section 1717A; an assessment of how the 
provision of family caregiver assistance fits into the 
continuum of VA home health services and benefits; and such 
recommendations, including recommendations for legislative or 
administrative action, as the Secretary considers appropriate 
in light of carrying out the requirements of section 1717A.

Sec. 103. Lodging and Subsistence for Attendants.

    Background. Section 103 of the Committee bill, which is 
derived from S. 801 as introduced, would modify current 
authority for beneficiary travel so as to authorize VA to pay 
certain costs of caregivers who must travel. Under Section 
111(e) of title 38, VA is authorized to pay qualifying travel 
expenses for an attendant traveling with an eligible veteran 
when the veteran requires an attendant in order to perform such 
travel. This provision does not provide authority for VA to pay 
for lodging and subsistence costs associated with this travel. 
The DOD, on the other hand, is authorized to provide for per 
diem and travel costs for up to three family members while the 
servicemember is an inpatient and during the outpatient 
rehabilitative phase for qualified servicemembers.
    Committee Bill. Section 103 of the Committee bill would 
amend section 111(e) of title 38, which authorizes VA to pay 
certain expenses of travel to an attendant who is required to 
accompany a veteran when the veteran is traveling to receive VA 
care, to add a new paragraph (2) which would authorize the 
Secretary to also pay lodging and subsistence expenses for the 
period consisting of travel to and from a treatment facility 
and the duration of treatment episode at that facility. New 
paragraph (2) would allow the Secretary to prescribe 
regulations to carry out this section, including regulations 
that limit the number of individuals who can receive these 
travel expenses for a single treatment episode of a veteran, 
and that require attendants to use certain travel services.
    This section of the Committee bill would also add a new 
paragraph (3) to section 111(e) of title 38 which would define 
the meaning of attendant for the purposes of this section. An 
attendant would be defined as a family member of the veteran; 
an individual eligible to receive ongoing caregiver assistance 
under other provisions of this title; or any other individual 
whom the Secretary determines has a preexisting relationship 
with the veteran and provides a significant portion of the 
veteran's care.

Sec. 104. Survey of Informal Caregivers.

    Background. Section 104 of the Committee bill, which is 
derived from S. 543, would require VA, working with the DOD, to 
survey family caregivers of veterans. In April 2009, the 
Veterans Health Administration conducted a survey to determine 
how many family caregivers had been referred by VA to home 
health agencies to be trained and certified as home health 
aides and to be hired by the agency as a paid caregiver for the 
veteran. In FY 2008, only 233 family caregivers were referred 
for such training and certification. VA was unable to provide 
the total number of family members serving as caregivers, or to 
provide additional information regarding this population.
    Committee Bill. Section 104 of the Committee bill, in a 
freestanding provision, would require VA, in collaboration with 
the DOD, to carry out a national survey of family caregivers of 
veterans and members of the Armed Forces who are seriously 
disabled in order to gain a better understanding of the size 
and characteristics of the population of such caregivers, and 
of the types of care they provide such veterans and members.
    This section would require VA to submit to Congress, in 
collaboration with DOD, a report containing the findings of the 
survey, with the results disaggregated by those who are 
veterans and those who are still members of the Armed Forces; 
by those who served in Operation Iraqi Freedom or Operation 
Enduring Freedom; and by those who live in rural areas. This 
report would be due not later than 540 days after the date of 
enactment of the Committee Bill.

                  TITLE II--RURAL HEALTH IMPROVEMENTS

    Title II of the Committee bill contains a variety of 
provisions that are designed to enhance the Department's 
ability to meet the needs of veterans living in rural areas.
    Those living in rural areas are more than twice as likely 
to serve in the armed services as those living in urban areas. 
More than one third of veterans currently enrolled with VA live 
in rural areas. This number can only be expected to grow as it 
was estimated by 2007 that 44 percent of the active duty 
military were from rural areas.
    Ensuring access to health care for rural veterans remains a 
challenge for VA. Hilda Heady, past president of the National 
Rural Health Association (hereinafter, ``NRHA''), testified 
during the Committee's April 22, 2009, health legislation 
hearing:

        There is a national misconception that all veterans 
        have access to comprehensive care. Unfortunately, this 
        is simply not true. Access to the most basic primary 
        care is often difficult in rural America. Access for 
        rural veterans can be daunting. Combat veterans 
        returning to their rural homes in need of specialized 
        care due to war injuries (both physical and mental) 
        will likely find access to that care extremely limited.

    Recognizing the need to improve access to health care for 
rural veterans, witnesses representing the NRHA, Paralyzed 
Veterans Association (hereinafter, ``PVA''), Disabled American 
Veterans (hereinafter, ``DAV''), and AFGE testified in support 
of the provisions contained in Title II of the Committee bill 
during the Committee's April 22, 2009, health legislation 
hearing.

Sec. 201. Enhancement of Department of Veterans Affairs Education Debt 
        Reduction Program.

    Section 201 of the Committee bill, which is derived from 
S. 734, would expand the authority of VA to provide education 
debt reduction to eligible employees, and require them to 
notify those employees of an award in a timely manner.
    Background. The Education Debt Reduction Program 
(hereinafter, ``EDRP'') was authorized by the Veterans Programs 
Enhancement Act of 1998 (Public Law 105-368), and amended by 
the Department of Veterans Affairs Health Care Programs 
Enhancement Act of 2001, Public Law 107-135. It provides loan 
repayment for employees recently appointed to title 38 
positions providing direct patient care services or services 
incident to direct patient care.
    Marisa Palkuti, Director of the Health Care Retention and 
Recruitment Office of the VA testified before the Committee on 
April 9, 2008, that the top three mission-critical occupations 
within VHA are registered nurses, physicians, and pharmacists. 
She also highlighted how VA must compete with the private 
sector to recruit these individuals. In 2009, Merritt Hawkins 
and Associates conducted an analysis entitled, ``Review of 
Physician and Certified Registered Nurse Anesthetist Recruiting 
Incentives.'' Of the 3,288 Merritt Hawkins assignments 
reviewed, 31 percent of physician and CRNA positions offered 
loan forgiveness, and 85 percent offered a signing bonus. The 
average amount of the signing bonus alone was $24,850.
    In VA, physicians providing direct patient care services 
are eligible for EDRP. Currently, section 7683 of title 38 
limits the award to a total of $44,000 over a 5-year period. VA 
offers no signing bonuses. The EDRP award limit applies 
regardless of occupation, difficulties in recruitment, or 
actual costs of education.
    The current statutory limit is particularly problematic 
when used as a recruitment or retention tool for physicians. It 
does not reflect the fact that, according to the American 
Association of Medical Colleges, the cost of tuition at medical 
schools has risen faster than the consumer price index for the 
last 20 years. In addition, the mean educational debt of 2008 
graduates from medical school was $154,607, or more than three 
times VA's current statutory authority to grant loan repayment. 
To enable VA to compete effectively with the private sector for 
physicians and other health care providers, VA must have the 
authority to provide loan repayment to the maximum extent 
possible with available funds.
    During recent oversight visits, majority Committee staff 
were told that employees were not made aware of VA's loan 
repayment program until after acceptance of employment, 
eliminating any opportunity for the program to serve as a 
recruitment incentive. Further, in some cases, employees did 
not learn of the program until after they were employed with VA 
for more than 6 months, eliminating their eligibility under 
VA's definition of ``recently appointed.''
    The ability of VA to recruit and retain health care workers 
will be critical in the near future. According to a March 17, 
2009, memorandum from the Congressional Research Service, there 
were 218,000 Veterans Health Administration employees in FY 
2007, and 11.5 percent of them were eligible to retire at the 
end of that year. The Congressional Research Service also noted 
that there were an estimated 1,700 vacancies for registered 
nurses nationwide. VA does not currently have the personnel to 
care for all veterans' health care needs. In FY 2008 alone, VA 
spent more than $244 million on contract care for outpatient 
services and $1.2 billion on fee-basis care.
    EDRP's role in the retention of nurses has been well-
documented. From May 2002 to September 2007, registered nurses 
received 2,704 of the 5,656 awards provided through EDRP, or 
almost half of all awards. Seventy five percent of nurses and 
pharmacists receiving those awards were still employed by VA 5 
years after the conclusion of their service periods.
    VA has the statutory authority to pay individuals through 
EDRP on a monthly or annual basis. VA has chosen to do so once 
a year. This means that employees must currently make student 
loan payments monthly, and then are reimbursed at the end of 
the year. Also, the statute allows VA to define ``recently 
appointed'' but does not specify how a potential recipient is 
made aware of the program, or when they would be notified of an 
award.
    VA has determined that an employee is recently appointed if 
the employee has held the position for less than 6 months. 
Therefore, after 6 months of employment with VA, an employee is 
no longer eligible to apply for the program. Awards are made 
for 1 to 5 years. Majority Committee staff have been told 
during oversight visits that qualifying potential employees do 
not currently routinely receive offers for loan repayment as 
part of VA's initial offer for employment.
    Committee Bill. Subsection (a) of section 201 of the 
Committee bill would amend subsection (d) of section 7683 of 
title 38, so as to remove the statutory limit to loan repayment 
under the EDRP, thereby allowing VA to pay the full cost of 
tuition and qualifying costs for a health care worker's 
education.
    Subsection (b) of section 201 of the Committee bill would 
further amend section 7682 of title 38 by adding a new 
subsection (d) which would require VA, to the maximum extent 
possible, to include in any offer of employment to an 
individual who would be eligible to participate in EDRP, 
information on their eligibility to participate in the program.
    Subsection (c) of section 201 of the Committee bill would 
further amend section 7683 of title 38 to add a new subsection 
(e) which would require VA to select for participation in EDRP 
each individual who was provided notice that he or she would be 
eligible for and selected to participate in EDRP upon 
employment. The new subsection would also allow VA to offer 
participation in EDRP to individuals who did not receive such 
notice.
    The Committee is aware of difficulties in determining award 
availability based on the variability in annual appropriations. 
The Committee therefore elected to qualify this provision, 
requiring the Secretary to meet these notice requirements ``to 
the maximum extent practicable.'' Nevertheless, it is the 
Committee's expectation that the Secretary will provide this 
notice in the vast majority of cases, because, without such 
notice, EDRP cannot function as a recruitment incentive.
    DAV, PVA, and AFGE testified in support of these provisions 
at the Committee's April 22, 2009, hearing on health 
legislation.

Sec. 202. Visual Impairment and Orientation and Mobility Professionals 
        Education Assistance Program.

    Section 202 of the Committee bill, which is derived from 
S. 793, would create a scholarship program for qualified 
individuals pursuing degrees or certificates in blind 
rehabilitation.
    Background. According to Tom Zampieri, Director of 
Government Relations at the Blinded Veterans Association, there 
are 163,000 legally blind veterans in the United States, with 
47,560 currently enrolled in VA. In addition, VA estimates that 
there are over 1 million low-vision veterans in the U.S., and 
incidences of blindness among the total veteran population of 
24 million are expected to increase by about 40 percent over 
the next two decades. This is because the most prevalent causes 
of legal blindness and low vision are age-related, and the 
average age of the veteran population is increasing.
    In addition to this aging population, DOD data compiled 
between 1999 and 2007 reported 182,828 eye injuries from all 
causes over a 10-year period and 4,970 evacuees from OIF and 
OEF operations with severe penetrating eye injuries. According 
to Tom Zampieri of the Blinded Veterans Association, with the 
growing numbers of wounded in both OIF and OEF who are entering 
the VA health care and benefits system today, 13.9 percent with 
a history of penetrating eye trauma and over 70 percent of 
traumatic brain injury (hereinafter, ``TBI'') patients with 
post trauma vision syndrome (hereinafter, ``PTVS''), more of 
these highly skilled professionals are necessary and critical 
for VA. While the number of legally blind OIF and OEF veterans 
enrolled in the VA Blind Rehabilitative Service is 
approximately 135, VA has identified 585 with functional visual 
impairments that benefit from the rehabilitative skills of 
Blind Rehabilitative Outpatient Specialists (hereinafter, 
``BROS'') and Blind Instructors.
    The health care costs of blindness are high. According to 
the Blinded Veterans Association, research on blind and low 
vision Americans show they are at high risk of falls or making 
medication mistakes, which results in costly hospital 
admissions every year and a loss of their ability to live 
independently at home. Falls are the sixth leading cause of 
death in senior citizens and a contributing factor to 40 
percent of all nursing home admissions with annual federal 
costs over $45,000 for each nursing home bed.
    Tom Zampieri testified before the House Committee on 
Veterans' Affairs, Subcommittee on Economic Opportunity, on 
March 4, 2009, that falls are the sixth leading cause of death 
in senior citizens and a contributing factor to 40 percent of 
all nursing home admissions with annual federal costs over 
$45,000 for each nursing home bed. In the Framingham Eye Study, 
18 percent of all hip fractures among senior citizens--about 
63,000 hip fractures a year--were attributable to vision 
impairment. The cost of medical-surgical treatment for every 
hip fracture is over $39,000; if outpatient rehabilitation 
services prevented even 20 percent of these hip fractures, the 
annual federal savings in health care costs would be over $441 
million. Essential outpatient, cost-effective services that 
would allow blind veterans to safely live independently at home 
are vitally important.
    Blind rehabilitation training can help give blind veterans 
the ability to function independently in their surroundings. 
Tom Zampieri also testified that, despite the demand for such 
services, there are only 39 filled BROS with 30 vacant 
positions. Only 19 U.S. universities in the nation offer 
training programs for training specialists to provide 
rehabilitation services and orientation and mobility 
instruction for blind persons. Six universities offer training 
in blind rehabilitation and 16 offer both blind instructor 
training and orientation and mobility education. The program 
for training Certified Vision Rehabilitation Therapists 
(hereinafter, ``CVRT'') and Certified Orientation and Mobility 
Specialists (hereinafter, ``COMS'') are located in programs 
that have academic internship positions at various VA Blind 
Centers but because of the cost of education and the higher 
compensation available in the private sector, students often 
enter private agency jobs after graduation.
    Committee Bill. Section 202 of the Committee bill would 
amend title 38 by adding a new Chapter 75, entitled ``Visual 
Impairment and Orientation and Mobility Professionals Education 
Assistance Program.'' This new chapter would consist of five 
new sections, described below.
    New section 7501--entitled, ``Establishment of scholarship 
program; purpose''--would, in subsection (a), subject to the 
availability of appropriations, establish a scholarship program 
to provide financial assistance to an individual accepted for 
enrollment or currently enrolled in a program of study leading 
to a certificate or degree in visual impairment or orientation 
and mobility or a dual degree in both such areas, at an 
accredited educational institution in the United States. Such 
individual would be required to enter into an agreement with 
the Secretary to receive such assistance.
    Subsection (b) of new section 7501 would provide that the 
purpose of the scholarship program is to increase the supply of 
qualified blind rehabilitation specialists for VA and the 
Nation.
    Subsection (c) of new section 7501 would require the 
Secretary to publicize the scholarship program established 
under this chapter to educational institutions throughout the 
United States, with an emphasis on disseminating information to 
institutions with high numbers of Hispanic students and to 
Historically Black Colleges and Universities.
    New section 7502--entitled ``Application and acceptance''--
would, in subsection (a), require individuals applying and 
participating in the scholarship program to submit an 
application together with an agreement described in new section 
7504, under which the participant would agree to serve a period 
of obligated service in the Department in return for payment of 
educational assistance. This section would define information 
that must be included with the application and agreement, 
including a fair summary of the rights and liabilities of an 
individual whose application is submitted and approved by the 
Secretary and a full description of the terms and conditions 
that apply to participation in the scholarship program and 
service in the Department.
    Subsection (b) of new section 7502 would require the 
Secretary to notify an individual in writing upon the 
Secretary's approval of the individual's participation in the 
scholarship program.
    New section 7503--entitled ``Amount of assistance; 
duration''--would, in subsection (a), specify that the amount 
of financial assistance provided will be determined by the 
Secretary as that necessary to pay the tuition and fees of the 
individual. For individuals enrolled in dual degree or 
certification programs, this provision would specify that the 
tuition and fees not exceed the amounts necessary for the 
minimum number of credit hours to achieve such dual 
certification or degree.
    Subsection (b) of new section 7503 would allow funds under 
this new program to supplement other educational assistance 
providing that the total amount of assistance does not exceed 
the total tuition and fees for the academic year.
    Subsection (c) of new section 7503 would set a maximum 
limit of $15,000 on the total amount of assistance provided 
under this chapter for an academic year to full-time students, 
and to part-time students at a ratio based on the relationship 
of the part-time study to full-time study. This section also 
would cap the total amounts of assistance under this program at 
$45,000.
    Subsection (d) of new section 7503 would place the maximum 
duration of assistance provided under this chapter at not more 
than 6 years.
    New section 7504--entitled ``Agreement''--would require 
that an agreement between the Secretary and a participant in 
the scholarship program be in writing and signed by the 
participant.
    Paragraph (1) of new section 7504 would mandate that the 
agreement contain the Secretary's agreement to provide the 
participant with financial assistance.
    Paragraph (2) would require the participant's agreement to 
a number of conditions, including to accept the financial 
assistance, to maintain enrollment and attendance in an 
approved program of study, to maintain an acceptable level of 
academic standing, and to serve as a full-time VA employee for 
3 years following completion of the program of study, with such 
service to be within the first 6 years after the participant 
has completed the program and received a degree or certificate.
    Paragraph (3) would permit the Secretary to set any other 
terms or conditions that the Secretary determined to be 
appropriate for carrying out this chapter.
    New section 7505--entitled ``Repayment for failure to 
satisfy requirements of agreement''--would provide for 
repayment of the unearned amount of educational assistance when 
the terms of the agreement are not satisfied and would allow 
for the Secretary to waive or suspend repayment when 
noncompliance is due to circumstances beyond the individual 
participant's control or in the best interest of the United 
States. A discharge in bankruptcy under title 11 would not 
discharge an individual from his or her obligation to repay the 
Secretary if the discharge order were entered less than 5 years 
after the date of the termination of the agreement or contract 
on which the debt were based.
    New chapter 75 of title 38 would be implemented not later 
than 6 months after the date of enactment of the Committee 
bill.
    DAV, PVA, and AFGE testified in support of these provisions 
at the Committee's hearing on health legislation on April 22, 
2009.

Sec. 203. Inclusion of Department of Veterans Affairs Facilities in 
        List of Facilities Eligible for Assignment of Participants in 
        National Health Service Corps Scholarship Program.

    Section 203 of the Committee bill, which is derived from 
S. 734, would require VA to transfer funds to the Department of 
Health and Human Services for the purpose of making VA 
facilities eligible for assignment of National Health Service 
Corps scholars.
    Background. The Department of Health and Human Services 
offers a number of programs designed to improve recruitment and 
retention in underserved areas known as health professional 
shortage areas. HPSAs are areas designated to have provider 
shortages based on geography, population groups or facilities 
with access barriers to primary care services.
    Section 254 of title 42, United States Code permits the 
Secretary of Health and Human Services to designate any public 
or nonprofit private medical facility a HPSA if the facility 
otherwise meets certain criteria. Section 254e(a)(2) expressly 
defines public or nonprofit private medical facilities to 
include Federal medical facilities. Section 254e(b) also 
authorizes the Secretary of Health and Human Services to 
establish regulations governing the designation of medical 
facilities as HPSAs.
    The Health Care Safety Net Amendments of 2002, Public Law 
107-251, granted automatic HPSA designations to all federally 
qualified health centers. This automatic designation granted to 
those facilities the right to recruit physicians through the 
National Health Service Corps (hereinafter, ``NHSC''). There is 
currently no statutory barrier to VA facilities being 
designated HPSA sites.
    The NHSC Scholarship Program, through scholarship and loan 
repayment programs, helps HPSAs throughout the country attract 
medical, dental and mental health providers. Since 1972, it is 
estimated that more than 30,000 clinicians have served in the 
Corps.
    The NHSC is a competitive program that pays tuition and 
fees and provides a living stipend to students enrolled in 
accredited medical (Medical Doctor or Doctor of Osteopathy), 
dental, nurse practitioner, certified nurse midwife and 
physician assistant training. Upon graduation, scholarship 
recipients serve as primary care providers between 2 and 4 
years in a community-based site in a high-need HPSA that has 
applied to and been approved by the NHSC as a service site.
    Currently, psychiatry is a qualifying NHSC occupation, and 
VA has listed this as its hardest specialty to fill. Also, no 
VA sites are listed on the NHSC placement list.
    Committee Bill. Section 203 of the Committee bill, in a 
freestanding provision, would mandate that VA transfer $20 
million to the Department of Health and Human Services for the 
purpose of including VA facilities on the list maintained by 
the Health Resources and Services Administration of facilities 
eligible for assignments of participants in the National Health 
Services Corps. This would enable veterans' health care 
facilities, which would otherwise not be able to apply for the 
Corps scholar placement, to do so.
    In testimony before the Committee on February 26, 2009, 
Kara Hawthorne, Director of the Office of Rural Health for the 
Veterans Health Administration, said:

        Every day, almost 60 million Americans in rural and 
        highly rural areas face numerous challenges regarding 
        health care, but one of the most significant in this 
        area is a shortage of providers--particularly specialty 
        providers. Recruitment and retention of health care 
        professionals in rural areas is a national problem, not 
        a VA-specific problem.

Sec. 204. Teleconsultation and Telemedicine.

    Section 204 of the Committee bill, which is derived from 
S. 734, would promote the increased utilization of 
teleconsultation and telemedicine by requiring all Veterans 
Integrated Service Networks (hereinafter, ``VISNs'') to fully 
implement the existing teleretinal imaging program, to use 
telehealth technologies for the screening of TBI and post 
traumatic stress disorder (hereinafter, ``PTSD'') patients in 
areas where these services are not otherwise available, and by 
providing appropriate financial incentives for program 
development.
    Background. For decades, telemedicine has been considered a 
means of overcoming barriers to providing rural health care. 
According to Dr. Michael Hatzakis et al., a VA physician 
writing in the Journal of Rehabilitation Research and 
Development in May/June 2003, experimental programs in 
telehealth were funded through existing grants on Indian 
reservations, in psychiatric hospitals, in the prison systems, 
and in medical schools between the 1950s and the 1970s. Dr. 
Hatzakis also noted that none have survived, reflecting in 
part, a failure to secure financial self-sufficiency. In recent 
years, technological advances have improved the cost-
effectiveness of telemedicine technologies. For example, costs 
for a telemedicine workstation were $50,000 to $100,000 in the 
mid-1990s, but less than $10,000 by the year 2000.
    Unlike private health care organizations, VA is not limited 
by interstate licensure limitations. Therefore, there is no 
concern regarding the practice of medicine across state lines. 
Yet telehealth services are not widely used, even in VA. In FY 
2008, for example, VA provided ambulatory services to a total 
of 4,901,797 veterans. But a telehealth technology allowing 
health care workers to monitor veterans' chronic diseases while 
the veteran was at home was used on only 36,400 patients. This 
is less than one percent of all veterans treated on an 
outpatient basis.
    In addition, while VA provides telemedicine services 
utilizing real time conferencing between VA medical centers and 
community based outpatient clinics (hereinafter, ``CBOCs''), it 
is not universally available. Currently, VA provides these 
services to some degree at most VA medical centers, but only at 
353 out of a possible 679 CBOCs.
    Under another program, VA provided general telehealth 
services using real time conferencing to an estimated 48,000 
veterans, 29,000 of which utilized the services for mental 
health purposes. Adam Darkins, Chief Consultant, Office of Care 
Coordination, in the Office of Patient Care Services, noted 
that outcomes data for tele-mental health have demonstrated a 
24.6 percent reduction in hospital admissions and a 24.4 
percent reduction in bed days of care when these services are 
utilized.
    VA also offers teleretinal imaging at some facilities. This 
is a method of taking digital images of the retina of the eye 
and transmitting them to eye specialists remotely who are able 
to interpret the images and diagnose disorders of the eye from 
those images. In FY 2008, VA had these services available at 
only 130 of its CBOCs.
    In a March 2007 position statement, the American Telehealth 
Association said:

        There is a growing consensus that the supply of health 
        care providers across the professions is going to be 
        inadequate to meet the expanding needs for health care 
        of the U.S. population--both in the short term and in 
        the long term. Telehealth, while not the entire 
        solution to the problems presented by the shortage and 
        maldistribution of health care providers, can make 
        important contributions to alleviating those problems.

    The ability of CBOCs to offer specialty services is 
particularly important to the needs of returning OEF/OIF 
veterans, many of whom return to remote areas with conditions 
like PTSD or TBI. In RAND's 2008 report, Invisible Wounds of 
War: Summary and Recommendations for Addressing Psychological 
and Cognitive Injuries, RAND estimated that there were 
approximately 300,000 servicemembers who had been deployed for 
OIF/OEF suffering from PTSD or major depression and that 
320,000 servicemembers reported experiencing a probable TBI 
during deployment.
    According to the report, among those with PTSD or major 
depression, only 53 percent had seen a physician or mental 
health provider for a mental health disorder in the past 12 
months and those who received care, just over half had received 
minimally adequate treatment.
    Captain Constance Walker, President of the Southern 
Maryland Chapter of the National Alliance on Mental Illness, 
testified before the Committee on October 24, 2007, that:

         * * * the likelihood of obtaining specialized services 
        [for PTSD and serious mental illnesses] on a consistent 
        basis is very small for veterans living in rural and 
        frontier areas beyond a reasonable commute to a VA 
        Medical Center or without access to an appropriately 
        and consistently staffed VA Community Based Outpatient 
        Clinic.

Tom Loftus, an American Legion Post Commander, also testified 
before the Committee on February 26, 2009, regarding the lack 
of availability of TBI and PTSD assessments in small 
communities.
    According to the National Rural Health Association, it has 
been estimated that about 20-23 percent of the U.S. population 
live in rural areas, but only 9-11 percent of physicians 
practice in rural areas. Among 1253 communities designated as 
Mental Health Professional Shortage Areas in 2007, for example, 
almost 75 percent did not have a psychiatrist. For this reason, 
VA psychiatrists, writing in the Journal of Academic Psychiatry 
in November 2007, recommended ensuring competency in 
telemedicine technologies as part of a curriculum designed to 
emphasize rural practice in psychiatry residency training.
    In addition, there is a need for more eye care services in 
rural areas. According to Dr. Anthony A. Cavallerano, and Dr. 
Paul R. Conlin, VA physicians writing in the Journal of 
Diabetes Science and Technology in January 2008, diabetic 
retinopathy, a condition of the eye resulting from diabetes, is 
the most common cause of visual loss in the U.S. These 
physicians further noted that only 60 percent of persons with 
diabetes receive timely and appropriate eye examinations. In FY 
2000, Congress recognized the importance of making eye care 
accessible to all veterans when, in Senate Report 106-410 to 
accompany the 2001 Department of Veterans Affairs and Housing 
and Urban Development, and Independent Agencies Appropriations 
Bill of 2001 (Public Law 106-271), the Appropriations Committee 
recommended that VA collaborate with the DOD and the Joslin 
Diabetes Center to implement the Joslin Vision Network. This 
collaboration created a system allowing specialists at a remote 
location to detect diabetic retinopathy and other eye 
conditions by reviewing images transmitted across a 
telecommunications network. Since that time, the program has 
expanded to assist in providing eye care to almost 20 percent 
of VA's diabetic veteran population.
    In 2001, VA convened an expert panel to evaluate 
teleretinal imaging to screen for diabetic retinopathy. In a 
statement regarding the implementation of VA's teleretinal 
program, this panel said:

        The VHA envisions developing and deploying a nationwide 
        teleretinal imaging system that will be regionalized by 
        VISN and will build on the VHA's robust information 
        technologies for acquiring, transmitting, interpreting, 
        and storing digital retinal images * * *. A similar 
        system for screening for [diabetic retinopathy] has 
        been established in the United Kingdom.

    The Committee is concerned that the VISNs currently have no 
financial incentive to invest in this important technology. The 
Veterans Equitable Resource Allocation (hereinafter, ``VERA'') 
system is the method VA uses to distribute resources among its 
21 VISNs. It distributes funds to each VISN based both on 
patient workload, as well as on the complexity of care 
provided. This system allocated $31.8 billion in general 
purpose funds during FY 2009. Currently, VERA does not factor 
all telemedicine and telehealth visits into its workload data.
    Committee Bill. Section 204 of the Committee bill would 
amend subchapter I of chapter 17 of title 38 by adding a new 
section 1709, entitled ``Teleconsultation and teleretinal 
imaging.''
    Subsection (a) of new section 1709 would require VA to 
carry out a program of teleconsultation for the provision of 
remote mental health and traumatic brain injury assessments in 
facilities of the Department that would not otherwise be able 
to provide these assessments without using outside providers. 
VA would be required to consult with appropriate professional 
services in the development of technical and clinical care 
standards for the use of teleconsultation services by VA.
    Subsection (b) of new section 1709 would require the 
Secretary to carry out a program of teleretinal imaging--
defined as a health care specialist using telecommunications, 
digital retinal imaging, and remote image interpretation to 
provide eye care--in each VISN.
    The Committee believes that mandating that VA carry out 
such a program in each VISN is necessary, particularly in light 
of a recent decision by VA to halt 45 Information Technology 
projects, including telehealth projects, that were either over 
budget or behind schedule. Although the Committee agrees that 
IT projects should be well-managed and resourceful, appropriate 
priority and focus need to be given to projects that hold the 
promise of delivering necessary patient care, including 
telehealth projects. On a recent oversight visit, it became 
clear that in certain areas, the number of telehealth visits is 
declining rather than increasing.
    Subsection (c) of new section 1709 would require that the 
Secretary submit a report in each of fiscal years 2010 through 
2015 to Congress on the teleconsultation and teleretinal 
imaging programs. Such report shall include a description of 
the efforts made by the Secretary to make available and utilize 
teleconsultation in rural areas, and the rates of utilization 
of teleconsultation by VISNs.
    Subsection (b) of section 204 of the Committee bill would 
require each VA facility that is involved in the training of 
medical residents to work with their affiliated universities to 
develop elective rotations in telemedicine for such residents.
    Subsection (c) of section 204 of the Committee bill would 
require VA to include telemedicine and telehealth visits in 
calculations of facility workload. It also would require the 
Secretary to provide incentives through the Department's 
resource allocation process for networks which utilize 
telemedicine and telehealth services.
    In testimony before the Committee on April 22, 2009, VA 
supported this section of the Committee bill.

Sec. 205. Demonstration Projects on Alternatives for Expanding Care for 
        Veterans in Rural Areas.

    Section 205, which is derived from S. 658, would authorize 
VA to develop pilot programs using innovative strategies to 
provide health care to rural areas.
    Background. The Consolidated Security, Disaster Assistance, 
and Continuing Appropriations Act of 2009, Public Law 110-329, 
appropriated $250 million to VA to carry-out rural veterans' 
health care demonstration projects. These funds have been used 
to expand telehealth initiatives, deploy mobile clinics, open 
new CBOCs and fund numerous other innovative ways of delivering 
health care to veterans in rural and highly rural areas. 
Similar funding is included in the Fiscal Year 2010 version of 
the bill.
    When VA receives funding for demonstration projects without 
those projects being prescribed by legislative action, VA can 
solicit ideas from the field and choose the best ideas for 
implementation. With the $250 million VA received in FY 2009 to 
fund rural health initiatives, for example, VA implemented 
projects partnering with the community to improve outreach, 
developed better ways of monitoring intensive care units and 
expanded telehealth initiatives.
    Committee Bill. Section 205, in a freestanding provision, 
would authorize the Secretary to carry out demonstration 
projects on alternatives for expanding rural veterans' health 
care.
    This provision would allow VA to consider innovative 
strategies for providing health care services to veterans who 
reside in rural and highly rural areas. These demonstration 
projects could include VA partnership with the Centers for 
Medicare and Medicaid Services to coordinate care for veterans 
in rural areas at critical access hospitals; VA partnership 
with the Department of Human Services to coordinate care for 
such veterans in community health centers; and increased 
coordination between VA and Indian Health Service to expand 
care for Indian veterans. The Secretary would ensure that the 
demonstration projects are located at facilities that are 
geographically distributed throughout the United States.
    The Committee expects VA to solicit proposals directly from 
field facilities so as to encourage local innovation.
    Section 205 of the Committee bill also requires VA to 
report to the Committees on Veterans' Affairs of the House of 
Representatives and the Senate and the Appropriations 
Committees of the House of Representatives and the Senate on 
the implementation of these projects 2 years after the date of 
enactment of this Act.

Sec. 206. Program on Provision of Readjustment and Mental Health Care 
        Services to Veterans Who Served in Operation Iraqi Freedom and 
        Operation Enduring Freedom.

    Section 206, which is derived from S. 658, would mandate 
that VA provide peer outreach and certain services to family 
members and of returning veterans and members themselves 
through Vet Centers.
    Background. There is a significant need for mental health 
providers throughout rural America, and VA and private practice 
often find themselves competing for the same pool of 
prospective employees. A recent report by the Inspector General 
found that, as a result of providing VA with authority to 
contract-out mental health services, the percentage of veterans 
within 30 minutes' drive of a mental health therapist or 
medication management rose from 60 percent to 90 percent.
    These services are particularly important, considering the 
numbers of Guard and Reservists returning to remote areas 
without the services found on a military base.
    Committee Bill. Section 206, in a freestanding provision, 
would require VA, not later than 180 days after the date of 
enactment of this Act, to establish a program to provide 
certain mental health services to veterans of OIF and OEF, 
especially those who served in the National Guard and Reserves, 
and to their immediate families.
    Under this program, VA would be required to provide peer 
outreach services, peer support services, readjustment 
counseling services, and mental health services to veterans.
    For immediate family members of such veterans during the 3-
year period following a veteran's return from OIF/OEF, VA would 
be required to provide education, support, counseling and 
mental health services to assist in the readjustment of such 
veterans to civilian life; in the recovery of any veteran 
sustaining an illness or injury during deployment; and in the 
readjustment of the family following the return of such 
veteran.
    Subsection (b) would require VA to contract with community 
mental health centers and other qualified entities to furnish 
services under the program in areas that VA determines are not 
adequately served by VA facilities. The community entities 
would be required, to the extent practicable, to use telehealth 
services and employ veterans trained to provide peer outreach 
and peer support.
    The community entities would be required to provide VA with 
clinical summary information for each veteran furnished mental 
health services. The community entities would be required to 
participate in specified VA training and comply with applicable 
VA protocols before incurring any liability on behalf of VA for 
the provision of services under the program.
    Subsection (c) would require VA to contract with a national 
not-for-profit mental health care organization to carry out a 
national program of training for veterans providing certain 
mental health services. VA would also be required to provide 
training programs for clinicians of community entities 
providing services under this program to ensure that such 
clinicians can furnish services in a way that recognizes 
factors unique to OIF/OEF veterans.
    VA would be required to submit a report, not later than 45 
days after the date of enactment of this Act, to the Committees 
on Veterans' Affairs of the House of Representatives and Senate 
which contains VA's plan for implementing this program.
    The provisions in this section of the Committee bill are 
not intended to replace the VA as a mental health provider for 
veterans, but rather to address a practical need in rural areas 
by providing a clear authority to contract for mental health 
services for OIF/OEF veterans in rural areas, when mental 
health services from VA are not available.

Sec. 207. Improvement of Care of American Indian Veterans.

    Section 207 of the Committee bill, which is derived from 
S. 658, would improve coordination between IHS and VA with 
respect to the treatment of American Indians, as well as the 
sharing of information and transfer of surplus equipment.
    Background. American Indians have a long history of service 
in the U.S. military, dating back to the American Indians who 
served alongside General George Washington. According to the 
DOD, per capita, American Indians and Alaska Natives are more 
likely to serve in the military than any other major racial or 
ethnic group. According to VA, American Indian and Alaska 
Native veterans are nearly 50 percent more likely than the 
average veteran to have a confirmed service-connected 
disability, and studies from the National Center for PTSD have 
found that American Indian veterans may be at a much-higher 
risk of PTSD. There is an obvious additional need for primary 
care and mental health services within this population. Despite 
a clear and historic participation in the military and current 
need for medical attention related to their service, American 
Indian veterans continue to face additional barriers to 
receiving quality care.
    American Indian veterans who reside in rural communities 
and on reservations often suffer disproportionate adverse 
health outcomes due to access limitations and under-resourced 
health care infrastructure. While IHS facilities are often more 
accessible to American Indian veterans, a lack of resources 
such as medical equipment and information technology limits the 
quality of care. Also, existing barriers between VHA and IHS in 
areas such as record-sharing have a negative impact on veterans 
who receive care at VHA and IHS. Additionally, there is a clear 
need to resolve cultural barriers that too often limit the 
effectiveness of VA care given to American Indian veterans. 
Improved collaboration and partnership between VA and IHS can 
improve care. Some VA facilities are making progress addressing 
these issues through the use of coordinators who address care 
issues for American Indians in a culturally-competent fashion.
    Committee Bill. Section 207 of the Committee bill would 
amend subchapter II of chapter 73 by adding a new section 
7330B--entitled ``Indian Veterans Health Care Coordinators''--
which would require VA to assign certain VA employees to the 
position of Indian Health Coordinator in each of the 10 VA 
Medical Centers that serve communities with the greatest number 
of Indian veterans per capita. These Coordinators would improve 
outreach to tribal communities; coordinate the medical needs of 
Indian veterans; expand the access and participation of the 
Department, the IHS, and tribal members in the Department of 
Veterans Affairs Tribal Veterans Representative program; act as 
ombudsmen for Indian veterans enrolled in the health care 
system of the VHA; and advocate for the incorporation of 
traditional medicine and healing in Department treatment plans 
for Indian veterans in need of care and services provided by 
the Department.
    This section of the Committee bill, in a freestanding 
provision, would require that not later than 1 year after the 
date of enactment of this Act, VA and the Department of Health 
and Human Services would enter into a Memorandum of 
Understanding to ensure that the health records of Indian 
veterans may be transferred electronically between VA and IHS.
    This section of the Committee bill, in a freestanding 
provision, would authorize VA to transfer surplus medical and 
information technology equipment to the IHS. VA would be 
authorized to transport and install medical or information 
technology equipment in IHS facilities. This section would 
provide that not later than 1 year after the date of enactment 
of this Act, the Secretary and the Secretary of Health and 
Human Services shall jointly submit to Congress a report on the 
feasibility and advisability of the joint establishment and 
operation by VHA and IHS of health clinics on Indian 
reservations to serve the populations of such reservations, 
including Indian veterans.

Sec. 208. Travel Reimbursement for Veterans Receiving Treatment at 
        Facilities of the Department of Veterans Affairs.

    Section 208, which is derived from both S. 658 and S. 734, 
would allow VA to adjust mileage rates and compensate veterans 
for airfare when that is the only practical way to reach a VA 
facility.
    Background. Under section III of title 38, VA is authorized 
to pay for an eligible veteran's travel to and from a facility 
for the purpose of examination, treatment or care. In addition 
to mileage amounts, VA can reimburse a veteran for the actual 
cost of ferry fares, and bridge, road and tunnel tolls. The 
statute does not authorize reimbursement for airfare.
    There are occasions when veterans must travel by air to 
receive health care, either because their physical condition 
requires it, or because that is the only practical way to reach 
a facility. States such as Hawaii and Alaska, for example, have 
unique geography requiring veterans to travel by air in order 
to obtain certain health care services. The expense of such 
services is often well beyond the means of the veterans who 
need these services.
    Committee Bill. Subsection (a) of section 208 of the 
Committee bill would amend section 111 of title 38, relating to 
VA payment of an allowance for certain travel, in two ways. 
First, it would amend subsection (a) of section 111 to insert a 
specific reimbursement rate--41.5 cents per mile. Second, it 
would amend subsection (g) of section 111 so as to, beginning 1 
year after the date of enactment of this Act, permit the 
Secretary to adjust the newly specified mileage rate for travel 
reimbursement so that that rate would be equal to the mileage 
reimbursement rate for the use of privately owned vehicles by 
Government employees on official business. If such an 
adjustment would result in a lower mileage rate than that which 
would be specified in subsection (a) of section 111, the 
Secretary would be required to submit to Congress, no later 
than 60 days before the implementation of the revised mileage 
rate, a report setting forth the justification for the decision 
to adjust the rate.
    Subsection (b) of section 208 of the Committee bill would 
further amend subsection (a) to specify that the actual 
necessary expense of travel would include travel by air if such 
travel is the only practical way for the person traveling to 
reach a VA facility.
    Subsection (c) of section 208 of the Committee bill would 
amend subsection (b)(1)(D)(i) to affect the limitation on 
travel eligibility related to pension rate.
    Subsection (d) of section 208 of the Committee bill would 
amend subsection (b) of section 111 by adding a new paragraph 
(4) which would require the Secretary to consider the medical 
condition of the veteran and any other impediments to ground 
transportation in determining whether travel by air is the only 
practical way to reach a VA facility.
    Subsection (e) of section 208 of the Committee bill would 
specify that the amendments to section 111 of title 38 made by 
subsections (b) and (d) of section 208 of the Committee bill, 
relating to travel by air, cannot be construed as expanding or 
modifying eligibility for payments or allowances for 
beneficiary travel.
    Subsection (f) of section 208 of the Committee bill would 
require VA, not later than 30 days after enactment of this 
legislation, to reverse the VHA handbook to clarify that an 
allowance for travel based on mileage paid under section 111(a) 
of title 38 may exceed the cost of such travel by public 
transportation regardless of medical necessity.
    The Committee believes it is an issue of equity to include 
travel by air. Expenses associated with air travel are 
generally much greater than those associated with ground 
transportation. For example, the average cost of travel by air 
is $60 per hour. Assuming mileage rates of 41.5 cents per mile 
at an average of 60 miles per hour, a vehicle can be operated 
for less than half the cost of airfare. Veterans traveling by 
air deserve special consideration regarding compensation for 
travel.

Sec. 209. Office of Rural Health Five-Year Strategic Plan.

    Section 209 of the Committee bill, which is derived from 
S. 734, would require VA's Office of Rural Health to develop a 
5-year strategic plan.
    Background. In 2006, Public Law 109-461 established the VA 
Office of Rural Health (hereinafter, ``ORH''). One of ORH's 
functions is to improve health care for veterans living in 
rural areas by developing best practices. In both FY 2008 and 
FY 2009, VA received $250 million for rural health initiatives.
    While VA has spent these funds on a variety of innovative 
pilot projects, it is important that ORH develop a strategy 
that will address the needs of veterans living in rural areas 
for years to come. Providing health care to veterans in rural 
areas is a national problem, not just a VA problem, and careful 
stewardship of available resources is important so as to ensure 
that VA meets the needs of the greatest number of veterans 
possible.
    Committee Bill. Section 209 of the Committee bill, in a 
freestanding provision, would require the Director of the 
Office of Rural Health to develop a 5-year strategic plan for 
the ORH not later than 180 days after the date of enactment of 
this Act. This provision would require that the plan contain 
specific goals for the recruitment and retention of health care 
personnel in rural areas; it be developed in conjunction with 
the Director of the Health Care Retention and Recruitment 
Office of the Department of Veterans Affairs; it include 
specific goals for ensuring the timeliness and quality of 
health care delivery in rural communities by contract and fee-
basis providers, developed in conjunction with the Director of 
the Office of Quality and Performance of the Department; it 
include specific goals for the expansion and implementation of 
telemedicine services in rural areas, developed in conjunction 
with the Director of the Office of Care Coordination Services 
of the Department; and it set incremental milestones describing 
specific actions to be taken to achieve the goals described 
above.
    The Committee expects that these provisions will ensure 
that ORH engages in sound fiscal planning with respect to the 
additional funds appropriated by Congress for rural health care 
development.
    PVA testified in support of this provision at the April 22, 
2009, health legislation hearing.

Sec. 210. Oversight of Contract and Fee-Basis Care.

    Section 210 of the Committee bill, which is derived from 
S. 734, would create incentives for providers paid by VA 
through contracts or on a fee-for-service basis to implement 
certain quality improvement measures.
    Background. In FY 2008, VA spent over $244 million for 
contracted outpatient care, and over $1.2 billion for 
outpatient fee-basis care. For providers paid on a fee-for-
service basis, VA measures the timeliness of claims processing 
but does not otherwise monitor the quality of patient care 
provided in a systematic way.
    In February 2007, the NRHA wrote in an issue paper 
addressing the quality of care provided to rural veterans:

        The NRHA calls on the VA and VHA to extend through 
        these contracts access for rural health providers and 
        facilities to the VA's exemplar[y] health care quality 
        improvements systems.

The NRHA also called on VA to improve coordination between 
community health providers and VA in rural areas.
    VA currently requires some indicators for services 
purchased by contract under Project Hero related to timeliness 
and access to care, but does not otherwise have uniform quality 
measures in place in all contracts for the provision of medical 
services. In the FY 2010 Independent Budget, the Independent 
Budget Veteran Service Organizations (hereinafter, ``IB VSOs'') 
recommended that VA develop a set of quality standards to 
ensure that contract providers maintain the same quality of 
care as VA health care providers.
    Committee Bill. Section 210 of the Committee bill would 
amend subchapter I of chapter 17 by adding a new section, 
section 1703A--entitled ``Oversight of contract and fee-basis 
care''--so as to provide for increased attention to the 
management of contract and fee-basis care in rural areas.
    Subsection (a) of new section 1703A would require the 
Secretary to designate a rural outreach coordinator at each 
CBOC where at least 50 percent of the veterans enrolled reside 
in a highly rural area. These coordinators would be responsible 
for coordinating care at and through the CBOC and collaborating 
with providers in the community who furnish care to enrolled 
veterans on fee-basis or under a contract.
    Subsection (b) of new section 1703A would mandate that the 
Secretary adjust fee-basis compensation paid to community 
providers in order to encourage such providers to obtain 
accreditation from recognized accrediting entities of their 
medical practice. In making the adjustments in compensation, 
the Secretary would be required to consider the increased costs 
of acquiring and maintaining such accreditation.
    Subsection (c) of new section 1703A would require the 
Secretary to adjust the fee-basis compensation of health care 
providers which are not accredited by a recognized 
accreditation entity to provide incentives for those providers 
to participate in a voluntary peer review program. In making 
the adjustments in compensation, the Secretary would be 
required to set such amounts as would be reasonably expected to 
encourage participation in voluntary peer review.
    Subsection (d) of new section 1703A would require VA to 
provide for the voluntary peer review of health care providers 
which provide health care services to VA on a fee basis and are 
not accredited by a recognized accrediting entity.
    The Chief Quality and Performance Officer (hereinafter, 
``CQPO'') in each VISN would be responsible for the oversight 
of this effort and would select a sample of patient records 
from each participating entity to be peer reviewed by a 
facility designated by the CQPO for such role.
    Each Department facility conducting peer review of 
community providers would be required to review the records in 
accordance with policies and procedures established by the 
Secretary, ensure that peer reviews are evaluated by the 
facility's Peer Review Committee, and develop a mechanism for 
notifying the Under Secretary for Health of any problems 
identified through peer review.
    The Under Secretary for Health would be required to develop 
a mechanism to terminate the use of fee-basis providers when 
quality of care concerns are identified through the peer review 
process.
    At the Committee's April 22, 2009, health legislation 
hearing, AFGE, DAV, NRHA and PVA testified in support of these 
provisions. These provisions are also consistent with the 
recommendations contained in the Independent Budget.

Sec. 211. Enhancement of Vet Centers to Meet Needs of Veterans of 
        Operation Iraqi Freedom and Operation Enduring Freedom.

    Section 211 of the Committee bill, which is derived from 
S. 734, would allow VA to use volunteers and other individuals 
to provide readjustment counseling, and to expedite the 
credentialing and privileging of licensed independent health 
care providers working on a volunteer basis in readjustment 
counseling centers.
    Background. In recognition that a significant number of 
Vietnam-era veterans were experiencing readjustment problems, 
in 1979, VA established the readjustment counseling service 
which created readjustment counseling centers, or ``Vet 
Centers.'' Congress has since made readjustment counseling 
services available to veterans serving during other periods of 
armed hostilities.
    Section 1712A of title 38 requires the Secretary to furnish 
readjustment counseling, which may include mental and 
psychological assessments, upon the request of veterans who 
served on active duty in a theater of combat operations or in 
any area in which a period of hostilities occurred. If an 
assessment completed by a physician or psychologist determines 
that mental health services are necessary to facilitate the 
successful readjustment of veterans to civilian life, services 
will be provided by the Department.
    Currently, clinical professionals who work in Vet Centers 
are required to undergo credentialing and privileging 
procedures in accordance with policies of VA. There is no 
distinction between paid and volunteer counselors. As 
previously noted, there is a national and VA-specific shortage 
of mental health care providers.
    Committee Bill. Section 211 of the Committee bill would 
amend Subsection (c) of section 1712A of title 38, relating to 
VA's readjustment counseling authority, to allow VA to use 
volunteer counselors in the provision of readjustment 
counseling and related mental health services.
    To serve as a volunteer counselor at a Vet Center, an 
individual would have to be a licensed psychologist or social 
worker who had never been named in a tort claim arising from 
professional activities and also had never had or have pending 
against them, any disciplinary action taken with respect to any 
license or certification qualifying the individual to provide 
counseling services.
    Eligible volunteer counselors would be issued credentials 
and privileges for the provision of counseling and related 
mental health services on an expedited basis, not later than 60 
days from the date the application is submitted.
    Subsection (b) of section 211 of the Committee bill would 
amend subsection (e) of section 1712A so as to require each Vet 
Center to develop an outreach plan to ensure that the community 
served by the center is made aware of the services offered by 
the center.
    The Committee is committed to ensuring that every attempt 
is made to add more providers to the VA health care system. 
Those individuals who provide high quality health care services 
and who voluntarily give their time and professional talents to 
care for veterans should not be unduly burdened by cumbersome 
bureaucratic processes. By streamlining the credentialing and 
privileging processes for those select providers, the Committee 
hopes to attract more high quality health care professionals to 
VA's health care 
system.

Sec. 212. Centers of Excellence for Rural Health Research, Education, 
        and Clinical Activities.

    Section 212, which is derived from S. 658, would create VA 
Rural Health Centers of Excellence.
    Background. Veterans who reside in rural areas often have 
worse health outcomes than veterans residing in urban areas. 
For example, in FY 2005 and FY 2006, the rate of suicide for 
veterans last utilizing a rural VA facility was 39.7/100,000 
persons per year compared to 35.0/100,000 persons per year for 
urban veterans. Research sponsored by VA's Health Services 
Research and Development division has cited worse health 
outcomes and health quality of life scores among rural veterans 
compared to urban veterans, and favorably recommended 
innovative approaches to improve access to care and quality of 
care in those areas.
    Committee Bill. The Committee bill would amend subchapter 
II of chapter 73, as amended by section 214, to add a new 
section 7330C, entitled ``Centers of excellence for rural 
health research, education, and clinical activities.''
    Under new section 7330C, the Secretary, through the 
Director of the Office of Rural Health, would be required to 
establish and operate at least one but not more than five 
centers of excellence for the conduct of research, education, 
and clinical activities relating to health services in rural 
areas.
    These centers would be required to develop specific models 
to be used in furnishing health services to veterans in rural 
areas, provide education and training for health care 
professionals on the furnishing of health services to veterans 
in rural areas, and develop and implement innovative clinical 
activities and systems of care for VA for the furnishing of 
health services to veterans in rural areas.
    VA would be permitted to designate an existing rural health 
resource center as a center of excellence. These centers of 
excellence would be required to be geographically dispersed 
throughout the United States.
    Subsection (d) of new section 7330C would authorize the 
appropriation of such sums as may be necessary to support the 
research and education activities of the centers of excellence 
and would authorize the Under Secretary for Health to allot to 
the centers funds appropriated to VA's Medical Care and Medical 
and Prosthetic Research accounts.
    This subsection would also specify that clinical and 
scientific investigation activities at each center would be 
eligible to compete for awards of funding from the Medical and 
Prosthetics Research Account, and would receive priority for 
funds awarded to projects for research in the care of rural 
veterans.
    The Committee believes that creating these centers will 
significantly enhance VA's ongoing efforts to meet the health 
care needs of veterans residing in rural areas.

Sec. 213. Pilot Program on Incentives for Physicians Who Assume 
        Inpatient Responsibilities at Community Hospitals in Health 
        Professional Shortage Areas.

    Section 213, which is derived from S. 734, would create a 
pilot program allowing VA physicians to provide care to 
veterans admitted to community hospitals, and providing 
financial incentives for them to do so.
    Background. The Census Bureau estimates that 8 percent of 
the population as a whole are veterans. The DOD does not track 
whether its veterans return to rural or urban areas, and there 
are no consistent Federal-wide definitions of a ``rural'' 
population. VA uses the Census Bureau's definition of rural. 
Using this definition, about 39 percent of current veterans 
enrolled in the VA health care system reside in rural areas and 
1.6 percent reside in highly rural areas.
    The high number of veterans returning to rural areas will 
likely continue with the newest generation. According to the 
National Rural Health Association's February 2007 Issue Paper, 
44 percent of new military recruits came from rural areas. In 
contrast, just 25 percent of the U.S. population is considered 
rural.
    As a result, there are far fewer VA inpatient facilities 
located in rural areas. For example, in FY 2008, VA had 633 
mental health beds in facilities operating in rural areas, 
compared to 4,088 mental health beds in facilities operating in 
urban areas. Building additional facilities in rural areas is 
problematic because rural veterans are, by definition, 
dispersed over a wide area. VA stated in a February 26, 2009, 
response to questions posed at the Committee's rural health 
hearing:

        Although the cumulative number of veterans living in 
        rural areas is high, the number living in any specific 
        rural area is relatively low. The need for high 
        intensity, low frequency health care services such as 
        admission to an inpatient mental health unit is likely 
        to be variable.

    VA must obtain care for veterans in many of these areas by 
paying community hospitals on a contractual or fee-for-service 
basis. This means that veterans treated and monitored by VA 
doctors in VA community based outpatient clinics must be 
treated by a non-VA doctor when admitted to a community 
hospital. This is because VA doctors do not have privileges at 
community hospitals because such facilities require that a 
physician occasionally accept responsibility for caring for 
patients needing hospital admission that do not otherwise have 
a doctor. Currently, VA doctors are not clearly authorized to 
see non-veteran patients, even if it is a condition of their 
ability to treat veterans in community hospitals.
    Committee Bill. Section 213 of the Committee bill, in a 
freestanding provision, would require VA to carry out a pilot 
program to assess the feasibility and advisability of (1) 
providing financial incentives to VA physicians who obtain and 
maintain inpatient privileges at certain community hospitals, 
and (2) the collection of payments from third parties for care 
provided by any such physicians to nonveterans while carrying 
out their responsibilities at the community hospital where they 
are privileged.
    The community hospitals that would be involved in the pilot 
program would be in health professional shortage areas where 
the number of physicians willing to assume inpatient 
responsibilities at the hospital is sufficient for the purposes 
of the pilot program. Eligible physicians would be primary care 
or mental health physicians employed by VA on a full-time basis 
who are in good standing with the Department, and who have 
primarily clinical responsibilities with the Department. 
Participation in the pilot program would be voluntary.
    The pilot program would be carried out during the 3-year 
period beginning on the date of the commencement of the pilot 
program in not less than five community hospitals in each of 
not less than two VISNs. The locations would be selected by the 
Secretary based on the results of a survey of eligible 
physicians to determine the extent of interest of such 
physicians in participating in the pilot program.
    The survey, which would be conducted not later than 120 
days after the date of enactment of this Act, would be required 
to disclose the type, amount and nature of the financial 
incentives to be provided to physicians participating in the 
pilot program.
    Physicians selected for the program would be required to 
assume and maintain inpatient responsibilities at one or more 
community hospitals selected by the Secretary for participation 
in the pilot.
    Any physician participating in the pilot program who would 
be required to see non-veteran patients as a condition of 
obtaining privileges would be deemed to be acting in the scope 
of the physician's office or employment for purposes of the 
Federal Torts Claim Act.
    The Secretary would be required to compensate eligible 
physicians participating in the pilot program with additional 
compensation as the Secretary considers appropriate for the 
discharge of inpatient responsibilities by such physician at a 
community hospital. The amount of such compensation would be 
set forth in a written agreement between VA and the physician.
    The Secretary would be required to consult with the 
Director of the Office of Personnel Management regarding how 
any additional compensation would be treated for the purposes 
of retirement and other purposes under the civil service laws.
    Subsection (i) of section 213 of the Committee bill would 
require VA to implement mechanisms to collect from third party 
payers for services provided by VA physicians to non-veterans 
as part of the pilot program.
    Subsection (j) of section 213 of the Committee bill would 
define inpatient responsibilities as on-call responsibilities 
required by a community hospital as a condition of granting 
privileges to the physician to practice in the hospital.
    Beginning not less than 1 year after the date of enactment 
of the Committee bill and annually thereafter, VA would be 
required to submit to Congress a report on the pilot program, 
including the Secretary's findings with regard thereto, the 
number of veterans and non-veterans provided inpatient care, 
and the amounts collected and payable.
    NRHA, PVA and AFGE testified in support of this specific 
pilot program at the Committee's April 22, 2009, health 
legislation hearing.
    The Committee's goal for this pilot program is to foster 
improved coordination between VA and community health 
organizations, as well as to ensure that veterans receive good 
continuity of care in the community. By allowing VA doctors to 
treat their VA patients admitted to community hospitals, the 
community and VA profit from the wise utilization of available 
health care resources.

Sec. 214. Annual Report on Matters Related to Care for Veterans Who 
        Live in Rural Areas.

    Background. According to VA, in FY 2008, contractual 
purchasing authority on outpatient care, including emergency 
room costs and inpatient ancillary costs, totaled $244,330,834. 
In FY 2008, VA also spent $1.27 billion on care provided on a 
fee-for- service basis.
    Information on how and under what circumstances these 
expenditures are made is not readily available. As this portion 
of VA's budget continues to expand, improving oversight becomes 
very important. In the FY 2010 Independent Budget, the IB VSOs 
expressed concern regarding VA's inability to monitor quality 
of care provided by contract providers.
    Committee Bill. Section 214 of the Committee bill, in a 
free standing provision, would require VA to submit an annual 
report on the implementation of the provisions in sections 209 
through 213 of the Committee bill and on the establishment and 
functions of the Office of Rural Health. In the first such 
report, VA would be required to include assessment of the fee-
basis health-care program required by section 212(b) of Public 
Law 109-461 and the outreach program required by section 213 of 
that Act.

Sec. 215. Transportation Grants for Rural Veterans Service 
        Organizations.

    Section 215, as derived from S. 658, would authorize grants 
to state veterans' service agencies and veterans' service 
organizations for the purposes of providing certain 
transportation services to veterans.
    Background. Transportation is often a problem for many 
veterans when making and keeping health care appointments. 
Cancellation rates for outpatient appointments have 
historically been high within VA, and transportation issues are 
commonly cited as a contributing factor.
    Veterans service organizations organize and offer van 
transportation services to veterans traveling to and from 
health care appointments. Their ability to offer these 
services, however, is often limited by the availability of 
funding. This is particularly true in areas where the distances 
between veterans' residences and VA facilities are great, such 
as in highly rural areas.
    Committee Bill. Section 215, in a freestanding provision, 
would require VA to establish a grant program to provide 
innovative transportation options to veterans in highly rural 
areas. The recipients of grants under the program would be 
state veterans' service agencies and veterans' service 
organizations. Entities receiving a grant would be required to 
use the funds to assist veterans in highly rural areas with 
transportation to and from VA medical centers and to otherwise 
assist in providing medical care to veterans residing in highly 
rural areas.
    The maximum amount of a grant under this program would be 
$50,000 and a recipient of a grant under this program would not 
be required to provide matching funds as a condition of 
receiving the grant.
    The provision would authorize the appropriation of $3 
million for each of the fiscal years 2010 through 2014 to carry 
out this grant program.

                  TITLE III--OTHER HEALTH CARE MATTERS

Sec. 301. Veterans' Emergency Care Fairness Act of 2009.

    Section 301, which is derived from S. 404, would allow 
veterans who meet certain criteria to be reimbursed for the 
difference between the maximum amount payable for emergency 
medical services and any amount paid by an existing insurance 
policy.
    Background. Under Public Law 110-387, originally enacted on 
November 30, 1999, a veteran who is enrolled in VA's health 
care system can be reimbursed for emergency treatment received 
at a non-VA hospital. However, the statute only permits such VA 
reimbursement if the veteran has no other outside health 
insurance, no matter how limited that other coverage might be. 
This sole payer provision means that a veteran who has any 
insurance is not entitled to reimbursement from VA for 
emergency medical treatment received at a non-VA facility, even 
if the veteran's insurance policy does not cover the full 
amount owed.
    Committee Bill. Section 301 of the Committee bill would 
amend Section 1725(b)(3)(C) of title 38, relating to VA 
reimbursement to veterans enrolled for VA care who receive 
emergency care from outside providers. Subsection (a) of 
section 301 of the Committee bill would amend section 
1725(b)(3)(C) of title 38 so as to strike the phrase ``in whole 
or in part,'' in order to authorize VA to provide reimbursement 
for emergency care when the veteran has some insurance coverage 
but that coverage is not sufficient to cover the cost of the 
care. Under this change VA would be authorized to cover the 
difference between the amount a veteran's insurance will pay 
for emergency care and the total cost of care, thus becoming 
the payer of last resort in such cases.
    Section 1725 is further amended by adding a new paragraph 
(4) to subsection (c) to specify that VA is to be a secondary 
payer, that payment by VA along with any insurance payment 
shall be payment in full, and that VA may not reimburse a 
veteran for any copayment the veterans owes a third party. 
These amendments would take effect on the date of enactment of 
this Act. In addition to amending current law in a prospective 
manner, Section 301 of the Committee bill, in a freestanding 
provision, would authorize VA to reimburse the cost of 
emergency care dating back to the effective date of the current 
law if the Secretary determines that it is appropriate to do 
so.

Sec. 302. Prohibition on Collection of Copayments from Veterans Who Are 
        Catastrophically Disabled.

    Section 302 of the Committee bill, derived from S. 821, 
would waive the collection of copayments from veterans who are 
catastrophically disabled.
    Background. In 1996, when Congress passed legislation 
establishing the priority for enrolling veterans in VA's health 
care system, it designated catastrophically disabled veterans 
as Category 4. If these veterans' income would otherwise place 
them in Categories 7 or 8, they are required to pay all fees 
and copayments for the care of their non-service-connected 
disabilities. The IB VSOs recommend that copayments for 
catastrophically disabled veterans be eliminated in light of 
the unique health care needs of this population. The veterans 
who would be affected by this change, such as those with spinal 
cord injury, require ongoing care and services.
    Private insurers often do not cover these kinds of 
services, and most other health programs do not offer the level 
of care provided by VA. These veterans should not be required 
to pay fees and copayments for their care, as they utilize and 
rely on VA health care at a much higher rate than many other 
veterans.
    Committee Bill. Section 302 of the Committee bill would 
amend subchapter III of chapter 17 by adding a new section 
1730A. New section 1730A--entitled, ``Prohibition on collection 
of copayments from veterans who are catastrophically 
disabled''--would prohibit VA from collecting any copayment for 
the receipt of hospital care or medical services from a veteran 
who is catastrophically disabled, even if due to a non-service-
connected injury.
    The Committee intends that this provision eliminate all 
copayments for medical care, including prescriptions and 
nursing home care, for catastrophically disabled veterans.
    DAV, PVA, and the National Multiple Sclerosis Society 
support this provision.
    In a letter dated April 23, 2009, Blinded Veterans wrote 
the following:

        [This] legislation will eliminate these co-payments for 
        severely disabled veterans who are blind, paralyzed, or 
        suffered amputations, who often as non-service 
        connected veterans live on small social security 
        disability SSDI payments, and unable to pay for these 
        admissions. With this change these disabled veterans 
        will be able to access daily living blind or other 
        rehabilitation training that will improve their ability 
        to live independently at home.

               TITLE IV--CONSTRUCTION AND NAMING MATTERS

Sec. 401. Major Medical Facility Project Department of Veterans Affairs 
        Medical Center, Walla Walla, Washington.

    Section 401, in a freestanding provision which is derived 
from S. 509, would authorize VA to design and construct a new 
multiple specialty outpatient facility, perform campus 
renovation and upgrades, and provide additional parking at the 
VA Medical Center, Walla Walla, Washington. According to VA, 
the project will serve nearly 50,000 enrolled veterans, and 
will be carried out in an amount not to exceed $71,400,000. 
These funds were already appropriated for this project in VA's 
fiscal year 2009 major construction budget.

Sec. 402. Merril Lundman Department of Veterans Affairs Outpatient 
        Clinic.

    Section 402, in a freestanding provision which is derived 
from S. 226, would allow for the VA outpatient clinic in Havre, 
Montana to be designated as the ``Merril Lundman Department of 
Veterans Affairs Outpatient Clinic.''
    In 2007, Merril Lundman, a veteran from Havre, Montana, 
started a petition drive to ask for a clinic in Havre. Merril 
Lundman died in December 2007, about a month before VA 
announced it would open a clinic in Havre. As required by the 
Committee's rules, the full Montana Congressional delegation, 
and the Montana State Veterans' Organizations with national 
membership of 500,000 or more, endorse this facility being 
named in honor of Merril Lundman.

                      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 $6.7 billion over the 2010-
2014 period, assuming appropriation of the necessary amounts. 
Enacting the bill would increase direct spending but those 
effects would not be significant. Enactment of the Committee 
bill would minimally affect receipts and would not affect the 
budget of state and local governments. Tribal governments would 
see minimal impact from enactment.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                               Congressional Budget Office,
                                   Washington, DC, August 31, 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. 801, the Caregiver 
and Veterans Health Services 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. 801--Caregiver and Veterans Health Services Act of 2009
    Summary: S. 801 would authorize new programs for caregivers 
of disabled veterans and make several changes to existing 
veterans' health care programs. In total, CBO estimates that 
implementing the bill would cost about $6.7 billion over the 
2010-2014 period, assuming appropriation of the specified and 
estimated amounts. Enacting the bill would increase direct 
spending, but CBO estimates those effects would not be 
significant. Enacting the bill would not affect revenues.
    S. 801 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act 
(hereinafter, ``UMRA'').
    Estimated cost to the Federal government: The estimated 
budgetary impact of S. 801 is shown in Table 1. The costs of 
this legislation fall within budget function 700 (veterans 
benefits and services).
    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 existing or similar programs.

           Table 1.--Budgetary Impact of S.801, the Caregiver and Veterans Health Services Act of 2009
----------------------------------------------------------------------------------------------------------------
                                                            By fiscal year, in millions of dollars--
                                               -----------------------------------------------------------------
                                                   2010       2011       2012       2013       2014    2010-2014
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATIONa

Assistance for Caregivers
    Estimated Authorization Level.............        125        249        913      1,509      2,154      4,950
    Estimated Outlays.........................        113        234        845      1,441      2,076      4,709
Rural Demonstration Projects
    Estimated Authorization Level.............        255        258        263        268        274      1,318
    Estimated Outlays.........................        230        255        261        266        272      1,284
Travel Reimbursements
    Estimated Authorization Level.............         22         45         91         92         93        343
    Estimated Outlays.........................         20         43         86         91         92        332
Education Assistance
    Estimated Authorization Level.............         22         30         41         51         62        206
    Estimated Outlays.........................         20         29         40         50         61        200
Medical Construction
    Authorization Level.......................         71          0          0          0          0         71
    Estimated Outlays.........................          3         19         23         17          6         68
Copayments from Certain Disabled Veterans
    Estimated Authorization Level.............          8          8          8          8          8         40
    Estimated Outlays.........................          7          8          8          8          8         39
Transportation Grants
    Authorization Level.......................          3          3          3          3          3         15
    Estimated Outlays.........................          3          3          3          3          3         15
Rural Centers of Excellence
    Estimated Authorization Level.............          2          2          2          2          2         10
    Estimated Outlays.........................          2          2          2          2          2         10
Coordinators of Care for Native American
 Veterans
    Authorization Level.......................          1          1          1          1          1          5
    Estimated Outlays.........................          1          1          1          1          1          5
Training for Mental Health Providers
    Authorization Level.......................          1          1          1          1          1          5
    Estimated Outlays.........................          1          1          1          1          1          5
Peer Reviews
    Authorization Level.......................          1          1          1          1          1          5
    Estimated Outlays.........................          1          1          1          1          1          5
Emergency Care
    Authorization Level.......................          1          1          1          1          1          5
    Estimated Outlays.........................          1          1          1          1          1          5
Other Provisions
    Authorization Level.......................          *          *          *          *          *          1
    Estimated Outlays.........................          *          *          *          *          *          1
                                               -----------------------------------------------------------------
      Total Changes
          Estimated Authorization Level.......        512        599      1,325      1,937      2,600      6,974
          Estimated Outlays...................        402        597      1,271      1,881      2,523     6,678
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000.
aIn addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
  enacting S.801 would increase direct spending by less than $500,000 over the 2010-2014 period and 2010-2019
  period.

Spending subject to appropriation
    CBO estimates that implementing S. 801 would cost $6.7 
billion over the 2010-2014 period, assuming appropriation of 
the specified and estimated amounts.
    Assistance for Caregivers. Title I would require the 
Department of Veterans Affairs (hereinafter, ``VA'') to provide 
several benefits to caregivers of certain disabled veterans. In 
total, CBO estimates that implementing those provisions would 
cost $4.7 billion over the 2010-2014 period, assuming 
appropriation of the necessary amounts (see Table 2).

   Table 2.--Components of the Estimated Changes in Spending Subject to Appropriation  Under Title I of S.801
----------------------------------------------------------------------------------------------------------------
                                                            By fiscal year, in millions of dollars--
                                               -----------------------------------------------------------------
                                                   2010       2011       2012       2013       2014    2010-2014
----------------------------------------------------------------------------------------------------------------
Stipends
    Estimated Authorization Level.............         14         33        401        838      1,313      2,599
    Estimated Outlays.........................         13         31        364        791      1,258      2,457
Travel Benefits
    Estimated Authorization Level.............         77        159        332        346        361      1,275
    Estimated Outlays.........................         69        150        314        342        357      1,232
Oversight of Caregivers
    Estimated Authorization Level.............          2          5         56        116        182        361
    Estimated Outlays.........................          2          4         50        110        174        340
Personnel and Other Costs
    Estimated Authorization Level.............         28         45         58         88        119        338
    Estimated Outlays.........................         26         43         56         84        115        324
Benefits During Caregiver Training
    Estimated Authorization Level.............          1          3         39         64         89        196
    Estimated Outlays.........................          1          2         36         61         86        186
Medical Care
    Estimated Authorization Level.............          1          3         21         44         69        138
    Estimated Outlays.........................          1          3         19         41         66        130
Respite Care
    Estimated Authorization Level.............          *          1          6         13         21         41
    Estimated Outlays.........................          *          *          6         12         20         38
Survey
    Estimated Authorization Level.............          2          0          0          0          0          2
    Estimated Outlays.........................          1          1          0          0          0          2
                                               -----------------------------------------------------------------
      Total Changes in Title I
          Estimated Authorization Level.......        125        249        913      1,509      2,154      4,950
          Estimated Outlays...................        113        234        844      1,441      2,076     4,709
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000.


    Stipends. Section 102 of the bill would require VA to pay a 
monthly stipend to caregivers of severely injured veterans. CBO 
estimates that implementing the provision would cost about $2.5 
billion over the 2010-2014 period.
    Under section 102, caregivers of veterans whose severe 
service-connected injuries were incurred or aggravated on or 
after September 11, 2001, would be eligible for monthly 
stipends and other benefits. (The other benefits are discussed 
below.) Based on information from the Department of Defense 
(hereinafter, ``DOD'') on military retirees, CBO estimates that 
in 2010 caregivers to about 2,000 veterans would be eligible 
for VA benefits. Starting in 2012, the bill would widen the 
eligible population to include caregivers of other veterans 
with severe service-connected injuries. Based on information 
from VA on how they would implement the bill, CBO estimates 
that caregivers to 52,500 veterans would become eligible for VA 
benefits. CBO further estimates that the program would be 
implemented gradually, with only 475 caregivers receiving 
stipends in 2010 and full implementation in 2015.
    Based on data from the Bureau of Labor Statistics on 
average hourly pay for home health care aides, CBO estimates 
that in 2010, VA would pay 475 family caregivers a stipend of 
$2,350 a month (an hourly rate of $10.50 for an average of 225 
hours a month), for a cost of $13 million in 2010. After 
adjusting for gradual implementation of the program over the 
2010-2014 period and for inflation, CBO estimates that number 
of family caregivers receiving stipends would grow to 39,400 in 
2014, at a cost of $1.3 billion that year.
    Travel Benefits. Section 103 would authorize VA to pay 
transportation, lodging, and subsistence expenses of family 
members and other caregivers of veterans. Over the 2010-2014 
period, CBO estimates that implementing this provision would 
cost $1.2 billion, assuming appropriation of the necessary 
amounts.
    Lodging and subsistence expenses of nonveterans are not 
reimbursable under current law. Based on information from VA 
about veterans who have received travel benefits in 2009, CBO 
estimates that in 2010 VA would reimburse $1,950 each to 34,000 
nonveterans (an average per diem rate of $130 for 15 days a 
year), for a cost of $66 million in 2010. After adjusting for 
gradual implementation of the program over the 2010-2014 period 
and for inflation, CBO estimates that the number of nonveterans 
receiving per diems would grow to almost 150,000 a year by 2014 
and VA would spend about $1.2 billion a year over the 2010-2014 
period.
    CBO estimates that under the bill almost all family members 
or caregivers would either travel in the same vehicle with the 
veteran or would be deemed medically necessary attendants (VA 
is currently authorized to pay transportation expenses in those 
instances), but that a few nonveterans would become newly 
eligible for reimbursement of travel costs starting in 2010. 
CBO further estimates that 6,000 nonveterans would receive 
reimbursements worth $500 in 2010, for a total cost that year 
of $3 million. After adjusting for gradual implementation of 
the program over the 2010-2014 period and for inflation, CBO 
estimates that VA would spend about $55 million on travel costs 
for nonveterans over the 2010-2014 period.
    Oversight of Caregivers. Section 102 also would require 
regular oversight of caregivers, including home visits. CBO 
estimates that implementing the provision would cost $340 
million over the 2010-2014 period.
    Based on information from VA, CBO estimates that VA would 
contract with home-health agencies to conduct oversight of 500 
caregivers at a cost of almost $325 a month per caregiver (an 
hourly rate of $108 for an average of 3 hours a month), for a 
cost of $2 million in 2010. After adjusting for gradual 
implementation of the program over the 2010-2014 period and for 
inflation, CBO estimates that the number of caregivers being 
overseen would grow to 39,400 in 2014, at a cost of about $175 
million that year.
    Personnel and Other Costs. To implement the new caregiver 
benefits under section 102 of the bill, VA would need 
additional personnel at medical centers and at its headquarters 
in Washington, DC. Those personnel would evaluate veterans and 
their caregivers to determine the type of care veterans need 
and the training their caregivers require, and provide 
training, counseling, and support to caregivers. VA also would 
be required to design an interactive Web site to provide 
information on caregiver services, conduct outreach, and report 
periodically to the Congress. CBO estimates that implementing 
those provisions would cost about $325 million over the 2010-
2014 period.
    Based on information from VA, CBO estimates that each of 
the 153 medical centers would require a team consisting of a 
nurse, a social worker, a psychologist, a physical therapist, 
an occupational therapist, and a program support assistant. An 
additional staff of three people would be required at VA 
headquarters to monitor and coordinate implementation. Assuming 
an average annual salary of $115,000 per person and after 
adjusting for inflation, CBO estimates that about 25 percent of 
the necessary staff would be hired in 2010 at an annual cost of 
$26 million, and that all necessary staff would be hired by 
2014, at a cost that year of $115 million.
    Benefits During Caregiver Training. Section 102 would 
provide respite care and travel benefits to caregivers while 
they undergo training at VA facilities. CBO estimates that 
implementing those provisions would cost about $185 million 
over the 2010-2014 period.
    The bill would require VA to provide training to family 
members or other individuals to prepare them to provide care to 
disabled veterans. Based on information from VA, CBO expects VA 
would provide initial training for two weeks and refresher 
training for one week each year. During those training periods, 
VA also would provide respite care (if the veteran had no 
substitute caregivers), reimbursement of travel costs, and per 
diem expenses.
    CBO estimates that in 2010 about 450 veterans would require 
respite care during the two-week period of initial training--at 
a daily cost of $210--for a total cost of $1 million that year. 
The following year, CBO estimates that 1,000 veterans would 
need respite care (550 during initial training and 450 during 
refresher training) at a total cost of $2 million in 2011. By 
2014, CBO estimates that almost 35,500 veterans would require 
respite care during training, for a cost of $57 million that 
year.
    CBO further estimates that 550 caregivers would undergo 
initial training and be eligible for travel benefits in 2010. 
(That figure is higher than the number of veterans requiring 
respite care because CBO assumes some veterans will have more 
than one caregiver.) CBO estimates that half--or 275--live 
close enough to the training site that they would commute daily 
and be eligible for mileage reimbursements averaging $375 (90 
miles round trip for 10 weekdays at a reimbursement rate of 
$0.415 per mile). The other 275 would travel to the training 
site and stay there for the duration of training. Those 
caregivers would be eligible for reimbursement for travel costs 
averaging $150 (two 180 mile round trips at $0.415 per mile) as 
well as per diems averaging $130 a day. CBO estimates that 
total costs for caregivers undergoing training in 2010 would be 
less than $500,000. In 2011, 605 caregivers would commute for 
training (330 for initial training and 275 for refresher 
training), while another 605 would travel to the training site 
and stay there for the duration of their training, for total 
costs that year of about $1 million. By 2014, CBO estimates 
that about 43,300 caregivers would undergo training and would 
receive travel benefits and per diems worth about $30 million 
that year.
    Medical Care. Section 102 also would authorize VA to 
provide medical care to caregivers, if such caregivers are not 
covered under other health plans. CBO estimates that 
implementing the provision would cost $130 million over the 
2010-2014 period.
    The population eligible for this benefit also is similar to 
the population eligible for the monthly stipend; however, CBO 
estimates that only one-quarter of the caregivers would be 
eligible (i.e. would not be covered under other health plans) 
and would seek medical care from VA. Based on information from 
VA on the cost of health care it provides to non-veterans, CBO 
estimates that in 2010 they would provide medical care to 250 
family caregivers at an average cost of almost $6,000 each, for 
a total cost of $1 million in 2010. After adjusting for 
inflation and gradual implementation of the program, CBO 
estimates that the number of family caregivers receiving 
medical care would grow to 13,100 by 2014, at a cost of $66 
million that year.
    In addition, section 101 would prohibit VA from recovering 
the cost of certain emergency care provided to family members 
and caregivers of veterans whose severe service-connected 
injuries were incurred or aggravated on or after September 11, 
2001. The bill would only affect emergencies that occur while 
the family member or caregiver accompanies a veteran who is 
receiving care at a VA facility (or a non-VA facility VA has 
contracted with). Based on information from VA, CBO estimates 
that about 250 people each year would receive such care at an 
average cost of $330 each, for total costs of less than 
$500,000 over the 2010-2014 period.
    Respite Care. Section 102 would expand VA's authority to 
provide respite care to veterans. CBO estimates that 
implementing that provision would cost $38 million over the 
2010-2014 period.
    Under current law, veterans who receive medical services, 
hospital care, nursing home care, or domiciliary care from VA 
are eligible for up to 30 days of respite care. The bill would 
extend eligibility for that benefit to enrolled veterans who do 
not receive such care. Based on information from VA, CBO 
estimates that the majority of disabled, enrolled veterans who 
require caregivers currently receive care from VA, and that 
about 50 additional veterans would receive respite care in 2010 
under this provision. CBO further estimates that VA would 
provide an average of 21 days of respite care to each veteran--
at a daily cost of $210 in 2010--for a total cost of less than 
$500,000 that year. After adjusting for inflation and gradual 
implementation of the program, CBO estimates that by 2014 about 
4,000 veterans would receive respite care at a total cost of 
$20 million.
    Survey. Section 104 would require VA and DOD to conduct a 
national survey of family caregivers of seriously disabled 
veterans and servicemembers (covering the size and 
characteristics of the population and types of care provided), 
and to report to the Congress on their findings. CBO estimates 
that implementing this provision would cost $2 million over the 
2010-2014 period.
    Rural Demonstration Projects. Section 205 would authorize 
VA to carry out demonstration projects, including by 
establishing partnerships with the Department of Health and 
Human Services and the Indian Health Service, to expand care 
for veterans in rural areas. In 2009, VA received 
appropriations of $250 million for similar purposes. After 
adjusting that amount for inflation, CBO estimates that 
implementing this provision would require additional 
appropriations of $255 million in 2010 and $1.3 billion over 
the 2010-2014 period.
    Travel Reimbursements. Section 208 would authorize VA to 
pay mileage reimbursements in excess of the cost of that travel 
by public transportation; under current law, VA pays the lesser 
of mileage reimbursements or the cost of public transportation. 
CBO estimates that implementing this provision would cost $332 
million over the 2010-2014 period, assuming appropriation of 
the necessary amounts.
    Based on VA's estimate that it expects to pay $300 million 
in mileage reimbursements in 2009 and data on bus fares to 
major VA medical facilities, CBO estimates that under the bill 
those costs would increase by 25 percent starting in 2010. 
After adjusting for gradual implementation of the program, CBO 
estimates that VA would pay an additional $272 million in 
travel reimbursements over the 2010-2014 period. Enacting this 
provision also would increase spending on VA's vocational 
rehabilitation program, however, CBO estimates those effects 
would be insignificant (see discussion under ``Direct 
Spending.'')
    Section 208 also would allow VA to reimburse the cost of 
air travel, if that mode of travel was the only practical way 
to reach a VA medical facility; under current law, VA pays for 
such travel in very few cases. VA was unable to provide data on 
the number of veterans currently using air travel or the cost 
of such travel. Assuming that 5 percent of the existing users 
of the beneficiary travel program--about 30,000 people--would 
each make one round trip a year at a cost of $500 and after 
adjusting for gradual implementation of the program, CBO 
estimates that VA would pay an additional $60 million over the 
2010-2014 period.
    Education Assistance. Two sections of the bill would 
authorize VA to provide scholarships and assistance with 
education loans to certain employees. Taken together, CBO 
estimates that implementing those provisions would cost $200 
million over the 2010-2014 period, assuming appropriation of 
the necessary amounts.
    Debt Reduction. Section 201 would amend the Education Debt 
Reduction Program, which helps certain employees repay 
education loans, by deleting the ceiling of $44,000 per 
employee and allowing VA to pay up to the total principal and 
interest owed. Section 201 also would require VA to inform 
those job applicants who would be eligible for the program of 
their eligibility when making job offers, and to accept into 
the program any applicants who accept a job offer. 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.
    CBO estimates that under the proposed program changes, 650 
additional employees each year would become eligible and that 
the average payment per new employee in 2010 would be $8,500. 
(Existing participants would receive an additional payment of 
$2,500 each in 2010.) After adjusting for inflation, CBO 
estimates that implementing this provision would cost $197 
million over the 2010-2014 period, assuming appropriation of 
the necessary amounts.
    Scholarship Program. Section 202 would authorize a new 
scholarship program for individuals studying to rehabilitate 
the visually impaired. Under the bill, VA would pay such 
individuals up to $15,000 a year for tuition and fees (each 
recipient could receive a maximum of $45,000), in exchange for 
the participant's agreement to work at VA for at least three 
years after graduation. Based on information from VA, CBO 
estimates that the department would offer 20 scholarships each 
year (each for a three-year period) to interns in occupations 
working with the visually impaired, and that the average 
payment would be $11,250 in 2010. After adjusting for 
inflation, CBO estimates that implementing this provision would 
cost $3 million over the 2010-2014 period, assuming 
appropriation of the necessary amounts.
    Medical Construction. Section 401 would authorize the 
appropriation of $71 million to construct a new outpatient 
facility and renovate existing facilities in Walla Walla, 
Washington. CBO estimates that implementing that provision 
would cost $68 million over the 2010-2014 period, assuming 
appropriation of the authorized amounts. (The remaining $3 
million would be spent after 2014.)
    Copayments from Certain Disabled Veterans. Section 302 
would prohibit the collection of copayments and other fees from 
catastrophically disabled veterans who receive hospital care or 
medical services from VA. In 2008, VA collected about $8 
million in copayments for medical care and prescription drugs 
from those veterans. CBO estimates that implementing this 
provision would decrease collections by $8 million per year. 
Such collections are offsets to discretionary appropriations. 
As part of the annual appropriations process, the Congress 
gives VA authority to spend those collections. Therefore, 
maintaining the same level of health care services for veterans 
would necessitate additional funding each year to make up for 
the loss of copayments under this bill. Thus, CBO estimates 
that implementing this provision would cost about $40 million 
over the 2010-2014 period, assuming appropriation of the 
necessary amounts.
    Transportation Grants. Section 215 would authorize the 
appropriation of $3 million each year over the 2010-2014 
period. VA would use those amounts to make grants to 
organizations that improve access to medical care for veterans 
living in highly rural areas (counties with a population 
density fewer than seven persons per square mile). CBO 
estimates that implementing that provision would cost $15 
million over the 2010-2014 period, assuming appropriation of 
the authorized amounts.
    Rural Centers of Excellence. Section 212 would require VA 
to establish between one and five centers of excellence for 
research, education, and clinical activities focused on rural 
health services. VA has indicated that the proposed centers of 
excellence would be similar to existing Rural Health Resource 
Centers, and that under the bill it would establish one center 
of excellence. Based on operating costs of the existing 
resource centers, CBO estimates that implementing this 
provision would cost $2 million a year over the 2010-2014 
period, assuming appropriation of the necessary amounts.
    Coordinators of Care for Native American Veterans. Section 
207 would require VA to appoint a coordinator of care for 
Native American veterans at each of the 10 medical centers that 
serve the greatest number of such veterans. The coordinators 
would improve outreach to and expand access to care for tribal 
communities, coordinate the medical needs of veterans living on 
reservations, act as an ombudsman for Native American veterans 
using the VA health care system, and advocate for the use of 
traditional medicine in VA treatments. CBO estimates that 
implementing this provision would require VA to hire 10 
employees at an annual cost of $1 million a year over the 2010-
2014 period, assuming appropriation of the necessary amounts.
    Training for Mental Health Providers. Section 206 would 
require VA to train veterans and clinicians to provide peer 
support, readjustment counseling, and other mental health 
services to veterans of Operation Iraqi Freedom and Operation 
Enduring Freedom (hereinafter, ``OIF/OEF'') and to assist 
family members of OIF/OEF veterans with their recovery and 
readjustment to civilian life. Under current law, VA has the 
authority to provide such services through Vet Centers and 
existing mental health programs, and may also contract with 
non-VA entities to provide services, especially in rural areas.
    Based on information from VA, CBO estimates that about 
20,000 veteran peer counselors and clinicians would undergo 
initial training in 2010 at a cost of $1 million. Additional 
training for new staff and refresher training for existing 
staff also would average about $1 million each year over the 
2011-2014 period. CBO estimates that implementing this 
provision would cost $5 million over the 2010-2014 period, 
assuming appropriation of the necessary amounts.
    Peer Reviews. Section 210 would authorize VA to review the 
quality of health care provided by non-VA contractors. Under 
the bill, non-VA providers in each of VA's 21 regional networks 
of medical facilities would provide a sample of patient records 
to VA for review. Based on information from VA, CBO estimates 
that VA would require 10 additional employees to analyze 
records and prepare reports at a cost of $1 million a year over 
the 2010-2014 period, assuming appropriation of the necessary 
amounts.
    Emergency Care. Section 301 would require VA to pay for the 
emergency care that certain veterans receive at non-VA medical 
facilities, or to reimburse veterans if they have paid for that 
care. It also would permit VA, subject to the Secretary's 
discretion, to reimburse veterans for emergency treatment that 
was provided prior to the date of enactment. CBO estimates that 
implementing those provisions would cost $5 million over the 
2010-2014 period, assuming appropriation of the necessary 
amounts.
    Under current law, VA has the authority to reimburse 
certain veterans or pay for emergency treatment of a 
nonservice-connected condition, if VA is the payer of last 
resort. Veterans who have recourse against a third party that 
would partly cover those medical expenses are not eligible for 
such reimbursement from VA. Section 301 would remove that 
restriction.
    Based on information from VA, CBO estimates that under the 
bill VA would approve about 700 new claims a year over the 
2010-2014 period and about 2,000 claims for emergency treatment 
provided over the 2005-2009 period. (CBO assumes that few 
veterans have retained records for emergency treatment provided 
before 2005.) CBO estimates that VA would pay an average of 
$730 per claim in 2010, rising to about $900 per claim in 2014, 
for total costs of $1 million a year.
    Other Provisions. Two sections of the bill, when taken 
individually, would increase spending subject to appropriation 
by less than $500,000 each year. Taken together, CBO estimates 
that implementing the following provisions would have a total 
cost of $1 million over the 2010-2014 period, assuming 
availability of appropriated funds:

     Section 209 would require the Office of Rural 
Health to develop a five-year strategic plan. VA has indicated 
that the office is developing a similar plan and that the 
necessary modifications would have insignificant costs.
     Section 214 would require annual reports to the 
Congress on the implementation of several sections of the bill.
Direct Spending
    Section 208 would increase mileage reimbursements paid to 
veterans using VA's vocational rehabilitation program. However, 
CBO estimates that few beneficiaries would be affected, that 
the increased amounts paid per veteran would be quite low, and 
thus, that enacting section 208 would increase direct spending 
by less than $500,000 each year and over the 2010-2014 and 
2010-2019 periods.
    Intergovernmental and private-sector impact: S. 801 
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 
program activities authorized in the bill.
    Previous CBO estimates: On July 23, 2009, CBO transmitted a 
cost estimate for H.R. 3155, the Caregiver Assistance and 
Resource Enhancement Act, as ordered reported by the House 
Committee on Veterans' Affairs on July 15, 2009. H.R. 3155 is 
similar to title I of S. 801, however H.R. 3155 affected a much 
smaller population, and its estimated costs were 
correspondingly lower.
    On July 23, 2009, CBO transmitted a cost estimate for H.R. 
3219, the Veterans' Insurance and Health Care Improvement Act 
of 2009, as ordered reported by the House Committee on 
Veterans' Affairs on July 15, 2009. Section 203 of H.R. 3219 is 
similar to section 302 of S. 801, and their estimated costs are 
identical.
    On March 25, 2009, CBO transmitted a cost estimate for H.R. 
1377, a bill to amend title38, United States Code, to expand 
veteran eligibility for reimbursement by the Secretary of 
Veterans Affairs for emergency treatment furnished in a non-
Department facility, and for other purposes, as ordered 
reported by the House Committee on Veterans' Affairs on March 
25, 2009. H.R. 1377 is similar to section 301 of S. 801, and 
their estimated costs are identical.
    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. 801 reported favorably to the Senate 
by roll call vote, without dissent.


----------------------------------------------------------------------------------------------------------------
                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 
various bills incorporated into the Committee bill. In 
addition, on May 14, 2009, VA provided views on S. 801. 
Excerpts of both the testimony and Department views are 
reprinted below:

   STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY UNDER 
       SECRETARY FOR HEALTH, U.S. 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. Unfortunately, we do not yet have 
views and estimates on several bills including S. 239, S. 498, 
S. 699, S. 772, S. 793, subsection (f) of S. 252 and S. 821. We 
will forward those as soon as they are available. Our support 
for the bill provisions discussed below is contingent upon VA's 
ability to fund such activities within the President's 2010 
budget.

           *       *       *       *       *       *       *


            S. 801 ``FAMILY CAREGIVER PROGRAM ACT OF 2009''

    S. 801 is divided into four separate sections. I will 
address each section separately; however, VA has not yet 
evaluated the costs of implementing the provisions of S. 801. 
We will provide an estimate to the Committee as soon as it is 
completed.
    Section 2 would authorize VA to waive charges for 
humanitarian care provided to caregivers accompanying certain 
severely injured veterans as they receive medical care. VA does 
not object to the concept of providing humanitarian medical 
benefits to caregivers but we must oppose this section. As 
currently written, Section 2 identifies an extensive list of 
family members as potential caregivers and provides no criteria 
regarding the extent or duration of their service to the 
Veteran. Family caregivers could change frequently and we are 
concerned that the provision of humanitarian care could become 
a primary factor in designating a caregiver rather than that 
person's ability to assist the veteran. Further, language that 
has historically appeared in VA appropriation statutes 
(requiring reimbursement for hospital care and medical services 
provided to individuals who are not otherwise eligible for 
these benefits) may restrict VA's ability to waive charges as 
outlined in this provision of the bill. We are also considering 
the impact of Section 2 on the implementation of the family 
medical care provisions of the National Defense Authorization 
Act of 2008 (Sec. 1672(b) of Public Law 110-181).
    Section 3 of S. 801 addresses family caregiver assistance. 
I have previously discussed the family caregiver provisions of 
S. 252 and S. 543, which would require the Secretary to conduct 
pilot programs to assess the feasibility of training family 
caregivers as personal care attendants. While the eligibility 
criteria for this section are very similar to those in S. 543, 
S. 801 differs dramatically from S. 252 and S. 543 because it 
would establish a program of instruction, preparation, 
training, certification and ongoing support for designated 
family caregivers across VA. The mechanics of the program under 
S. 801 are also different as eligible veterans and their family 
member (or other designated individual) would make a joint 
application to VA which would then evaluate the veteran to 
identify the personal care services needed by that individual 
and determine if they could be provided by a family member. The 
applicant family member is also evaluated to determine the 
training they would need to provide those services. Unlike 
S. 252 and S. 253, S. 801 does not address the development of 
the training curriculum. However, it does distinguish between a 
family member who provides personal care services and a family 
member who is designated as the veteran's primary personal care 
attendant. The agency would be required to provide training, 
certification, technical support, and counseling to both; 
however, a primary personal care attendant would also be 
furnished mental health services, medical care under 38 U.S.C. 
1781, respite care and a stipend.
    VA strongly opposes Section 3. The same concerns identified 
in conjunction with caregiver provisions of S. 252 and S. 543 
apply here as well. VA currently contracts for caregiver 
services with various providers and this arrangement is 
preferable because it does not divert VA from its primary 
mission of treating veterans and training clinicians. We also 
would like to reiterate that S. 801 would establish the 
caregiver program across the agency and we caution against 
implementing a program of this magnitude without first 
exploring its feasibility and effectiveness. Should the 
Committee decide to proceed with a caregiver assistance 
proposal, we urge you to opt for the program defined in section 
209 of S. 252 which would allow VA to conduct a three-year 
pilot providing assistance to caregivers of TBI patients. 
Moreover, the concerns that I addressed in discussing Section 2 
relative to the large cadre of eligible caregivers would make 
this proposal challenging to administer and monitor for quality 
and effectiveness. The administrative burden on VA to re-
identify and track caregivers could be considerable.
    Finally, S. 801 in general, and Section 3 in particular, 
would create preferential benefits for one generation of 
Veterans that are not available to others. VA believes that 
caregiver assistance would benefit veterans of all ages and 
periods of service and any initiative to support caregivers 
should not be limited to post-September 11 veterans.
    Section 4 would amend VA's beneficiary travel statute (38 
U.S.C. 111) to include lodging and subsistence as travel 
expenses for attendants of certain veterans receiving VA health 
care. This provision would also define the travel period to 
include travel to and from the facility and the duration of the 
treatment episode. We believe that the proposed amendments 
would apply to all attendants eligible for beneficiary travel 
under 38 U.S.C. 111, not just those attendants defined by 
S. 801. VA opposes Section 4 as this benefit expansion would 
divert resources from medical care. In addition, 38 U.S.C. 111 
already provides travel benefit attendants for severely injured 
veterans.
                                ------                                

                         The Secretary of Veterans Affairs,
                                      Washington, DC, May 14, 2009.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: This letter is in response to your 
invitation to submit for the record the Department's views on 
six bills, S. 239, S. 498, S. 699, S. 772, S. 793, and S. 821. 
As you know, we received some of these legislative items too 
late to address in testimony before the Committee on April 22, 
2009. In addition, while our views remain the same, we are 
submitting additional information and costs on four bills that 
were addressed in the April 22 testimony, S. 252, S. 404, 
S. 423, and S. 801. Thank you for giving us this valuable 
opportunity to submit our views before the hearing record 
closes.

           *       *       *       *       *       *       *


            S. 801 ``FAMILY CAREGIVER PROGRAM ACT OF 2009''

    VA's opposition to S. 801 was detailed in the April 22, 
2009, testimony. The costs for each section of the bill are 
outlined below.
    Section 2 would amend 38 U.S.C. Sec. 1784 to allow for 
waiver of charges for hospital care or medical services 
provided to certain family members of Veterans receiving VA 
health care. We project that this provision would cost 
approximately $330,000 in 2010, $2 million over five years, and 
$5.3 million over ten years.
    Section 3 addresses family caregiver assistance. VA has 
identified 65,798 Veterans with a serious injury incurred on or 
after September 11, 2001, that would be eligible for this 
program during its first two years. It is expected that an 
additional 1,440 Veterans would become eligible each subsequent 
year. VA estimates that this provision would cost $5.056 
billion in fiscal year 2010, $26.859 billion over five years, 
and $62.8 billion over 10 years. Note that these costs do not 
include Veterans severely injured prior to September 11, 2001, 
that may become eligible for this program after the first two 
years.
    Section 4, Lodging and Subsistence for Attendants, would 
amend 38 U.S.C. Sec. 111 to allow for travel, including lodging 
and subsistence, for the period consisting of travel to and 
from a treatment facility and the duration of the treatment 
episode for certain family members of certain Veterans 
receiving VA health care. We estimate the cost of this 
provision to be $8.6 million in 2010, $57.7 million over five 
years, and $163 million over ten years.

           *       *       *       *       *       *       *

    The Office of Management and Budget advises that there is 
no objection to the submission of this letter from the 
standpoint of the Administration.
    Thank you again Mr. Chairman, for the opportunity to 
provide VA's views on these bills.
            Sincerely,
Eric K. Shinseki.

           *       *       *       *       *       *       *


      Excerpt from April 22, 2009, Hearing Record Regarding S. 801

  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
                  U.S. Department of Veterans Affairs

    Question 1. In written testimony, the Department expressed 
concern ``that the provision of humanitarian care could become 
a primary factor in designating a caregiver rather than the 
person's ability to assist the Veteran.'' Since the legislation 
states that the designated caregiver receives waived charges 
for emergency medical care in the sole instance he or she is 
accompanying the Veteran, the likelihood of the caregiver 
receiving health care benefits is very small. Please elaborate 
as to why VA has a reservation with this provision?
    Response. Given the extensive list of persons eligible to 
be the Veteran's caregiver, the Veteran may elect to designate, 
or be under pressure to designate, as their caregiver someone 
who has need for medical care and would benefit greatly from 
the Department of Veterans Affairs' (VA) providing that care. 
This person may not be the best choice to assist the Veteran 
with their daily needs. Moreover, the legislation does not 
provide for limits on the number of times or how frequently the 
Veteran may change caregivers. Potentially, a number of persons 
could receive needed medical care by being designated as 
caregiver.
    Question 2. The Department objects to section 3 of S. 801 
because of a concern that it will force VA to create 
preferential benefits for one group of Veterans. Yet, the 
legislation allows VA to extend this benefit to ``include the 
largest number of Veterans possible.'' Please explain, in 
detail, why the Department raises an objection to this 
provision?
    Response. The number of Veterans meeting the eligibility of 
section 3 for the first 2 years of enactment is small compared 
to eligible Veterans from previous generations. VA believes 
that any program that would benefit one cadre of combat 
Veterans over another is inequitable, whether for a 2-year 
period or permanently.
    VA has been working on the family caregiver issue for some 
time and believes that the newly developed Veteran directed-
home and community-based service (VD-HCBS) creates a workable 
infrastructure for family caregivers to be paid for the 
relevant service they provide. The VD-HCBS program provides 
Veterans of all ages the opportunity to receive home and 
community based services in a consumer-directed fashion that 
enables them to avoid nursing home placement and continue to 
live in their homes. The VD-HCBS program addresses the home 
care needs for Veterans of all ages, allowing services to be 
provided to younger, seriously-injured and Traumatic Brain 
Injury (TBI) Veterans. This program will also help address the 
demand for paid family caregivers in a comprehensive and 
structured manner.
    We would be pleased to discuss this program and other 
alternatives to section 3 of S. 801 with Members of the 
Committee staff. VA is committed to working with the Congress 
to create a viable family caregiver program.
            Sincerely,
Eric K. Shinseki.

           *       *       *       *       *       *       *


                        Changes in Existing Law

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

TITLE 38. VETERANS' BENEFITS

           *       *       *       *       *       *       *


PART I. GENERAL PROVISIONS

           *       *       *       *       *       *       *


             PART V. BOARDS, ADMINISTRATIONS, AND SERVICES

Chapter                                                             Sec.
      Board of Veterans' Appeals....................................7101
      United States Court of Appeals for Veterans Claims............7251
      Veterans Health Administration--Organization and Functions....7301
      Veterans Health Administration--Personnel.....................7401
      Visual Impairment and Orientation and Mobility Professionals   75.
        Education Assistance Program................................7501
7601Health Professionals Educational Assistance Program...............

           *       *       *       *       *       *       *


PART I. GENERAL PROVISIONS

           *       *       *       *       *       *       *


                           CHAPTER 1. GENERAL

SEC. 101. DEFINITIONS

           *       *       *       *       *       *       *


SEC. 111. PAYMENTS OR ALLOWANCES FOR BENEFICIARY TRAVEL

    (a) Under regulations prescribed by the President pursuant 
to the provisions of this section, the Secretary may pay the 
actual necessary expense of travel (including lodging and 
subsistence), or in lieu thereof an allowance based upon 
mileage [traveled,] (at a rate of 41.5 cents per mile) when not 
traveling by air, of any person to or from a Department 
facility or other place in connection with vocational 
rehabilitation, counseling required by the Secretary pursuant 
to chapter 34 or 35 of this title, or for the purpose of 
examination, treatment, or care. Actual necessary expense of 
travel includes the reasonable costs of airfare if travel by 
air is the only practical way to reach a Department facility. 
In addition to the mileage allowance authorized by this 
section, there may be allowed reimbursement for the actual cost 
of ferry fares, and bridge, road, and tunnel tolls.
    (b)(1) * * *

           *       *       *       *       *       *       *

    (4) In determining for purposes of subsection (a) whether 
travel by air is the only practical way for a veteran to reach 
a Department facility, the Secretary shall consider the medical 
condition of the veteran and any other impediments to the use 
of ground transportation by the veteran.

           *       *       *       *       *       *       *

    (e) [When any] (1) When any person entitled to mileage 
under this section requires an attendant (other than an 
employee of the Department) in order to perform such travel, 
the attendant may be allowed expenses of travel (including 
lodging and subsistence) upon the same basis as such person for 
the period consisting of travel to and from a treatment 
facility and the duration of the treatment episode at that 
facility.
    (2) The Secretary may prescribe regulations to carry out 
this subsection. Such regulations may include provisions--
          (A) to limit the number of individuals that may 
        receive expenses of travel under paragraph (1) for a 
        single treatment episode of a person; and
          (B) to require attendants to use certain travel 
        services.
    (3) In this subsection:
          (A) The term ``attendant'' includes, with respect to 
        a person described in paragraph (1), the following:
                  (i) A family member of the person.
                  (ii) An individual approved as a personal 
                care attendant under section 1717A(d)(3) of 
                this title.
                  (iii) Any other individual whom the Secretary 
                determines--
                          (I) has a preexisting relationship 
                        with the person; and
                          (II) provides a significant portion 
                        of the person's care.
          (B) The term ``family member'' shall have such 
        meaning as the Secretary shall determine by policy or 
        regulation.

           *       *       *       *       *       *       *

    [(g)(1) Subject to paragraph (3), in determining the amount 
of allowances or reimbursement to be paid under this section, 
the Secretary shall use the mileage reimbursement rate for the 
use of privately owned vehicles by Government employees on 
official business (when a Government vehicle is available), as 
prescribed by the Administrator of General Services under 
section 5707(b) of title 5.
    [(2) In no event shall payment be provided under this 
section--
          [(A) unless the person claiming reimbursement has 
        been determined, pursuant to regulations which the 
        Secretary shall prescribe, to be unable to defray the 
        expenses of such travel (except with respect to a 
        person receiving benefits for or in connection with a 
        service-connected disability under this title, a 
        veteran receiving or eligible to receive pension under 
        section 1521 of this title, or a person whose annual 
        income, determined in accordance with section 1503 of 
        this title, does not exceed the maximum annual rate of 
        pension which would be payable to such person if such 
        person were eligible for pension under section 1521 of 
        this title;
          [(B) to reimburse for the cost of travel by privately 
        owned vehicle in any amount in excess of the cost of 
        such travel by public transportation unless (i) public 
        transportation is not reasonably accessible or would be 
        medically inadvisable, or (ii) the cost of such travel 
        is not greater than the cost of public transportation; 
        and
          [(C) in excess of the actual expense incurred by such 
        person as certified in writing by such person.
    [(3) Subject to the availability of appropriations, the 
Secretary may modify the amount of allowances or reimbursement 
to be paid under this section using a mileage reimbursement 
rate in excess of that prescribed under paragraph (1).]
    (g)(1) Beginning one year after the date of the enactment 
of the Caregiver and Veterans Health Services Act of 2009, the 
Secretary may adjust the mileage rate described in subsection 
(a) to be equal to the mileage reimbursement rate for the use 
of privately owned vehicles by Government employees on official 
business (when a Government vehicle is available), as 
prescribed by the Administrator of General Services under 
section 5707(b) of title 5.
    (2) If an adjustment in the mileage rate under paragraph 
(1) results in a lower mileage rate than the mileage rate 
otherwise specified in subsection (a), the Secretary shall, not 
later than 60 days before the date of the implementation of the 
mileage rate as so adjusted, submit to Congress a written 
report setting forth the adjustment in the mileage rate under 
this subsection, together with a justification for the decision 
to make the adjustment in the mileage rate under this 
subsection.

           *       *       *       *       *       *       *


PART II. GENERAL BENEFITS

           *       *       *       *       *       *       *


CHAPTER 11. COMPENSATION FOR SERVICE-CONNECTED DISABILITY OR DEATH

           *       *       *       *       *       *       *


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

                         SUBCHAPTER I. GENERAL

SEC.

1701. DEFINITIONS.

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

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

1703A. OVERSIGHT OF CONTRACT AND FEE-BASIS CARE.

           *       *       *       *       *       *       *


1709. TELECONSULTATION AND TELERETINAL IMAGING.

           *       *       *       *       *       *       *


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

1710. ELIGIBILITY FOR HOSPITAL, NURSING HOME, AND DOMICILIARY CARE.

           *       *       *       *       *       *       *


1717. HOME HEALTH SERVICES; INVALID LIFTS AND OTHER DEVICES.

1717A. FAMILY CAREGIVER ASSISTANCE.

           *       *       *       *       *       *       *


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

1721. POWER TO MAKE RULES AND REGULATIONS.

           *       *       *       *       *       *       *


1730. COMMUNITY RESIDENTIAL CARE.

1730A. PROHIBITION ON COLLECTION OF COPAYMENTS FROM CATASTROPHICALLY 
                    DISABLED VETERANS.

           *       *       *       *       *       *       *


                         Subchapter I. General

SEC. 1701. DEFINITIONS

           *       *       *       *       *       *       *


SEC. 1703A. OVERSIGHT OF CONTRACT AND FEE-BASIS CARE

    (a) Rural Outreach Coordinators.--The Secretary shall 
designate a rural outreach coordinator at each Department 
community based outpatient clinic at which not less than 50 
percent of the veterans enrolled at such clinic reside in a 
highly rural area. The coordinator at a clinic shall be 
responsible for coordinating care and collaborating with 
community contract and fee-basis providers with respect to the 
clinic.
    (b) Incentives To Obtain Accreditation of Medical 
Practice.--(1) The Secretary shall adjust the fee-basis 
compensation of providers of health care services under the 
Department to encourage such providers to obtain accreditation 
of their medical practice from recognized accrediting entities.
    (2) In making adjustments under paragraph (1), the 
Secretary shall consider the increased overhead costs of 
accreditation described in paragraph (1) and the costs of 
achieving and maintaining such accreditation.
    (c) Incentives for Participation in Peer Review.--(1) The 
Secretary shall adjust the fee-basis compensation of providers 
of health care services under the Department that do not 
provide such services as part of a medical practice accredited 
by a recognized accrediting entity to encourage such providers 
to participate in peer review under subsection (e).
    (2) The Secretary shall provide incentives under paragraph 
(1) to a provider of health care services under the Department 
in an amount which may reasonably be expected (as determined by 
the Secretary) to encourage participation in the voluntary peer 
review under subsection (d).
    (d) Peer Review.--(1) The Secretary shall provide for the 
voluntary peer review of providers of health care services 
under the Department who provide such services on a fee basis 
as part of a medical practice that is not accredited by a 
recognized accrediting entity.
    (2) Each year, beginning with the first fiscal year 
beginning after the date of the enactment of this section, the 
Chief Quality and Performance Officer in each Veterans 
Integrated Services Network (VISN) shall select a sample of 
patient records from each participating provider in the 
Officer's Veterans Integrated Services Network to be peer 
reviewed by a facility designated under paragraph (3).
    (3) The Chief Quality and Performance Officer in each 
Veterans Integrated Services Network shall designate Department 
facilities in such network for the peer review of patient 
records submitted under this subsection.
    (4) Each year, beginning with the first fiscal year 
beginning after the date of the enactment of this section, each 
provider who elects to participate in the program shall submit 
the patient records selected under paragraph (2) to a facility 
selected under paragraph (3) to be peer reviewed by such 
facility.
    (5) Each Department facility designated under paragraph (3) 
that receives patient records under paragraph (4) shall--
          (A) peer review such records in accordance with 
        policies and procedures established by the Secretary;
          (B) ensure that peer reviews are evaluated by the 
        Peer Review Committee; and
          (C) develop a mechanism for notifying the Under 
        Secretary for Health of problems identified through 
        such peer review.
    (6) The Under Secretary for Health shall develop a 
mechanism by which the use of fee-basis providers of health 
care are terminated when quality of care concerns are 
identified with respect to such providers.
    (7) The Chief Quality and Performance Officer in each 
Veterans Integrated Services Network shall be responsible for 
the oversight of the program of peer review under this 
subsection in that network.

           *       *       *       *       *       *       *


SEC. 1709. TELECONSULTATION AND TELERETINAL IMAGING

    (a) Teleconsultation.--(1) The Secretary shall carry out a 
program of teleconsultation for the provision of remote mental 
health and traumatic brain injury assessments in facilities of 
the Department that are not otherwise able to provide such 
assessments without contracting with third party providers or 
reimbursing providers through a fee-basis system.
    (2) The Secretary shall, in consultation with appropriate 
professional societies, promulgate technical and clinical care 
standards for the use of teleconsultation services within 
facilities of the Department.
    (b) Teleretinal Imaging.--The Secretary shall carry out a 
program of teleretinal imaging in each Veterans Integrated 
Services Network (VISN).
    (c) Annual Reports.--In each fiscal year beginning with 
fiscal year 2010 and ending with fiscal year 2015, the 
Secretary shall submit to Congress a report on the programs 
required by subsections (a) and (b). Such report shall include 
the following:
          (1) A description of the efforts made by the 
        Secretary to make teleconsultation available in rural 
        areas and to utilize teleconsultation in rural areas.
          (2) The rates of utilization of teleconsultation by 
        Veterans Integrated Services Network disaggregated by 
        each fiscal year for which a report is submitted under 
        this subsection.
    (d) Definitions.--In this section:
          (1) The term ``teleconsultation'' means the use by a 
        health care specialist of telecommunications to assist 
        another health care provider in rendering a diagnosis 
        or treatment.
          (2) The term ``teleretinal imaging'' means the use by 
        a health care specialist of telecommunications, digital 
        retinal imaging, and remote image interpretation to 
        provide eye care.

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

SEC. 1710. ELIGIBILITY FOR HOSPITAL, NURSING HOME, AND DOMICILIARY CARE

           *       *       *       *       *       *       *


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

    (a) * * *

           *       *       *       *       *       *       *

    (c) [The Under Secretary] (1) 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].
    (2) In carrying out this section, the Under Secretary may 
utilize the services of the following:
          (A) 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.
          (B) Eligible volunteer counselors in the provision of 
        counseling and related mental health services.
    (3) For purposes of this subsection, an eligible volunteer 
counselor is an individual--
          (A) who--
                  (i) provides counseling services without 
                compensation at a center;
                  (ii) is a licensed psychologist or social 
                worker;
                  (iii) has never been named in a tort claim 
                arising from professional activities; and
                  (iv) has never had, and has no pending, 
                disciplinary action taken with respect to any 
                license or certification qualifying that 
                individual to provide counseling services; or
          (B) who is otherwise credentialed and privileged to 
        perform counseling services by the Secretary.
    (4) Eligible volunteer counselors shall be issued 
credentials and privileges for the provision of counseling and 
related mental health services under this section on an 
expedited basis in accordance with such procedures as the 
Secretary shall establish. Such procedures shall provide for 
the completion by the Secretary of the processing of an 
application for such credentials and privileges not later than 
60 days after receipt of the application.
    (d) * * *
    (e) [The Secretary] (1) 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.
    (2) Each center shall develop an outreach plan to ensure 
that the community served by the center is aware of the 
services offered by the center.

           *       *       *       *       *       *       *


SEC. 1717A. FAMILY CAREGIVER ASSISTANCE

    (a) In General.--(1) As part of home health services 
provided under section 1717 of this title, the Secretary shall, 
upon the joint application of an eligible veteran and a family 
member of such veteran (or other individual designated by such 
veteran), furnish to such family member (or designee) family 
caregiver assistance in accordance with this section. The 
purpose of providing family caregiver assistance under this 
section is--
          (A) to reduce the number of veterans who are 
        receiving institutional care, or who are in need of 
        institutional care, whose personal care service needs 
        could be substantially satisfied with the provision of 
        such services by a family member (or designee); and
          (B) to provide eligible veterans with additional 
        options so that they can choose the setting for the 
        receipt of personal care services that best suits their 
        needs.
    (2) The Secretary shall only furnish family caregiver 
assistance under this section to a family member of an eligible 
veteran (or other individual designated by such veteran) if the 
Secretary determines it is in the best interest of the eligible 
veteran to do so.
    (b) Eligible Veterans.--(1) For purposes of this section, 
an eligible veteran is a veteran (or member of the Armed Forces 
undergoing medical discharge from the Armed Forces)--
          (A) who has a serious injury (including traumatic 
        brain injury, psychological trauma, or other mental 
        disorder) incurred or aggravated in the line of duty in 
        the active military, naval, or air service on or after 
        the date described in paragraph (2); and
          (B) whom the Secretary determines, in consultation 
        with the Secretary of Defense as necessary, is in need 
        of personal care services because of--
                  (i) an inability to perform one or more 
                independent activities of daily living;
                  (ii) a need for supervision or protection 
                based on symptoms or residuals of neurological 
                or other impairment or injury; or
                  (iii) such other matters as the Secretary 
                shall establish in consultation with the 
                Secretary of Defense as appropriate.
    (2) The date described in this paragraph--
          (A) during the period beginning on the date of the 
        enactment of the Caregiver and Veterans Health Services 
        Act of 2009 and ending two years after the date of the 
        enactment of that Act, is September 11, 2001; and
          (B) beginning on the first day after the date that is 
        two years after the date of the enactment of the 
        Caregiver and Veterans Health Services Act of 2009, is 
        the earliest date the Secretary determines is 
        appropriate to include the largest number of veterans 
        (and members of the Armed Forces) possible under this 
        section without reducing the quality of care provided 
        to such veterans (and members).
    (c) Evaluation of Eligible Veterans and Family 
Caregivers.--(1) The Secretary shall evaluate each eligible 
veteran who makes a joint application under subsection (a)(1)--
          (A) to identify the personal care services required 
        by such veteran; and
          (B) to determine whether such requirements could be 
        significantly or substantially satisfied with the 
        provision of personal care services from a family 
        member (or other individual designated by the veteran).
    (2) The Secretary shall evaluate each family member of an 
eligible veteran (or other individual designated by the 
veteran) who makes a joint application under subsection (a)(1) 
to determine--
          (A) the basic amount of instruction, preparation, and 
        training such family member (or designee) requires, if 
        any, to provide the personal care services required by 
        such veteran; and
          (B) the amount of additional instruction, 
        preparation, and training such family member (or 
        designee) requires, if any, to be the primary personal 
        care attendant designated for such veteran under 
        subsection (e).
    (3) An evaluation carried out under paragraph (1) may be 
carried out--
          (A) at a Department facility;
          (B) at a non-Department facility determined 
        appropriate by the Secretary for purposes of such 
        evaluation; and
          (C) at such other locations as the Secretary 
        considers appropriate.
    (d) Training and Approval.--(1) Except as provided in 
subsection (a)(2), the Secretary shall provide each family 
member of an eligible veteran (or other individual designated 
by the veteran) who makes a joint application under subsection 
(a)(1) the basic instruction, preparation, and training 
determined to be required by such family member (or designee) 
under subsection (c)(2)(A).
    (2) The Secretary may provide to a family member of an 
eligible veteran (or other individual designated by the 
veteran) the additional instruction, preparation, and training 
determined to be required by such family member (or designee) 
under subsection (c)(2)(B) if such family member (or 
designee)--
          (A) is approved as a personal care attendant for the 
        veteran under paragraph (3); and
          (B) requests, with concurrence of the veteran, such 
        additional instruction, preparation, and training.
    (3) Upon the successful completion by a family member of an 
eligible veteran (or other individual designated by the 
veteran) of basic instruction, preparation, and training 
provided under paragraph (1), the Secretary shall approve the 
family member as a personal care attendant for the veteran.
    (4) If the Secretary determines that a primary personal 
care attendant designated under subsection (e) requires 
additional training to maintain such designation, the Secretary 
shall make such training available to the primary personal care 
attendant.
    (5) The Secretary shall, subject to regulations the 
Secretary shall prescribe, provide for necessary travel, 
lodging, and per diem expenses incurred by a family member of 
an eligible veteran (or other individual designated by the 
veteran) in undergoing training under this subsection.
    (6) If the participation of a family member of an eligible 
veteran (or other individual designated by the veteran) in 
training under this subsection would interfere with the 
provision of personal care services to the veteran, the 
Secretary shall, subject to regulations as the Secretary shall 
prescribe and in consultation with the veteran, provide respite 
care to the veteran during the provision of such training to 
the family member so that such family caregiver (or designee) 
can participate in such training without interfering with the 
provision of such services.
    (e) Designation of Primary Personal Care Attendant.--(1) 
For each eligible veteran with at least one family member (or 
other individual designated by the veteran) who is described by 
subparagraphs (A) through (E) of paragraph (2), the Secretary 
shall designate one family member of such veteran (or other 
individual designated by the veteran) as the primary personal 
care attendant for such veteran to be the primary provider of 
personal care services for such veteran.
    (2) A primary personal care attendant designated for an 
eligible veteran under paragraph (1) shall be selected from 
among family members of such veteran (or other individuals 
designated by such veteran) who--
          (A) are approved under subsection (d)(3) as a 
        personal care attendant for such veteran;
          (B) complete all additional instruction, preparation, 
        and training, if any, provided under subsection (d)(2);
          (C) elect to provide the personal care services to 
        such veteran that the Secretary determines such veteran 
        requires under subsection (c)(1);
          (D) has the consent of such veteran to be the primary 
        provider of such services for such veteran; and
          (E) the Secretary considers competent to be the 
        primary provider of such services for such veteran.
    (3) An eligible veteran receiving personal care services 
from a family member (or other individual designated by the 
veteran) designated as the primary personal care attendant for 
the veteran under paragraph (1) may revoke consent with respect 
to such family member (or designee) under paragraph (2)(D) at 
any time.
    (4) If an individual designated as the primary personal 
care attendant of an eligible veteran under paragraph (1) 
subsequently fails to meet the requirements set forth in 
paragraph (2), the Secretary--
          (A) shall immediately revoke the individual's 
        designation under paragraph (1); and
          (B) may designate, in consultation with the eligible 
        veteran or the eligible veteran's surrogate appointed 
        under subsection (g), a new primary personal care 
        attendant for the veteran under such paragraph.
    (5) The Secretary shall take such actions as may be 
necessary to ensure that the revocation of a designation under 
paragraph (1) does not interfere with the provision of personal 
care services required by a veteran.
    (f) Ongoing Family Caregiver Assistance.--(1) Except as 
provided in subsection (a)(2) and subject to the provisions of 
this subsection, the Secretary shall provide ongoing family 
caregiver assistance to family members of eligible veterans (or 
other individuals designated by such veterans) as follows:
          (A) To each family member of an eligible veteran (or 
        designee) who is approved under subsection (d)(3) as a 
        personal care attendant for the veteran the following:
                  (i) Direct technical support consisting of 
                information and assistance to timely address 
                routine, emergency, and specialized caregiving 
                needs.
                  (ii) Counseling.
                  (iii) Access to an interactive Internet 
                website on caregiver services that addresses 
                all aspects of the provision of personal care 
                services under this section.
          (B) To each family member of an eligible veteran (or 
        designee) who is designated as the primary personal 
        care attendant for the veteran under subsection (e) the 
        following:
                  (i) The ongoing family caregiver assistance 
                described in subparagraph (A).
                  (ii) Mental health services.
                  (iii) Respite care of not less than 30 days 
                annually, including 24-hour per day care of the 
                veteran commensurate with the care provided by 
                the family caregiver to permit extended 
                respite.
                  (iv) Medical care under section 1781 of this 
                title if such family member (or designee) is 
                not entitled to care or services under a 
                health-plan contract (as defined in section 
                1725(f) of this title).
                  (v) A monthly personal caregiver stipend.
    (2)(A) The Secretary shall provide respite care under 
paragraph (1)(B)(iii), at the election of the Secretary--
          (i) through facilities of the Department that are 
        appropriate for the veteran; or
          (ii) through contracts under section 1720B(c) of this 
        title.
    (B) If the primary personal care attendant of an eligible 
veteran designated under subsection (e)(1) determines in 
consultation with the veteran or the veteran's surrogate 
appointed under subsection (g), and the Secretary concurs, that 
the needs of the veteran cannot be accommodated through the 
facilities and contracts described in subparagraph (A), the 
Secretary shall, in consultation with the primary personal care 
attendant and the veteran (or the veteran's surrogate), provide 
respite care through other facilities or arrangements that are 
medically and age appropriate.
    (3) If the Secretary determines that the Department lacks 
the capacity to furnish medical care under clause (iv) of 
paragraph (1)(B), the Secretary may contract, in accordance 
with such regulations as the Secretary shall prescribe, for 
such insurance, medical services, or health plans as the 
Secretary considers appropriate to furnish such medical care.
    (4)(A) The Secretary shall provide monthly personal 
caregiver stipends under paragraph (1)(B)(v) in accordance with 
a schedule established by the Secretary that specifies stipends 
provided based upon the amount and degree of personal care 
services provided.
    (B) The Secretary shall ensure, to the extent practicable, 
that the schedule required by subparagraph (A) specifies that 
the amount of the personal caregiver stipend provided to a 
primary personal care attendant designated under subsection 
(e)(1) for the provision of personal care services to an 
eligible veteran is not less than the amount a commercial home 
health care entity would pay an individual in the geographic 
area of the veteran to provide equivalent personal care 
services to the veteran.
    (C) If personal care services are not available from a 
commercial provider in the geographic area of an eligible 
veteran, the Secretary may establish the schedule required by 
subparagraph (A) with respect to the veteran by considering the 
costs of commercial providers of personal care services in 
geographic areas other than the geographic area of the veteran 
with similar costs of living.
    (5) Provision of ongoing family caregiver assistance under 
this subsection for provision of personal care services to an 
eligible veteran shall terminate if the veteran no longer 
requires the personal care services.
    (g) Surrogates.--If an eligible veteran lacks the capacity 
to submit an application, provide consent, make a request, or 
concur with a request under this section, the Secretary may, in 
accordance with regulations and policies of the Department 
regarding the appointment of guardians or the use of powers of 
attorney, appoint a surrogate for the veteran who may submit 
applications, provide consent, make requests, or concur with 
requests on behalf of the veteran under this section.
    (h) Oversight.--(1) The Secretary shall enter into 
contracts with appropriate entities to provide oversight of the 
provision of personal care services under this section by 
primary personal care attendants designated under subsection 
(e)(1).
    (2) The Secretary shall ensure that each eligible veteran 
receiving personal care services under this section from a 
primary personal care attendant designated under subsection 
(e)(1) is visited in the veteran's home by an entity providing 
oversight under paragraph (1) at such frequency as the 
Secretary shall determine under paragraph (3).
    (3)(A) Except as provided in subparagraph (B), the 
Secretary shall determine the manner of oversight provided 
under paragraph (1) and the frequency of visits under paragraph 
(2) for an eligible veteran as the Secretary considers 
commensurate with the needs of such veteran.
    (B) The frequency of visits under paragraph (2) for an 
eligible veteran shall be not less frequent than once every six 
months.
    (4)(A) An entity visiting an eligible veteran under 
paragraph (2) shall submit to the Secretary the findings of the 
entity with respect to each visit, including whether the 
veteran is receiving the care the veteran requires.
    (B) If an entity finds under subparagraph (A) that an 
eligible veteran is not receiving the care the veteran 
requires, the entity shall submit to the Secretary a 
recommendation on the corrective actions that should be taken 
to ensure that the veteran receives the care the veteran 
requires, including, if the entity considers appropriate, a 
recommendation for revocation of a caregiver's approval under 
subsection (d)(3) or revocation of the designation of an 
individual under subsection (e)(1).
    (5) After receiving findings and recommendations, if any, 
under paragraph (4) with respect to an eligible veteran, the 
Secretary may take such actions as the Secretary considers 
appropriate to ensure that the veteran receives the care the 
veteran requires, including the following:
          (A) Revocation of a caregiver's approval under 
        subsection (d)(3).
          (B) Revocation of the designation of an individual 
        under subsection (e)(1).
    (6) If the Secretary terminates the provision of ongoing 
family caregiver assistance under subsection (f) to a family 
member of an eligible veteran (or other individual designated 
by the veteran) because of findings of an entity submitted to 
the Secretary under paragraph (4), the Secretary may not 
provide compensation to such entity for the provision of 
personal care services to such veteran, unless the Secretary 
determines it would be in the best interest of such veteran to 
provide compensation to such entity to provide such services.
    (i) Outreach.--The Secretary shall carry out a program of 
outreach to inform eligible veterans and their family members 
of the availability and nature of family caregiver assistance 
under this section.
    (j) Construction.--(1) A decision by the Secretary under 
this section affecting the furnishing of family caregiver 
assistance shall be considered a medical determination.
    (2) Nothing in this section shall be construed to create an 
employment relationship between the Secretary and an individual 
in receipt of family caregiver assistance under this section.
    (3) Nothing in this section shall be construed to create 
any entitlement to any services or stipends provided under this 
section.
    (k) Definitions.--In this section:
          (1) The term ``family caregiver assistance'' includes 
        the instruction, preparation, training, and approval 
        provided under subsection (d) and the ongoing family 
        caregiver assistance provided under subsection (f).
          (2) The term ``family member'' shall have such 
        meaning as the Secretary shall determine by policy or 
        regulation.
          (3) The term ``personal care services'', with respect 
        to a veteran, includes the following:
                  (A) Supervision of the veteran.
                  (B) Protection of the veteran.
                  (C) Services to assist the veteran with one 
                or more independent activities of daily living.
                  (D) Such other services as the Secretary 
                considers appropriate.

           *       *       *       *       *       *       *


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

SEC. 1725. REIMBURSEMENT FOR EMERGENCY TREATMENT

           *       *       *       *       *       *       *


    (b) Eligibility.

           *       *       *       *       *       *       *

          (3) * * *

           *       *       *       *       *       *       *

                  (C) has no other contractual or legal 
                recourse against a third party that would[, in 
                whole or in part,] extinguish such liability to 
                the provider; and

           *       *       *       *       *       *       *

    (c) Limitations on reimbursement.

           *       *       *       *       *       *       *

          (4)(A) If the veteran has contractual or legal 
        recourse against a third party that would, in part, 
        extinguish the veteran's liability to the provider of 
        the emergency treatment and payment for the treatment 
        may be made both under subsection (a) and by the third 
        party, the amount payable for such treatment under such 
        subsection shall be the amount by which the costs for 
        the emergency treatment exceed the amount payable or 
        paid by the third party, except that the amount payable 
        may not exceed the maximum amount payable established 
        under paragraph (1)(A).
          (B) In any case in which a third party is financially 
        responsible for part of the veteran's emergency 
        treatment expenses, the Secretary shall be the 
        secondary payer.
          (C) A payment in the amount payable under 
        subparagraph (A) shall be considered payment in full 
        and shall extinguish the veteran's liability to the 
        provider.
          (D) The Secretary may not reimburse a veteran under 
        this section for any copayment or similar payment that 
        the veteran owes the third party or for which the 
        veteran is responsible under a health-plan contract.

           *       *       *       *       *       *       *

    (f) Definitions.--For purposes of this section:

           *       *       *       *       *       *       *

          (3) The term ``third party'' means any of the 
        following:
                  (A) A Federal entity, including the Secretary 
                of Health and Human Services with respect to 
                the Medicare program under title XVIII of the 
                Social Security Act (42 U.S.C. 1395 et seq.) 
                and the Medicaid program under title XIX of 
                such Act (42 U.S.C. 1396 et seq.).
                  (B) A State or political subdivision of a 
                State, including a State Medicaid agency with 
                respect to payments made under a State plan for 
                medical assistance approved under title XIX of 
                such Act (42 U.S.C. 1396 et seq.).

           *       *       *       *       *       *       *


SEC. 1730A. PROHIBITION ON COLLECTION OF COPAYMENTS FROM 
                    CATASTROPHICALLY DISABLED VETERANS

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

      Subchapter VIII. Health Care of Persons Other Than Veterans

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

    (a) The Secretary is authorized to provide medical care, in 
accordance with the provisions of subsection (b) of this 
section, for--
          (1) the spouse or child of a veteran who has a total 
        disability, permanent in nature, resulting from a 
        service-connected disability,
          (2) a family member of a veteran (or other individual 
        designated by the veteran) designated as the primary 
        personal care attendant for such veteran under section 
        1717A(e) of this title who is not entitled to care or 
        services under a health-plan contract (as defined in 
        section 1725(f) of this title),
          [(2)] (3) the surviving spouse or child of a veteran 
        who (A) died as a result of a service-connected 
        disability, or (B) at the time of death had a total 
        disability permanent in nature, and
          [(3)] (4) the surviving spouse or child of a person 
        who died in the active military, naval, or air service 
        in the line of duty and not due to such person's own 
        misconduct,
who are not otherwise eligible for medical care under chapter 
55 of title 10 (CHAMPUS).

           *       *       *       *       *       *       *


SEC. 1784. HUMANITARIAN CARE

    [The Secretary may furnish hospital care or medical 
services as a humanitarian service in emergency cases, but the 
Secretary shall charge for such care and services at rates 
prescribed by the Secretary.]
    (a) In General.--The Secretary may furnish hospital care or 
medical services as a humanitarian service in emergency cases.
    (b) Reimbursement.--Except as provided in subsection (c), 
the Secretary shall charge for care and services provided under 
subsection (a) at rates prescribed by the Secretary.
    (c) Waiver of Charges.--(1) Except as provided in paragraph 
(2), the Secretary shall waive the charges required by 
subsection (b) for care or services provided under subsection 
(a) to an attendant of a covered veteran if such care or 
services are provided to such attendant for an emergency that 
occurs while such attendant is accompanying such veteran while 
such veteran is receiving approved inpatient or outpatient 
treatment at--
          (A) a Department facility; or
          (B) a non-Department facility--
                  (i) that is under contract with the 
                Department; or
                  (ii) at which the veteran is receiving fee-
                basis care.
    (2) If an attendant is entitled to care or services under a 
health-plan contract (as that term is defined in section 
1725(f) of this title) or other contractual or legal recourse 
against a third party that would, in part, extinguish liability 
for charges described by subsection (b), the amount of such 
charges waived under paragraph (1) shall be the amount by which 
such charges exceed the amount of such charges covered by the 
health-plan contract or other contractual or legal recourse 
against the third party.
    (d) Definitions.--In this section:
          (1) The term ``attendant'', with respect to a 
        veteran, includes the following:
                  (A) A family member of the veteran.
                  (B) An individual eligible to receive ongoing 
                family caregiver assistance under section 
                1717A(e)(1) of this title for the provision of 
                personal care services to the veteran.
                  (C) Any other individual whom the Secretary 
                determines--
                          (i) has a relationship with the 
                        veteran sufficient to demonstrate a 
                        close affinity with the veteran; and
                          (ii) provides a significant portion 
                        of the veteran's care.
          (2) The term ``covered veteran'' means any veteran 
        with a severe injury incurred or aggravated in the line 
        of duty in the active military, naval, or air service 
        on or after September 11, 2001.
          (3) The term ``family member'' shall have such 
        meaning as the Secretary shall determine by policy or 
        regulation.
          (4) The term ``severe injury'', in the case of a 
        covered veteran, means any physiological, 
        psychological, or neurological condition that renders a 
        veteran unable to live independently as determined by 
        the Secretary.

           *       *       *       *       *       *       *


                   PART V. BOARDS, ADMINISTRATIONS, 
                              AND SERVICES

Chapter                                                             Sec.
      Board of Veterans' Appeals....................................7101
      United States Court of Appeals for Veterans Claims............7251
      Veterans Health Administration--Organization and Functions....7301
      Veterans Health Administration--Personnel.....................7401
      Visual Impairment and Orientation and Mobility Professionals   75.
        Education Assistance Program................................7501
7601Health Professionals Educational Assistance Program...............

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CHAPTER 73. VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS

           *       *       *       *       *       *       *


          SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION

SEC.

7311. QUALITY ASSURANCE.

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7330A. EPILEPSY CENTERS OF EXCELLENCE

7330B. INDIAN VETERANS HEALTH CARE COORDINATORS.

7330C. CENTERS OF EXCELLENCE FOR RURAL HEALTH RESEARCH, EDUCATION, AND 
                    CLINICAL ACTIVITIES.

           *       *       *       *       *       *       *


Subchapter II. General Authority and Administration

           *       *       *       *       *       *       *


SEC. 7330A. EPILEPSY CENTERS OF EXCELLENCE

           *       *       *       *       *       *       *


SEC. 7330B. INDIAN VETERANS HEALTH CARE COORDINATORS

    (a) In General.--(1) The Secretary shall assign at each of 
the 10 Department Medical Centers that serve communities with 
the greatest number of Indian veterans per capita an official 
or employee of the Department to act as the coordinator of 
health care for Indian veterans at such Medical Center. The 
official or employee so assigned at a Department Medical Center 
shall be known as the ``Indian Veterans Health Care 
Coordinator'' for the Medical Center.
    (2) The Secretary shall, from time to time--
          (A) survey the Department Medical Centers for 
        purposes of identifying the 10 Department Medical 
        Centers that currently serve communities with the 
        greatest number of Indian veterans per capita; and
          (B) utilizing the results of the most recent survey 
        conducted under subparagraph (A), revise the assignment 
        of Indian Veterans Health Care Coordinators in order to 
        assure the assignment of such coordinators to 
        appropriate Department Medical Centers as required by 
        paragraph (1).
    (b) Duties.--The duties of an Indian Veterans Health Care 
Coordinator shall include the following:
          (1) Improving outreach to tribal communities.
          (2) Coordinating the medical needs of Indian veterans 
        on Indian reservations with the Veterans Health 
        Administration and the Indian Health Service.
          (3) Expanding the access and participation of the 
        Department of Veterans Affairs, the Indian Health 
        Service, and tribal members in the Department of 
        Veterans Affairs Tribal Veterans Representative 
        program.
          (4) Acting as an ombudsman for Indian veterans 
        enrolled in the health care system of the Veterans 
        Health Administration.
          (5) Advocating for the incorporation of traditional 
        medicine and healing in Department treatment plans for 
        Indian veterans in need of care and services provided 
        by the Department.
    (c) Indian Defined.--In this section, the term ``Indian'' 
has the meaning given the term in section 4 of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450b).

SEC. 7330C. CENTERS OF EXCELLENCE FOR RURAL HEALTH RESEARCH, EDUCATION, 
                    AND CLINICAL ACTIVITIES

    (a) Establishment of Centers.--The Secretary, through the 
Director of the Office of Rural Health, shall establish and 
operate at least one and not more than five centers of 
excellence for rural health research, education, and clinical 
activities, which shall--
          (1) conduct research on the furnishing of health 
        services in rural areas;
          (2) develop specific models to be used by the 
        Department in furnishing health services to veterans in 
        rural areas;
          (3) provide education and training for health care 
        professionals of the Department on the furnishing of 
        health services to veterans in rural areas; and
          (4) develop and implement innovative clinical 
        activities and systems of care for the Department for 
        the furnishing of health services to veterans in rural 
        areas.
    (b) Use of Rural Health Resource Centers.--In selecting 
locations for the establishment of centers of excellence under 
subsection (a), the Secretary may select a rural health 
resource center that meets the requirements of subsection (a).
    (c) Geographic Dispersion.--The Secretary shall ensure that 
the centers established under this section are located at 
health care facilities that are geographically dispersed 
throughout the United States.
    (d) Funding.--(1) There are authorized to be appropriated 
to the Medical Care Account and the Medical and Prosthetics 
Research Account of the Department of Veterans Affairs such 
sums as may be necessary for the support of the research and 
education activities of the centers operated under this 
section.
    (2) There shall be allocated to the centers operated under 
this section, from amounts authorized to be appropriated to the 
Medical Care Account and the Medical and Prosthetics Research 
Account by paragraph (1), such amounts as the Under Secretary 
of health considers appropriate for such centers. Such amounts 
shall be allocated through the Director of the Office of Rural 
Health.
    (3) Activities of clinical and scientific investigation at 
each center operated under this section--
          (A) shall be eligible to compete for the award of 
        funding from funds appropriated for the Medical and 
        Prosthetics Research Account; and
          (B) shall receive priority in the award of funding 
        from such account to the extent that funds are awarded 
        to projects for research in the care of rural veterans.

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CHAPTER 74. VETERANS HEALTH ADMINISTRATION--PERSONNEL

           *       *       *       *       *       *       *


      CHAPTER 75. VISUAL IMPAIRMENT AND ORIENTATION AND MOBILITY 
               PROFESSIONALS EDUCATION ASSISTANCE PROGRAM

SEC.

7501. ESTABLISHMENT OF SCHOLARSHIP PROGRAM; PURPOSE.

7502. APPLICATION AND ACCEPTANCE.

7503. AMOUNT OF ASSISTANCE; DURATION.

7504. AGREEMENT.

7505. REPAYMENT FOR FAILURE TO SATISFY REQUIREMENTS OF AGREEMENT.

SEC. 7501. ESTABLISHMENT OF SCHOLARSHIP PROGRAM; PURPOSE

    (a) Establishment.--Subject to the availability of 
appropriations, the Secretary shall establish and carry out a 
scholarship program to provide financial assistance in 
accordance with this chapter to an individual--
          (1) who is accepted for enrollment or currently 
        enrolled in a program of study leading to a degree or 
        certificate in visual impairment or orientation and 
        mobility, or a dual degree or certification in both 
        such areas, at an accredited (as determined by the 
        Secretary) educational institution that is in a State; 
        and
          (2) who enters into an agreement with the Secretary 
        as described in section 7504 of this chapter.
    (b) Purpose.--The purpose of the scholarship program 
established under this chapter is to increase the supply of 
qualified blind rehabilitation specialists for the Department 
and the Nation.
    (c) Outreach.--The Secretary shall publicize the 
scholarship program established under this chapter to 
educational institutions throughout the United States, with an 
emphasis on disseminating information to such institutions with 
high numbers of Hispanic students and to Historically Black 
Colleges and Universities.

SEC. 7502. APPLICATION AND ACCEPTANCE

    (a) Application.--(1) To apply and participate in the 
scholarship program under this chapter, an individual shall 
submit to the Secretary an application for such participation 
together with an agreement described in section 7504 of this 
chapter under which the participant agrees to serve a period of 
obligated service in the Department as provided in the 
agreement in return for payment of educational assistance as 
provided in the agreement.
    (2) In distributing application forms and agreement forms 
to individuals desiring to participate in the scholarship 
program, the Secretary shall include with such forms the 
following:
          (A) A fair summary of the rights and liabilities of 
        an individual whose application is approved (and whose 
        agreement is accepted) by the Secretary.
          (B) A full description of the terms and conditions 
        that apply to participation in the scholarship program 
        and service in the Department.
    (b) Approval.--(1) Upon the Secretary's approval of an 
individual's participation in the scholarship program, the 
Secretary shall, in writing, promptly notify the individual of 
that acceptance.
    (2) An individual becomes a participant in the scholarship 
program upon such approval by the Secretary.

SEC. 7503. AMOUNT OF ASSISTANCE; DURATION

    (a) Amount of Assistance.--The amount of the financial 
assistance provided for an individual under this chapter shall 
be the amount determined by the Secretary as being necessary to 
pay the tuition and fees of the individual. In the case of an 
individual enrolled in a program of study leading to a dual 
degree or certification in both the areas of study described in 
section 7501(a)(1) of this chapter, the tuition and fees shall 
not exceed the amounts necessary for the minimum number of 
credit hours to achieve such dual certification or degree.
    (b) Relationship to Other Assistance.--Financial assistance 
may be provided to an individual under this chapter to 
supplement other educational assistance to the extent that the 
total amount of educational assistance received by the 
individual during an academic year does not exceed the total 
tuition and fees for such academic year.
    (c) Maximum Amount of Assistance.--(1) In no case may the 
total amount of assistance provided under this chapter for an 
academic year to an individual who is a full-time student 
exceed $15,000.
    (2) In the case of an individual who is a part-time 
student, the total amount of assistance provided under this 
chapter shall bear the same ratio to the amount that would be 
paid under paragraph (1) if the participant were a full-time 
student in the program of study being pursued by the individual 
as the coursework carried by the individual to full-time 
coursework in that program of study.
    (3) In no case may the total amount of assistance provided 
to an individual under this chapter exceed $45,000.
    (d) Maximum Duration of Assistance.--The Secretary may 
provide financial assistance to an individual under this 
chapter for not more than six years.

SEC. 7504. AGREEMENT

    An agreement between the Secretary and a participant in the 
scholarship program under this chapter shall be in writing, 
shall be signed by the participant, and shall include--
          (1) the Secretary's agreement to provide the 
        participant with financial assistance as authorized 
        under this chapter;
          (2) the participant's agreement--
                  (A) to accept such financial assistance;
                  (B) to maintain enrollment and attendance in 
                the program of study described in section 
                7501(a)(1) of this chapter;
                  (C) while enrolled in such program, to 
                maintain an acceptable level of academic 
                standing (as determined by the educational 
                institution offering such program under 
                regulations prescribed by the Secretary); and
                  (D) after completion of the program, to serve 
                as a full-time employee in the Department for a 
                period of three years, to be served within the 
                first six years after the participant has 
                completed such program and received a degree or 
                certificate described in section 7501(a)(1) of 
                this chapter; and
          (3) any other terms and conditions that the Secretary 
        determines appropriate for carrying out this chapter.

SEC. 7505. REPAYMENT FOR FAILURE TO SATISFY REQUIREMENTS OF AGREEMENT

    (a) In General.--An individual who receives educational 
assistance under this chapter shall repay to the Secretary an 
amount equal to the unearned portion of such assistance if the 
individual fails to satisfy the requirements of the agreement 
entered into under section 7504 of this chapter, except in 
circumstances authorized by the Secretary.
    (b) Amount of Repayment.--The Secretary shall establish, by 
regulations, procedures for determining the amount of the 
repayment required under this subsection and the circumstances 
under which an exception to the required repayment may be 
granted.
    (c) Waiver or Suspension of Compliance.--The Secretary 
shall prescribe regulations providing for the waiver or 
suspension of any obligation of an individual for service or 
payment under this chapter (or an agreement under this chapter) 
whenever noncompliance by the individual is due to 
circumstances beyond the control of the individual or whenever 
the Secretary determines that the waiver or suspension of 
compliance is in the best interest of the United States.
    (d) Obligation as Debt to United States.--An obligation to 
repay the Secretary under this section is, for all purposes, a 
debt owed the United States. A discharge in bankruptcy under 
title 11 does not discharge a person from such debt if the 
discharge order is entered less than five years after the date 
of the termination of the agreement or contract on which the 
debt is based.

CHAPTER 76. HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM

           *       *       *       *       *       *       *


Subchapter VII. Education Debt Reduction Program

           *       *       *       *       *       *       *


SEC. 7682. ELIGIBILITY

           *       *       *       *       *       *       *


    (d) Notice to Potential Employees.--In each offer of 
employment made by the Secretary to an individual who, upon 
acceptance of such offer would be treated as eligible to 
participate in the Education Debt Reduction Program, the 
Secretary shall, to the maximum extent practicable, include the 
following:
          (1) A notice that the individual will be treated as 
        eligible to participate in the Education Debt Reduction 
        Program upon the individual's acceptance of such offer.
          (2) A notice of the determination of the Secretary 
        whether or not the individual will be selected as a 
        participant in the Education Debt Reduction Program as 
        of the individual's acceptance of such offer.

SEC. 7683. EDUCATION DEBT REDUCTION

           *       *       *       *       *       *       *


    (d) Maximum annual amount.--(1) Subject to paragraph (2), 
the amount of education debt reduction payments made to a 
participant under the Education Debt Reduction Program may not 
exceed [$44,000 over a total of five years of participation in 
the Program, of which not more than $10,000 of such payments 
may be made in each of the fourth and fifth years of 
participation in the Program] the total amount of principle and 
interest owed by the participant on loans referred to in 
subsection (a).
    (2) * * *
    (e) Selection of Participants.--(1) The Secretary shall 
select for participation in the Education Debt Reduction 
Program each individual eligible for participation in the 
Education Debt Reduction Program who--
          (A) the Secretary provided notice with an offer of 
        employment under section 7682(d) of this title that 
        indicated the individual would, upon the individual's 
        acceptance of such offer of employment, be--
                  (i) eligible to participate in the Education 
                Debt Reduction Program; and
                  (ii) selected to participate in the Education 
                Debt Reduction Program; and
          (B) accepts such offer of employment.
    (2) The Secretary may select for participation in the 
Education Debt Reduction Program an individual eligible for 
participation in the Education Debt Reduction Program who is 
not described by subparagraphs (A) and (B) of paragraph (1).

           *       *       *       *       *       *       *

  

                                  
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