[Senate Report 114-34]
[From the U.S. Government Publishing Office]
114th Congress } { Report
SENATE
1st Session } { 114-34
======================================================================
CLAY HUNT SUICIDE PREVENTION FOR
AMERICAN VETERANS ACT
_______
April 23, 2015.--Ordered to be printed
_______
Mr. Isakson, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
[To accompany H.R. 203]
The Committee on Veterans' Affairs (hereinafter, ``the
Committee''), to which was referred the bill (H.R. 203), to
amend title 38, United States Code (hereinafter, ``U.S.C.''),
to provide for the conduct of annual evaluations of mental
health care and suicide prevention programs of the Department
of Veterans Affairs (hereinafter, ``VA'' or ``the
Department''), to require a pilot program on loan repayment for
psychiatrists who agree to serve in the Veterans Health
Administration (hereinafter, ``VHA'') of the Department, and
for other purposes, having considered the same, reports
favorably thereon without amendment and recommends that the
bill do pass.
Introduction
On January 7, 2015, Representative Timothy Walz introduced
H.R. 203, to provide for the conduct of annual evaluations of
mental health care and suicide prevention programs of the
Department, to require a pilot program on loan repayment for
psychiatrists who agree to serve in VHA of the Department, and
for other purposes. Representatives Courtney, Duckworth, Esty,
Kirkpatrick, Miller (FL), Murphy (PA), O'Rourke, Rush, Scott
(GA), Slaughter, and Smith (NJ) were original cosponsors.
Representatives Bonamici, Brown (FL), Bustos, Cicilline,
Cleaver, Costello, Cramer, Fitzpatrick, Foster, Garamendi,
Gibson, Israel, Kline, Kuster, Lujan, Lujan Grisham, Murphy
(FL), Nolan, Paulsen, Peters, Peterson, Pingree, Quigley,
Sinema, Walters, Welch, Wenstrup, and Young (IN) were later
added as cosponsors.
On January 12, 2015, the House of Representatives suspended
the rules and passed H.R. 203 by a vote of 403-0. On January
13, 2015, Senator McCain introduced S. 167, the Clay Hunt
Suicide Prevention for American Veterans Act. Senators
Blumenthal, Blunt, Boozman, Brown, Burr, Casey, Donnelly,
Durbin, Flake, Gillibrand, Hirono, Klobuchar, Manchin,
Menendez, Moran, Murkowski, Murray, Sanders, Sullivan, and
Tester were original cosponsors. On January 13, 2015, the bill
was referred to the Committee. Senators Ayotte, Baldwin,
Bennet, Boxer, Cantwell, Capito, Cardin, Collins, Coons,
Cornyn, Daines, Feinstein, Franken, Grassley, Heitkamp, Heller,
Hoeven, Inhofe, Johnson, King, Kirk, Markey, Murphy, Nelson,
Peters, Reed, Schumer, Sessions, Shaheen, Stabenow, Tillis, and
Wyden were later added as cosponsors.
Committee Meeting
On January 21, 2015, the Committee met to consider
H.R. 203. The bill was ordered to be reported favorably without
amendment.
Summary of H.R. 203 as Reported
H.R. 203, as reported (hereinafter, ``the Committee
bill''), would provide for the conduct of annual evaluations of
mental health care and suicide prevention programs of VA,
require a pilot program on loan repayment for psychiatrists who
agree to serve in VHA, and serve other purposes.
Section 1 provides a short title of, the ``Clay Hunt
Suicide Prevention for American Veterans Act'' or the ``Clay
Hunt SAV Act.''
Section 2 would require VA to obtain an independent third
party evaluation of VA's mental health care and suicide
prevention programs to include: (1) use of metrics that are
common and useful for mental health and suicide prevention
practitioners; (2) identifying the most effective programs; (3)
identifying the cost-effectiveness of each program; and (4)
proposing best practices. The first report will be due no later
than December 1, 2018, and subsequent reports will be required
annually thereafter; two interim reports cataloging and
reporting data on existing programs will be required.
Section 3 would require VA to publish an interactive Web
site designed to serve as a centralized source of information
regarding all VA mental health services.
Section 4 would require VA to establish a pilot program to
repay education loans relating to psychiatric medicine for no
less than ten individuals on the condition that they agree to
serve no less than 2 years of obligated service within VA.
Section 5 would require VA to establish a pilot program in
no less than five Veterans Integrated Service Networks
(hereinafter, ``VISNs'') to assist veterans transitioning from
active duty to veteran status and to improve veteran access to
mental health services with community cooperation.
Section 6 would authorize VA to collaborate with non-profit
mental health organizations to: (1) improve the efficiency and
effectiveness of suicide prevention efforts; (2) assist non-
profit mental health organizations through VA expertise; and
(3) jointly carry out suicide prevention efforts.
Section 7 would extend an additional 1 year of eligibility
for VA health care services for certain combat veterans who
have not enrolled and whose 5-year combat eligibility period
recently expired.
Section 8 stipulates that no additional funds are
authorized to be appropriated to carry out this Act.
Background and Discussion
Background. The number of veterans using VA mental health
care treatment has risen from about 900,000 in 2006 to more
than 1.4 million in 2013 and is expected to increase as
servicemembers exit the military and enter the VA health care
system. VA has attributed this increase to the improved
screening, awareness, and understanding of post traumatic
stress disorder (hereinafter, ``PTSD'') and other common mental
health conditions. In testimony submitted for the Committee's
November 19, 2014, hearing on Mental Health and Suicide Among
Veterans, Dr. Harold Kudler, Chief Mental Health Consultant for
VHA, noted the Department ``anticipate(s) that VA's
requirements for providing mental health care will continue to
grow for a decade or more after current operational missions
have come to an end.''
Mental health diagnoses of veterans range from mild
depression to severe PTSD, requiring an equally broad range of
treatment options. According to statistics from VA, since 2002,
more than 1.7 million servicemembers have left active duty and
become eligible for VA care. Fifty-eight percent of those
individuals have sought care from VA and, of those, 55 percent
have been either diagnosed provisionally or confirmed with a
mental health condition.
Additionally, different veterans with the same diagnosis
may respond differently to the same treatment. The most severe
cases of PTSD are frequently treated with intensive therapies
at VA medical centers. Less severe cases can be treated at Vet
Centers, which often appeal to veterans because of their
welcoming, home-like nature. Certain veterans respond better to
one-on-one therapies, while others respond well to group
environments. Community Based Outpatient Clinics (hereinafter,
``CBOC'') play an important role in telehealth delivery by
connecting rural veterans to psychiatry services from the
medical center.
In an effort to meet the needs of veterans, VA began
offering expanded access to mental health services through
extended evening and weekend clinic hours at larger VA medical
centers. Moreover, VA began offering same day appointments at
some VA medical centers and services are available to veterans
in an emergency situation. Another important change has been
the inclusion of mental health professionals into primary care
delivery through VA's Patient Aligned Care Teams. This improves
the screening process to recognize and treat those veterans who
present in their primary care location.
VA clinicians are now trained in--and utilizing--a variety
of evidence-based therapies, including Cognitive Behavioral
Therapy and Prolonged Exposure Therapy. The use of these
therapies helps ensure veterans throughout the country are
receiving the high-quality care most likely to assist them in
the treatment and recovery of a broad spectrum of mental health
diagnoses. However, VA must do a better job tracking
utilization of these services to ensure clinicians are using
them appropriately and to make sure they are being used across
VHA.
Despite these changes to VA's mental health program,
difficulties still exist. Over the last few years, the
Committee has heard from stakeholders about several ongoing
concerns, which will be discussed below in further detail.
SUICIDE
Tragically, over the past year, it is estimated this nation
has lost, on average, twenty-two veterans a day to suicide.
While much of the attention has been focused on the youngest
cohort of veterans returning from the wars in Iraq and
Afghanistan, it is reported to be the older cohort of veterans
who are committing suicide at higher rates. VA's Suicide Data
Report 2012 found more than 69 percent of veteran suicides are
among those age 50 years or older.
Among the youngest cohort of VHA users, the largest
increase in suicide rates has been among males under 30,
especially those between 18-25 years of age, according to VA's
2014 Suicide Data Report Update. This report also highlighted
an increase in the suicide rate in female VHA users since the
start of the wars in Iraq and Afghanistan. It is important to
note, however, that the increase seen in this population is
comparable to the increases among non-veteran women in the
United States.
ACCESS AND SCOPE OF CARE
The events at the Phoenix VA Health Care System in 2014
underscored VA's inability to provide timely access to medical
services, including mental health appointments. Concerns about
the Department's scheduling practices had been raised by the
VA's Office of Inspector General (hereinafter, ``VAOIG'') and
the Government Accountability Office as early as the 1990s. In
fact, in April 2012, the VAOIG released a report entitled
Review of Veterans' Access to Mental Health Care, which showed
VA was not meeting benchmarks for timely access to mental
health care services. Some veterans were waiting as long as 60
days for an evaluation.
In her written testimony for the Committee hearing entitled
VA Mental Health Care: Ensuring Timely Access to High-Quality
Care on March 20, 2013, Kim Ruocco, National Director of
Suicide Postvention Programs, Tragedy Assistance Program for
Survivors, provided several examples of veterans who struggled
to get timely access to treatment. She also discussed the
challenges of navigating the system:
At some point, the veteran may decide to go to the VA
because he or she is struggling and needs help. Often
this happens after a long battle and the
servicemember's life is already falling apart and he or
she is very sick. The servicemember then contacts the
VA looking for help with his or her symptoms, whether
it is addiction, anxiety, depression, uncontrollable
outbursts of rage, etc. This is a critical time for the
veteran . . . . Very often the veteran's suffering is
complicated with combinations of physical and emotional
pain including issues like traumatic brain injury,
post-traumatic stress, depression, moral injury, and
survivor guilt. These issues become the veteran's own
personal barriers to care. In this population we see
avoidance, anxiety and trouble concentrating. Symptoms
like panic attacks, flashbacks and hyper-vigilance
among this population of veterans are often described
to us by our surviving families.
These symptoms run counterintutitive to navigating a
complex system of paperwork, crowded waiting rooms,
extended wait times for appointments, referrals and
disability ratings. The veteran enters the system
tentatively with trepidation and some fear. The veteran
is barely holding on. The veteran may feel like people
do not understand him and that the public does not
appreciate what he or she has sacrificed for this
country . . . . When the veteran asks for help, he or
she is desperate, and may be thinking of killing
himself or herself because he or she is losing hope
that things will get better. This is the composite
profile of the veteran who dies by suicide, who
initially approaches the VA for help.
During the Committee's November 19, 2014, hearing, Susan
Selke, Clay Hunt's mother, testified that her son exclusively
used VA for his medical care after leaving the Marine Corps.
She went on to note:
Clay constantly voiced concerns about the care he was
receiving, both in terms of the challenges he faced
with scheduling appointments as well as the treatment
he was receiving for PTS, which consisted primarily of
medication . . . . Clay used to say, ``I am a guinea
pig for drugs.''
Mrs. Selke also recalled a conversation she had with her
son 2 weeks before his death:
Clay had only two appointments in January and
February 2011, and neither was with a psychiatrist. It
was not until March 15 that Clay was finally able to
see a psychiatrist at the Houston VA medical center.
But after the appointment, Clay called me on his way
home and said, ``Mom, I can't go back there. The VA is
way too stressful and not a place I can go. I will have
to find a Vet Center or something.''
Ensuring VA is providing veterans with the types of mental
health care they want is paramount. In testimony before the
House Committee on Veterans' Affairs on July 10, 2014, Warren
Goldstein, Assistant Director for Traumatic Brain Injury and
PTSD programs in the National Veterans Affairs and
Rehabilitation Commission of The American Legion, discussed the
findings of a survey conducted by the organization, which found
more than half of the 3,100 veterans surveyed did not believe
their symptoms improved as a result of psychotherapy or
medication prescribed at VA. Furthermore, nearly a third of
veterans actually terminated their treatment before it
concluded. They cited reasons like stigma, travel burden, side
effects, and frustration with the lack of progress that drove
veterans to discontinue treatment before the end of the
treatment cycle.
STAFFING SHORTAGES
Presenting testimony on behalf of the American Federation
of Government Employees (hereinafter, ``AFGE''), AFL-CIO, and
the AFGE National VA Council, Michelle Williams, Ph.D., a
coordinator of PTSD Services and Evidence Based Psychotherapy
at the Wilmington VA Medical Center, recounted numerous stories
about staffing issues related to mental health providers during
the November 30, 2011, hearing on VA Mental Health Care:
Addressing Wait Times and Access to Care. In one instance, a
psychiatrist in a general mental health clinic stated he felt
like ``staffing levels [would] `never catch up' with the
growing demand for services and that at his medical center,
trying to keep up with patients' needs [is] like `a finger in
the dike'.'' Another psychologist at a CBOC noted she was
overbooked every day, as she was the only mental health
provider at that facility. She found herself handling
individual and group appointments, walk-ins, and call-ins, as
well as some compensation and pension examinations. This
provider had a caseload of more than 200 patients, many of whom
were considered high-risk patients.
In an effort to address staffing shortages, on August 31,
2012, President Obama signed an Executive Order directing VA to
hire 1,600 more mental health professionals. Despite these
additions, the Committee continued to hear concerns about
shortages of mental health professionals across the country. As
a result, recruitment and retention of medical professionals at
VA became a focus during the 113th Congress as events at
Phoenix and other VA facilities came to light during the summer
of 2014. The Veterans Access, Choice, and Accountability Act of
2014 (hereinafter, ``VACAA'') sought to increase the number of
graduate medical education residency slots by up to 1,500 over
a 5-year period, with an emphasis on those pursuing primary
care, mental health, and other specialties the Secretary deems
appropriate; gave priority to the five medical occupations the
VAOIG has identified as having the largest staffing shortages;
and increased the maximum amount of money available to eligible
VA health care professionals in their Education Debt Reduction
Program.
However, given the extent of the national shortage of
mental health care professionals across the United States, VA
must continue to enhance its ability to recruit and retain
staff. Rural and highly rural parts of the country face the
largest burden.
In the months following VACAA's implementation, the
Committee heard from Dr. Elspeth Cameron Ritchie, Chief
Clinical Officer, District of Columbia Department of Mental
Health and Member of the Committee on the Assessment of Ongoing
Efforts in the Treatment of Posttraumatic Stress Disorder,
Institute Of Medicine, The National Academies, during the
Committee's November 19, 2014, hearing on Mental Health and
Suicide Among Veterans. She stated:
[The Department of Defense] and VA have substantially
increased their mental health staffing--both direct
care and purchased care. However, staffing increases do
not appear to have kept pace with the demand for PTSD
services. Staffing shortages can result in clinicians
not having sufficient time to provide evidence-based
psychotherapies readily and with fidelity. The lack of
time to deliver psychotherapy with fidelity is
reflected in the fact that in 2013 only 53 percent of
[Operation Enduring Freedom (hereinafter, ``OEF'')] and
[Operation Iraqi Freedom (hereinafter, ``OIF'')]
veterans who had a primary diagnosis of PTSD and sought
care in the VA received the recommended eight sessions
within 14 weeks.
In an effort to better meet the needs of veterans with
mental health conditions, as a part of the President's 2012
Executive Order to hire additional mental health staff, VA
announced some of those slots would be used to hire peer
support specialists. Within the last 2 years, VA has been able
to hire 900 peer support specialists and apprentices to be
incorporated into VA's mental health programs. These peer
support specialists are uniquely positioned to relate to
veterans and can serve on the front line of support for those
veterans who are hesitant to seek care. VA has announced that
it will start piloting the expansion of peer support to
veterans in primary care settings. The pilot is expected to
place one to two peer specialists in 25 primary care sites
across the country.
The Committee has heard from multiple witnesses over the
years about the value of peer support. For example, in his
written testimony to the Committee on November 30, 2011, John
Roberts, the Executive Vice President of Mental Health and
Family Services for the Wounded Warrior Project (hereinafter,
``WWP'') drew attention to this when he discussed the findings
of a survey of WWP alumni. He stated that ``nearly 30 percent
identified talking with another OEF/OIF veteran as the most
effective resource in coping with stress--the highest response
rate of all the resources cited, including VA care (24
percent), medication (15 percent) and talking with non-military
family or friend (8 percent).''
OVERMEDICATION
The effect of combat does not end when veterans return from
the battlefield. For many servicemembers returning home from
war, chronic pain is part of daily life. VA's latest health
care utilization report notes musculoskeletal ailments--like
joint, neck, and back disorders--are the most frequent
conditions diagnosed among post-9/11 veterans. A common symptom
of these ailments is chronic pain. In fact, VA's own statistics
from the Office of Health Service Research & Development show
50 percent of male veterans treated by VHA suffer from chronic
pain and among female veterans the prevalence may be higher. As
noted earlier in this report, 55 percent of the 58 percent of
post-9/11 veterans seeking care at VA have a mental health
diagnosis. Treating the invisible wounds of war can be
challenging and often requires veterans to take multiple
medications in order to help these individuals live fuller
lives. However, these drugs come with significant risk if not
properly monitored. In response to numerous stories in the
media highlighting the problem of overmedication as it relates
to servicemembers and veterans, especially in regards to
opioids, the Committee held a hearing on the subject on April
30, 2014.
Recognizing both the need for these medications in order to
properly treat veterans as well as the risks associated with
their misuse, VA has taken steps to address this issue. One of
the Department's most recent efforts is the Opioid Safety
Initiative (hereinafter, ``OSI''). Started in October 2013 in
Minneapolis, Minnesota, with a goal of reducing dependency on
opioid use, this initiative includes a team approach that
educates veterans and provides patient monitoring with
feedback. This program also helps ensure access to, and
encourages the use of, Complementary and Alternative Medicine
therapies for its participants. In written testimony to the
Committee on April 30, 2014, Dr. Robert Petzel, Under Secretary
for Health at VHA, noted that, as a result of implementing the
OSI, ``Minneapolis has seen a nearly 70 percent decrease in
high-dose opioid prescribing for chronic non-cancer pain
patients.'' Given the positive results seen in Minnesota, VA
decided to implement this initiative nationwide.
VA has also begun a program known as the Academic Detailing
Service to identify and disseminate best practices for
evidence-based mental health treatments. It also seeks to
improve treatment outcomes while reducing reliance on high-dose
medications to treat chronic mental health conditions. This
initiative was initially piloted in VISNs 21 and 22. Following
its success, VISNs 3, 12, 17, 19, and 23 are preparing to
implement the program as well.
While these efforts to reduce the use of opioids at VA are
commendable, more remains to be done. A recent Administrative
Closure by the VAOIG for alleged inappropriate prescribing
practices of opioids at the VA Medical Center in Tomah,
Wisconsin, has raised new concerns about the overuse of opioids
at VA.
OUTREACH
The Committee has heard regularly from witnesses and
constituents that VA's outreach efforts are inadequate. Many
have discussed the difficulties of not only navigating the
system but also knowing what services are available. In an
effort to address some of these concerns, the Committee held a
hearing entitled Call to Action: VA Outreach and Community
Partnerships on April 23, 2013. During the hearing, it was
highlighted that from fiscal year (hereinafter, ``FY'') 2009
through 2013, VA spent a total of $83.7 million on its outreach
efforts, yet a 2010 survey found 60 percent of veterans knew
``very little'' or ``nothing at all'' about their VA benefits,
including access to health care.
One of the main reasons a veteran may be reluctant to seek
mental health treatment is the stigma surrounding such
treatment. In his written testimony for the Committee on April
23, 2013, Eric Weingarter, the Managing Director of the
Survival and Veterans program at the Robin Hood Foundation
observed:
Many individuals fear that seeking mental health
services will jeopardize their career, community
standing or both. Others are reluctant to expose their
vulnerabilities to providers who may also be Armed
Forces personnel themselves, given the military's
emphasis on strength, confidence, and bravery. And some
veterans have found the settings or providers they used
especially bureaucratic or unsatisfactory in other
ways, and would pursue a different option if available.
A similar sentiment was expressed by Lieutenant Colonel
(hereinafter, ``LTC'') Kenny Allred, U.S. Army (Ret.), Chair of
the Veterans and Military Council of the National Alliance on
Mental Illness (hereinafter, ``NAMI''), in written testimony
provided to the Committee on March 20, 2013, for its hearing
about mental health wait times. LTC Allred stated:
``NAMI believes that the key to reducing stigma and
strengthening suicide prevention is a change in the way
we approach these problems. It is absolutely
unacceptable to be applying the resources we have over
the last 10 years and to see suicides grow at a rate of
twenty-percent among veterans from eighteen to twenty-
two a day. Many of these suicides are occurring among
those who have never been in combat. In 2012, suicide
deaths among soldiers were higher than combat deaths.''
He also stressed the need for ``addressing the health and
mental health care needs of National Guard and Reservists who
are not considered `veterans' despite their service. These
individuals have frequently experienced the same challenges and
trauma as those in the more traditional branches of the
military.''
EXPANDED ACCESS
Under current law, section 1710(e) of title 38, U.S.C.,
combat veterans are eligible to enroll in the VA health care
system up to 5 years post discharge. During such time, veterans
are eligible for enrollment in Priority Group 6. Those who
receive a service-connected disability rating are reassigned to
the highest applicable health care priority group. At the end
of the 5-year period, all others are moved to Priority Group 7
or 8, depending on income level. Veterans in health care
Priority Groups 7 and 8 generally pay copayments for treatments
and medications.
VA reports nearly 1 million of the 1.6 million veterans,
discharged from active duty since 2002, have received VA health
care services. Furthermore, OEF/OIF/Operation New Dawn veterans
constitute 9 percent of the 6.3 million individuals who
received VA health care during FY 2012.\1\
---------------------------------------------------------------------------
\1\Epidemiology Program, Veterans Health Administration, Dep't of
Veterans Affairs, Analysis of VA Health Care Utilization among
Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and
Operation New Dawn (OND) Veterans 5 (2013).
---------------------------------------------------------------------------
Based on anecdotes and research, it has been suggested the
5-year period under current law may be inadequate. A 2012 study
found the median time for initiation of mental health
outpatient care was 4.1 years for veterans. The time between
first mental health outpatient clinic care and initiation of
minimally adequate care was 2 years longer for male veterans
than for female veterans (8.02 and 5.98 years, respectively,
p<.001), thus supporting the need for a 1-year extension of
combat veterans health care.\2\
---------------------------------------------------------------------------
\2\Maguen, S., Madden, E., Cohen, B. E., Bertenthal, D., & Seal, K.
H. ``Time to Treatment Among Veterans of Conflicts in Iraq and
Afghanistan with Psychiatric Diagnosis'' Psychiatric Services 63 (12)
1206-1212.
---------------------------------------------------------------------------
In his testimony before the Committee on November 19, 2014,
to support an earlier version of the Clay Hunt SAV Act, Senator
Walsh reiterated this sentiment when he discussed delayed onset
PTSD. He noted:
According to the National Comorbidity Survey, only 7
percent of people with PTSD seek treatment within 1
year of their initial trauma event. The average time it
takes to seek treatment is well beyond the current 5-
year combat eligibility period. Several major studies
have also shown that between 16 and 20 percent of
combat troops with mental illness suffered from delayed
onset PTSD, the symptoms of which may not appear for
several years.
Committee Bill. The Committee bill would provide for annual
evaluations of mental health care and suicide prevention
programs of VA. The Committee bill would direct VA to publish
on their Web site the mental health services available at VA.
The Committee bill would establish a pilot program on loan
repayment for psychiatrists who agree to serve in VHA. The
Committee bill would improve access to mental health services
of transitioning servicemembers. The Committee bill would
provide for collaboration between VHA and non-profit mental
health providers. The Committee bill would extend for 1
additional year the period of eligibility of certain combat
veterans for enrollment in VHA for health care. Specifically,
the changes made by each section of the bill are outlined
below.
Section 2(a) of the bill would amend chapter 17 of title
38, U.S.C., to provide for annual independent third-party
evaluations of VA's mental health and suicide prevention
programs. This section would also provide for VA to submit to
the Senate Committee on Veterans' Affairs and the House
Committee on Veterans' Affairs the most recent evaluation and
any recommendations VA considers appropriate.
The Committee intends that the required ``evaluation[s] of
the mental health care and suicide prevention programs''
described in this provision will include a review of opioid
prescription trends by doctors in the VA system. The review of
opioid prescription practices shall include, but not be limited
to: (1) an evaluation of VA opioid prescription patterns of
take-home opioids, including frequency of written prescriptions
for opioids, amount of opioids prescribed, and medications
(type and amount) that are concurrently prescribed with opioids
to patients; (2) an evaluation of VA dispensing patterns,
including data on early refill requests and how often those
early refill requests are granted; (3) a description of both
the prevalence of VA patients who filled any take-home opioid
prescriptions at a VA facility in the given fiscal year and
those patients' baseline characteristics; (4) an assessment on
whether VA facilities are adequately following VA/Department of
Defense Clinical Practice Guidelines for Management of Opioid
Therapy for Chronic Pain screening and monitoring guidelines
for patients prescribed opioids; and (5) an assessment of VA
patterns for prescribing opioid treatment for patients
suffering from mental health disorders.
Section 2(b) of the bill would direct VA to submit interim
reports on VA's mental health and suicide prevention programs
to the Senate Committee on Veterans' Affairs and the House
Committee on Veterans' Affairs.
Section 3(a) of the bill would direct VA to publish on the
Internet information regarding all of the mental health
services provided by VA.
Section 3(b) of the bill describes the elements VA must
include on the Web site directed to be built under section
3(a), which includes the mental health care services available
to veterans, contact information of each social work office and
mental health clinic, and a list of mental health staff
supporting these offices.
Section 3(c) of the bill would direct VA to update the
information on the Web site directed to be built under section
3(a) at least every 90 days.
Section 3(d) of the bill would direct VA to ensure that
outreach directed under section 1720F(i) of title 38, U.S.C.,
regarding VA's outreach of the comprehensive suicide prevention
program includes information about the Web site directed to be
built under section 3(a).
Section 4(a) of the bill would require VA to establish a
pilot program to provide for the repayment of educational loans
of certain psychiatrists.
Section 4(b) of the bill would establish those eligible for
the pilot program would be psychiatrists licensed or eligible
to practice medicine at VA or in their final year of a
residency program leading to a specialty in psychiatry, if they
demonstrate a commitment to a long-term career at VHA. Section
4(b) would also prohibit an individual who is participating in
any other Federal government educational loan repayment program
from participating in this pilot program.
Section 4(c) of the bill would limit the participation of
this program to not less than ten individuals.
Section 4(d) of the bill would create, for those
participating in the pilot program, an obligatory period of
service of 2 or more years at VA.
Section 4(e) of the bill outlines that the loan repayment
may consist of the principal, interest, and related expenses
and limits the amount paid to $30,000 for each year of
obligated service.
Section 4(f) of the bill would provide that an individual
who does not satisfy the period of obligatory service under
section 4(d) would be liable to repay to the United States the
amount that had been paid on behalf of the individual, reduced
proportionally based on the service completed.
Section 4(g) of the bill directs VA to submit to the Senate
Committee on Veterans' Affairs and the House Committee on
Veterans' Affairs an initial report 2 years after the pilot
program commences and a final report 90 days after it ends.
Section 4(h) of the bill directs VA to prescribe
regulations to carry out this section.
Section 4(i) of the bill would terminate the pilot program
3 years after the date on which it commences.
Section 5(a) of the bill would require VA to create a pilot
program to improve access to mental health services for
transitioning servicemembers with mental health conditions.
Section 5(b) of the bill would limit the locations of the
pilot program created under section 5(a) to not less than five
Veterans Integrated Service Networks with a large population of
veterans who have served in the National Guard or reserves or
with a large population of veterans transitioning back to
Veterans Integrated Service Networks with large established
veterans' populations.
Section 5(c) of the bill describes the functions of the
pilot program established by section 5(a). The program would
include a community oriented veteran peer support program and a
community outreach team for one VA medical center in each of
the participating VISNs.
Section 5(d) of the bill directs VA to submit to the Senate
Committee on Veterans' Affairs and the House Committee on
Veterans' Affairs an initial report 18 months after the pilot
program starts and a final report not later than 90 days before
the pilot program ends.
Section 5(e) of the bill stipulates that section 5 will not
be construed as authorizing VA to hire additional employees to
carry out this section.
Section 5(f) of the bill would terminate this pilot program
3 years after it commences.
Section 6(a) of the bill authorizes VA to collaborate with
non-profit mental health organizations to improve efficiency
and effectiveness of VA's suicide prevention programs; assist
the non-profits through the use of the expertise of VA
employees; and jointly carry out suicide prevention efforts.
Section 6(b) of the bill directs VA, if VA engages any non-
profits for that purpose, to collaborate with those non-profit
mental health organizations to share best practices and
exchange training sessions.
Section 6(c) of the bill directs VA to designate a Director
of Suicide Prevention Coordination to implement this section.
Section 7 of the bill would, for certain combat veterans
whose period of eligibility under section 1710(e)(3) of title
38, U.S.C., has expired, extend for 1 additional year
eligibility for health care at VHA.
Section 8 of the bill stipulates that no new appropriations
shall be used to carry out this Act. It is the Committee's
intent that VA use funding otherwise made available for mental
health and suicide prevention programs.
Committee Bill Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the
Standing Rules of the Senate, the Committee, based on
information supplied by the Congressional Budget Office
(hereinafter, ``CBO''), estimates that enactment of the
Committee bill would, relative to current law, cost $24 million
over the 2015-2020 period, subject to appropriation of the
necessary amounts, but would not affect direct spending or
revenues. Enactment of the Committee bill would not affect the
budget of state, local, or tribal governments.
The cost estimate provided by CBO, setting forth a detailed
breakdown of costs, follows:
Congressional Budget Office,
Washington, DC, January 28, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 203, the Clay Hunt
Suicide Prevention for American Veterans Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann E.
Futrell.
Sincerely,
Douglas W. Elmendorf,
Director.
Enclosure.
H.R. 203--Clay Hunt Suicide Prevention for American Veterans Act
Summary: H.R. 203 would require the Department of Veterans
Affairs (VA) to have programs for mental health care and
suicide prevention evaluated annually. The bill also would
extend the period of eligibility for health care for combat
veterans and establish pilot programs for community outreach
and repayment of education loans. In total, CBO estimates that
implementing the bill would cost $24 million over the 2015-2020
period, subject to appropriation of the necessary amounts.
Pay-as-you-go procedures do not apply to this legislation
because it would not affect direct spending or revenues.
H.R. 203 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would not affect the budgets of state, local, or tribal
governments.
Estimated cost to the Federal Government: The estimated
budgetary effect of H.R. 203 is shown in the following table.
The costs of this legislation fall within budget function 700
(veterans benefits and services).
Basis of estimate: For this estimate, CBO assumes that the
legislation will be enacted early in calendar year 2015, that
the necessary amounts will be appropriated for each year, and
that outlays will follow historical spending patterns for
similar and existing programs.
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
----------------------------------------------------
2015 2016 2017 2018 2019 2020 2015-2020
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Evaluations of Mental Health Care and Suicide Prevention
Programs
Estimated Authorization Level.......................... 0 0 0 2 2 2 6
Estimated Outlays...................................... 0 0 0 2 2 2 6
Web site on Mental Health Care Services
Estimated Authorization Level.......................... * * * * * * 1
Estimated Outlays...................................... * * * * * * 1
Pilot Program for Repayment of Education Loans for Certain
Psychiatrists
Estimated Authorization Level.......................... * 1 1 1 0 0 3
Estimated Outlays...................................... * 1 1 1 * 0 3
Pilot Program on Community Outreach
Estimated Authorization Level.......................... 1 2 2 2 0 0 7
Estimated Outlays...................................... 1 2 2 2 * 0 7
Collaborative Efforts to Prevent Suicide
Estimated Authorization Level.......................... * * * * * * 1
Estimated Outlays...................................... * * * * * * 1
Extension of Enhanced Eligibility for Certain Veterans
Estimated Authorization Level.......................... 1 1 1 1 1 1 7
Estimated Outlays...................................... 1 1 1 1 1 1 7
----------------------------------------------------
Total Changes
Estimated Authorization Level...................... 3 4 5 6 3 3 24
Estimated Outlays.................................. 3 4 5 6 3 3 24
----------------------------------------------------------------------------------------------------------------
Note: Components may not sum to totals because of rounding; * = less than $500,000.
CBO estimates that implementing H.R. 203 would have a
discretionary cost of $24 million over the 2015-2020 period,
assuming appropriation of the estimated amounts.
Evaluations of Mental Health Care and Suicide Prevention Programs
Section 2 would require VA to have an independent entity
conduct annual evaluations of the mental health care and
suicide prevention programs at the department. In 2013, VA
entered into a 4-year contract with an independent entity for
$7.7 million to perform a comprehensive assessment of VA's
mental health care system. That study will be completed at the
end of fiscal year 2017. CBO assumes that assessment will
address the requirements of this provision through 2017. As a
result, we assume no additional cost from 2015 through 2017.
Based on the costs of that assessment and adjusting for
inflation, CBO estimates that section 2 would cost $6 million
over the 2018-2020 period for ongoing evaluations, assuming
appropriation of the necessary amounts.
Web site on Mental Health Care Services
Section 3 would require VA to publish, at a centralized
location on the Internet, up-to-date information for each
Veteran Integrated Service Network (a regional VA health care
system). That information would have to include the following
items:
Name and contact information of VA social work
offices,
Locations of VA mental health clinics, and
Contact information of VA practitioners of mental
health care.
We assume that VA would provide this information on their
existing mental health care Web site. Based on previous efforts
by VA to compile and publish information online, we estimate
upfront costs in 2015 for information technology to revise the
mental health care Web site and compile the data would total
less than $500,000. Thereafter, VA would be required to update
the online material at least four times each year. Over the
2015-2020 period, CBO estimates the total cost of this
provision would be $1 million, assuming availability of
discretionary funds.
Pilot Program for Repayment of Education Loans for Certain
Psychiatrists
Section 4 would require VA to carry out a 3-year pilot
program to repay the education loans of certain psychiatrists.
Eligible psychiatrists would include those who are licensed as
well as those in their last year of residency who agree to work
at VA for a certain period of time. The department would be
required to select at least 10 individuals each year for this
pilot program, and to repay up to $30,000 per individual for
every year of obligated service.
For this estimate, CBO assumes that VA would completely
repay the loans of 10 individuals in each year of the pilot
program, and that half of the participants would be newly
licensed psychiatrists and half would be established
psychiatrists. Based on information from the National Center
for Education Statistics and the Association of American
Medical Colleges, we estimate that newly licensed and
established psychiatrists would have average education loan
debts of $120,000 and $50,000, respectively, in 2015. After
factoring in the growth in costs for higher education, CBO
estimates that implementing the pilot program would cost $3
million over the 2015-2020 period, assuming appropriation of
the necessary amounts.
Pilot Program on Community Outreach
Section 5 would require VA to conduct a 3-year pilot
program to assist veterans who recently left active-duty
service in accessing mental health services offered by the
department. The program would operate peer support networks and
outreach programs at the local level in five regions of the VA
health care system. To carry out this program, we estimate that
VA would hire five peer support specialists at an annual salary
of $60,000 each, five clinical support staff (certified mental
health professionals) at a salary of $120,000 each, and a total
of 10 support staff for the community outreach teams at a
salary of $60,000 each. After including benefits and taking
account of inflation, CBO estimates that implementing this
provision would increase costs for salary and benefits by $6
million over the 2015-2020 period.
Section 5 also would require VA to hold an annual mental
health summit during the 3-year period of the pilot program.
After factoring in costs for transportation, hotel
accommodations, food, and conference space, CBO estimates
discretionary costs of roughly $200,000 each year for the
annual summit. In total, CBO estimates that implementing
section 5 would cost $7 million over the 2015-2020 period,
assuming appropriation of the necessary amounts.
Collaborative Efforts to Prevent Suicide
Section 6 would authorize VA to collaborate with nonprofit
organizations that provide mental health services. This section
also would require VA to appoint a Director of Suicide
Prevention Coordination to manage the collaborative efforts.
According to VA, such collaboration is already ongoing. As a
result, we estimate that the only additional cost would be for
hiring a new director. Assuming a salary level of GS-15, CBO
estimates those costs would total $1 million over the 2015-2020
period.
Extension of Enhanced Eligibility for Certain Veterans
Section 7 would extend--for 1 year after the date of
enactment of H.R. 203--the period of enhanced enrollment in the
VA health care system for certain veterans. Under current law,
veterans who served after 2003 have up to 5 years after being
discharged from the military to enroll in the VA health care
system with enhanced priority (priority group 6).\1\ This
section would extend that window by 1 year for veterans who
separated from active-duty service between January 1, 2009, and
January 1, 2011.
---------------------------------------------------------------------------
\1\Enrollment in the VA health care system is based on eight
priority groups. The highest priority group consists of veterans who
have the most severe service-connected disabilities (priority groups 1-
3); the lowest priority group consists of higher-income veterans who
have no compensable service-connected disabilities (priority groups 7-
8). Section 7 would allow certain veterans to enroll under priority
group 6, which makes veterans eligible for lower copayments when they
receive services.
---------------------------------------------------------------------------
Based on data from VA on historical participation rates,
CBO estimates that about 4,600 veterans would take advantage of
the extended period of enhanced enrollment. This number does
not include veterans who would qualify for higher priority
groups (1 through 5). Using income data from the U.S. Census
Bureau, we estimate that 3,200 of those veterans (or 70
percent) would have qualified and enrolled for VA health
benefits under the income criteria of the lowest priority
groups (priority groups 7 and 8). For those veterans, during
the 1-year period of enhanced eligibility, we estimate an
annual difference in VA health care costs per enrollee of $200.
After the enhanced eligibility expires, we assume VA would
shift those veterans to the lower priority groups that they
would have otherwise enrolled in--therefore resulting in no
additional costs in those years.
We expect that the remaining 1,400 veterans would not be
eligible to enroll in the VA health care system under current
law. For those veterans we estimate average annual costs of
$1,000 per enrollee, during the 1-year period of enhanced
eligibility. After that period, we assume VA would shift those
veterans to the lower priority groups--with average annual
costs of about $800 per enrollee.
In total, CBO estimates that implementing this section
would cost $7 million over the 2015-2019 period, assuming
appropriation of the necessary amounts.
Pay-As-You-Go Considerations: None.
Intergovernmental and private-sector impact: H.R. 203
contains no intergovernmental or private-sector mandates as
defined in UMRA and would not affect the budgets of state,
local, or tribal governments.
Estimate prepared by: Federal Costs: Ann E. Futrell; Impact
on State, Local, and Tribal Governments: Jon Sperl; Impact on
the Private Sector: Paige Piper-Bach.
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(b) 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 January 21, 2015, meeting.
----------------------------------------------------------------------------------------------------------------
Yeas Senator Nays
----------------------------------------------------------------------------------------------------------------
X Mr. Moran
X Mr. Boozman
X Mr. Heller
X Mr. Cassidy
X Mr. Rounds
X Mr. Tillis
X Mr. Sullivan
X Mr. Blumenthal
X (by proxy) Mrs. Murray
X (by proxy) Mr. Sanders
X Mr. Brown
X (by proxy) Mr. Tester
X Mr. Hirono
X Mr. Manchin
X Mr. Isakson, Chairman
----------------------------------------------------------------------------------------------------------------
15 TALLY 0
----------------------------------------------------------------------------------------------------------------
Agency Report
On March 23, 2015, Robert A. McDonald, Secretary, U.S.
Department of Veterans Affairs, provided views on H.R. 203,
among other issues. An excerpt from the Department views is
reprinted below:
The Secretary of Veterans Affairs,
Washington, DC, March 23, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: I am pleased to provide the Department
of Veteran Affairs views on H.R. 203, the Clay Hunt Suicide
Prevention for American Veterans Act, also referred to as the
Clay Hunt SAV Act. As you know, the President signed the bill
into law on February 12, 2015, and in his remarks at the
signing expressed in detail the Administration's support for
the bill and the critical importance of the areas touched on by
H.R. 203.
Mental health care and suicide prevention are among VA's
highest priorities. Veterans who need help must receive that
help when and where they need it. VA supports the Clay Hunt SAV
Act and believes this bill complements VA's on-going multi-
faceted efforts to improving mental health care for our
Nation's Veterans. These efforts include our implementation of
the President's Executive Actions announced this summer, which
focused on improving the transition from Department of Defense
to VA for servicemembers with mental health needs, improving
mental health peer support, and promoting mental health
awareness and training.
We are committed to excellence in mental health treatment
through regular program monitoring and working with staff to
make program improvements. VA's mental health program not only
addresses medical treatment, but also encompasses training,
research, support services for Veterans and their families,
partnerships with community organizations, expanded
eligibility, hiring efforts, technology advances, and
innovative communications strategies to reduce negative
perceptions of seeking mental health care.
VA has seen improvements in our mental health program, but
we know that there is more work to be done so that Veterans can
reach out for help and connect with services. We appreciate the
steps Congress has taken to support this goal through the
passage of the Clay Hunt SAV Act.
In the 113th Congress, VA testified before the House
Veterans' Affairs Health Subcommittee on November 19, 2014
regarding the introduced version of the Clay Hunt SAV Act, H.R.
5059. H.R. 203 includes many but not all of the provisions of
H.R. 5059 in substantially similar form--specifically sections
1, 2, 4, 6, and 9 of H.R. 5059 as introduced. Enclosed please
find for reference relevant testimony excerpts from that
hearing. VA's detailed views on these provisions as provided
then are unchanged.
Thank you for your continued support of our Nation's
Veterans.
Sincerely,
Robert A. McDonald
Enclosure.
Enclosure
Excerpts from Testimony Regarding H.R. 5059 (113th
Congress) as introduced, delivered before the House Veterans'
Affairs Health Subcommittee on November 19, 2014:
* * * * * * *
H.R. 5059, CLAY HUNT SUICIDE PREVENTION FOR
AMERICAN VETERANS ACT
Mental health care and suicide prevention are among VA's
highest priorities, and we appreciate that the Congress
continues to raise awareness of these important issues. VA
agrees with many of the goals of the bill, and as expressed
below, existing efforts of the Department are aligned with
those goals. VA would welcome discussion with the Committee to
examine how some provisions could be adjusted to complement
VA's ongoing multi-faceted efforts.
Turning to the specifics of the bill, Section 2 of H.R.
5059 would require VA and DOD to each have an independent third
party conduct annual evaluations of the mental health care and
suicide prevention programs that are carried out by the
respective Departments.
VA supports the intent of this provision to further suicide
prevention but has recommendations to improve its effectiveness
to combat Veteran suicide, including addressing issues where
there is duplication of robust activity that is ongoing at VA.
VA does not believe that requiring an additional ongoing
evaluation effort is necessary for its mental health and
suicide prevention programs, as they are regularly reviewed by
external accrediting bodies including the Joint Commission and
Commission on Accreditation of Rehabilitation Facilities (CARF)
as well as many internal review processes. In addition, VA
already has robust evaluation efforts focused on mental health
care and suicide prevention. For example, in prior years the
Congress mandated programs such as the North East Program
Evaluation Center (NEPEC), Serious Mental Illness Treatment,
Resource and Evaluation Center (SMITREC), and the Program
Evaluation Resource Center (PERC). These internal resources
allow for timely reports from subject matter experts in
evaluation who are familiar with the complexities of using and
analyzing VA's administrative data. Additionally, VA complies
with current the Congressionally-mandated reporting
requirements, which include posting of information online,
pursuant to Public Law 112-239 (FY 2013 NDAA), section 726.
Section 726 requirements overlap with some of the areas
mentioned in section 2 of the proposed bill to report on the
annual evaluation of VA mental health programs to the Congress
and the public. Section 726 calls for the establishment of a
contract with the National Academy of Sciences (NAS) to conduct
an assessment and provide an analysis and recommendations on
the state of VA mental health services. VA has actually already
embarked on such a project with NAS that is closely aligned
with this requirement. For suicide prevention, VA has been
increasing our understanding of suicide among Veterans by
developing data sharing agreements with all 50 U.S. states and
several U.S. territories. The initial VA Suicide Data Report
issued in February 2013 was the first effort to analyze these
more complete and timely data points and provide a more
comprehensive understanding of Veteran suicide to inform VA's
suicide prevention efforts. The February 2013 report contained
data and analysis from 21 states.
In an effort to understand the picture of Veteran suicide
more completely, VA has advanced development of a VA/DOD
Suicide Data Repository (SDR). The January 2014 update to the
VA Suicide Data Report is the first analysis using the SDR
information. This update also incorporates more recent data
from the National Death Index and provides information about
suicide rates, which the initial VA Suicide Data Report issued
in February 2013, did not.
VA does support, with some modification, the bill's
requirement for review of the Department's suicide prevention
programs, and looks forward to discussion of this important
element of the bill. A Joint VA/DOD Clinical Practice Guideline
(CPG) for the Assessment and Management of Patients at Risk for
Suicide was released in 2013. VA recommends that a one-time
evaluation of the suicide prevention program be conducted to
support implementation of these guidelines. VA believes it can
benefit from a one-time, targeted evaluation of this effort.
[Testimony regarding Section 3 omitted]
VA supports the intent of section 4. This section would
require VA to: (1) provide Veterans information regarding all
of the mental health care services available in the VISN where
the Veteran is seeking such services, including the name and
contact of each social work office, mental health clinic, and a
list of appropriate staff; (2) update the information every 90
days; and (3) include information about the Web site in
outreach efforts.
This requirement generally aligns with the goals and
efforts currently underway for ensuring that Veterans can
easily locate information about VA mental health services on
the Internet. Each VISN and facility maintains their own Web
site. National policy could be reviewed and updated to meet the
requirements of this section, ensuring that appropriate
information on mental health services is available and updated
on those Web sites. VA recommends conducting an assessment of
available tools for locating information about mental health
services, including seeking input from Veterans in order to
determine the most useful framework through which VA can
provide such information. This requirement should also be
considered in the context of the Secretary's goal of creating
one phone number and one Web site for all VA services. VA would
welcome discussion with the Committee on how the goals of this
section can be furthered.
[Testimony regarding Section 5 omitted]
Section 6 would establish a pilot program for the repayment
of educational loans for mental health professionals. VA
supports the aims of section 6, but we believe the recent
enactment of significant changes to VA's education-debt
repayment programs (in section 302 of Public Law 113-146 and
section 408 of Public Law 113-175) make some parts of section 6
obsolete. We would welcome discussion of this provision with
the Committee in light of these developments.
[Testimony regarding Section 7-8 omitted]
Section 9 of H.R. 5059 would require VA to establish a
pilot program focused on assisting Veterans transitioning from
active duty. The pilot program would be established in at least
5 VISNs and would establish a community-oriented peer support
network and a community outreach team for each medical center
in those VISNs.
VA fully supports the intent of this section but views it
as duplicative and redundant with work that is already being
done in every VISN throughout the country. With regard to peer
support, VHA has a very robust peer support program that
includes outreach and community integration as a major focus.
There are at least 3 peer specialists for every VA medical
center and 2 for each ``very large'' Community Based Outpatient
Clinic (CBOC) and a total of 973 peer specialists nationwide.
As required by Public Law 110-387, VA has established training
guidelines and has instituted a training program that results
in certification of peer specialists. VA has a very active
national network that includes a peer specialist and a mental
health professional from each VISN. These individuals provide
linkages to the peer support network throughout the country and
mentorship to peer specialists in each VISN. VA's peer support
teams interact a great deal with community Veterans'
organizations and mental health organizations via the mental
health summits that occur at each medical center as well as
other activities.
In 2013, VA implemented a national requirement for each
medical facility to host a mental health community summit
annually. During the summits each facility invites community
providers in their area to begin new partnerships or strengthen
existing partnerships based on Veteran and family needs in
their geographic location. In 2014, each facility selected a
community mental health point of contact to provide ready
access to information about VA eligibility and available
clinical services, ensure warm handoffs at critical points of
transition between systems of care, and provide an ongoing
liaison between VA and community partners. VA created an online
map containing the name and contact information for all
facility POCs by state. http://www.mentalhealth.va.gov/
communityPOC.asp
Costs associated with the provisions of H.R. 5059 cannot be
provided at this time.
* * * * * * *
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
H.R. 203 are shown as follows (existing law proposed to be
omitted is enclosed in black brackets, new matter is printed in
italic, and existing law in which no change is proposed is
shown in roman).
Title 38. Veterans' Benefits
* * * * * * *
Part II. General Benefits
* * * * * * *
Chapter 17. Hospital, Nursing Home, Domiciliary, and Medical Care
* * * * * * *
SEC.
SUBCHAPTER I. GENERAL
1701. DEFINITIONS.
* * * * * * *
1709A. TELECONSULTATION.
1709B. EVALUATIONS OF MENTAL HEALTH CARE AND SUICIDE PREVENTION
PROGRAMS.
SUBCHAPTER II. HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL
TREATMENT
* * * * * * *
Subchapter I. General
* * * * * * *
1709B. EVALUATIONS OF MENTAL HEALTH CARE AND SUICIDE PREVENTION
PROGRAMS
(a) Evaluations.--(1) Not less frequently than once during
each period specified in paragraph (3), the Secretary shall
provide for the conduct of an evaluation of the mental health
care and suicide prevention programs carried out under the laws
administered by the Secretary.
(2) Each evaluation conducted under paragraph (1) shall--
(A) use metrics that are common among and useful for
practitioners in the field of mental health care and
suicide prevention;
(B) identify the most effective mental health care
and suicide prevention programs conducted by the
Secretary, including such programs conducted at a
Center of Excellence;
(C) identify the cost-effectiveness of each program
identified under subparagraph (B);
(D) measure the satisfaction of patients with respect
to the care provided under each such program; and
(E) propose best practices for caring for individuals
who suffer from mental health disorders or are at risk
of suicide, including such practices conducted or
suggested by other departments or agencies of the
Federal Government, including the Substance Abuse and
Mental Health Services Administration of the Department
of Health and Human Services.
(3) The periods specified in this paragraph are the
following:
(A) The period beginning on the date on which the
Secretary awards the contract under paragraph (4) and
ending on September 30, 2018.
(B) Each fiscal year beginning on or after October 1,
2018.
(4) Not later than 180 days after the date of the enactment
of this section, the Secretary shall seek to enter into a
contract with an independent third party unaffiliated with the
Department of Veterans Affairs to conduct evaluations under
paragraph (1).
(5) The independent third party that is awarded the
contract under paragraph (4) shall submit to the Secretary each
evaluation conducted under paragraph (1).
(b) Annual Submission.--Not later than December 1, 2018,
and each year thereafter, the Secretary shall submit to the
Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a report
that contains the following:
(1) The most recent evaluations submitted to the
Secretary under subsection (a)(5) that the Secretary
has not previously submitted to such Committees.
(2) Any recommendations the Secretary considers
appropriate.
Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical
Treatment
SEC. 1710. ELIGIBILITY FOR HOSPITAL, NURSING HOME, AND DOMICILIARY CARE
* * * * * * *
(e)(1) * * *
* * * * * * *
[(3) Hospital care, medical services, and nursing home care
may not be provided under or by virtue of subsection (a)(2)(F)
in the case of care for a veteran described in paragraph (1)(D)
who--
[(A) is discharged or released from the active
military, naval, or air service after the date that is
five years before the date of the enactment of the
National Defense Authorization Act for Fiscal Year
2008, after a period of five years beginning on the
date of such discharge or release; or
[(B) is so discharged or released more than five
years before the date of the enactment of that Act and
who did not enroll in the patient enrollment system
under section 1705 of this title before such date,
after a period of three years beginning on the date of
the enactment of that Act.]
(3) In the case of care for a veteran described in
paragraph (1)(D), hospital care, medical services, and nursing
home care may be provided under or by virtue of subsection
(a)(2)(F) only during the following periods:
(A) Except as provided by subparagraph (B), with
respect to a veteran described in paragraph (1)(D) who
is discharged or released from the active military,
naval, or air service after January 27, 2003, the five-
year period beginning on the date of such discharge or
release.
(B) With respect to a veteran described in paragraph
(1)(D) who is discharged or released from the active
military, naval, or air service after January 1, 2009,
and before January 1, 2011, but did not enroll to
receive such hospital care, medical services, or
nursing home care pursuant to such paragraph during the
five-year period described in subparagraph (A), the
one-year period beginning on the date of the enactment
of the Clay Hunt Suicide Prevention for American
Veterans Act.
(C) With respect to a veteran described in paragraph
(1)(D) who is discharged or released from the active
military, naval, or air service on or before January
27, 2003, and did not enroll in the patient enrollment
system under section 1705 of this title on or before
such date, the three-year period beginning on January
27, 2008.
* * * * * * *