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[Senate Report 114-395]
[From the U.S. Government Publishing Office]

                                                      Calendar No. 716
114th Congress    }                                      {      Report
                                 SENATE
 2d Session       }                                      {     114-395

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

 
               HOMELESS VETERANS' REINTEGRATION PROGRAMS 
                      REAUTHORIZATION ACT OF 2015

                                _______
                                

                December 7, 2016.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                             together with

                           SUPPLEMENTAL VIEWS

                         [To accompany S. 425]

    The Committee on Veterans' Affairs (hereinafter, 
``Committee''), to which was referred the bill (S. 425) to 
amend title 38, United States Code (hereinafter, ``U.S.C.''), 
to provide for a five-year extension to the homeless veterans 
reintegration programs and to provide clarification regarding 
eligibility for services under such programs, having considered 
the same, reports favorably thereon with an amendment in the 
nature of a substitute and an amendment to the title, and 
recommends that the bill, as amended, do pass.

                              Introduction

    On February 10, 2015, Senator Boozman introduced S. 425, 
the proposed Homeless Veterans' Reintegration Programs 
Reauthorization Act of 2015. S. 425 would reauthorize homeless 
veterans' reintegration programs through fiscal year 2020 and 
expand eligibility for those reintegration programs to veterans 
participating in the Department of Housing and Urban 
Development-Veterans Affairs Supportive Housing (hereinafter, 
``HUD-VASH'') program, Indian veterans receiving assistance 
under the Native American Housing Assistance and Self 
Determination Act of 1996 (hereinafter, ``NAHASDA''), and 
veterans transitioning from being incarcerated. Senator Tester 
is an original cosponsor. Senators Inhofe and Schumer were 
later added as cosponsors. The bill was referred to the 
Committee.
    On February 26, 2015, Senator Wyden introduced S. 602, the 
proposed GI Bill Fairness Act of 2015. S. 602 would consider 
certain time spent by members of the reserves while receiving 
medical care from the Secretary of Defense as active duty for 
purposes of eligibility for Post-9/11 Educational Assistance 
and would make that change apply retroactively as if it were 
enacted immediately after the enactment of the Post-9/11 
Veterans Educational Assistance Act of 2008. Senator Boozman is 
an original cosponsor. Senators Markey and McCain were later 
added as cosponsors of the bill. The bill was referred to the 
Committee.
    On March 10, 2015, Senator Burr introduced S. 684, the 
proposed Homeless Veterans Prevention Act of 2015. S. 684 would 
increase per diem payments for transitional housing for 
homeless veterans placed in housing that will become permanent, 
authorize per diem payments for entities furnishing care for 
dependents of certain homeless veterans, authorize the 
Department of Veterans Affairs (hereinafter, ``VA'' or 
``Department'') to partner with public or private entities to 
provide legal services to homeless veterans, expand VA 
authority to provide dental care to certain veterans, repeal 
the sunset on referral and counseling programs for veterans at 
risk of homelessness and transitioning from certain 
institutions, extend supportive services assistance for low-
income veteran families in permanent housing, direct VA to 
assess comprehensive service programs for homeless veterans, 
require a Government Accountability Office (hereinafter, 
``GAO'') study of VA homeless programs, and repeal a 
requirement for annual reports from VA on assistance to 
homeless veterans. Senator Manchin is an original cosponsor. 
Senator King was later added as a cosponsor. The bill was 
referred to the Committee.
    On April 23, 2015, Senator Murray introduced S. 1085, the 
proposed Military and Veteran Caregiver Services Improvement 
Act of 2015. S. 1085 would expand eligibility for the program 
of comprehensive assistance for family caregivers to include 
veterans who were injured or fell ill in the line of duty prior 
to September 11, 2001; include child care, financial planning, 
and legal services in the program of comprehensive assistance 
for family caregivers; authorize the transfer of entitlement to 
Post-9/11 education assistance to family members by veterans 
who are in the program of comprehensive assistance for family 
caregivers, without regard to length-of-service requirements; 
expand eligibility for special compensation for members of the 
uniformed services with catastrophic injuries or illnesses 
requiring assistance in everyday living; authorize VA to 
provide certain caregiver assistance to family caregivers of a 
member in receipt of monthly special compensation; authorize 
flexible work schedules or telework for Federal employees who 
are caregivers of veterans; designate a veteran participating 
in the program of comprehensive assistance for family 
caregivers as an adult with a special need for purposes of the 
lifespan respite care program; establish an interagency working 
group to review policies relating to the caregivers of veterans 
and members of the Armed Forces; and require studies on members 
of the Armed Forces who commenced service after September 11, 
2001, and veterans who have incurred a serious injury or 
illness, including a mental health injury, and their 
caregivers. Senators Brown, Collins, Coons, Durbin, and Tester 
are original cosponsors. Senators Baldwin, Bennet, Blumenthal, 
Boxer, Cantwell, Franken, Hirono, King, Markey, Menendez, 
Peters, Sanders, Schatz, Schumer, and Warner were later added 
as cosponsors. The bill was referred to the Committee.
    On May 21, 2015, Senator Hirono introduced S. 1450, the 
proposed Department of Veterans Affairs Emergency Medical 
Staffing Recruitment and Retention Act. S. 1450 would authorize 
VA to modify the hours of employment for a physician or 
physician assistant appointed in VA on a full-time basis to 
more or less than 80 hours in a biweekly pay period provided 
the employee's total hours of employment in a calendar year do 
not exceed 2,080. The bill was referred to the Committee.
    On May 21, 2015, Senator Hirono introduced S. 1451, the 
proposed Veterans' Survivors Claims Processing Automation Act 
of 2015. S. 1451 would authorize VA to provide certain benefits 
to a survivor of a veteran who has not filed a formal claim, if 
VA determines that the record contains sufficient evidence to 
establish the survivor's entitlement to such benefits. The bill 
was referred to the Committee.
    On May 22, 2015, Senator Brown introduced S. 1460, the 
proposed Fry Scholarship Enhancement Act of 2015. S. 1460 would 
include under the Yellow Ribbon G.I. Education Enhancement 
Program (hereinafter, ``Yellow Ribbon Program'') the child of 
an individual who, on or after September 11, 2001, dies in the 
line of duty while serving on active duty. Senator Tillis is an 
original cosponsor. Senators Blumenthal and Coons were later 
added as cosponsors. The bill was referred to the Committee.
    On June 22, 2015, Senator Baldwin introduced S. 1641, the 
proposed Jason Simcakoski Memorial Opioid Safety Act. S. 1641 
would direct VA and the Department of Defense (hereinafter, 
``DOD'') to jointly update the VA/DOD Clinical Practice 
Guideline for Management of Opioid Therapy for Chronic Pain; 
establish a working group on pain management and opioid therapy 
for individuals receiving VA or DOD health care within the 
Health Executive Committee (hereinafter, ``HEC'') of the VA/DOD 
Joint Executive Committee (hereinafter, ``JEC''); require GAO 
to report to Congress on VA's Opioid Safety Initiative 
(hereinafter, ``OSI'') and VA's opioid prescribing practices 
and the Patient Advocacy Program; and require VA to request 
information on medical license violations during the past 20 
years and on whether the health care provider has entered into 
any settlement agreement for a medical-related disciplinary 
charge. Senators Blumenthal, Brown, Capito, Hirono, Johnson, 
Kaine, Manchin, Markey, Moran, Murray, Sanders, and Tester are 
original cosponsors. Senators Durbin, Feinstein, Franken, Kirk, 
Klobuchar, McCaskill, Schumer, and Warner were later added as 
cosponsors. The bill was referred to the Committee.
    On June 24, 2015, Senator Tester introduced S. 1676, the 
proposed Delivering Opportunities for Care and Services for 
Veterans Act of 2015. S. 1676 would prohibit the U.S. 
Department of Health and Human Services from including in 
determining the limitation on the total number of residents the 
residents for allopathic or osteopathic medicine who count 
towards meeting VA's obligation under the Veterans Access, 
Choice, and Accountability Act of 2014 (Public Law 113-146) to 
increase the number of graduate medical education (hereinafter, 
``GME'') residency positions at VA; extend the period for VA to 
increase graduate medical education residency positions to 10 
years; require VA and the Department of Health and Human 
Services to conduct a pilot program on graduate behavioral 
medicine residency programs; include education and training of 
marriage and family therapists and mental health professionals 
in VA education and training programs; allow appointment of 
mental health counseling doctors to be eligible for appointment 
to VA counselor positions; offer competitive pay for physician 
assistants at VA; provide at least 30 percent of annual debt 
reduction payments to rural medical practices; address the pay 
for VA's Directors of Veterans Integrated Service Networks 
(hereinafter, ``VISNs''); and conduct a pilot program to assess 
the feasibility of implementing a nurse advice line for rural 
areas. Senator McCaskill is an original cosponsor. Senators 
Bennet, Blumenthal, Brown, Durbin, Schatz, and Udall were later 
added as cosponsors. The bill was referred to the Committee.
    On July 14, 2015, Senator Shaheen introduced S. 1754, which 
would make permanent the temporary increase in the maximum 
number of judges presiding over the U.S. Court of Appeals for 
Veterans Claims (hereinafter, ``Veterans Court''). Senator 
Blumenthal was later added as a cosponsor. The bill was 
referred to the Committee.
    On July 23, 2015, Senator Blumenthal introduced S. 1856, 
the proposed Department of Veterans Affairs Equitable Employee 
Accountability Act of 2015. S. 1856 would allow VA to suspend 
employees without pay based on performance or misconduct and 
remove such suspended individuals if it is determined necessary 
after investigation and review; allow suspended or removed 
individuals to appeal to the Merit Systems Protection Board and 
receive back pay if the suspension or removal is found to be 
unwarranted. Senators Brown, Hirono, Murray, Sanders, and 
Tester are original cosponsors. Senators Baldwin, Bennet, 
Booker, Boxer, Cantwell, Cardin, Casey, Durbin, Franken, 
Gillibrand, Heinrich, Kaine, Leahy, Markey, Menendez, Mikulski, 
Peters, Schumer, Shaheen, Stabenow, Udall, Warren, and 
Whitehouse were later added as cosponsors. The bill was 
referred to the Committee.
    On July 29, 2015, Senator Blumenthal introduced S. 1885, 
the proposed Veteran Housing Stability Act of 2015. S. 1885 
would expand VA's definition of homeless veteran to include 
those fleeing domestic violence; direct VA to provide intensive 
case management interventions for veterans enrolled in the 
homeless registry and the annual patient enrollment system; 
provide case management services to improve housing retention 
for transitioning or previously homeless veterans; expand the 
VA housing assistance program to include assistance for at risk 
and low-income veterans and their families transitioning to 
permanent housing; direct VA to conduct community outreach on 
the housing needs of veterans; codify the National Center on 
Homelessness Among Veterans; and require an annual review of 
each grant recipient and eligible entity that receives per diem 
payments for homeless services to evaluate its performance. 
Senators Brown, Hirono, and Sanders are original cosponsors. 
Senators Boxer and Schumer were later added as cosponsors. The 
bill was referred to the Committee.
    On August 5, 2015, Senator Blumenthal introduced S. 1938, 
the proposed Career-Ready Student Veterans Act of 2015. S. 1938 
would modify the criteria for approving educational 
institutions providing programs leading to licensure or 
certification to require that they meet certain state 
requirements or are approved by an appropriate state board or 
agency. Senators Brown, Carper, Cassidy, Coons, Durbin, 
Feinstein, Gillibrand, Merkley, Murphy, Reed, Schumer, Shaheen, 
and Tillis are original cosponsors. Senator Warren was later 
added as a cosponsor. The bill was referred to the Committee.
    On August 5, 2015, Senator Hoeven introduced S. 2000, the 
proposed Veterans Access to Long Term Care and Health Services 
Act. S. 2000 would authorize VA to enter into a Veterans Care 
Agreement with an eligible provider to furnish certain care and 
services if VA is unable to do so, establish a process for 
certification of eligible providers, monitor the quality of 
care furnished to veterans, and allow the agreements to be made 
to provide veterans with nursing home care. Senator Manchin is 
an original cosponsor. Senator Rounds was later added as a 
cosponsor. The bill was referred to the Committee.
    On September 10, 2015, Senator Graham introduced S. 2022, 
which would increase the special monthly pension for living 
Medal of Honor recipients. Senators Blumenthal and Markey were 
later added as cosponsors. The bill was referred to the 
Committee.
    On October 5, 2015, Senator Tester introduced S. 2134, the 
proposed Grow Our Own Directive: Physician Assistant Employment 
and Education Act of 2015. S. 2134 would direct VA to carry out 
a pilot program to provide educational assistance to certain 
former members of the Armed Forces for education and training 
as a VA physician assistant, provide educational assistance to 
program participants for the cost of obtaining a master's 
degree in physician assistant studies or a similar master's 
degree, ensure mentors are available for program participants 
at each VA facility where a participant is employed, partner 
with specified government programs and appropriate educational 
institutions that offer degrees in physician assistant studies, 
establish standards to improve education and hiring of 
physician assistants, and implement a national plan for 
retention and recruitment that includes adoption of competitive 
pay standards. Senator Moran is an original cosponsor. Senators 
Baldwin and Brown were later added as cosponsors. The bill was 
referred to the Committee.
    On November 5, 2015, Senator Blumenthal introduced S. 2253, 
the proposed Department of Veterans Affairs Veterans Education 
Relief and Restoration Act of 2015. S. 2253 would provide that, 
if a veteran is forced to discontinue a course as a result of 
an educational institution's permanent closure and did not 
receive credit or lost time training toward completion of the 
educational program, VA educational assistance payments will 
not be charged against the individual's entitlement to 
educational assistance or against the aggregate period for 
which such assistance may be provided (for school closures 
beginning with fiscal year 2015), and allow VA to continue 
paying a monthly housing stipend following a permanent school 
closure for a limited period of time. Senators Baldwin, Brown, 
Durbin, Gillibrand, Hirono, Murphy, Reed, Tillis, Warren, and 
Wyden are original cosponsors. Senators Boxer, Carper, Heller, 
Klobuchar, McCaskill, Murray, Peters, Sanders, and Schumer were 
later added as cosponsors. The bill was referred to the 
Committee.

                           Committee Hearings

    On May 13, 2015, the Committee held a hearing on 
legislation pending before the Committee. Testimony was 
received from David R. McLenachen, Acting Deputy Under 
Secretary for Disability Assistance, U.S. Department of 
Veterans Affairs; Anthony Kurta, Deputy Assistant Secretary of 
Defense, Military Personnel Policy, U.S. Department of Defense; 
Teresa W. Gerton, Deputy Assistant Secretary for Policy, 
Veterans' Employment and Training Service, U.S. Department of 
Labor; Alphonso Maldon, Jr., Chairman, Military Compensation 
and Retirement Modernization Commission; Jeffrey E. Phillips, 
Executive Director, Reserve Officers Association; and Aleks 
Morosky, Deputy Legislative Director, National Legislative 
Service, Veterans of Foreign Wars.
    On June 3, 2015, the Committee held a hearing on 
legislation pending before the Committee. Testimony was 
received from Thomas Lynch, Assistant Deputy Under Secretary 
for Health Clinical Operations, Veterans Health Administration, 
U.S. Department of Veterans Affairs; Adrian Atizado, Assistant 
National Legislative Director, Disabled American Veterans; Fred 
Benjamin, Vice President and Chief Operating Officer, 
Medicalodges, Inc.; Thomas J. Snee, National Executive 
Director, Fleet Reserve Association; and Sergeant First Class 
Victor Medina, U.S. Army, Retired.
    On June 24, 2015, the Committee held a hearing on 
legislation pending before the Committee. Testimony was 
received from Dr. Rajiv Jain, Assistant Deputy Under Secretary 
for Health for Patient Care Services, Veterans Health 
Administration, U.S. Department of Veterans Affairs; Ian de 
Planque, Legislative Director, The American Legion; Pete 
Hegseth, CEO, Concerned Veterans of America; Adrian Atizado, 
Assistant National Legislative Director, Disabled American 
Veterans; Carl Blake, Associate Executive Director, Paralyzed 
Veterans of America; Max Stier, President and CEO, Partnership 
for Public Service; and John Rowan, National President, Vietnam 
Veterans of America.
    On September 16, 2015, the Committee held a hearing on 
legislation pending before the Committee. Testimony was 
received from Thomas Lynch, Assistant Deputy Under Secretary 
for Health Clinical Operations, Veterans Health Administration, 
U.S. Department of Veterans Affairs; Joseph W. Wescott II, 
Legislative Director, National Association of State Approving 
Agencies; Roscoe G. Butler, Deputy Director for Health Care, 
The American Legion; Aleks Morosky, Deputy Director, National 
Legislative Service, Veterans of Foreign Wars; and Donald F. 
Kettl, Professor, School of Public Policy, University of 
Maryland.
    On October 6, 2015, the Committee held a hearing on 
legislation pending before the Committee. Testimony was 
received from Thomas Lynch, Assistant Deputy Under Secretary 
for Health Clinical Operations, Veterans Health Administration, 
U.S. Department of Veterans Affairs; Lauren Augustine, 
Legislative Associate, Iraq and Afghanistan Veterans of 
America; Lou Celli, Director, Veterans Affairs and 
Rehabilitation Division, The American Legion; Elisha Harig-
Blaine, Principal Associate, Housing (Veterans and Special 
Needs), National League of Cities; and David Norris, National 
Legislative Committee Vice-Chairman, Veterans of Foreign Wars.
    On November 18, 2015, the Committee held a hearing on 
legislation pending before the Committee. Testimony was 
received from Curtis L. Coy, Deputy Under Secretary for 
Economic Opportunity, Veterans Benefits Administration, U.S. 
Department of Veterans Affairs; Elizabeth Hempowicz, Public 
Policy Associate, Project on Government Oversight; William 
Hubbard, Vice President of Government Affairs, Student Veterans 
of America; Aleks Morosky, Deputy Director, National 
Legislative Service, Veterans of Foreign Wars; Thomas Porter, 
Legislative Director, Iraq and Afghanistan Veterans of America; 
and Diane Zumatto, National Legislative Director, AMVETS.

                           Committee Meeting

    After reviewing the testimony from the foregoing hearings, 
the Committee met in open session on December 9, 2015, to 
consider, among other legislation, an amended version of 
S. 425, including provisions derived from S. 425 as introduced 
and provisions derived from the other legislation noted above. 
The Committee voted by voice vote, without objection, to report 
favorably to the Senate S. 425 as amended and as subsequently 
amended at the Committee meeting.*
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    *The Committee notes that the information outlined in this report 
was current as of the December 2015 Committee meeting at which the 
Committee bill was ordered favorably reported. With regard to sections 
416, 417, 418, 422, 423, 425, 431, 432, 433, 434, 441, and 442, the 
Committee also notes that, after that Committee meeting, Public Law 
114-198 was enacted, which incorporated in title IX numerous provisions 
derived from the Committee bill and from S. 2921 as favorably reported 
by the Committee regarding opioid therapy and pain management at VA. 
For purposes of explaining the Committee's December 2015 actions, the 
Committee generally opted to retain the then-current background 
information in this report.
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                     Summary of S. 425 as Reported

    S. 425, as reported (hereinafter, ``the Committee bill''), 
consists of 57 sections, summarized below.
    Section 1 provides a short title and a table of contents.

                           TITLE I--BENEFITS

    Section 101 would amend section 5101 of title 38, U.S.C., 
to provide that VA may pay benefits under chapter 13 
(dependency and indemnity compensation) and chapter 15 
(pension) and sections 2302 (funeral expenses), 2307 (burial 
benefits), and 5121 (accrued benefits) of title 38, U.S.C., to 
a survivor of a veteran who has not filed a formal claim, if VA 
determines that the record contains sufficient evidence to 
establish the survivor's entitlement to those benefits.
    Section 102 would amend section 1562 of title 38, U.S.C., 
to increase from $1,299 to $3,000 the monthly special pension 
VA provides to Medal of Honor recipients.

                      TITLE II--EDUCATION MATTERS

    Section 201(a) would amend section 3312 of title 38, 
U.S.C., to provide that any payment of educational assistance 
to an individual for pursuit of a course or courses under the 
Post-9/11 GI Bill, if VA finds that the individual was forced 
to discontinue pursuit as a result of permanent closure of the 
institution and did not receive credit or lost training time 
toward completion of the program for that course or courses, 
will not be charged against the individual's entitlement to 
benefits under the Post-9/11 GI Bill or counted against the 
aggregate period for which section 3695 of title 38, U.S.C., 
limits the individual's receipt of educational assistance.
    Section 201(b) would amend section 3680(a) of title 38, 
U.S.C., to provide that VA may continue to pay educational 
allowances to certain veterans and other education 
beneficiaries in order to pay the Post-9/11 GI Bill housing 
allowance during periods following a permanent closure of an 
educational institution, except that the payments may be 
continued only until the earlier of the date of the end of the 
term during which the closure occurred and the date 4 months 
after the school closure.
    Section 202 would modify section 3319 of title 38, U.S.C., 
so that a servicemember must serve 10 years and agree to serve 
an additional 2 years in order to be eligible to transfer 
unused Post-9/11 GI Bill benefits.
    Section 202 would amend section 3319 of title 38, U.S.C., 
to cap monthly housing allowance payments at 50 percent of the 
housing allowance that would otherwise be payable to a child 
using transferred Post-9/11 GI Bill benefits.
    Section 203 would codify in a new section 3326 of title 38, 
U.S.C., the provisions now found in section 5003(c) of Public 
Law 110-252 and would add a provision to that new section 
providing that, in the case of an individual who on or after 
January 1, 2016, submits to VA an election of which program to 
use that VA determines is clearly against the interests of the 
individual or who fails to make an election, VA may make an 
alternative election on behalf of the individual that VA 
determines is in the best interests of the individual. This 
section would also provide that VA must promptly notify the 
veteran of such alternate election and allow the veteran 30 
days to modify the election.
    Section 204 would modify section 3684 of title 38, U.S.C., 
so that an ``educational institution'' for purposes of 
reporting to VA enrollments in education programs would include 
a group, district, or consortium of separately accredited 
educational institutions located in the same state that are 
organized in a manner that facilitates the centralized 
reporting of enrollments in the group, district, or consortium 
of institutions.
    Section 205 would amend section 3672 of title 38, U.S.C., 
so that an education program would be deemed approved for 
purposes of VA education benefits only if a state approving 
agency determines that the program meets the deemed-approved 
criteria. It would also modify section 3675 of title 38, 
U.S.C., so that a program that is not subject to approval under 
section 3672 of title 38, U.S.C., may be approved by a state 
approving agency or VA acting in the role of a state approving 
agency when the criteria for approval of accredited programs at 
for-profit institutions are met.
    Section 206 would modify section 3676 of title 38, U.S.C., 
so that additional criteria for approval of a non-accredited 
course may be required by a state approving agency only if the 
Secretary of Veterans Affairs, in consultation with the state 
approving agency and pursuant to regulations prescribed to 
carry out this requirement, determines that the additional 
criteria are necessary and treat public, private, and 
proprietary for-profit educational institutions equitably. 
Section 206 would modify section 3675 of title 38, U.S.C., so 
that accredited courses must also meet those additional 
criteria to be approved.
    Section 207 of the bill would amend section 3693 of title 
38, U.S.C., to modify the conditions under which VA generally 
must conduct compliance surveys of educational institutions and 
training establishments offering approved courses.
    Section 208 would amend sections 3675(b) and 3676(c) of 
title 38, U.S.C., to provide that, in order to be approved for 
purposes of VA education benefits, a program designed to 
prepare an individual for licensure or certification in a 
state, or for employment pursuant to standards developed by a 
board or agency of a state in an occupation that requires 
approval or licensure, the program also must meet any 
instructional curriculum licensure or certification 
requirements of the state, or meet such standards developed by 
a board or agency of a state. It would also require that any 
course of education designed to prepare a student for licensure 
to practice law be accredited by a recognized party and 
authorize the VA Secretary to waive any of those requirements 
in certain circumstances. It would add a subsection (d) to 
section 3679 of title 38, U.S.C., providing that VA must 
disapprove a course of education described above unless the 
educational institution providing the course publicly discloses 
any conditions or additional requirements to obtain the 
license, certification, or approval for which the course is 
designed to provide preparation. Finally, it would provide 
that, if, after enrollment in a course that is subject to 
disapproval by reason of these changes, an individual pursues 
courses at the same educational institution while remaining 
continuously enrolled, any course pursued by the individual at 
that institution will not be subject to disapproval.
    Section 209 would amend section 3317 of title 38, U.S.C., 
to allow Marine Gunnery Sergeant John David Fry Scholarship 
(hereinafter, ``Fry Scholarship'') recipients to participate in 
the Yellow Ribbon Program.
    Section 210 would amend section 3301 of title 38, U.S.C., 
to count as active duty for purposes of the Post-9/11 GI Bill 
reservists' service under section 12301(h) of title 10, U.S.C., 
under which the Secretary of a military department may order a 
reservist to active duty ``to receive authorized medical 
care''; ``to be medically evaluated for disability''; or ``to 
complete a required Department of Defense health care study''.

                  TITLE III--HOMELESS VETERANS MATTERS

    Section 301 would amend section 2002(1) of title 38, 
U.S.C., so that the VA definition of homeless would include 
those individuals described in section 11302(b) of title 42, 
U.S.C., such as an individual fleeing domestic violence.
    Section 302 would amend section 2012 of title 38, U.S.C., 
to provide that the per diem rate paid to certain entities that 
provide services to homeless veterans may exceed the rate paid 
to State homes in the case of services provided to a homeless 
veteran who is placed in housing that will become permanent 
housing upon termination of those services (transition-in-
place). In those cases, the maximum per diem would be 150 
percent of the State home rate.
    Section 303 would amend section 2062 of title 38, U.S.C., 
to provide that dental services may be provided to a veteran 
who, for 60 consecutive days, has been housed using the Housing 
and Urban Development-VA Supportive Housing program.
    Section 304 would amend section 2021 of title 38, U.S.C., 
to expand the scope of the homeless veterans' reintegration 
program to include veterans participating in VA's supported 
housing program for which rental assistance is provided under 
section 8(o)(19) of the United States Housing Act; Indians who 
are veterans and receiving assistance under the Native American 
Housing Assistance and Self Determination Act; and veterans who 
are transitioning from being incarcerated.
    Section 305 would add a new section 2013 to title 38, 
U.S.C., to require VA to carry out a program under which VA 
provides case management services to improve the retention of 
housing by veterans who were previously homeless and are 
transitioning to permanent housing and veterans who are at risk 
of becoming homeless. VA would be required to provide a report 
to Congress on the results of the program.
    Section 306, in a freestanding provision, would require VA 
to carry out a pilot program under which the VA Secretary will 
provide intensive case management interventions to a veteran 
who is enrolled in the VA homeless registry and the VA health 
care system. VA would be required to provide a report to 
Congress on the results of the pilot program.
    Section 307 would add a new section 2067 to title 38, 
U.S.C., to require VA to establish and operate a center known 
as the National Center on Homelessness Among Veterans, thereby 
codifying the already existing Center.
    Section 308 would add a new section 2022A to title 38, 
U.S.C., to authorize VA to enter into partnerships with public 
or private entities to fund a portion of the general legal 
services provided by those entities to homeless veterans and 
veterans at risk of homelessness.
    Section 309 would amend section 2012 of title 38, U.S.C., 
to require VA, each year, to review each grant recipient and 
eligible entity that received a per diem payment under section 
2012 of title 38, U.S.C., for a service furnished to a veteran 
during the 1-year period preceding the review to evaluate the 
performance of the grant recipient or eligible entity during 
that period. For any grant recipient or eligible entity whose 
performance was evaluated, VA may only provide per diem to that 
grant recipient or eligible entity in the following year if VA 
determines that such performance merits continued receipt of 
per diem. Also, VA would be required to establish uniform 
performance targets throughout the United States for all grant 
recipients and eligible entities that receive per diem payments 
for purposes of evaluating their performance.
    Section 310 would repeal section 2065 of title 38, U.S.C., 
to remove a requirement that VA provide an annual report to 
Congress on the activities of VA's programs for homeless 
veterans.
    Section 311 would require that, not later than 270 days 
after enactment, GAO must complete a study of VA programs that 
provide assistance to homeless veterans, including an 
assessment of whether those programs are meeting the needs of 
veterans and a review of recent efforts by VA to improve the 
privacy, safety, and security of female veterans.
    Section 312, in a freestanding provision, would require VA 
to assess and measure the capacity of programs that receive 
grants or per diem payments. VA would be required to develop 
and use tools to examine the capacity of those programs at both 
the national and local level.
    Section 313, in a freestanding provision, would require VA 
to submit a report to Congress describing and assessing 
outreach conducted by VA to realtors, landlords, property 
management companies, and developers to educate them about the 
housing needs of veterans and the benefits of having veterans 
as tenants.

                     TITLE IV--HEALTH CARE MATTERS

    Section 401 provides a short title for Title IV of the 
bill: Jason Simcakoski Memorial Act.

     SUBTITLE A--EMPLOYMENT OF DIRECTORS AND HEALTH CARE PROVIDERS

    Section 411 would amend Public Law 113-146 to require VA to 
increase the number of graduate medical education residency 
positions at VA medical facilities by up to 1,500 positions 
over the next 10 years, rather than the current 5-year 
requirement, and would extend an annual reporting requirement 
through 2024.
    Section 412 would amend section 7423(a) of title 38, 
U.S.C., to provide an exception to the requirement that the 
hours of employment for a full-time VA physician or physician 
assistant must consist of not less than 80 hours in a biweekly 
pay period, so that VA may modify the hours of employment for a 
full-time physician or physician assistant to be more or less 
than 80 hours in a biweekly pay period if the total hours for 
the employee do not exceed 2,080 hours in a calendar year.
    Section 413 would modify section 7451(a)(2) of title 38, 
U.S.C., to allow VA to offer rates of pay that are competitive 
with non-VA facilities within the same labor market areas when 
hiring for physician assistant positions.
    Section 414 would amend section 7306 of title 38, U.S.C., 
to require the Office of the Under Secretary for Health to 
include such Directors of Veterans Integrated Service Networks 
as may be appointed to suit VA's needs and would strike the 
requirement that directors be either a qualified doctor of 
medicine or a qualified doctor of dental surgery or dental 
medicine.
    Section 415 would add a new section 7481 to title 38, 
U.S.C., providing that pay for a Medical Director or Director 
of a Veterans Integrated Service Network will consist of basic 
pay set forth under section 7404(a) of title 38, U.S.C., 
(setting grades and pay scales for VA health professionals) and 
market pay determined under this new authority. The amount of 
market pay would be determined by the Secretary on a case-by-
case basis and must consist of pay intended to reflect the 
needs of VA with respect to the recruitment and retention of 
the Director.
    Section 416, in a freestanding provision, would require VA, 
as part of the hiring process for each health care provider 
after the date of enactment, to request from the medical board 
of each state in which the health care provider has a medical 
license information on any violation of the requirements of the 
medical license of the health care provider and information on 
whether the health care provider has entered into any 
settlement agreement for a disciplinary charge relating to the 
practice of medicine.
    Section 417, in a freestanding provision, would provide 
that, notwithstanding section 552a of title 5, U.S.C., 
(regarding disclosure of Federal records about an individual), 
VA must, with respect to any VA health care provider that has 
violated a requirement of his/her medical license, provide to 
the medical board of each state in which the health care 
provider is licensed or practices all relevant information 
contained in the State Licensing Board Reporting File or any 
successor file.
    Section 418, in a freestanding provision, would provide 
that, not later than 2 years after enactment, VA would be 
required to submit to the Committee on Veterans' Affairs of the 
Senate and House of Representatives a report on VA's compliance 
with its policy to conduct a review of each VA health care 
provider who transfers to another VA medical facility or leaves 
VA to determine whether there are any concerns, complaints, or 
allegations of violations relating to the provider and, if 
there are, to take appropriate action.

             SUBTITLE B--OPIOID THERAPY AND PAIN MANAGEMENT

    Section 421, in a freestanding provision, would provide 
that, not later than 1 year after enactment, VA and the 
Department of Defense must jointly update the VA/DOD Clinical 
Practice Guideline for Management of Opioid Therapy for Chronic 
Pain.
    Section 422, in a freestanding provision, would provide 
that, not later than 180 days after enactment, VA would be 
required to expand VA's Opioid Safety Initiative to include all 
VA medical facilities; require all employees responsible for 
prescribing opioids to receive increased education and 
training; establish a pain management team at each medical 
facility; require participation in the state prescription drug 
monitoring programs (hereinafter, ``PDMP''); report on the 
feasibility and advisability of advanced real-time tracking of 
opioid use data in the Opioid Therapy Risk Report tool; 
increase the availability of opioid receptor antagonists such 
as naloxone and provide a report on compliance; include in the 
Opioid Therapy Risk Report tool information on when health care 
providers access the tool and the most recent urine drug test 
for each veteran; and require notification of opioid abuse risk 
in the computerized patient record system.
    Section 423, in a freestanding provision, would require 
that VA and DOD ensure that the Pain Management Working Group 
(hereinafter, ``PMWG'') of the VA-DOD Health Executive 
Committee includes a focus on the opioid prescribing practices 
of health care providers of each Department; the ability of 
each Department to manage acute and chronic pain, including 
training health care providers with respect to pain management; 
the use by each Department of complementary and integrative 
health (hereinafter, ``CIH''); the concurrent use by health 
care providers of each Department of opioids and prescription 
drugs to treat mental health disorders, including 
benzodiazepines; the practice by health care providers of each 
Department of prescribing opioids to treat mental health 
disorders; the coordination in coverage of and consistent 
access to medications prescribed for patients transitioning 
from receiving health care from DOD to VA; and the ability of 
each Department to identify and treat substance use disorders.
    Section 424 would add a new section 7309A to title 38, 
U.S.C., to require VA to establish within each Veterans 
Integrated Service Network a Pain Management Board.
    Section 425, in a freestanding provision, would require VA, 
not later than 2 years after enactment, to enter into a 
contract with an independent entity to conduct an independent 
review of the Opioid Safety Initiative and the opioid 
prescribing practices of VA health care providers. The VA 
Secretary must review annually the prescription rates of each 
medical facility and conduct investigations, through the Office 
of the Medical Inspector, on prescription rates that conflict 
with or are otherwise inconsistent with the standards of 
appropriate and safe care.

                      SUBTITLE C--PATIENT ADVOCACY

    Section 431 would add a new section 7309B to title 38, 
U.S.C., to establish in the Office of the Under Secretary for 
Health an Office of Patient Advocacy to carry out VA's Patient 
Advocacy Program. The Director would be appointed by the Under 
Secretary for Health and would report directly to the Under 
Secretary for Health.
    Section 432, in a freestanding provision, would provide 
that, not later than 90 days after enactment, and not less 
frequently than once every 90 days thereafter, each VA medical 
center must host a community meeting open to the public on 
improving VA health care and that, not later than 1 year after 
enactment, and not less frequently than annually thereafter, 
each community based outpatient clinic must host a community 
meeting open to the public on improving VA health care.
    Section 433, in a freestanding provision, would provide 
that, not later than 90 days after enactment, VA must, in as 
many prominent locations as appropriate to be seen by the 
largest percentage of patients and family members at each 
medical facility, display the purposes of the Patient Advocacy 
Program and the contact information for the patient advocate at 
such medical facility and display the rights and 
responsibilities of patients and family members of patients and 
with respect to community living centers and other VA 
residential facilities, residents and family members of 
residents at such medical facility.
    Section 434, in a freestanding provision, would provide 
that, not later than 3 years after enactment, GAO must submit 
to the Committee on Veterans' Affairs of the Senate and House 
of Representatives a report on the Patient Advocacy Program.

            SUBTITLE D--COMPLEMENTARY AND INTEGRATIVE HEALTH

    Section 441, in a freestanding provision, would provide 
that, not later than 180 days after enactment, VA must develop 
a plan to expand materially and substantially the scope of the 
effectiveness of research and education on, and delivery and 
integration of, complementary and integrative health services 
into the health care services provided to veterans.
    Section 442, in a freestanding provision, would provide 
that, not later than 180 days after completion of the plan to 
expand research and education on, and delivery and integration 
of, complementary and integrative health services, VA would be 
required to carry out a pilot program to assess the feasibility 
and advisability of integrating the delivery of complementary 
and integrative health services with other health care services 
provided by VA for veterans with mental health conditions, 
chronic pain conditions, other chronic conditions, and such 
other conditions as the VA Secretary determines appropriate.

                     SUBTITLE E--FAMILY CAREGIVERS

    Section 451 would amend section 1720G of title 38, U.S.C., 
to expand eligibility for VA's Program of Comprehensive 
Assistance for Family Caregivers to veterans with a serious 
injury incurred or aggravated in the line of duty in the active 
military, naval, or air service on or before May 7, 1975, 
during the 2-year period following the date on which the VA 
Secretary submits to Congress a certification that the 
Department has fully implemented the information technology 
system required by section 452(a) of the bill. After the date 
that is 2 years after the date on which the certification is 
submitted, eligibility would be expanded to also include 
veterans with a serious injury incurred or aggravated in the 
line of duty in the active military, naval, or air service 
after May 7, 1975, and before September 11, 2001.
    Section 452, in a freestanding provision, would require VA 
to implement an information technology system that fully 
supports the Family Caregiver Program and allows for data 
assessment and comprehensive monitoring by not later than 
December 31, 2016.
    Section 453 would amend requirements in Public Law 111-163 
for VA's annual evaluation report on the Program of 
Comprehensive Assistance for Family Caregivers and the Program 
of General Caregiver Support to include a description of any 
barriers to accessing and receiving care and services. The 
report on the Program of Comprehensive Assistance for Family 
Caregivers would also include an evaluation of the sufficiency 
and consistency of the training provided to family caregivers.
    Section 454, in a freestanding provision, would establish a 
VA advisory committee on caregiver policy.
    Section 455, in a freestanding provision, would require VA 
to contract with an independent entity to conduct a 
comprehensive study on veterans who have incurred a serious 
injury or illness and individuals acting as caregivers for 
veterans.

                 SUBTITLE F--OTHER HEALTH CARE MATTERS

    Section 461 would add a new section 1703A to title 38, 
U.S.C., to provide that VA may enter into agreements to provide 
nursing home care and those agreements may be entered into 
without regard to any law that would require VA to use 
competitive procedures in selecting the party with which to 
enter into the agreement. Generally, a nursing home in carrying 
out that agreement would not be subject to any law that 
Medicare providers are not subject to.
    Section 462 would amend section 1745 of title 38, U.S.C., 
to provide that VA may enter into agreements to provide nursing 
home care and those agreements may be entered into without 
regard to any law that would require VA to use competitive 
procedures in selecting the party with which to enter into the 
agreement. Generally, a State home in carrying out that 
agreement would not be subject to any law that Medicare 
providers are not subject to.

                         TITLE V--OTHER MATTERS

    Section 501 would amend section 7253 of title 38, U.S.C., 
to temporarily expand the U.S. Court of Appeals for Veterans 
Claims from 7 to 9 judges through 2020.
    Section 502 would repeal section 604(b) of Public Law 113-
291 in order to realign the housing allowance provided to VA 
beneficiaries using Post-9/11 GI Bill benefits so it is paid at 
the same rate as the Basic Allowance for Housing provided to 
active duty military personnel in pay grade E-5 at the ``with 
dependents'' rate.
    Section 503 would add a new section 527A to title 38, 
U.S.C., to require VA to carry out a program of internal audits 
and self-analysis to improve the furnishing of benefits and 
health care to veterans and their families. VA would be 
required to carry out the program through an office established 
for that purpose within the Office of the Secretary that is 
interdisciplinary and independent of the other offices within 
the Office of the Secretary and the administrations, staff 
organizations, and staff offices identified for audits.
    Section 504, in a freestanding provision, would require the 
VA Secretary to provide each VA employee who is in a managerial 
position with periodic training on the rights of whistleblowers 
and how to address a report by an employee of a hostile work 
environment, reprisal, or harassment; how to effectively 
motivate, manage, and reward the employees who report to the 
manager; and how to effectively manage employees who are 
performing at an unacceptable level and access assistance from 
the VA human resources office and the Office of General Counsel 
with respect to those employees.

                       Background and Discussion

                           TITLE I--BENEFITS

Sec. 101. Expedited payment of survivor benefits.

    Section 101 of the Committee bill, which is derived from 
S. 1451, would authorize VA to pay benefits to a survivor of a 
veteran who has not filed a formal claim, if the record 
contains sufficient evidence to establish the survivor's 
entitlement to such benefits.
    Background. Section 5101 of title 38, U.S.C., requires a 
claimant to file a formal claim as a condition of receiving VA 
benefits. When a survivor of a veteran files a claim for VA 
benefits based upon the veteran's death, however, the 
information and evidence necessary to decide the claim is often 
already in the veteran's claims file. In its Fiscal Year 2016 
Budget, VA included a legislative proposal that would authorize 
VA to initiate and pay a survivor's claim without receipt of a 
formal application whenever sufficient evidence is in the 
veteran's record to begin processing such claim. Elimination of 
the claim requirement would allow VA to automate the delivery 
of uninterrupted benefits to qualifying survivors.
    Committee Bill. Subsection (a) of section 101 of the 
Committee bill would amend section 5101 of title 38, U.S.C., to 
authorize VA to pay benefits under chapter 13 (dependency and 
indemnity compensation) and chapter 15 (pension) and sections 
2302 (funeral expenses), 2307 (burial benefits), and 5121 
(accrued benefits) of title 38, U.S.C., to a survivor of a 
veteran who has not filed a formal claim if VA determines that 
the record contains sufficient evidence to establish the 
survivor's entitlement to those benefits. For purposes of 
establishing an effective date under section 5110 of title 38, 
U.S.C., the date on which VA is notified of the death of the 
veteran will be treated as the date of the receipt of the 
survivor's application for benefits. These changes would apply 
with respect to claims for benefits based on a death occurring 
on or after the date of enactment.

Sec. 102. Increase in special pension for Medal of Honor recipients.

    Section 102 of the Committee bill, which is derived from 
S. 2022, would amend section 1562 of title 38, U.S.C., to 
increase from $1,299.61 to $3,000 the monthly special pension 
VA provides to Medal of Honor recipients.
    Background. Under section 1562(a) of title 38, U.S.C., VA 
provides a monthly special pension to individuals who have been 
entered on the Medal of Honor roll of a military service. The 
current monthly payment is $1,299.61. Under section 1562(e) of 
title 38, U.S.C., VA is required to increase the monthly 
stipend effective December 1 of each year by the same percent 
increase as any cost-of-living adjustment provided to 
recipients of Social Security benefits.
    Committee Bill. Section 102 of the Committee bill would 
amend section 1562(a) of title 38, U.S.C., to increase to 
$3,000 the monthly special pension provided to Medal of Honor 
recipients. That change would take effect 1 year after the date 
of enactment, except that, if that date is not the first day of 
a month, the change would take effect on the first day of the 
first month beginning after that date. If the increase takes 
effect before December 1, 2016, VA would not make a cost-of-
living adjustment to the special pension amount until December 
1, 2017.
    The Committee is of the view that an increase is warranted 
to help to defray the out-of-pocket costs incurred by Medal of 
Honor recipients in order to speak at or attend events around 
the country.

                      TITLE II--EDUCATION MATTERS

Sec. 201. Restoration of entitlement to Post-9/11 educational 
        assistance for veterans affected by closures of educational 
        institutions.

    Section 201 of the Committee bill, which is derived from 
S. 2253, would require VA to provide a continued monthly 
housing stipend and restore educational benefits to veterans 
affected by the permanent closures of educational institutions 
if a veteran is forced to discontinue a course and did not 
receive credit, or lost training time, toward completion of the 
educational program.
    Background. Section 3680 of title 38, U.S.C., describes the 
manner in which VA is to provide educational assistance 
payments and subsistence allowances during the period of 
veterans' or dependents' enrollment in an educational program. 
At the 100 percent level of entitlement of the Post-9/11 GI 
Bill, veterans are eligible for 36 months of tuition benefits 
and a monthly stipend equivalent to the amount of basic 
allowance for housing payable under section 403 of title 37, 
U.S.C., for a member with dependents in pay grade E-5. This 
stipend is intended to cover housing, food, utilities, and 
other expenses while attending school.
    Currently, section 3680, subsection (a)(3)(B), of title 38, 
U.S.C., authorizes VA to continue to pay educational assistance 
and subsistence allowances during certain temporary school 
closures. These temporary closures are subject to regulations 
the VA Secretary shall prescribe and include periods when 
schools are temporarily closed due to an emergency, such as a 
strike, or under established policy, such as the issuance of a 
presidential Executive Order. However, this temporary 
continuance of benefit payments may not exceed 4 weeks in any 
12-month period and the VA Secretary is not granted similar 
statutory authority to continue benefit payments in the event 
of a permanent school closure.
    VA pays benefits for the term, quarter, or semester up to 
the time of the school's permanent closure, but the student 
beneficiary is charged education entitlement for the period 
prior to the closure for which benefits are received, even 
though he/she does not earn credit toward his/her program due 
to the unexpected closure. In some instances, this could result 
in a beneficiary exhausting entitlement prior to completing an 
educational program. There is no statutory authority that would 
allow VA to restore Post-9/11 GI Bill entitlement for a term, 
quarter, or semester for which a beneficiary fails to receive 
credit toward program completion due to such a closure.
    In April 2015, Corinthian Colleges, Inc., filed for 
bankruptcy and abruptly closed 28 schools while students were 
actively attending classes. Approximately 422 Post-9/11 GI Bill 
beneficiaries were adversely impacted by these closures and 
stopped receiving their housing allowances. In some instances, 
this resulted in a beneficiary exhausting his or her Post-9/11 
GI Bill entitlement prior to completing an educational program 
with no additional VA benefits to complete their degree. This 
may cause a significant financial burden for veterans and other 
beneficiaries, as the monthly housing payments are often a 
primary source of income, and may prevent veterans from 
achieving their educational goals.
    Committee Bill. Section 201(a) of the Committee bill would 
add a new subsection (d) to section 3312 of title 38, U.S.C., 
to allow for the restoration of entitlement to educational 
assistance and provide other relief for veterans affected by a 
school closure. Specifically, if VA determines that a 
beneficiary was forced to discontinue a course or courses as a 
result of a permanent school closure and did not receive 
credit, or lost training time, toward completion of the 
educational program, no payment of educational assistance would 
be charged against an individual's entitlement to educational 
assistance under the Post-9/11 GI Bill, or counted against the 
aggregate period for which an individual may receive 
educational assistance under two or more programs. Pursuant to 
subsection 201(a)(2) of the Committee bill, this provision 
would apply to any beneficiary impacted by education 
discontinuance in fiscal year 2015, so as to include those 
impacted by the Corinthian closures, and would apply to any 
beneficiaries impacted by future school closures.
    Section 201(b) of the Committee bill would amend section 
3680(a) of title 38, U.S.C., and grant the VA Secretary the 
authority to continue payments of monthly housing stipends 
until the date of the end of the term, quarter, or semester 
during which the school closure occurred, or the date that is 4 
months after the date of the school closure, whichever date is 
soonest. The Committee intends for this time to allow veterans 
and their dependents the ability to make alternative 
arrangements for income or enroll in a different educational 
institution to complete a course or program.

Sec. 202. Modification and improvement of transfer of unused Post-9/11 
        Educational Assistance to family members.

    Section 202 of the Committee bill, which is an original 
provision, would modify section 3319 of title 38, U.S.C., so 
that a servicemember must serve 10 years and agree to serve an 
additional 2 years in order to be eligible to transfer unused 
Post-9/11 GI Bill benefits. Section 202 would also amend 
section 3319 of title 38, U.S.C., to cap monthly housing 
allowance payments at 50 percent of the housing allowance that 
would otherwise be payable to a child using transferred Post-9/
11 GI Bill benefits.
    Background. The National Defense Authorization Act of 
Fiscal Year 2013 (Public Law 112-239) established the Military 
Compensation and Retirement Modernization Commission 
(hereinafter, ``MCRMC'') to conduct a review of the military 
compensation and retirement systems and to make recommendations 
to modernize such systems. The MCRMC issued its final report in 
January 2015 that included 15 recommendations around Pay and 
Benefits, Health Benefits, and Quality of Life for 
Servicemembers and Retirees. Recommendations 11 and 12 focused 
largely on education benefits and transition programs. In May 
2015, the MCRMC issued an addendum to its report updating its 
recommendations.
    The Post-9/11 GI Bill allows the Secretary of Defense to 
authorize transfer of unused education benefits to dependent 
family members as a retention tool when a servicemember meets 
basic eligibility criteria. In its final report, the MCRMC 
noted a misalignment of Post-9/11 GI Bill benefits and certain 
retention needs of the military services. Specifically, they 
noted that the years of service required to transfer unused 
education benefits to dependents was not aligned with the years 
of service in which the continuation rate, or retention, was 
lower. The MCRMC reported that continuation rates for 
servicemembers at 6 years of service averaged 35.3 percent from 
1980 to 2010, but the continuation rate of servicemembers with 
10 years of service averaged only 19.3 percent from 1980 to 
2010.\1\ The MCRMC recommended changing the current requirement 
that a servicemember complete 6 years of service and agree to 4 
more years in order to transfer his/her unused education 
benefits to dependents, and require that servicemembers 
complete 10 years of service and agree to serve 2 more years to 
be eligible for transferring the benefits.
---------------------------------------------------------------------------
    \1\Final Report of the Military Compensation and Retirement 
Modernization Commission, at 166. www.mcrmc.gov/public/docs/report/
mcrmc-finalreport-29jan15-lo.pdf.
---------------------------------------------------------------------------
    Another part of the MCRMC recommendation to improve 
education benefits noted the disparity in housing allowances 
paid to dependents using transferred education benefits when 
compared to the actual on-campus costs of room and board. 
Recommendation 11 of the Final Report cited two annual studies 
from October 2013 in which the highest on-campus room and board 
fees and the lowest on-campus room and board fees were 
identified, and then compared those costs to the amount in 
housing allowances paid to Post-9/11 GI Bill beneficiaries. The 
amount of housing allowances paid for the least expensive and 
most expensive room and board costs were 171 percent and 222 
percent of the actual costs, respectively.\2\ Based on this 
finding, the MCRMC recommended eliminating the monthly housing 
allowance portion of Post-9/11 GI Bill benefits for spouses and 
children using transferred education benefits.
---------------------------------------------------------------------------
    \2\Final Report of the Military Compensation and Retirement 
Modernization Commission, at 167-168. www.mcrmc.gov/public/docs/report/
mcrmc-finalreport-29jan15-lo.pdf.
---------------------------------------------------------------------------
    Committee Bill. Section 202(a) of the Committee bill would 
amend subsection 3319(b)(1) of title 38, U.S.C., to replace the 
required completed 6 years of service with a requirement to 
complete 10 years of service. It would also amend that 
subsection to replace the required agreement to serve at least 
4 more years as a member of the uniformed services with an 
agreement to serve at least 2 more years. Section 202(b) of the 
Committee bill would amend subsection 3319(g)(1)(A) of title 
38, U.S.C., to require that a servicemember transferring 
benefits to a spouse complete at least 10 years of service 
instead of only 6 years of service, before the spouse to whom 
benefits were transferred may commence using the benefits.
    Section 202(c) of the Committee bill adds to subsection 
3319(h)(3)(B) of title 38, U.S.C., an exception to the monthly 
rate of educational assistance payable to a child using 
transferred entitlement. The exception specifies that monthly 
housing stipends under section 3313 of title 38, U.S.C., paid 
to children using transferred benefits when they pursue degree 
programs or non-college degree programs, shall be paid at 50 
percent of the rate they would otherwise be paid if the veteran 
was using the benefit.
    Section 202 of the Committee bill also includes a technical 
correction to change ``armed forces'' to ``Armed Forces'' each 
place it appears in section 3319 of title 38, U.S.C., and 
specifies that the changes made by subsections (a) through (c) 
of the Committee bill will apply to the transfer of unused 
education benefits initiated beginning 180 days after 
enactment. Unused education benefits transferred to dependents 
prior to 180 days after enactment would not be subject to the 
new service requirements or to the exception for rate of 
monthly stipend payments to children using transferred benefits 
as implemented by the Committee bill.

Sec. 203. Codification and improvement of election process for Post-9/
        11 Educational Assistance.

    Section 203 of the Committee bill, which is an original 
provision, would codify in a new section 3326 of title 38, 
U.S.C., the provisions now found in section 5003(c) of Public 
Law 110-252 and would add a provision to that new section 
providing that, in the case of an individual who on or after 
January 1, 2016, submits to VA an election of which program to 
use that VA determines is clearly against the interests of the 
individual or who fails to make an election, VA may make an 
alternative election on behalf of the individual that VA 
determines is in the best interests of the individual. This 
section would also provide that VA must promptly notify the 
veteran of such alternate election and allow the veteran 30 
days to modify the election.
    Background. Section 5003 of the Post-9/11 Veterans 
Educational Assistance Act of 2008 (Public Law 110-252) created 
the Post-9/11 GI Bill by adding chapter 33 to title 38, U.S.C. 
Section 5003(c) of that law was added as a note to the newly 
created section 3301 of title 38, U.S.C., specifying procedures 
and rules for individuals with eligibility for the Montgomery 
GI Bill to use the Post-9/11 GI Bill instead. Part of those 
procedures for using the Post-9/11 GI Bill instead of another 
education benefit included requiring the veteran to make an 
irrevocable election to give up entitlement to a previous 
benefit in order to use the Post-9/11 GI Bill instead.
    VA staff have reported to Congressional staff that the 
requirement for making an irrevocable election frequently 
delays processing new claims for Post-9/11 GI Bill benefits. 
This is due to veterans often electing to give up entitlement 
to a benefit to which they are not entitled, or they may make 
an election that goes against their best interests. When this 
occurs, VA staff must send clarification to the veteran in 
writing and request return of written confirmation of the 
election or an election to give up a different benefit 
entitlement to which the veteran is entitled.
    Committee Bill. Section 203 of the Committee bill would 
create a new section 3326 in title 38, U.S.C. This new section 
would put into code the procedures and rules for an individual 
to use the Post-9/11 GI Bill benefit instead of another 
education benefit to which they are entitled. In addition to 
the existing procedures and rules governing this process, the 
Committee bill would authorize the VA Secretary to change the 
individual's irrevocable election to give up entitlement to a 
certain benefit when the original election is clearly against 
the individual's interest or when no such election was made. 
This section of the Committee bill would also repeal section 
5003(c) of the Post-9/11 Veterans Educational Assistance Act of 
2008 (Public Law 110-252; 38 U.S.C. 3301 note).

Sec. 204. Centralized reporting of veteran enrollment by certain 
        groups, districts, and consortiums of educational institutions.

    Section 204 of the Committee bill, which is an original 
provision, would modify section 3684 of title 38, U.S.C., so 
that an ``educational institution'' for purposes of reporting 
to VA enrollments in education programs would include a group, 
district, or consortium of separately accredited educational 
institutions located in the same state that are organized in a 
manner that facilitates the centralized reporting of 
enrollments in the group, district, or consortium of 
institutions.
    Background. Some educational institutions operate as part 
of a district or consortium even though each school is 
individually accredited. Consolidation of certain functions can 
streamline administration and reporting. Under section 3684 of 
title 38, U.S.C., each separate educational institution must 
certify enrollment of students using VA educational benefits in 
order for those benefits to be paid. This applies to each 
institution even in cases where they otherwise operate as part 
of a consortium for purposes of reporting enrollment and 
student information.
    Committee Bill. Section 204 of the Committee bill would 
amend section 3684 of title 38, U.S.C., to add chapters 32 and 
33 of title 38, U.S.C., to the list of benefits requiring 
educational institutions to report enrollments of students to 
VA. Section 204 of the Committee bill also defines the term 
``educational institution'' for purposes of section 3684(a) of 
title 38, U.S.C. This added definition specifies that an 
educational institution includes a group, consortium, or 
district composed of separately accredited schools in the same 
state, so long as they are organized to facilitate central 
reporting of enrollments from across the group of institutions.

Sec. 205. Improved role of state approving agencies in administration 
        of veterans educational benefits.

    Section 205 of the Committee bill, which is an original 
provision, would amend section 3672 of title 38, U.S.C., so 
that an education program would be deemed approved for purposes 
of VA education benefits only if a state approving agency 
determines that the program meets the deemed-approved criteria. 
It would also modify section 3675 of title 38, U.S.C., so that 
a program that is not subject to approval under section 3672 of 
title 38, U.S.C., may be approved by a state approving agency 
or VA acting in the role of a state approving agency when the 
criteria for approval of accredited programs at for-profit 
institutions are met.
    Background. The Post-9/11 Veterans Educational Assistance 
Improvements Act of 2010 (Public Law 111-377) added section 
3672(b)(2) to title 38, U.S.C., in order to streamline approval 
of education programs at certain educational institutions. This 
new provision made it easier for new programs at existing 
institutions to be approved for educational assistance but it 
also took the state approving agencies out of the approval 
process and limited their ability to deny approval to programs.
    Committee Bill. In order to strengthen the ability of state 
approving agencies to oversee the approval of new courses of 
education, section 205 of the Committee bill amends section 
3672 of title 38, U.S.C., to require that a state approving 
agency determine whether or not an educational institution is 
within one of the five listed categories before it can be 
deemed approved. The Committee bill also amends section 3675 of 
title 38, U.S.C., to clarify that only state approving 
agencies, or the VA Secretary when acting as the state 
approving agency, has the authority to approve accredited 
programs that are not covered under section 3672 of title 38, 
U.S.C.

Sec. 206. Modification of criteria used to approve courses for purposes 
        of veterans educational benefits.

    Section 206 of the Committee bill, which is an original 
provision, would modify section 3676 of title 38, U.S.C., so 
that additional criteria for approval of a non-accredited 
course may be required by a state approving agency only if the 
VA Secretary, in consultation with the state approving agency 
and pursuant to regulations prescribed to carry out this 
requirement, determines that the additional criteria are 
necessary and treat public, private, and proprietary for-profit 
educational institutions equitably. Section 206 would modify 
section 3675 of title 38, U.S.C., so that accredited courses 
must also meet those additional criteria to be approved.
    Background. Section 3676 of title 38, U.S.C., specifies 
criteria for state approving agencies to use in approving 
nonaccredited courses for the use of VA education benefits. One 
such criteria in paragraph (14) of subsection (c) of that 
section authorizes the individual state approving agency to 
establish additional criteria in addition to those listed in 
section 3676(c) of title 38, U.S.C. Although intended to allow 
for use of relatively minor additional criteria, in 2014 a 
state passed a law requiring additional criteria that were not 
applied equally to all institutions and created a significant 
new criteria for certain schools to meet.
    Committee Bill. Section 206 of the Committee bill would 
amend section 3676(c)(14) of title 38, U.S.C., to require the 
VA Secretary to approve any additional criteria deemed 
necessary by a state approving agency. In making that 
determination, the VA Secretary must ensure such additional 
criteria treat all educational institutions equitably. This 
change would apply to additional criteria developed after 
January 1, 2013, or to investigations conducted on or after 
October 1, 2015, pursuant to section 3674 of title 38, U.S.C.

Sec. 207. Surveys for compliance of educational institutions and 
        training establishments with requirements relating to 
        administration of veterans educational benefits.

    Section 207 of the Committee bill, which is an original 
provision, would amend section 3693 of title 38, U.S.C., to 
modify the conditions under which VA generally must conduct 
compliance surveys of educational institutions and training 
establishments offering approved courses.
    Background. Section 3693 of title 38, U.S.C., directs the 
VA Secretary to conduct annual compliance surveys of 
institutions that enroll veterans or eligible individuals using 
educational assistance. These surveys are intended to ensure 
educational institutions and their courses comply with the 
relevant requirements under chapters 30 through 36 of title 38, 
U.S.C. In testimony before the Committee on September 16, 2015, 
Dr. Joseph W. Wescott II, of the National Association of State 
Approving Agencies, noted that the current requirements for VA, 
and state approving agencies that assist VA, to conduct 
compliance surveys are onerous and do not allow VA the needed 
flexibility to focus compliance surveys on the schools most in 
need of oversight. The National Association of State Approving 
Agencies submitted a legislative proposal to ensure more 
institutions receive compliance surveys at least once every 2 
years. Their proposal also directed VA to identify which 
institutions would receive surveys in advance each year and 
preserved the ability for the VA Secretary to waive the 
compliance survey requirement for institutions with a record of 
demonstrated compliance.
    Committee Bill. Section 207 of the Committee bill would 
amend section 3693 of title 38, U.S.C., to require VA to 
perform a compliance survey at least once every 2 years for 
each educational institution or training establishment which 
enrolls 20 or more individuals eligible for VA educational 
assistance. This section of the Committee bill also directs the 
VA Secretary to design the compliance surveys to ensure all 
applicable provisions of chapters 30 through 36 of title 38, 
U.S.C., are followed by the institution, that each compliance 
survey specialist not perform more than 40 surveys per year, 
and that VA provide to the state approving agencies in advance 
of each fiscal year a list of the institutions to be surveyed 
for that year.

Sec. 208. Modification of requirements for approval for purposes of 
        educational assistance provided by Department of Veterans 
        Affairs of programs designed to prepare individuals for 
        licensure or certification.

    Section 208 of the Committee bill, which is derived from 
S. 1938, would improve the approval of certain programs of 
education for purposes of VA educational assistance provided by 
requiring that educational programs meet state instructional 
curriculum licensure or certification requirements.
    Background. State approving agencies were established by 
each state after the passage of the original ``GI Bill,'' the 
Veterans' Readjustment Act of 1944, to approve, disapprove, and 
monitor education and training programs, specifically regarding 
oversight and approval of quality educational programming in 
which a veteran or dependent can enroll while using GI Bill 
benefits. In addition to program approval, state approving 
agencies conduct compliance, training, liaison, and outreach 
efforts.
    However, due to different requirements for certification or 
licensure across states and differences in state approving 
agency approval practices, some veterans may use GI Bill 
benefits for educational programs that cannot count towards a 
credentialing requirement. Although a school has institutional 
accreditation, it may lack appropriate programmatic 
accreditation or fail to meet state-specific criteria required 
for certification or licensure. Examples of this have been 
found in programs teaching law, education, criminal justice, 
and health care, including nursing, psychology, medical 
assisting, dental assisting, and surgical technology. Veterans 
who graduate from programs that do not meet licensing or 
credentialing requirements are unable to sit for a qualifying 
examination to be hired in the field in which they studied. 
According to testimony from the National Association of State 
Approving Agencies in September 2015, ``while it is true that 
all persons that attend career schools, such as law or nursing, 
do not always seek or find satisfying employment in that 
particular career field, it is certainly not an unfair 
expectation for a veteran who graduates from such programs to 
be qualified to sit for the license or certification exam.''
    The issue of unlicensed or unapproved programs that do not 
meet appropriate career qualifications is particularly evident 
when veterans attend law schools in California that are not 
approved by the American Bar Association. California allows 
graduates of an unaccredited law school to take the bar 
examination. Veterans who have used GI Bill benefits to attend 
unaccredited California law schools would be prohibited from 
taking the bar examination in other states or, in some cases, 
would have to first practice law in California for a period of 
time before being allowed to sit for the bar examination.
    Educational assistance provided by the Department of 
Defense is subject to requirements meant to ensure that 
programs of education lead to employment. Section 541 of Public 
Law 113-66, the Fiscal Year 2014 National Defense Authorization 
Act, prohibits the use of Department of Defense educational 
assistance programs and authorities for education programs that 
do not meet the licensure or certification requirements of a 
state, or are not approved or licensed by the appropriate state 
board or agency. This policy change has not yet been applied to 
all VA educational assistance.
    Committee Bill. Subsection (a) of section 208 of the 
Committee bill would amend subsection (c) of section 3676 of 
title 38, U.S.C., by requiring the appropriate state approving 
agency to approve the VA educational assistance application of 
an unaccredited educational course, which is designed to 
prepare a student for licensure or certification, only if the 
course meets the instructional curriculum requirements of such 
state. Section 208(a) of the Committee bill would further amend 
subsection (c) of section 3676 of title 38, U.S.C., by 
requiring that all courses designed to prepare an individual to 
practice law be accredited by an accrediting agency or 
association recognized by the Secretary of Education specified 
in section 1099(b) of title 20, U.S.C., namely the American Bar 
Association. This provision would require that Post-9/11 GI 
Bill beneficiaries only attend accredited law schools and 
ensure that beneficiaries attending law school in California 
would be eligible to take the bar examination in any state.
    Subsection (b) of section 208 of the Committee bill would 
amend subsection (c) of section 3676 of title 38, U.S.C., by 
adding a new subsection stipulating conditions under which the 
VA Secretary could administer a waiver to override the 
aforementioned approval requirements for unaccredited 
educational courses. VA could waive approval requirements if 
the course does not meet requirements at any time during the 2-
year period preceding the date of the waiver, but the waiver 
would further the purposes of VA educational assistance 
programs or further an individual's education interests, and 
the educational institution does not provide any commission, 
bonus, or incentive payment based on success in securing 
enrollments or financial aid during student recruiting or 
admission activities. The Committee intends this provision to 
allow the VA Secretary flexibility in allowing the use of GI 
Bill benefits at an educational institution that will further 
serve the education or employment interests of a veteran or 
dependent.
    Subsection (c) of section 208 of the Committee bill would 
amend section 3675(b)(3) of title 38, U.S.C., and would apply 
the standards of approval for VA educational assistance 
established in subsections (b) and (c) of the Committee bill to 
already accredited courses, including non-degree accredited 
programs offered by for-profit educational institutions. 
Subsection (d) of section 208 of the Committee bill would amend 
section 3672(b)(2) of title 38, U.S.C., to further apply these 
standards of approval to accredited standard college degree 
programs offered at public or not-for-profit educational 
institutions. Both subsections (c) and (d) of the Committee 
bill are intended to ensure that the new standards of approval 
for VA educational assistance are applied equitably across all 
sectors of education.
    Subsection (e) of section 208 of the Committee bill would 
amend section 3679 of title 38, U.S.C., by requiring the VA 
Secretary or state approving agency to disapprove any course of 
education unless the educational institution publicly discloses 
any conditions or additional requirements, including training, 
experience, or examinations, required to obtain the state 
license or certification and discloses each condition or 
requirement publicly. The Committee included this provision in 
order to ensure that GI Bill beneficiaries are aware of state 
requirements in order to gain employment in their field of 
study before pursuing a course of education.
    Subsection (f) of section 208 of the Committee bill would 
ensure that, if a student is enrolled in a course of education 
that is subject to disapproval for VA educational assistance, 
but continuously enrolled at the institution for another course 
of education that is not disapproved, this course would not be 
subject to disapproval and the student could continue in the 
approved course. This provision would ensure that VA education 
benefits are only prohibited from unaccredited programs, rather 
than entire institutions, if beneficiaries were to pursue more 
than one course of education at the same educational 
institution.

Sec. 209. Expansion of Yellow Ribbon G.I. Education Enhancement 
        Program.

    Section 209 of the Committee bill, which was derived from 
S. 1460, would extend the Yellow Ribbon Program to cover 
recipients of the Marine Gunnery Sergeant John David Fry 
Scholarship, a benefit available to surviving spouses and 
dependents of a servicemember who died in the line of duty, 
while serving on active duty, on or after September 11, 2001.
    Background. The Fry Scholarship provides Post-9/11 GI Bill 
benefits specifically to the surviving spouses and children of 
servicemembers who died in the line of duty while on active 
duty after September 10, 2001. Fry Scholarship beneficiaries 
receive up to 36 months of benefits, including tuition and fees 
paid directly to the school, a monthly housing allowance, and a 
books and supplies stipend.
    Tuition and fees at private schools may exceed the 
statutory limit on Post-9/11 GI Bill benefits. Subsection 
(e)(II) of section 3313 of title 38, U.S.C., stipulates that 
the Post-9/11 GI Bill benefit is capped at $17,500 per academic 
year at non-public or foreign institutions of higher education 
beginning on August 1, 2011. This rate is adjusted each 
subsequent academic year based on the yearly increase in the 
average cost of undergraduate tuition due to inflation (section 
3015(h), title 38, U.S.C.). From August 2015 to July 31, 2016, 
Post-9/11 GI Bill payment rates to a private or foreign school 
will be capped at up to $21,084.89 per academic year.
    In order to assist with tuition and fees in excess of the 
academic year cap, many institutions participate in the Yellow 
Ribbon Program. This program is a voluntary agreement between 
VA and the participating educational institution in which an 
institution agrees to make additional funds available for an 
eligible beneficiary and VA matches that amount and issues 
payments directly to the institution. This program provides 
additional funding for eligible Post-9/11 GI Bill beneficiaries 
when tuition and fee costs exceed the annual cap provided for 
under section 3313 of title 38, U.S.C.
    The Yellow Ribbon Program is available to veterans and most 
transferred entitlement recipients receiving Post-9/11 GI Bill 
benefits at the 100 percent benefit level attending private 
institutions. However, Fry Scholarship beneficiaries are 
prohibited by law from receiving Yellow Ribbon Program funding. 
This creates inequity in eligibility for supplemental funding, 
as the children and spouses of a servicemember who died in 
service may face educational costs that children and spouses of 
a veteran who did not make the ultimate sacrifice do not.
    Committee Bill. Section 209(a) of the Committee bill would 
amend section 3317(a) of title 38, U.S.C., to include children 
and spouses of a servicemember who died in service as ``covered 
individuals'' under section 3311(b) for educational assistance, 
thus making them eligible for the Yellow Ribbon Program. This 
provision would ensure that all Post-9/11 GI Bill education 
benefit recipients, including veterans, transferees, and Fry 
scholars, are eligible to apply for supplemental Yellow Ribbon 
Program funding if they meet the basic eligibility requirements 
and their institution is a participating partner with VA. The 
Committee intends to remedy the inequity between Post-9/11 GI 
Bill recipients and ensure that surviving spouses and 
dependents are eligible for supplemental funding when 
applicable. Section 209(b) of the Committee bill would 
implement this expanded eligibility for academic years 
beginning after the date that is 1 year after enactment.

Sec. 210. Consideration of certain time spent receiving medical care 
        from Secretary of Defense as active duty for purposes of 
        eligibility for Post-9/11 Educational Assistance.

    Section 210 of the Committee bill, which is derived from 
S. 602, would count as active duty for purposes of the Post-9/
11 GI Bill reservists' service under section 12301(h) of title 
10, U.S.C., under which the Secretary of a military department 
may order a reservist to active duty to receive authorized 
medical care, be medically evaluated for disability, or 
complete a required Department of Defense health care study.
    Background. Section 3301 of title 38, U.S.C., defines 
active duty for purposes of determining eligibility for the 
Post-9/11 GI Bill. Members of the reserve components are 
considered to have served on active duty for purposes of 
determining eligibility based on specific authorities in 
sections from titles 10, 14, and 32, U.S.C. Not included on 
this list of authorities is section 12301(h) of title 10, 
U.S.C. Reserve component members are ordered to serve under 
section 12301(h) when they are receiving medical care, being 
evaluated for disability, or completing a health care study. 
The Department of Defense, in its testimony before the 
Committee on May 13, 2015, noted that reserve component members 
wounded in combat or injured in the line of duty are moved from 
service under an authority that qualifies for Post-9/11 GI Bill 
eligibility to serve under section 12301(h) instead. The effect 
of this administrative move results in less accrual of 
eligibility for Post-9/11 GI Bill benefits than their 
counterparts in the active components who are wounded or 
injured.
    Committee Bill. Section 210 of the Committee bill would 
amend section 3301 of title 38, U.S.C., to add service under 
section 12301(h) of title 10, U.S.C., to the list of orders 
under which reserve component members can serve to earn active 
duty service time that counts towards their eligibility for the 
Post-9/11 GI Bill. This amendment would take effect 1 year 
after the date of enactment in order to allow VA sufficient 
time to implement changes to how it calculates eligibility for 
affected individuals. Any payment of benefits under chapter 33 
of title 38, U.S.C., after 1 year from enactment would reflect 
eligibility based on the relevant service under section 
12301(h) of title 38, U.S.C.

                  TITLE III--HOMELESS VETERANS MATTERS

Sec. 301. Expansion of definition of homeless veterans for purposes of 
        benefits under the laws administered by the Secretary of 
        Veterans Affairs.

    Section 301 of the Committee bill, which is derived from 
S. 1885, would expand the definition of homeless veteran for 
purposes of eligibility for VA benefits, to include a veteran 
or veteran's family member fleeing domestic or dating violence, 
sexual assault, stalking, or other dangerous or life-
threatening conditions in their current housing situation.
    Background. Congress has authorized several initiatives to 
provide VA with the tools necessary to end veteran 
homelessness. Those who meet the definition of homeless veteran 
are eligible to participate in these initiatives. Section 
2002(1) of title 38, U.S.C., defines ``homeless veteran,'' for 
purposes of eligibility for VA homeless programs, as the term 
is defined in section 11302(a) of title 42, U.S.C., which 
stipulates that a homeless individual must meet the following 
criteria: lacks a fixed, regular, and adequate place to sleep 
at night; has a primary nighttime residence that is a public or 
private place not designed for, or ordinarily used as, a 
regular sleeping accommodation, including a car or park; lives 
in a transitional housing setting; resides in a location not 
meant for human habitation; will imminently lose his/her 
housing; or has experienced persistent housing instability.
    The definition that the Department of Housing and Urban 
Development (hereinafter, ``HUD'') uses to describe a homeless 
individual includes the aforementioned definition, but also 
includes an additional class of individuals, as defined by 
section 11302(b) of title 42, U.S.C. This class of individuals 
is comprised of ``any individual or family who is fleeing, or 
is attempting to flee, domestic violence, dating violence, 
sexual assault, stalking, or other dangerous or life-
threatening conditions in the individual's or family's current 
housing situation, including where the health and safety of 
children are jeopardized, and who have no other residence and 
lack the resources or support networks to obtain other 
permanent housing.''
    In July 2011, a team led by Dr. Melissa E. Dichter, 
Research Health Scientist at VA's Center for Health Equity 
Research and Promotion, published a study entitled ``Intimate 
Partner Violence Victimization Among Women Veterans and 
Associated Heart Health Risks.'' The study found almost one-
third of the veteran participants had experienced intimate 
partner, domestic or dating violence, as compared with less 
than one-quarter of civilian participants. Within that sample, 
veterans experienced intimate partner violence at a higher rate 
than civilians.
    Committee Bill. Section 301 of the Committee bill would 
expand the definition of homeless veteran by amending section 
2002(1) of title 38, U.S.C., to include veterans and their 
families who may be homeless based on the circumstances defined 
in section 11302(b) of title 42, U.S.C. It is the intent of the 
Committee to align VA's definition of ``homeless veteran'' with 
HUD's, and expand the current VA definition to ensure that 
veterans fleeing domestic or dating violence and other life-
threatening situations are eligible to participate in VA's 
programs for homeless veterans.

Sec. 302. Increased per diem payments for transitional housing 
        assistance that becomes permanent housing for homeless 
        veterans.

    Section 302 of the Committee bill, which is derived from 
S. 684, would increase the maximum per diem rate VA is 
authorized to pay to providers that offer homeless veterans 
transitional housing units and allow the veterans to transition 
into permanent housing in the same unit.
    Background. The Homeless Providers Grant and Per Diem 
(hereinafter, ``GPD'') program was first established as a pilot 
program, known as the Comprehensive Service Programs, in 1992, 
through the Homeless Veterans Comprehensive Service Programs 
Act of 1992 (Public Law 102-590). Congress established it as 
the Homeless Providers GPD program in the Homeless Veterans 
Comprehensive Assistance Act of 2001 (Public Law 107-95).
    Under current law, section 2012 of title 38, U.S.C., VA 
awards grants and provides per diem payments to public and non-
profit private entities operating transitional housing 
facilities and supportive services programs for veterans. The 
per diem payment, which is set at a maximum of $43.32 per day, 
per veteran housed, is calculated based on the daily cost of 
care, but may not exceed the rate paid to State homes for 
domiciliary care. The GPD program is VA's largest transitional 
housing program.
    In 2012, VA established the Transition in Place 
(hereinafter, ``TIP'') program for GPD providers, and it 
subsequently awarded grants to 31 GPD providers to carry out 
TIP. Following this model, providers offer transitional housing 
assistance in apartment-style housing and allow veterans to 
assume responsibility for the lease upon the end of 
participation in transitional housing. Implementation of this 
model, however, may cause an increase in operational costs for 
the providers.
    Committee Bill. Section 302 of the Committee bill would 
amend section 2012(a)(2) of title 38, U.S.C., to increase the 
maximum per diem rate for homeless veteran service providers 
participating in the TIP program to compensate for an increase 
in operational costs. It would authorize the per diem rate VA 
provides to certain entities that provide services to homeless 
veterans to exceed the rate paid to State homes in the case of 
services provided to a homeless veteran who is placed in 
housing that will become permanent housing upon termination of 
those services (transition-in-place). In those cases, the 
maximum per diem would be 150 percent of the State home rate.
    It is the Committee's intent to provide an incentive for 
GPD providers to join the TIP program and increase permanent 
housing opportunities for homeless veterans.

Sec. 303. Expansion of Department of Veterans Affairs authority to 
        provide dental care to homeless veterans.

    Section 303 of the Committee bill, which is derived from 
S. 684, would expand eligibility for the Homeless Veteran 
Dental Program (hereinafter, ``HVDP'').
    Background. The Homeless Veterans Comprehensive Assistance 
Act of 2001 (Public Law 107-95) expanded VA's authority to 
provide one-time outpatient dental services and treatment for 
certain veterans who, for a minimum of 60 consecutive days, are 
receiving care in a domiciliary, a therapeutic residence, 
community residential care, or a setting for which VA provides 
funds for a GPD provider. VA provides these dental services to 
eligible homeless veterans through HVDP. Dental services 
provided include those necessary for the veteran to gain or 
regain employment, to alleviate pain, or to treat moderate, 
severe, or complicated and severe gingival and periodontal 
pathology.
    Section 303 of the Committee bill would expand eligibility 
to include veterans receiving assistance under section 8(o) of 
the United States Housing Act, which includes veterans 
receiving housing through the HUD-VASH program. Expanding 
services to this group of veterans is aligned with VA's 
implementation of the Housing First model. Historically, VA has 
provided permanent housing to homeless veterans only after 
compliance with treatment or other requirements while veterans 
resided in other non-permanent housing. In January 2013, all VA 
facilities implemented the Housing First model, which provides 
access to permanent housing accompanied by access to supportive 
services. With this transition in strategy, veterans may be 
placed in permanent housing through HUD-VASH who could benefit 
from certain services currently only available to those 
considered homeless.
    Committee Bill. Section 303 of the Committee bill would 
amend subsection (b) of section 2062 of title 38, U.S.C., to 
expand eligibility for HVDP to include veterans who, for 60 
consecutive days, have been housed under section 8(o) of the 
United States Housing Act, which would include those veterans 
participating in the HUD-VASH program.

Sec. 304. Clarification of eligibility for services under homeless 
        veterans reintegration programs.

    Section 304 of the Committee bill, which is derived from 
S. 425, would expand eligibility for the Department of Labor's 
Homeless Veterans' Reintegration Program (hereinafter, 
``HVRP'').
    Background. The Stewart B. McKinney Homeless Assistance Act 
(Public Law 100-77) established HVRP. Through this program, 
competitive grants are annually awarded to public and private 
entities that provide employment and training services that 
veterans need to re-enter the labor force.
    Under current law, section 2021 of title 38, U.S.C., HVRP 
is only open to homeless veterans. Section 304 would expand 
eligibility to veterans participating in HUD-VASH, Indians who 
are veterans and receiving assistance under NAHASDA, and 
veterans who are transitioning from being incarcerated.
    Under VA's Housing First model, veterans placed in the HUD-
VASH program are not required to meet any standards of 
employment prior to entry in the program. As a result, there 
are veterans, including those coming out of chronic 
homelessness, in HUD-VASH who are in need of employment 
assistance and could benefit from a program like HVRP, but are 
not eligible. In addition, veterans transitioning from being 
incarcerated and Indians who are veterans and receiving 
assistance under NAHASDA, since the HUD-VASH program is not 
widely available on reservations, could also benefit from the 
availability of additional job training and assistance 
resources.
    Committee Bill. Section 304 of the Committee bill would 
amend section 2021(a) of title 38, U.S.C., to include among 
those eligible for HVRP veterans participating in VA's 
supported housing program for which rental assistance is 
provided under section 8(o)(19) of the United States Housing 
Act of 1937; Indians who are veterans and receiving assistance 
under NAHASDA; and veterans who are transitioning from being 
incarcerated. The Committee recognizes that certain Federal 
programs that require homelessness for eligibility were 
established prior to the implementation of VA's Housing First 
strategy, therefore, restricting access to those who may be 
transitioning from homelessness to the HUD-VASH program.

Sec. 305. Program to improve retention of housing by formerly homeless 
        veterans and veterans at risk of becoming homeless.

    Section 305 of the Committee bill, which is derived from 
S. 1885, would require VA to award grants for the provision of 
case management services for veterans who are transitioning to 
permanent housing and those who are at risk for homelessness, 
addressing a current gap in case management service delivery.
    Background. The Administration set a goal in 2009 to end 
nationwide veteran homelessness by 2015. The 2015 Annual 
Homeless Assessment Report indicated that homelessness among 
veterans has declined by 35 percent, or 25,642 veterans, since 
2009. Despite this significant progress, 47,725 veterans 
remained homeless on a single night in January 2015 according 
to HUD's Point in Time count from January 2015.
    As communities nationwide reach critical junctures in their 
efforts to end veteran homelessness, occupancy in transitional 
housing programs continues to decrease. In testimony before the 
Committee in October 2015, Dr. Thomas Lynch, Assistant Deputy 
Under Secretary for Health Clinical Operations at the Veterans 
Health Administration (hereinafter, ``VHA''), stated: ``As the 
number of homeless veterans decreases, the need for some of 
this transitional housing will diminish, but there will be a 
continued need for permanent housing interventions like rapid 
re-housing and permanent supportive housing.'' Many homeless 
veterans participating in transitional housing programs and 
seeking to transition to permanent housing are eligible to 
participate in HUD-VASH. Despite access to HUD-VASH vouchers, 
many veterans are finding that insufficient availability of 
affordable and safe permanent housing options is limiting the 
ability to secure long-term permanent housing.
    In communities that have made significant progress in 
ending homelessness among veterans, the declining necessity of 
transitional housing but continued need for permanent housing 
interventions is especially challenging. Because there are 
fewer veterans in need of transitional housing facilities, 
facilities are receiving less funding based on the per diem 
payment structure. Veterans at risk of homelessness in these 
communities have less transitional housing opportunities and 
these facilities risk insolvency. VA and community partners 
must ensure there is sufficient availability of affordable 
permanent housing for veterans seeking long-term housing 
solutions. VA's GPD program should be restructured to include 
an option for GPD grantees to focus efforts on shorter lengths 
of stay in transitional housing, achieve quicker permanent 
housing planning, and repurpose existing transitional housing 
facilities into permanent housing units to ensure long-term 
solutions for homeless veterans.
    Committee Bill. Subsection (a) of section 305 of the 
Committee bill would amend title 38, U.S.C., to redesignate 
current section 2013 as 2014 and insert a new section 2013 to 
require VA to carry out a program to increase housing stability 
and retention by providing grants to community organizations 
that provide case management to formerly homeless veterans. 
This new section would require VA to implement a program to 
provide case management services to improve housing retention 
by formerly homeless veterans who are transitioning to 
permanent housing, and veterans who are at risk of becoming 
homeless. Subsection (b) of new section 2013 of title 38, 
U.S.C., would provide for the VA Secretary's provision of 
grants, in which the Secretary would be required to give 
priority to organizations that demonstrate a capability to 
provide such case management services previously described, 
particularly organizations that have, or are currently, 
providing transitional housing services and decide to convert 
their transitional housing programs into permanent housing for 
homeless veterans. These grants include the per diem payments 
established in section 2012 of title 38, U.S.C., and the grant 
program for homeless veterans stipulated in section 2061 of 
title 38, U.S.C. This provision would allow communities that 
are reaching critical junctures in the fight to end 
homelessness to repurpose existing transitional housing 
capacity for more pressing needs, such as permanent housing 
opportunities for veterans.
    Subsection (b) of new section 2013 of title 38, U.S.C., 
would additionally require the VA Secretary to give grant 
provision priority to an organization that voluntarily stops 
receiving GPD payments and converts an existing transitional 
housing facility into a permanent housing facility that meets 
housing quality standards established in section 1437f(o)(8)(B) 
of title 42, U.S.C. This section would enable GPD grantees with 
the expertise and capacity to provide for homeless veterans to 
repurpose existing transitional housing facilities into 
permanent housing units without losing current GPD funding.
    Subsection (c) of section 305 of the Committee bill would 
additionally require VA to submit a report to Congress within 1 
year of enactment to assess the new program, which will include 
the following reporting requirements: percentage of veterans 
who received case management services who were able to retain 
permanent housing; percentage of veterans who were not in 
permanent housing at the end of the program; program use by 
veterans who received case management services provided through 
VA housing assistance; and an assessment of the employment 
status of veterans who received case management services under 
the program.

Sec. 306. Pilot program on provision of intensive case management 
        interventions to homeless veterans who receive the most health 
        care from the Department of Veterans Affairs.

    Section 306 of the Committee bill, which is derived from 
S. 1885, would require VA to implement a 3-year pilot program 
in at least six locations to assess the feasibility and 
advisability of providing intensive case management 
interventions to homeless veterans who receive the most health 
care from VA.
    Background. Those who may be considered health care super-
utilizers often struggle with chronic conditions or behavioral 
health needs, which lead them to make frequent trips to the 
emergency room and have many hospital admissions. Treating 
these most frequent health care users is challenging and 
costly, particularly when they face difficult environmental 
situations, such as unsanitary housing or homelessness.
    Dr. Jeffrey Brenner, the executive director of the Camden 
Coalition of Healthcare Providers in New Jersey determined that 
treatment, particularly hospital admission and repeated use of 
expensive diagnostic tests, provided to a small group of 
individuals who were utilizing the most health care was 
accounting for the bulk of health care costs in the local area. 
Using this data, he established a program model that reduced 
health care costs by targeting the population that was 
utilizing the most health care and enrolling them in care 
coordination services and providing case management through a 
team of nurses, social workers, community health workers, and 
health coaches. These interventions build relationships 
necessary to facilitate the provision of health care services 
to the most vulnerable individuals and empower patients with 
skills and support to avoid hospital readmission, thus lowering 
health care costs.
    This model may have similar success when applied to 
homeless veterans who use the most VA health care. On May 4, 
2012, the VA Office of Inspector General (hereinafter, ``OIG'') 
published a report, ``Homeless Incidence and Risk Factors for 
Becoming Homeless in Veterans,'' which analyzed a study 
conducted to estimate incidences and risk factors of veterans. 
In the report, the OIG concluded that the presence of mental 
health or substance abuse disorders or mental illness is the 
strongest predictor of homelessness among veterans. Almost half 
or more of the surveyed homeless veterans were diagnosed with 
mental disorders, including 48 percent of male Operation 
Enduring Freedom/Operation Iraqi Freedom veterans and 67 
percent of women who were not Operation Enduring Freedom/
Operation Iraqi Freedom veterans. Additionally, homeless 
veterans were more likely to receive VA disability benefits for 
service-connected disabilities than their domiciliary 
counterparts, and more than half of the homeless veterans 
studied were receiving VA compensation for these disabilities.
    When left untreated, these behavioral conditions pose 
significant challenges to attaining and maintaining permanent 
housing and gainful employment, and substandard living 
conditions and homelessness often exacerbate existing health 
conditions. Applying the management intervention model that 
proved successful in New Jersey to veterans who use the most VA 
health care could address the health care needs of the most 
vulnerable veterans while simultaneously decreasing VA health 
care costs.
    Committee Bill. Section 306 of the Committee bill would, in 
a freestanding provision, require VA to commence a pilot 
program on the provision of case management interventions to 
homeless veterans who receive the most health care from VA. 
Subsection (a) of section 306 of the Committee bill would 
require VA to commence a pilot program by September 1, 2016, 
that would assess the feasibility and advisability of providing 
intensive case management interventions to ``covered 
veterans.'' Subsection 306(b) of the Committee bill would 
define ``covered veterans'' as a veteran enrolled in the VA 
homeless registry and the annual patient enrollment system, 
section 1705(a) of title 38, U.S.C.
    The pilot program would be carried out at not fewer than 
six locations as selected by the VA Secretary, as established 
in subsection (c) of section 306. The Committee intends that, 
by requiring VA to implement the program in at least six 
locations, VA will be able to determine the extent to which the 
program is successful before considering expansion or 
continuation of the program. The bill would direct the VA 
Secretary to select at least three locations in cities with the 
largest populations of homeless veterans in the United States 
and at least three locations in suburban or rural settings. 
Subsection 306(c) of the Committee bill additionally would 
establish that the VA Secretary shall only select locations for 
the pilot program in areas with an existing high degree of 
interaction and coordination between VA and community 
organizations that provide housing and social services for 
homeless veterans, veterans at risk of homelessness, and low-
income veterans. The Committee intends this section to ensure 
that the pilot program is carried out in areas where a 
successful track record of coordination between VA and local 
organizations will increase the likelihood of success for the 
pilot and its ability to serve as a model to establish case 
management interventions nationwide.
    Subsection (d) of section 306 of the Committee bill would 
require the VA Secretary to provide intensive case management 
services to at least 20 covered veterans who receive the most 
VA health care and related services at each location. These 
individuals would receive intensive case management assistance 
related to gaining and maintaining access to housing and 
services in order to improve the stability of their housing and 
the appropriateness of the health care that they receive.
    Subsection (e) of section 306 of the Committee bill would 
require that no later than December 1, 2018, the VA Secretary 
submit to the Committee on Veterans' Affairs of the Senate and 
House of Representatives a report on the pilot program. The 
report must include assessments of: the types and frequencies 
of intensive case management interventions provided under the 
pilot program; the housing and employment status of each 
veteran who received an intensive case management intervention, 
including a comparison of employment status of each veteran 
before and after the intervention; the VA health care and 
related services used by veterans who received intensive case 
management interventions, including the cost incurred by VA to 
provide such care and services before and after receiving such 
interventions; the number of veterans who received intensive 
case management interventions based on urban versus suburban or 
rural locations; a comparison of the cost incurred by VA based 
on the pilot program carried out in urban versus rural or 
suburban locations; and a comparison of the costs VA would have 
incurred for the provision of health care and services without 
the intensive case management interventions in urban versus 
suburban or rural locations of the pilot program.
    The Committee intends that VA deploy this pilot program in 
different communities nationwide to determine the success of 
the care model in the veteran population, as well as any 
reduction in health care costs by improving the efficacy of 
outreach teams providing intensive case management 
interventions to homeless veterans.

Sec. 307. Establishment of National Center on Homelessness Among 
        Veterans.

    Section 307 of the Committee bill, which is derived from 
S. 1885, would codify the current role of the VA National 
Center on Homelessness Among Veterans (hereinafter, ``NCHAV'') 
as a center of research, evaluation, and dissemination of best 
practices regarding services for homeless veterans.
    Background. The NCHAV was established in 2009 to support 
VA's Five Year Plan to End Homelessness Among Veterans, as 
outlined in the Administration's ``Opening Doors: Federal 
Strategic Plan to Prevent and End Homelessness.'' The 
University of Pennsylvania serves as the NCHAV's primary 
academic partner and, as such, the center is located in 
Philadelphia, Pennsylvania. The center also has satellite 
facilities in Tampa, Florida, in partnership with the 
University of South Florida, and Bedford, Massachusetts, in 
partnership with the University of Massachusetts Medical 
School. The NCHAV has been an important contributor to the 
Administration's goal of ending veteran homelessness and, 
according to its Web site, ``works in collaboration with [the 
Veterans Health Administration's] Homeless Programs Office, 
network directors, network homeless coordinators, national 
professional associations, and community partners as well as 
with their academic partners.'' This independent center has 
worked to ensure that VA is effectively collaborating with 
community partners and applying the necessary tools to reshape 
the housing and service delivery model in urban and rural 
communities that experience veteran homelessness. By analyzing 
VA homelessness programs and disseminating research and 
homeless program models to the field, the NCHAV has played an 
important role in ensuring continued progress in decreasing the 
number of homeless veterans nationwide. The success of the 
Housing First model is an example of how NCHAV research can be 
translated into more informed policy for homeless veterans.
    Committee Bill. Subsection (a) of section 307 of the 
Committee bill would add a new section 2067 to title 38, 
U.S.C., to codify the existing NCHAV. This would require the VA 
Secretary to oversee a center that operates independently of 
other VA homelessness programs. Subsection (a) of new section 
2067 of title 38, U.S.C., would require that the NCHAV 
implement the following functions: carry out and promote 
research into the causes and contributing factors to veteran 
homelessness; assess the effectiveness of VA programs to meet 
the needs of homeless veterans; identify and disseminate best 
practices with regard to housing stabilization, income support, 
employment assistance, community partnerships, and other 
matters as the VA Secretary deems appropriate; integrate 
evidence-based best practices, policies, and programs into VA 
programs for homeless veterans and ensure VA staff and 
community partners are effectively able to implement them; and 
serve as a resource center for all research and training 
activities carried out by VA, Federal entities, and community 
partners to promote the exchange of information with respect to 
veteran homelessness.
    As more communities have ended, or are close to ending, 
veteran homelessness, VA will need to examine how to best 
allocate funding between various programs aimed at ending 
veteran homelessness. The Committee intends to codify the NCHAV 
to make permanent the important research regarding the most 
cost-effective approaches to ending veteran homelessness and 
the continuation of support to VA homelessness programs in 
order to fully eliminate veteran homelessness.

Sec. 308. Partnerships with public and private entities to provide 
        legal services to homeless veterans and veterans at risk of 
        homelessness.

    Section 308 of the Committee bill, which is derived from 
S. 684, would authorize VA to enter into partnerships with 
public or private entities to fund a portion of the general 
legal services provided by those entities to homeless veterans 
and veterans at risk of homelessness.
    Background. VA conducts an annual Community Homelessness 
Assessment, Local Education and Networking Groups (hereinafter, 
``CHALENG'') survey to identify the needs of homeless veterans. 
The 2014 CHALENG survey results indicated that legal assistance 
was among the top ten highest unmet needs among both male and 
female veterans. Collectively, they indicated needing legal 
assistance to prevent eviction and foreclosure, for child 
support issues, to help restore a driver's license, and for 
outstanding warrants and fines. Such issues can be a result of 
homelessness, or can contribute to homelessness.
    VA does not currently have statutory authority to fund any 
portion of legal services, but a number of VA facilities host 
non-VA legal service providers, such as law school clinics, 
private pro bono lawyers, and Legal Aid clinics to assist 
veterans who are homeless or at risk of homelessness.
    In addition, the Supportive Services for Veteran Families 
Program (hereinafter, ``SSVF'') provides grants to 
organizations who will coordinate or provide supportive 
services to very low-income veteran families who are homeless 
or at risk of becoming homeless. Through this program, grantees 
are authorized to partner with legal services providers to 
address unmet legal needs that may be a barrier to stable 
housing. Providing legal services is not a requirement, 
however, and as a result, not all veterans who receive 
assistance through SSVF have access to legal services.
    Committee Bill. Section 308 of the Committee bill would 
amend chapter 20 of title 38, U.S.C., by inserting a new 
section, 2022A, after section 2022, to authorize VA to enter 
into partnerships with public and private entities to fund a 
portion of legal services provided to homeless veterans and 
veterans at risk of homelessness. VA would also be required to 
ensure that, to the extent practicable, the partnerships are 
made with entities equitably distributed across the geographic 
regions of the United States, including rural communities, 
tribal lands of the United States, Native Americans, and tribal 
organizations. It is the intent of the Committee to expand 
legal services for homeless veterans and veterans at risk of 
homelessness by authorizing VA to partner with public or 
private entities to fund a portion of the cost of providing 
legal services.

Sec. 309. Administrative improvements to grant and per diem programs of 
        Department of Veterans Affairs.

    Section 309 of the Committee bill, which is derived from 
S. 1885, would implement administrative improvements to the GPD 
program of the Department.
    Background. VA provides Federal funding to many 
transitional housing grantees to support their efforts to 
decrease veteran homelessness nationwide. These GPD program 
grantees help veterans secure residential stability, increase 
their skills and income, and achieve greater self-determination 
to support their transition from transitional to permanent 
housing.
    There is currently no national standard among GPD grantees 
that serve homeless veterans, and GPD grantees are not required 
to demonstrate success in assisting veterans into permanent 
housing or increasing their income level. In testimony before 
the Committee on July 29, 2015, Lisa Tepper Bates, the 
Executive Director of the Connecticut Coalition to End 
Homelessness, recommended a policy change that would require 
the GPD program to move ``away from the per diem payment 
structure to a competitive grant program or performance-based 
contract'' to ensure that programs are outcome-oriented. By 
setting national performance targets for the housing placement 
rates and the average income improvements of veterans served by 
transitional housing grantees, VA will be equipped to assess 
whether the performance of a GPD grantee merits continued 
funding, ensure financial integrity among GPD grantees, and 
increase the use of performance outcomes as an oversight tool 
to reduce waste or abuse.
    Committee Bill. Section 309 of the Committee bill would 
amend section 2012 of title 38, U.S.C., by requiring the VA 
Secretary to review, on a yearly basis, each eligible GPD 
grantee to evaluate the performance of the grant recipient or 
per diem entity. This evaluation would assess the success of 
the grant recipient or eligible entity in assisting veterans to 
obtain, transition into, and retain permanent housing and 
increasing the income of veterans, whether by helping veterans 
obtain employment or receive income-related benefits for which 
the veteran may be eligible.
    Section 309 of the Committee bill would require the VA 
Secretary to utilize these performance evaluations to determine 
whether the GPD grantee's performance merits continued receipt 
of GPD payments, and require the VA Secretary to only authorize 
continued funding if the aforementioned evaluation affirms the 
efficacy of the GPD grantee in assisting veterans' transition 
into permanent housing. This provision would additionally 
require the VA Secretary to establish uniform, nationwide 
performance targets for all grantees and eligible entities that 
receive per diem payments for the purpose of conducting fair 
and equitable performance evaluations. The Committee intends 
this section to ensure that GPD grantees are best utilizing 
these payments in a manner that will support homeless veterans. 
If the performance evaluations of grant recipients or eligible 
entities do not merit continued VA payments, this section 
grants the VA Secretary the authority to discontinue such 
payments to such grantees.

Sec. 310. Repeal of requirement for annual reports on assistance to 
        homeless veterans.

    Section 310 of the Committee bill, which is derived from 
S. 684, would repeal the requirement that VA annually submit to 
Congress a report on assistance to homeless veterans.
    Background. The Homeless Veterans Comprehensive Assistance 
Act of 2001 (Public Law 107-95) established a requirement that 
VA submit an annual report to the Committee on Veterans' 
Affairs of the Senate and House of Representatives on its 
homelessness programs. The reports detail VA services for 
homeless veterans, including data from the previous year and an 
overview of Veterans Health Administration and Veterans 
Benefits Administration programs that serve homeless veterans.
    Committee Bill. Section 310 of the Committee bill would 
repeal section 2065 of title 38, U.S.C., which requires VA to 
provide an annual report to Congress on the activities of VA's 
programs for homeless veterans. The Committee does not believe 
that this report continues to be necessary and believes VA 
could more effectively utilize the time and resources spent on 
the report to further support efforts to serve homeless 
veterans. The Committee expects VA to be responsive and 
transparent when requested to respond to questions about its 
programs for homeless veterans and recognizes that VA collects 
data and conducts analysis, regardless of a Congressional 
reporting requirement.

Sec. 311. Comptroller General of the United States study on homeless 
        veterans programs of the Department of Veterans Affairs.

    Section 311 of the Committee bill, which is derived from 
S. 684, would require the Comptroller General to complete an 
assessment of VA programs that provide assistance to homeless 
veterans and a review of VA efforts to improve the safety and 
security of female veterans participating in the programs.
    Background. VA has six strategic pillars that include at 
least 25 programs intended to assist homeless veterans. These 
pillars include outreach and communication, treatment, 
prevention, housing/supportive services, income/employment/
benefits, and community partnerships.
    Nine percent of the 47,725 homeless veterans identified in 
HUD's Point in Time count from January 2015 were women. A 
September 2011 report by VA's OIG, entitled ``Safety, Security, 
and Privacy for Female Veterans at a Chicago, IL Homeless Grant 
Provider Facility,'' a December 2011 GAO report entitled 
``Homeless Women Veterans: Actions Needed to Ensure Safe and 
Appropriate Housing,'' and a March 2012 OIG report entitled 
``Audit of the Homeless Providers Grant and Per Diem Program'' 
highlighted safety and security risks affecting women veterans 
within the GPD program. GAO recommended that VA establish 
gender-specific safety and security standards for GPD programs, 
especially those serving both men and women. In its 2012 
report, the OIG made a similar recommendation, in addition to 
recommending that the GPD program application process include 
provider commitment to veteran safety, security, and privacy.
    According to GAO, in response to one of its 
recommendations, in July 2013, VA revised and published its GPD 
Handbook, which included a new section on services for female 
veterans. GAO also indicated that VA changed its GPD 
application process to require new applicants to include 
information about the gender of the homeless population the 
applicant plans to serve.
    Committee Bill. Section 311 of the Committee bill would 
require that, not later than 270 days after enactment, the 
Comptroller General complete a study of VA programs that 
provide assistance to homeless veterans, including an 
assessment of whether those programs are meeting the needs of 
veterans, any gaps or duplication in the provision of services, 
and a review of recent efforts by VA to improve the privacy, 
safety, and security of female veterans.
    As the number of homeless veterans continues to decline, it 
is important to ensure homeless programs are targeted to the 
demographics in the geographic areas that need them. A full 
assessment of VA's homelessness programs would also assist with 
identifying gaps or duplication in services in order to more 
effectively utilize resources and serve homeless veterans.
    The OIG and GAO findings in regard to the safety and 
security risks faced by female veterans within VA GPD programs 
are alarming. It is important to ensure policies and procedures 
are in place to protect female veterans in VA homeless 
programs.

Sec. 312. Requirement for Department of Veterans Affairs to assess 
        comprehensive service programs for homeless veterans.

    Section 312 of the Committee bill, which is derived from 
S. 684, would require VA to assess and measure the capacity of 
programs that receive grants or per diem payments in addition 
to developing and using tools to examine the capacity of those 
programs at both the national and local level.
    Background. A March 2012 VA OIG report entitled ``Audit of 
the Homeless Providers Grant and Per Diem Program'' found that 
VA's GPD program did not assess bed capacity to inform funding 
priorities and needs in underserved geographic areas and did 
not accurately report program outcomes. The OIG determined that 
the improvement of program evaluation would ensure program 
funding is aligned with program goals. This report followed the 
December 2011 GAO report entitled ``Homeless Women Veterans: 
Actions Needed to Ensure Safe and Appropriate Housing,'' which 
found that VA lacked data on the needs and characteristics of 
homeless women veterans at the national, state, and local 
levels. GAO indicated that, without this information, VA is 
unable to effectively plan services, allocate grants, and 
monitor progress in ending veteran homelessness.
    Committee Bill. Section 312(a) of the Committee bill, in a 
freestanding provision, would require VA to assess and measure 
the capacity of GPD programs, including how well they achieve 
their stated goals at the national level, placements in 
permanent housing and employment, and increases in the regular 
income of participants in the programs. Section 312(b) of the 
Committee bill would require that, in conducting the required 
assessment, VA develop and use tools to examine the capacity of 
the programs at the national and local levels in order to 
assess whether sufficient capacity exists to meet the needs of 
homeless veterans in each geographic area; whether existing 
capacity meets the needs of the subpopulations of homeless 
veterans located in each geographic area; and the amount of 
capacity that GPD providers have to provide TIP services. In 
its assessment, VA would also be required to consider the 
availability of resources to GPD programs. Section 312(d) of 
the Committee bill would require VA to utilize information 
collected under this section to set specific goals to ensure 
the GPD programs are effectively serving homeless veterans, to 
assess whether the programs are meeting the specific goals, to 
inform funding allocations for the programs, and to improve the 
referral of homeless veterans to GPD programs. Section 312(e) 
of the Committee bill would require that not later than 180 
days after the assessment is completed, VA submit a report to 
the Committee on Veterans' Affairs of the Senate and House of 
Representatives on the assessment and include recommendations 
for legislative and administrative actions for improving the 
programs.
    As the number of homeless veterans continues to decrease, 
it is important that VA assess the demographics and geographic 
region of those who could benefit from transitional housing to 
ensure appropriate allocation of resources. In addition, proper 
assessment of the program will also help inform VA efforts to 
establish specific goals to ensure the program is effectively 
meeting the needs of homeless veterans.

Sec. 313. Report on outreach relating to increasing the amount of 
        housing available to veterans.

    Section 313 of the Committee bill, which is derived from 
S. 1885, would require a VA report on outreach related to the 
amount of housing available to veterans.
    Background. In order to combat veteran homelessness, VA is 
conducting outreach to ensure that veterans are appropriately 
connected with VA and community services. VA is currently 
working to proactively seek out veterans in need of assistance 
and connect veterans with housing solutions, health care, and 
employment services. This outreach to identify and engage 
veterans who have experienced chronic homelessness is necessary 
to facilitate connections between homeless veterans and 
community-based providers.
    VA is additionally collaborating with Federal, state, and 
local agencies to expand employment and affordable housing 
options for veterans seeking transitional and permanent 
housing. The Committee is aware of current VA efforts to 
conduct outreach to realtors, landlords, property management 
companies, and developers, particularly in communities with 
competitive housing markets. Given the shortage of safe and 
affordable permanent housing, these outreach efforts may help 
to ensure that more housing opportunities are made available to 
veterans who are currently homeless or at risk for 
homelessness. Greater information is necessary to determine 
whether VA's current outreach efforts are effectively 
increasing availability of safe and affordable housing options 
nationwide, particularly in communities with a high level of 
veteran homelessness. With additional information about current 
outreach, VA could explore additional measures that could be 
implemented to encourage entities to rent to homeless or 
formerly homeless veterans.
    Committee Bill. Section 313 of the Committee bill, in a 
freestanding provision, would require the VA Secretary to 
submit to the Committee on Veterans' Affairs of the Senate and 
House of Representatives a report describing and assessing VA 
outreach to realtors, landlords, property management companies, 
and developers to educate them about the housing needs of 
veterans as well as the benefits of having veterans as tenants. 
The Committee intends this report to serve as a resource to 
assess the current outreach and determine its success in 
decreasing homelessness among veterans.

                     TITLE IV--HEALTH CARE MATTERS

Sec. 401. Short title.

    Section 401 of the Committee bill, which is derived from 
S. 1641, would establish the short title of Title IV as the 
Jason Simcakoski Memorial Act.
    Background. On August 30, 2014, U.S. Marine veteran Jason 
Simcakoski died at the Tomah Veterans Affairs Medical Center 
(hereinafter, ``VAMC'') in Tomah, Wisconsin, as a result of 
mixed drug toxicity. Jason was 35 when he died.
    Since 2003, Jason was a patient at the Tomah VAMC, 
primarily being treated for anxiety, post traumatic stress 
disorder (hereinafter, ``PTSD'') and substance use disorder. At 
the time of his death, he was prescribed numerous medications 
including opioids, specifically buprenorphine along with 
benzodiazepines. While he occasionally presented with 
intermittent pain, not chronic pain, VA providers at the VAMC 
prescribed a number of opioid pain medications in combination 
with benzodiazepines. In addition to other prescribed 
analgesics, commonly known as painkillers, at the time of his 
death, Jason was given buprenorphine--an opioid intended to 
treat addiction--at a higher than the U.S. Food and Drug 
Administration recommended dose, although he was not diagnosed 
with an opioid addiction. He was also prescribed several 
benzodiazepines including diazepam, which, together with the 
buprenorphine, produced a known dangerous interaction that 
ultimately led to his death.\3\
---------------------------------------------------------------------------
    \3\Office of Inspector General, Department of Veterans Affairs; 
``Unexpected Death of a Patient During Treatment with Multiple 
Medications Tomah VA Medical Center Tomah, Wisconsin.'' Report No: 15-
02131-471; August 6, 2015.
---------------------------------------------------------------------------
    The growing use and abuse of prescription painkillers such 
as opioids is a growing public health crisis in the United 
Sates. More Americans now die every year from drug overdoses, 
mostly from prescription painkillers, than they do in motor 
vehicle crashes. In 2012, health care providers wrote 259 
million prescriptions for opioid pain medications-- enough for 
every American adult to have a bottle of pills.\4\ 
Inappropriate use of opioids is a particular problem in the 
veteran community and at VA. Jason's tragic story illustrates a 
larger, ongoing problem of dangerous use and over prescription 
of opioids at the Tomah facility as well as throughout the VA.
---------------------------------------------------------------------------
    \4\Centers for Disease Control and Prevention (CDC); CDC Vital 
Signs, ``Opioid Painkiller Prescribing.'' July 2014; http://
www.cdc.gov/vitalsigns/opioid-prescribing/.
---------------------------------------------------------------------------
    Committee Bill. Section 401 of the Committee bill would 
name Title IV of the Committee bill in honor of Jason's memory. 
The Committee believes the Jason Simcakoski Memorial Act would 
aid VA in providing safer and more effective pain management 
care to our nation's veterans.

     SUBTITLE A--EMPLOYMENT OF DIRECTORS AND HEALTH CARE PROVIDERS

Sec. 411. Extension of period for increase in graduate medical 
        education residency positions at medical facilities of the 
        Department of Veterans Affairs.

    Section 411 of the Committee bill, which is derived from 
S. 1676, allows VA an additional 5 years to increase the number 
of graduate medical education residency positions at medical 
facilities of VA by 1,500 positions.
    Background. The Veterans Access, Choice, and Accountability 
Act of 2014 (P.L. 113-146; 38 U.S.C. 7302 note), requires the 
VA Secretary to increase the number of GME residency positions 
by 1,500 residency slots during the 5-year period that began 1 
year after enactment of Public Law 113-146. In filling the 
increased residency slots, the VA Secretary is required to 
focus on residencies in the areas of primary care, mental 
health, and any other specialty the Secretary determines 
appropriate. Furthermore, P.L. 113-146 requires the Secretary 
to give a priority to GME residency slots at medical facilities 
that do not have existing medical residency programs and that 
are located in communities that have a high concentration of 
veterans. As of January 2016, only 372 new residency positions 
have been filled. The Committee has learned that expanding 
these residency slots requires VA employees to conduct many 
hours of outreach to facilities and academic medical centers 
that would potentially serve as partners for the residency 
slots, particularly because of the requirement that VA focus on 
facilities that do not have existing medical residency 
programs. As a result, the full increase in residency slots is 
not expected to be complete within the originally mandated 
timeline.
    Committee Bill. Section 411 of the Committee bill would 
amend paragraph (2) of section 301(b) of P.L. 113-146 by 
extending the timeline for completing the expansion of the 
residency slots from 5 years to 10 years.

Sec. 412. Modification of hours of employment for physicians and 
        physician assistants employed by the Department of Veterans 
        Affairs.

    Section 412 of the Committee bill, which is derived from 
S. 1450, would modify the requirements for full-time employee 
status for physicians and physician assistants employed by VA.
    Background. Section 7423(a) of title 38, U.S.C., 
establishes the hours that are used to determine whether an 
employee physician or physician assistant is a full-time 
employee. A full-time employee is one who works eighty hours 
over a 2-week period. The Committee has learned that these 
strict hour requirements for physicians and physician 
assistants, while similar to those of other VA employees, can 
create complications, particularly when scheduling physicians 
and physician assistants for emergency call schedules. The 
Committee has heard from stakeholders that allowing more 
flexible scheduling when determining whether a physician or 
physician assistant employee is a full-time employee would 
simplify staffing for VA medical facilities and make it easier 
to ensure facilities are appropriately staffed.
    Federal agencies, including VA, are able to implement 
alternative work schedules including flexible work schedules 
and compressed work schedules in order to help the employee 
balance work and family or personal responsibilities.
    Committee Bill. Section 412 of the Committee bill would 
create an exception for determining full-time employee status 
for physicians and physician assistants by amending section 
7423(a) of title 38, U.S.C., as long as the total hours of 
employment for a calendar year do not exceed 2,080 hours.
    The Committee intends that this provision allow VA 
flexibility in scheduling physicians and physician assistants 
to better reflect the schedules that those providers typically 
keep in health care systems outside of VA. The Committee does 
not intend that this provision affect the current requirements 
related to overtime pay or flexible work schedules.

Sec. 413. Requirement that physician assistants employed by the 
        Department of Veterans Affairs receive competitive pay.

    Section 413 of the Committee bill, which is derived from 
S. 1676, would include physician assistants in the types of 
providers who are eligible for locality pay.
    Background. Section 7451(a)(2) of title 38, U.S.C., allows 
VA to ensure that rates of pay for health care personnel 
positions within VA facilities are competitive with the rates 
of pay in non-VA facilities in the same labor market area. This 
allows VA to operate on fair footing with other potential 
health care employers that would be competing to hire for the 
same or similar positions. VA is explicitly authorized to use 
locality pay for registered nurses and the positions listed in 
section 7401(1) and (3) of title 38, U.S.C. Although the VA 
Secretary is able to appoint other specialties to the list, 
this authority has yet to be utilized. VA is affiliated with 
more than 30 accredited physician assistant education programs 
and offers continuing medical education programs, tuition 
support programs, education debt reduction programs, and 
employee incentive scholarship programs as incentives to help 
grow the number of physician assistants within VA. However, 
physician assistant positions can still be difficult for 
facilities to fill. According to a September 2015 VA OIG review 
entitled, ``Office of Inspector General Determination of 
Veterans Health Administration's Occupational Staffing 
Shortages,'' physician assistants were the occupation with the 
fourth largest staffing shortages for 2014.
    Committee Bill. Section 413 of the Committee bill would 
amend section 7451(a)(2) of title 38, U.S.C., to allow VA to 
offer rates of pay that are competitive with non-VA facilities 
within the same labor market areas when hiring for physician 
assistant positions.

Sec. 414. Establishment of positions of Directors of Veterans 
        Integrated Service Networks in Office of Under Secretary for 
        Health of Department of Veterans Affairs and modification of 
        qualifications for Medical Directors.

    Section 414 of the Committee bill, which is derived from 
S. 1676, would amend section 7306 of title 38, U.S.C., to 
create positions of Directors of Veterans Integrated Service 
Networks and change the qualifications for a Medical Director.
    Background. Under section 7306(a)(4) of title 38, U.S.C., 
the Office of the Under Secretary for Health consists in part 
of ``[s]uch Medical Directors as may be appointed to suit the 
needs of the Department, who shall be either a qualified doctor 
of medicine or a qualified doctor of dental surgery or dental 
medicine.'' Under current law, a VISN Director or Medical 
Director is not eligible to be hired under VA's hiring 
authority provided by title 38, U.S.C., because VA is not able 
to appoint non-physicians using its title 38 hiring authority. 
Both Medical Directors and VISN Directors are hired under title 
5, U.S.C., as part of the Senior Executive Service 
(hereinafter, ``SES'') of the government. Even though 
individuals hired to these positions are hired as an SES and 
paid at a higher rate than the general schedule pay for title 5 
employees, they are paid substantially less than their private 
sector counterparts as well as the VA medical providers 
reporting to them. This pay disparity makes it difficult for VA 
to recruit non-VA employees and current VA providers to fill 
positions of VISN Directors and Medical Directors.
    Committee Bill. Section 414 of the Committee bill would 
amend section 7306(a)(4) of title 38, U.S.C., by inserting 
``and Directors of Veterans Integrated Service Networks'' after 
``such Medical Directors'' and further amend the section by 
deleting the requirement that Medical Directors appointed under 
this section shall be a qualified physician or dentist.

Sec. 415. Pay for Medical Directors and Directors of Veterans 
        Integrated Service Networks.

    Section 415 of the Committee bill, which is derived from 
S. 1676, would add a new section 7481 to title 38, U.S.C., 
providing that pay for a Medical Director or Director of a 
Veterans Integrated Service Network will consist of basic pay 
set forth under section 7404(a) of title 38, U.S.C., (setting 
grades and pay scales for VA health professionals) and market 
pay determined under this new authority.
    Background. Under current law, a VISN Director or Medical 
Director is not eligible to be hired under VA's hiring 
authority provided by title 38, U.S.C., because VA is not able 
to appoint non-physicians using its title 38 hiring authority. 
Both Medical Directors and VISN Directors are hired under title 
5, U.S.C., as part of the SES. Even though people appointed to 
these positions are hired as an SES and paid at a higher rate 
than the general schedule pay for title 5 employees, they are 
paid substantially less than their private sector counterparts 
as well as the VA medical providers reporting to them. This pay 
disparity makes it difficult for VA to recruit non-VA employees 
and current VA providers to fill positions of VISN Directors 
and Medical Directors.
    Committee Bill. Section 415 of the Committee bill would 
change how the pay for VISN Directors and Medical Directors is 
calculated.
    Section 415(a) of the Committee bill would create a new 
subchapter VII in chapter 74 of title 38, U.S.C., to create a 
new section 7481 entitled ``Pay for Medical Directors and 
Directors of Veterans Integrated Service Networks.'' Section 
7481(a), as added, would direct that the basic pay for a 
Medical Director or VISN Director will be set under section 
7404(a) of title 38, U.S.C. Section 7481(b) would allow for 
market pay through an adjustment of such pay dependent on the 
experience of the Directors, the complexity of the facility, 
the labor market in the geographic area, and other 
considerations as deemed appropriate by the VA Secretary. Under 
section 7481(c), the VA Secretary would be directed to 
determine every 2 years a maximum and minimum level of pay for 
Medical Directors and VISN Directors and publish those amounts 
in the Federal Register. Section 7481(d) would clarify that pay 
received under this section would be considered pay for the 
purposes of receiving retirement benefits under chapters 83 and 
84 of title 5, U.S.C. Subsection 7481(e) would clarify that a 
decrease in pay due to an adjustment by the Secretary to the 
market pay for Medical Directors and VISN Directors will not be 
treated as an adverse action.
    Section 415(b) of the Committee bill would make a clerical 
change to add the new subchapter VII to the table of contents 
in title 38, U.S.C.
    Section 415(c) of the Committee bill would provide for an 
effective date that is 1 year after the date of enactment.

Sec. 416. Additional requirements for hiring of health care providers 
        by the Department of Veterans Affairs.

    Section 416 of the Committee bill, which is derived from 
S. 1641, would require the VA Secretary to consider information 
from the medical boards of each state in which a health care 
provider holds or has held a medical license during the hiring 
process at VA.
    Background. When hiring health care providers, VA's policy 
is to conduct license verification of all active and currently 
held licenses as part of credentialing, which must be completed 
before any provider delivers health care at a VA facility. This 
is typically accomplished by querying the respective state 
licensure board's (hereinafter, ``SLB'' or ``board'') public 
facing Web site in the state where the provider holds a 
license. If the licensure board has taken an action on the 
license, that information will be available. This practice is 
outlined in VHA Handbook 1100.19 and VHA Directive 2012-030. 
However, recent media reports regarding practicing VA providers 
whose credentials have not been verified, who have been 
misrepresented, and who have previously entered into 
settlements or completed disciplinary actions in other states 
where they may hold a medical license have highlighted the need 
to ensure protocols are being followed.\5\ VA must do more to 
guarantee its providers are of the highest quality and are, at 
the very least, in good standing with each SLB in which they 
hold a license to protect our nation's veterans.
---------------------------------------------------------------------------
    \5\http://www.desmoinesregister.com/story/opinion/editorials/2016/
01/04/editorial-va-doctors-should-licensed-where-they-practice/
78127258/ and http://www.kare11.com/story/news/investigations/2015/11/
20/va-doctor-certification-scandal-grows/76130672/
---------------------------------------------------------------------------
    Committee Bill. Section 416 of the Committee bill would, in 
a freestanding provision, require the Department to issue 
regulations that require, as part of the hiring process, VA to 
obtain information on medical license violations from each SLB 
where a provider holds or has held a license during the 
provider's career as well as information on whether the 
provider has entered into any settlement agreements with the 
board for disciplinary charges relating to medical practice.

Sec. 417. Provision of information on health care providers for 
        Department of Veterans Affairs to state medical boards.

    Section 417 of the Committee bill, which is derived from 
S. 1641, would require VA to send to each state licensing 
board, where a provider holds a license, and the board in the 
state where the provider practices, information concerning a 
report of a violation during the provider's practice at VA 
without the board making a request for such information.
    Background. Under the current policy outlined in VHA 
Handbook 1100.18, medical facilities must report each licensed 
health care professional whose behavior or clinical practice so 
substantially fails to meet generally accepted standards of 
clinical practice as to raise reasonable concern for the safety 
of patients. In each instance, the medical facility Director 
must prepare a Reporting File to submit to each SLB where the 
professional holds a license.\6\ However, the report statement 
sent to the SLB is typically limited to a generic description 
of the clinical shortcomings involved, unless the SLB responds 
to the Director with a formal request for more information. 
SLBs and the Federation of State Medical Boards have indicated 
that it is quite difficult for boards to receive up-front, 
timely, and comprehensive information on violations or 
assistance with investigations from VA. SLBs also highlighted 
that they find it extremely difficult to gain any information 
even if the SLBs follow VA's exact procedure to gain such 
information. Material received is so heavily redacted it is of 
little use. It is critical VA improve communication with SLBs 
and improve transparency surrounding medical practice 
violations to remain accountable for high-quality and safe 
care.
---------------------------------------------------------------------------
    \6\VA Views for S. 1641, Testimony submitted before the Senate 
Veterans' Affairs Committee, ``Legislative Hearing'' on June 24, 2015.
---------------------------------------------------------------------------
    Committee Bill. Section 417 of the Committee bill would, in 
a freestanding provision, require the Department to send each 
SLB where a provider holds a license, and the SLB in the state 
where the provider practices, the full information concerning a 
report of a violation during the provider's practice at VA 
without the board making a request for such information. While 
VA providers are not required to hold a license in the same 
state where the medical facility resides, the Committee 
believes that such state's board should, nonetheless, have 
access to information about a clinical violation committed at a 
facility in their state to ensure the board can fulfill its 
obligation to uphold safe medical practice.

Sec. 418. Report on compliance by Department of Veterans Affairs with 
        reviews of health care providers leaving the Department or 
        transferring to other facilities.

    Section 418 of the Committee bill, which is derived from 
S. 1641, would require VA to submit a report to Congress on 
compliance with the VA policy to conduct a review of every VA 
clinician leaving or transferring to another facility to 
uncover any concerns, complaints, or allegations of violations 
of medical practice and to take appropriate action.
    Background. There are approximately 1400 points of care 
across VA's health care system. Transfers of health care 
providers to different VA facilities can occur as a positive 
job opportunity for providers,\7\ as a result of need for 
providers in specific facilities, or as a major adverse 
employment action.\8\ Because a provider transferring to a new 
facility can occur for a variety of reasons, it can be 
difficult to determine whether a provider has left a facility 
with outstanding allegations of violations related to their 
medical practice without an active review of their employment 
records being conducted. This is also true when a provider 
moves to a non-VA medical facility.
---------------------------------------------------------------------------
    \7\http://www.vacareers.va.gov/students-trainees/physicians.asp.
    \8\VA Handbook 5021/10 Transmittal Sheet, Employee/Management 
Relations, updated November 8, 2012.
---------------------------------------------------------------------------
    VHA has the authority under section 501 of title 38, 
U.S.C., to report medical professionals employed at VA whose 
behavior or clinical practice failed to meet the generally 
accepted standards of clinical practice as to raise reasonable 
concerns for patient safety. VHA Handbook 1100.18 requires VA 
to cooperate with SLBs by initiating reports regarding concerns 
about patient safety and in terms of cooperating with inquiries 
from an SLB. VA's quality assurance program authorized under 
Public Law 99-660, the Public Health Service Act, requires the 
Department to report to the relevant SLBs any licensed health 
care professional who was fired or who resigned following the 
completion of a disciplinary action relating to such 
professional's clinical competence, resigned after having had 
his or her clinical privileges restricted or revoked, or 
resigned after serious concerns about such professional's 
clinical competence had been raised but not resolved. The 
Committee has heard from stakeholders that compliance with the 
reporting requirements in VHA Handbook 1100.18 to SLBs varies 
from facility to facility.
    Committee Bill. Section 418 of the Committee bill would, in 
a freestanding provision, require VA to report to the Committee 
on Veterans' Affairs of the Senate and House of Representatives 
its compliance with the VA policy of review and credentialing 
to ensure it is carried out consistently across facilities to 
maintain accountability for safe, high-quality care within 2 
years of enactment of the Committee bill. This report would 
include a review of whether VA took appropriate action on 
concerns, complaints, or allegations of violations that relate 
to the medical practice of health care providers. The report 
would be due not later than 2 years from the enactment of the 
Committee bill.

             SUBTITLE B--OPIOID THERAPY AND PAIN MANAGEMENT

Sec. 421. Guidelines on management of opioid therapy by Department of 
        Veterans Affairs and Department of Defense and implementation 
        of such guidelines by Department of Veterans Affairs.

    Section 421 of the Committee bill, which is derived from 
S. 1641, would require the Secretaries of Veterans Affairs and 
Defense to update the joint VA/DOD Clinical Practice Guideline 
for Management of Opioid Therapy for Chronic Pain.
    Background. In 2010, VA and DOD updated the joint VA/DOD 
CPG for Management of Opioid Therapy for Chronic Pain. However, 
despite the growing number of opioid prescriptions and changes 
in best practices and treatments, the CPG, which guides 
clinicians in making treatment decisions regarding prescription 
of opioids for patients suffering from chronic pain, has not 
been updated for more than 5 years. Additionally, a 2014 OIG 
report found that not all of VA's practices concerning opioid 
prescribing align with recommendations in the CPG.\9\
---------------------------------------------------------------------------
    \9\Office of Inspector General, Department of Veterans Affairs; 
``Healthcare Inspection--VA Patterns of Dispensing Take-Home Opioids 
and Monitoring Patients on Opioid Therapy.'' Report No. 14-00895-163; 
May 14, 2014.
---------------------------------------------------------------------------
    Committee Bill. Section 421 of the Committee bill would, in 
a freestanding provision, outline requirements for updating the 
joint VA/DOD CPG for Management of Opioid Therapy for Chronic 
Pain. Subsection (a) of section 421 of the Committee bill would 
require VA and DOD to update and enhance the joint VA/DOD CPG 
for Management of Opioid Therapy for Chronic Pain. It would 
further require the updated CPG to incorporate the Centers for 
Disease Control and Prevention's (hereinafter, ``CDC'') safe 
opioid prescribing guidelines for the treatment of chronic, 
non-cancer pain in outpatient settings where practical. The 
Committee believes it is critical for opioid prescribing 
guidance to be up-to-date and consistent across Federal 
agencies to ensure that all providers have access to the same 
tools to make the best treatment decisions for their patients. 
The Committee expects VA and DOD to incorporate CDC guidelines 
where applicable and acknowledges that some CDC recommendations 
may not be appropriate for the veteran community. The Committee 
also expects that CDC guidelines alone, which only address 
chronic pain in outpatient settings, would not be sufficient to 
serve as an update to the CPG and directs VA and DOD to 
consider all relevant evidence to ensure that the final CPG is 
robust and relevant to the patient population of both 
departments.
    This subsection would also require the updated CPG to 
enhance guidance concerning absolute contraindications for 
opioid therapy, including prescribing opioids and 
benzodiazepines concurrently, and prescribing opioids to treat 
mental health conditions and patients without any pain. 
Stronger guidance is needed because the OIG found that VA's 
practice of prescribing and dispensing benzodiazepines 
concurrently with opioids was not fully in alignment with 
acceptable standards.\10\ This is despite the fact that the 
current CPG advises clinicians against this practice and notes 
it as an absolute contraindication.\11\ Updated recommendations 
against prescribing opioid therapy for patients with severe 
mental health conditions, including PTSD and substance use 
disorder, as well as to treat mental health conditions are also 
needed due to the inappropriate practices at the Tomah VAMC 
where a psychiatrist was among the top opioid prescribers--
providing large amounts of narcotics to patients with mental 
health issues.\12\
---------------------------------------------------------------------------
    \10\OIG report; VA Patterns of Dispensing Opioids, May 2014.
    \11\VA/DOD Clinical Practice Guideline for the Management of Opioid 
Therapy for Chronic Pain; May, 2010, at 25.
    \12\OIG; Administrative Closure, Tomah VA Medical Center.
---------------------------------------------------------------------------
    Moreover, section 421 would require the CPG to include 
stronger recommendations regarding consistent urine drug 
screenings--including that such screenings should be done at 
least once a year--for patients on long term opioid therapy and 
guidance that clinicians must appropriately interpret and act 
on the results. At the Tomah VAMC and throughout VHA, reports 
show that clinicians have not been consistently conducting or 
taking appropriate action based on urine drug screenings to 
determine if a patient on opioid therapy is misusing 
opioids.\13\
---------------------------------------------------------------------------
    \13\OIG; Administrative Closure, Tomah VA Medical Center and OIG 
report; VA Patterns of Dispensing Opioids, May 2014.
---------------------------------------------------------------------------
    The Committee recognizes the CPG contains non-binding 
recommendations aimed to inform and help clinicians in 
decisionmaking, and that providers' practices will vary when 
they appropriately take into account the needs of their 
individual patients. However, the Committee is concerned that, 
despite the recommendations in the 2010 CPG, overprescribing 
and abuse of opioids within VA has risen dramatically. Further, 
evidence indicates VA's opioid prescribing practices are not 
always consistent with acceptable standards as recommended in 
the CPG. As such, the Committee expects the updated CPG to 
include stronger and more robust recommendations to help 
guarantee clinicians deliver the safest and most effective 
care.
    Finally, subsection (a) of section 421 would direct the 
updated CPG to include a requirement that all VA providers 
utilize the VA Opioid Therapy Risk Report tool prior to 
starting a patient on opioid therapy. Comprehensive use of this 
electronic tool, which helps providers manage their entire 
panel of patients' prescribed pharmacotherapy for acute or 
chronic pain, for all VA patients on opioid therapy, is 
absolutely essential to ensuring providers deliver and are held 
accountable for high quality and safe care.
    Subsection (b) of section 421 would require the VA 
Secretary and the Secretary of Defense to jointly consult with 
the Pain Management Working Group of the Health Executive 
Committee of the Department of Veterans Affairs-Department of 
Defense Joint Executive Committee before updating the CPG.
    Subsection (c) of section 421 would define the term 
``controlled substance'' as having the same meaning as in 
section 802 of title 21, U.S.C. The Committee intends to ensure 
consistency in defining ``controlled substance'' for the 
purpose of this bill.

Sec. 422. Improvement of opioid safety measures by Department of 
        Veterans Affairs.

    Section 422 of the Committee bill, which is derived from 
S. 1641, would require VA to expand the Opioid Safety 
Initiative across all medical facilities; enhance pain 
management education and training for VA providers; identify 
and designate pain management teams at each VA medical 
facility; augment tracking and monitoring of opioid use at the 
Department; increase the availability of opioid receptor 
antagonists; include certain information and capabilities on 
the Opioid Risk Report tool; and incorporate notification of 
risk in the computerized health record.
    Background. Started in August 2012 as a pilot program in 
Minneapolis, Minnesota, to reduce dependency on opioid use, the 
OSI was implemented nationwide a year later. In written 
testimony to the Committee on March 26, 2015, the then Interim 
Under Secretary for Health at VHA, Dr. Carolyn Clancy, noted 
key clinical metrics measured by the OSI from quarter 4, fiscal 
year 2012 to quarter 1, fiscal year 2015 indicated a 13 percent 
reduction in the number of patients receiving opioids. It 
should be noted VA saw a 2 percent increase in the number of 
patients utilizing its outpatient pharmacy services during that 
same period. Given the relative success of OSI to date, it is 
critical VHA expand and fully implement the initiative in all 
of its facilities as soon as possible to improve safe pain 
management.
    The OSI and VHA's National Pain Management Strategy offers 
providers education and training to enhance competencies and to 
promote the CPG for Management of Opioid Therapy for Chronic 
Pain, including through such efforts as the dissemination of 
the OSI toolkit.\14\ To enhance this effort and ensure 
consistency across the whole system, VHA should leverage the 
existing Interdisciplinary Chronic Pain Management Training 
Team Program to provide education on the CPG, additional 
training on screening, and improve identification and referral 
of patients with substance use disorder.
---------------------------------------------------------------------------
    \14\VHA National Pain Management Strategy, Implementation of the 
Stepped Care Model; October 2012. Power Point Presentation. http://
www.va.gov/PAINMANAGEMENT/docs/VHA_Natl_ 
Pain_Mgmt_Strategy_Kerns_Oct2012.pptx
---------------------------------------------------------------------------
    Limiting the provision of opioids, as appropriate, to 
providers with expertise in analgesics or pain care is critical 
in holding providers accountable for safe care and to prevent 
patient abuse and diversion. For example, at the Tomah VAMC, 
one of the most prolific prescribers of opioids was a 
psychiatrist without expertise in pain management. The use of 
interdisciplinary pain medicine specialty teams at VA 
facilities should serve as a valuable resource in combating 
such abuse and be implemented system-wide. As of 2014, 40 
facilities (28 percent) have fully implemented 
interdisciplinary pain medicine specialty teams while another 
56 (40 percent) have partially implemented these teams.
    A critical aspect of the OSI is the Opioid Therapy Risk 
Report tool, an electronic tool that helps providers manage 
their entire panel of patients prescribed pharmacotherapy for 
acute or chronic pain. Not all VA providers currently use this 
tool, as VA does not mandate its use. VA providers who 
prescribe opioids should use this tool consistently to ensure 
safe prescribing and to help prevent diversion, abuse, and 
double-prescribing.
    The Opioid Therapy Risk Report tool should also be enhanced 
to provide real-time data updates on patient information, 
rather than once in a 24 hour period, and by better interacting 
with providers in the community. Many veterans who access care 
at VA also obtain care in the community who may also prescribe 
them medication. The lack of access to a state's prescription 
drug monitoring program presents VA providers a challenge in 
safely prescribing opioids to their patients. Therefore, the 
Opioid Therapy Risk Report tool could be further enhanced by 
allowing VA providers to access the state PDMPs in an effort to 
see a patient's opioid therapy history from outside providers. 
Moreover, VHA should seek to fully implement its clinicians' 
ability to transmit VA prescription information to state PDMPs 
to guarantee that private clinicians have comprehensive 
information about their patients' history of prescribed 
controlled substances. Currently, 83 of the 130 VAMCs are 
transmitting prescription drug information to their respective 
state PDMPs.
    Finally, while all VA facilities have naloxone on emergency 
crash carts, only 77 percent of VA facilities are currently 
dispensing naloxone rescue kits for patient take home use. Not 
all facility pharmacies have such kits immediately on hand for 
dispensing and must order it or have it mailed to a patient who 
is prescribed a rescue kit. In an effort to improve VA's 
Overdose Education and Naloxone Distribution Program, the 
Department should expand access to naloxone and other opioid 
receptor antagonists by requiring every medical facility 
pharmacy to have opioid receptor antagonists on hand for 
dispensing and to expand the naloxone take home program.
    Committee Bill. Section 422 of the Committee bill would, in 
a freestanding provision, outline requirements for improving 
VA's opioid safety measures. Subsection (a) of section 422 of 
the Committee bill would require an expansion of the OSI to all 
medical facilities within 180 days of enactment of the 
Committee bill. The Committee believes it is critical the OSI 
be expanded and fully implemented in all VA facilities as soon 
as possible to improve safe pain management. Subsection (b) 
would require all prescribers of opioid medications to receive 
pain management and safe opioid prescribing education and 
training to safely and effectively manage patients with chronic 
pain, and to appropriately comply with the updated CPG. 
Subsection (c) would require each medical facility to identify 
and designate a pain management team of clinicians. Each VISN 
would establish protocols for the designation of such teams 
that specify that providers without expertise in prescribing 
analgesics or who have not completed the education and training 
may not prescribe opioids unless done in consultation with a 
provider with pain management expertise or who is on the pain 
management team, and refers such patient to the team for any 
subsequent prescriptions and related therapy.
    Subsection (d) would require VA to improve the Opioid 
Therapy Risk Report tool by enabling access to information from 
state PDMPs to help clinicians identify opioid use by veterans 
outside VA and must also submit information to the state PDMP. 
It would also require VA to conduct a feasibility study on 
further enhancements to the real-time tracking of, and access 
to data on, opioid use by veterans, concurrent prescribing of 
opioids in different health care settings, and mail-order 
prescriptions of opioids to veterans.
    To help reduce overdose deaths, subsection (e) would 
require the Department to increase the availability of opioid 
receptor antagonists, such as naloxone, for veterans. Every 
medical facility pharmacy would be required to have opioid 
receptor antagonists on hand for dispensing. All veterans at 
risk of opioid overdose would have greater access to an opioid 
receptor antagonist kit and receive training on the proper 
administration of such drugs. VA would be required to report to 
Congress regarding implementation of this requirement.
    Subsection (f) would require the VA Secretary to include 
information on the most recent time a health care provider 
accessed the tool and information on the results of the most 
recent urine drug test for each veteran. The VA Secretary would 
also be required to ensure the Opioid Therapy Risk Report tool 
could determine whether a VA health care provider prescribed 
opioids without accessing the information in the tool.
    Subsection (g) would require VA to update its Computerized 
Patient Record System with an alert that a patient is at high 
risk of being an opioid abuser, or has a history of opioid 
abuse to help all clinicians prevent abuse and diversion, and 
to help improve identification and treatment of substance use 
disorders.
    Subsection (h) would define the term ``controlled 
substance'' as having the same meaning as in section 802 of 
title 21, U.S.C. The Committee intends to ensure consistency in 
defining ``controlled substance'' for the purpose of this bill.

Sec. 423. Enhancement of joint working group on pain management of the 
        Department of Veterans Affairs and the Department of Defense.

    Section 423 of the Committee bill, which is derived from 
S. 1641, would enhance the existing Health Executive Committee 
working group on pain management, established through the VA/
DOD Joint Executive Committee, by incorporating opioid therapy 
issues. It would also require the HEC working group to work 
with other relevant working groups to address opioid 
prescribing practices, the management of chronic pain and 
substance use disorders, the use of complementary and 
integrative health services, and continuum of care issues 
related to the military to civilian transition. The VA and DOD 
Secretaries would also be required to consult with the HEC 
working group prior to release of any updates to the CPG on 
opioid therapy.
    Background. As part of the VHA National Pain Management 
Strategy, the HEC Pain Management Working Group, established 
through the JEC, is working to consider the current clinical 
practice guidelines for opioid therapy and the opioid risk 
strategy.\15\ The HEC PMWG focuses on efforts to improve pain 
management for VA and DOD beneficiaries that are complementary 
to the Institute of Medicine (hereinafter, ``IOM'') report on 
pain and the forthcoming National Pain Action Plan being 
developed by the Interagency Pain Research Coordinating 
Committee through the National Institutes of Health 
(hereinafter, ``NIH''). Recent HEC activities include 
developing a standardized pain screening and assessment 
protocol, clinical pain policy support for VA and DOD 
providers, the creation of a new VA/DOD pain management 
curriculum, and integration of nonpharmacologic treatment 
options or integrative medicine into practice. As part of this 
work, the HEC PMWG addresses some issues surrounding the use of 
opioid therapy, such as developing a coordinated program for 
long-term opioid therapy principles of practice to include 
prescribing practices and provider/patient agreement 
standards.\16\
---------------------------------------------------------------------------
    \15\http://www.va.gov/PAINMANAGEMENT/docs/
VHA_Natl_Pain_Mgmt_Strategy_Kerns_ Oct2012.pptx
    \16\VA/DOD Joint Executive Committee Annual Report, Fiscal Year 
2014, at 37.
---------------------------------------------------------------------------
    Opioid therapy has become a primary component of pain 
management and treatment within VA/DOD, so it is critical that 
the HEC PMWG officially incorporate issues surrounding opioid 
therapy as a key, consistent focus of its work. Due to the 
comprehensive expertise of the HEC, the group should be 
required to consult and review any updates to the CPG on opioid 
therapy before release. Further, issues surrounding opioid 
therapy fundamentally overlay with the wide-range of pain 
related issues considered by the HEC and other relevant 
committees, such as the HEC on mental health.
    Committee Bill. Section 423 of the Committee bill would, in 
a freestanding provision, outline requirements for the HEC 
PMWG. Subsection (a) of section 423 of the Committee bill would 
require the HEC PMWG to include issues related to opioid 
prescribing practices, the management of chronic pain, as well 
as substance use disorders, the use of CIH services and 
continuum of care issues surrounding servicemembers' 
transitioning from the Armed Services to the civilian sector in 
its areas of focus. Subsection (b) of section 423 of the 
Committee bill would further require the HEC PMWG to coordinate 
and consult with other relevant Federal agencies, including the 
CDC, to review and comment on the VA/DOD CPG for Management of 
Opioid Therapy for Chronic Pain, or any successor guideline, 
before any update is released. During this process, the 
Committee expects that the working group closely coordinate 
with related HEC working groups on related issues, including 
the concurrent use of opioids and prescription drugs such as 
benzodiazepines, and the use of opioids to treat mental health 
disorders. Subsection (c) of section 423 of the Committee bill 
would require the HEC working group to report, within a year of 
enactment of the Committee bill, on VA/DOD efforts to update 
their joint CPG for Management of Opioid Therapy for Chronic 
Pain as required in subsection (a) of section 421 of the 
Committee bill.

Sec. 424. Establishment of pain management boards of the Department of 
        Veterans Affairs.

    Section 424 of the Committee bill, which is derived from 
S. 1641, would create a pain management board in each VISN to 
serve as an expert resource for patients, families, providers, 
and other employees of VA on the treatment of veterans with 
pain.
    Background. VA currently offers multidisciplinary chronic 
pain management services through pain medicine, neurology, 
anesthesia, physical medicine and rehabilitation, psychology, 
psychiatry, nursing, and integrated medical teams. These 
services can include comprehensive pain assessment, pain 
psychology, acupuncture, interventional procedures, physical 
therapy, medication management, yoga, psychoeducation, aquatic 
therapy, and biofeedback. VA also provides training and 
resources for providers through the Opioid Safety Initiative 
toolkit that was developed through a national task force 
convened by the National Pain Management Program.
    The March 2014 OIG Administrative Closure on opioid 
prescribing at the Tomah VAMC recommended that the facility 
should consider some variant of the tumor board model as one 
avenue by which to foster interdisciplinary management when 
presented with very complex cases requesting early opioid 
refills.\17\ Tumor board reviews are interdisciplinary 
treatment plans in which doctors from different specialties 
discuss the care plan for a specific patient.
---------------------------------------------------------------------------
    \17\Office of Inspector General, ``Administrative Closure, Alleged 
Inappropriate Prescribing of Controlled Substances and Alleged Abuse of 
Authority, Tomah VA Medical Center.'' Tomah, Wisconsin. March 2014 at 
11.
---------------------------------------------------------------------------
    On March 30, 2015, the Senate Homeland Security and 
Governmental Affairs Committee and House Committee on Veterans' 
Affairs held a joint oversight hearing on the Tomah VAMC. At 
that hearing, Dr. Carolyn Clancy testified on behalf of VA and 
supported the inclusion of pain management boards at VA. Dr. 
Clancy expressly supported the inclusion of veterans and family 
members on pain management boards.\18\
---------------------------------------------------------------------------
    \18\Response to Representative Kind from Dr. Carolyn Clancy, M.D., 
Interim Under Secretary for Health, Veterans Health Administration 
before the U.S. Senate Homeland Security and Governmental Affairs 
hearing on Tomah VAMC Oversight; March 30, 2014. http://www.cq.com/doc/
congressionaltranscripts-4656019?4
---------------------------------------------------------------------------
    Committee Bill. Subsection (a) of section 424 of the 
Committee bill would add a new section 7309A to title 38, 
U.S.C., to establish pain management boards in each VISN. These 
pain management boards would supplement the Department's 
ability to provide recommendations for treatment of patients 
with complex pain; provide consultations with health care 
professionals, patients, and family members about pain 
management resources and best practices of the Department; 
oversee compliance with and provide recommendations to improve 
compliance with the best pain management practices of 
providers, including the prescribing guidelines; oversee the 
pain management practices of the pain management teams of each 
medical facility of the Department in the VISN covered by the 
pain management board; host education events on pain management 
and treatment; and hold public events on best practices on pain 
management and CIH.
    The VA Secretary would be required to appoint individuals 
to each pain management board. Membership would include a board 
certified pain medicine specialist, a trained and qualified 
member of the primary care team of a VA medical facility with 
experience in pain care, a pain psychologist, a pain social 
worker, a clinical pharmacist, a pain point of contact for the 
VISN, a physician with addiction and psychopharmacology 
experience and expertise, an allied health care professional, a 
clinician with expertise in CIH, a clinical behavioral 
therapist, a patient advocate, a representative of the labor 
interests of employees of the Department who are responsible 
for prescribing drugs, two current or former clinical patients 
who are representative of the demographic of patients covered 
by the VISN, and a family member of a current or former 
clinical patient who is representative of the demographic of 
patients served by the VISN. The Committee intends that one 
individual be able to meet the criteria for multiple required 
categories.
    The VA Secretary would be required to take into 
consideration the clinical duties of Department employees in 
determining their terms of service. Members of the pain 
management board would not be paid for their service on the 
pain management board except to receive travel expenses, 
including per diem, in lieu of subsistence for travel that 
relates to their duties as pain management board members. 
Members of the pain management board may be temporarily excused 
from their clinical duties as an officer or employee of the 
Department when they are needed to carry out their duties as 
members of the pain management board. However, should the 
Department determine that such employees are needed for 
clinical care duties at a given time in order to maintain 
patient access to quality health services, their clinical 
duties would supersede their duties for the pain management 
board. In order to protect patient privacy and confidentiality, 
certain pain management board members, including patient 
advocates, labor union representatives as described above, and 
current or former clinical patients or their family members 
would not have access to identifying information of a patient 
or other confidential information to a patient unless that 
individual is the patient advocate and has been granted 
permission by the patient to be present in order to represent 
the interest of the patient. The Committee intends membership 
on the pain management board to be non-disruptive to VA 
employees' other duties. An employee of the Department may not 
have an adverse personnel action taken against them as a result 
of communicating with a member of a pain management board.
    Each pain management board may provide treatment 
recommendations for patients with complex clinical pain cases. 
Each pain management board may only provide specific clinical 
recommendations concerning a patient's complex pain management 
case if the patient or other qualifying individual has already 
requested and received a recommendation from the pain 
management team at their respective facility and is not 
satisfied with the team's recommendation. Members of the board 
who are not clinical professionals would not be permitted to 
participate in treatment recommendations and would not be 
permitted to access patient information. However, at the 
request and consent of the patient, a patient advocate may be 
present to ensure that the patient's interests are represented 
and that the veteran has a stronger voice in his or her care 
decisions. An individual may request a clinical recommendation 
if that individual is a patient, the spouse of a patient, an 
individual who has been designated by the patient to make 
health care decisions for the patient or to receive health care 
information for the patient, a physician of the patient or an 
employee of a Department medical facility. It is not the 
Committee's intent that treatment recommendations dictate the 
treatment plan to be used by the health care provider, but 
rather would be used to assist the patient and health care 
provider in determining the best treatment plan. Based on the 
board activities and treatment recommendations, each pain 
management board may provide recommendations on best practices 
regarding pain management in cases of complex clinical pain to 
VISN-level health care professionals.
    Not later than January 31 of each year, each pain 
management board must submit a report to the Committee on 
Veterans' Affairs of the Senate and House of Representatives on 
the pain management practices carried out in the VISN including 
a summary and explanation of the treatment recommendations made 
throughout the previous year and recommendations for best 
practices that were provided to health care professionals in 
the previous year.
    Subsection (b) of section 424 of the Committee bill would 
modify the table of sections at the beginning of chapter 73 of 
title 38, U.S.C., to include pain management boards. Subsection 
(c) of section 424 of the Committee bill would make the 
amendments in this section effective 1 year from enactment of 
the Committee bill.

Sec. 425. Review, investigation, and report on use of opioids in 
        treatment by Department of Veterans Affairs.

    Section 425 of the Committee bill, which is derived from 
S. 1641, would direct VA, within 2 years of the enactment of 
this bill, to enter into a contract with an independent expert 
on clinical prescribing practices to conduct a review of the 
VA's OSI and VA providers' opioid prescribing practices. In 
addition, this section would require VA to conduct an internal 
annual review, investigate certain opioid prescribing patterns, 
and report on its use of opioid therapy.
    Background. According to the March 2014 OIG Administrative 
Closure concerning opioid prescribing at the Tomah VAMC, 
providers at Tomah were among the highest opioid prescribers in 
the region and their prescribing practices varied considerably 
among their peers.\19\ At the request of this Committee, the 
OIG recently conducted a general investigation on VA opioid 
prescribing patterns and submitted a report to Congress, which 
found that not all of VA's practices concerning opioid 
prescribing aligned with recommendations in the VA/DOD Clinical 
Practice Guideline for Management of Opioid Therapy for Chronic 
Pain.\20\
---------------------------------------------------------------------------
    \19\Office of Inspector General, ``Administrative Closure, Alleged 
Inappropriate Prescribing of Controlled Substances and Alleged Abuse of 
Authority, Tomah VA Medical Center.'' Tomah, Wisconsin, March 2014.
    \20\Office of Inspector General, Department of Veterans Affairs; 
``Healthcare Inspection--VA Patterns of Dispensing Take-Home Opioids 
and Monitoring Patients on Opioid Therapy.'' Report No. 14-00895-163; 
May 14, 2014.
---------------------------------------------------------------------------
    Currently, VA does not have a process in place for a 
systematic and regular review, investigation, and reporting of 
its opioid prescription practices and trends by medical 
facility and by provider. Such information would allow Congress 
to conduct more effective oversight of VA and would allow VA to 
more effectively manage this important aspect of patient care. 
Similarly, ensuring that the Committee and members of Congress 
from the areas where VA's opioid use requires investigation are 
informed of this scenario in a timely way allows for better 
oversight and any intervention that may be helpful in 
supporting patients in these facilities.
    Committee Bill. Section 425 of the Committee bill would, in 
a freestanding provision, outline the requirements for a review 
of VA's use of opioids in treatment. Subsection (a) of section 
425 of the Committee bill would require VA to contract, within 
2 years of the enactment of this bill, with an independent 
party experienced with assessing clinical prescribing practices 
to conduct a review of VA's OSI and VA health care providers' 
opioid prescribing practices. The Committee intends for VA to 
identify a credible expert or organization such as an 
appropriate component of the National Academies of Science, 
Engineering, and Medicine to carry out this review. This 
subsection would require the independent entity conducting the 
review to provide a report on its findings and recommendations 
within 30 days after completing the review. The report would be 
submitted to the VA Secretary and the Committee on Veterans' 
Affairs of the Senate and House of Representatives.
    This subsection further details the specific elements that 
would be required in the report, including: recommendations for 
improvements to the OSI; information on veteran deaths as a 
result of sentinel events related to opioids prescribed by a VA 
provider; VA prescription rates and indications for opioid 
prescriptions at all VA medical facilities where opioids are 
used to treat non-cancer, non-palliative, and non-hospice care 
patients; prescription rates and indications by provider for 
benzodiazepines and opioids prescribed concurrently; an 
assessment of the extent to which VA prescription rates are 
aligned with standards for appropriate care; an assessment of 
the practice and effectiveness of VA providers treating 
patients without any pain, including patients with mental 
health conditions, with opioids; and an assessment of the 
extent to which VA is in compliance with the VA/DOD Clinical 
Practice Guideline for Management of Opioid Therapy for Chronic 
Pain. In addition, this subsection would provide additional 
topics that could be covered in the review, such as policy 
recommendations for VA employee performance management 
practices to address VA providers who are not practicing 
according to VA standards or are not following the VA/DOD 
clinical guidelines for contraindications for opioid use. The 
Committee intends to use this report as a means of holding the 
Department accountable for safe opioid prescribing practices.
    Subsection (b) of section 425 of the Committee bill would 
require VA to conduct an internal annual review, investigation, 
and report on its use of opioid therapy. Within 1 year of 
enactment of this bill and at least annually thereafter, VA 
would be required to collect and review data on opioid 
prescriptions at each VA medical facility for non-cancer, non-
palliative, and non-hospice care patients. The review would 
include rates, by health care provider, of (1) concurrent 
prescriptions for benzodiazepines and opioids, (2) prescribed 
or dispensed mail-order opioids to patients who were 
simultaneously being treated with opioids as in-patients, and 
(3) prescribed opioids for patients who were concurrently 
prescribed opioids by a non-VA provider. The Committee intends 
for this review to provide a baseline of information about the 
opioid prescribing practices and patterns of specific 
facilities and providers which may help in identifying trends 
and outliers in this area of clinical practice.
    This section would also require VA to investigate opioid 
prescription rates when the Secretary determines that they are 
inconsistent with the standards of appropriate and safe use. 
Such investigations would include information on the specific 
facility and provider rates of opioid prescription and must be 
conducted through the VHA Office of the Medical Inspector. The 
bill would require that VA immediately notify the Committee on 
Veterans' Affairs of the Senate and House of Representatives 
and each member of the Senate and House who represent the area 
in which the investigation is being conducted. The Committee 
intends to ensure that information on relevant opioid use is 
shared in a timely manner with appropriate members of Congress, 
including Committee members and local delegations. In addition, 
within 1 year of the enactment of this bill and at least 
annually thereafter, VA would be required to submit a report to 
the Committee on Veterans' Affairs of the Senate and House of 
Representatives that includes the previous year's number of 
patients and percentage of VA patients who were prescribed 
opioids absent any pain or were prescribed benzodiazepines and 
opioids concurrently by VA providers. The report must also 
include the number and percentage of non-cancer, non-
palliative, and non-hospice care patients treated with opioids, 
both as an in-patient and by mail-order prescription or who 
received opioid prescriptions from VA and non-VA providers 
concurrently. In addition, VA must report, by medical facility, 
the number of times a pharmacist overrode a critical drug 
interaction involving opioids, the full results of the review 
and investigation referenced above, and an assessment of VA's 
compliance with the VA/DOD CPG for Management of Opioid Therapy 
for Chronic Pain. In general, the Committee intends for these 
reviewing, reporting, and investigating measures to reveal the 
opioid prescribing practices of VA providers, including 
compliance with the updated guidelines, deaths from opioids, 
prescribing rates, and concurrent use of opioids and 
benzodiazepines and to add a measure of accountability for VA's 
opioid use.
    Subsection (c) of section 425 of the Committee bill would 
define the term ``prescription rate'' as the number of patients 
treated with opioids divided by the total number of pharmacy 
users of a particular facility or provider, the average number 
of morphine equivalents per day prescribed for patients being 
treated with opioids, and the average number of opioid 
prescriptions per patient of the patients being treated with 
opioids at a particular facility by a particular provider.

                      SUBTITLE C--PATIENT ADVOCACY

Sec. 431. Establishment of Office of Patient Advocacy of the Department 
        of Veterans Affairs.

    Section 431 of the Committee bill, which is derived from 
S. 1641, would create an Office of Patient Advocacy that 
reports to the Under Secretary for Health to manage the 
responsibilities of patient advocates, and to ensure that the 
mission of the program is focused on advocating on behalf of 
patients. The Office of Patient Advocacy would ensure that 
patient advocates receive appropriate training in patient 
advocacy that is consistent throughout VA. In addition, VA 
would be required to submit an annual report to Congress on the 
activities of the Office of Patient Advocacy.
    Background. In 2010, when the Office of Patient Centered 
Care and Cultural Transformation (hereinafter, ``OPCC&CT'') was 
initially stood up, VA's Office of Patient Advocacy functions 
were moved to this office. As a result, VA does not currently 
have a stand-alone Office of Patient Advocacy. The Associate 
Director for Veteran Experience within VA coordinates a Patient 
Advocacy Program, which VA plans to update to ensure that the 
functions are clearly meeting the needs of veterans and 
prioritizing veteran experience with VA services.
    A number of veterans and veterans service organizations 
have noted that VA's patient advocates are often ineffective or 
experience barriers to effectively advocating for veterans due 
to a conflict of interest inherent in the current structure of 
the program. Specifically, the written testimony that the 
Veterans of Foreign Wars provided for the legislative hearing 
on June 24, 2015, raised concerns that patient advocates cannot 
effectively meet their obligations to veterans when their chain 
of command includes VA medical facility staff who are 
responsible for the actions and policies they are required to 
address. These concerns about a conflict of interest based on 
the organization of the program have been echoed by other 
stakeholders.
    Committee Bill. Subsection (a) of section 431 of the 
Committee bill would amend subchapter I of chapter 73 of title 
38, U.S.C., to establish an Office of Patient Advocacy 
(hereinafter, ``Office'') within the Office of the Under 
Secretary for Health. The bill would require the VA Secretary 
to appoint a Director of the Office of Patient Advocacy to lead 
the Office and report to the Under Secretary for Health.
    Creating a dedicated Office is central to achieving this 
goal. Establishing the Office within the Office of the Under 
Secretary for Health and having the Director report to the 
Under Secretary would signal the Committee's commitment to 
elevating the responsibility for patient advocacy to top 
leadership within VA. In addition, a dedicated office reporting 
to the Under Secretary for Health would ensure that the program 
remains accountable to the needs of veterans and their 
families, would help prevent any undue pressure on advocates 
from the local medical facility leadership and would help to 
ensure that patient advocates perform their duties with an 
emphasis on addressing the patients' concerns rather than 
protecting the medical facility's leadership.
    Further, this section would establish that the function of 
the Office is to carry out VA's Patient Advocacy Program. While 
VA is working to re-focus the Patient Advocacy Program on 
veteran experience, the Committee believes that this essential 
program needs to be strengthened and intends that the Patient 
Advocacy Program would guarantee that the veteran is at the 
center of patient advocacy efforts. This section would also 
delineate that patient advocacy responsibilities include: 
resolving complaints by veterans, presenting issues experienced 
by veterans to a variety of audiences, apprising veterans of 
their rights and responsibilities as patients in the VA system, 
tracking and compiling data on veteran complaints, establishing 
a process for sharing that data, identifying--at least 
quarterly--opportunities to improve health care services based 
on veteran complaints, elevating significant complaints to 
appropriate staff for further review, supporting any VA patient 
advocacy programs, ensuring that all appeals and final 
decisions regarding veteran health care issues handled through 
patient advocacy programs are tracked, understanding all 
relevant laws and directives related to veterans' rights in 
receiving health care, ensuring veterans receiving mental 
health care services are aware of their rights established 
under the Protection and Advocacy for Mentally Ill Individuals 
Act of 1986, fulfilling requirements for the inspection of 
controlled substances, and documenting and reporting any 
potentially threatening behavior to appropriate authorities. 
The Committee intends that establishing these responsibilities 
in statute would further advance the effort to keep the patient 
as the top priority in its advocacy efforts.
    In addition, this section would require the Director of the 
Office to provide training to patient advocates and ensure that 
the training is consistent throughout VA. The Committee intends 
that the Director establish a uniform means of training patient 
advocates to ensure that a consistent message and instruction 
would be conveyed across all VA locations. Lastly, the section 
would define the term ``controlled substance'' as having the 
same meaning as in section 802 of title 21, U.S.C. The 
Committee intends to ensure consistency in defining 
``controlled substance'' for the purpose of this bill.
    Subsection (b) of section 431 of the Committee bill would 
add ``7309B. Office of Patient Advocacy'' to the table of 
sections at the beginning of chapter 73 as amended by section 
424(b). Subsection (c) of section 431 of the Committee bill 
would direct VA to establish the Office referenced in section 
(a) and would ensure that it is fully operational by 1 year 
after enactment. The Committee intends to allow VA the 
necessary time to stand up the new Office, but also to ensure 
VA does so in a timely way so that veterans receive the benefit 
of the work of the Office quickly.

Sec. 432. Community meetings on improving care from Department of 
        Veterans Affairs.

    Section 432 of the Committee bill, which is derived from 
S. 1641, would require each medical facility to host public, 
community meetings on improving VA's health care services.
    Background. In October 2014, following a series of town 
hall meetings held at each VA medical facility and regional 
benefits office in August and September 2014, the VA Secretary 
directed all medical and benefits facilities to hold similar 
town hall meetings on a quarterly basis to improve 
communication with and to hear feedback directly from veterans 
across the country on their experiences with VA benefits and 
services. The Secretary noted that, at that time, VA was taking 
a hard look at all of its practices and functions in order to 
reorganize the Department around the needs of veterans. The 
Secretary emphasized that direct feedback from veterans, 
employees, and stakeholders was an important component of that 
reorganization, and key to improving VA's services and 
operations.
    Committee Bill. Section 432 of the Committee bill would, in 
a freestanding provision, outline requirements for community 
meetings. Subsection (a) of section 432 of the Committee bill 
would require each VA medical center to host a community 
meeting--open to the public--on improving VA health care. The 
Committee believes that formalizing these meetings would help 
to ensure that veterans, families, staff, and other 
stakeholders have a stronger voice as VA plans and implements 
its strategy for transforming the Department to make it more 
veteran-centric.
    The Committee bill would require that the first meeting 
take place not later than 90 days after enactment and that 
subsequent meetings take place at least every 90 days 
thereafter. In addition, this section would require Community 
Based Outpatient Clinics to hold, at least annually, publicly 
open community meetings on improving VA health care, the first 
of which to be convened no later than 1 year after the 
enactment of this bill.
    Subsection (b) of section 432 of the Committee bill would 
require the VISN Director to attend at least one community 
meeting per year at each medical center in the VISN. The VISN 
Director may send a designee to attend at least one community 
meeting per year at each of the Community Based Outpatient 
Clinics in the VISN. Subsection (c) of section 432 of the 
Committee bill would require each VA medical center and 
Community Based Outpatient Clinic to announce its schedule of 
community meetings to the Committee on Veterans' Affairs of the 
Senate and House of Representatives and to each member of 
Congress who represents the region where the meetings are being 
held.
    The Committee believes that this section of the bill is 
consistent with Secretary McDonald's earlier efforts to solicit 
feedback from veterans by hosting town hall meetings to hear 
the concerns of veterans, families, staff, and other 
stakeholders.\21\
---------------------------------------------------------------------------
    \21\VA Views for S. 1641, Testimony submitted before the Senate 
Veterans' Affairs Committee, ``Legislative Hearing'' on June 24, 2015.
---------------------------------------------------------------------------

Sec. 433. Improvement of awareness of patient advocacy program and 
        patient bill of rights of Department of Veterans Affairs.

    Section 433 of the Committee bill, which is derived from 
S. 1641, would require VA to prominently display information on 
the Patient Advocacy Program in each medical facility, 
including contact information for that facility's patient 
advocate. VA would also be required to display the VA patients' 
bill of rights in a well-traveled area of each medical 
facility.
    Background. VA currently posts information in medical 
facilities concerning the contact information for the patient 
advocate and the rights and responsibilities of patients and 
family members. This bill would require VA to also post the 
Patient Advocacy Program's purpose and to enhance the 
visibility of all of this information in medical facilities 
nationwide, thus giving it greater prominence and creating 
better visibility on this information for patients and family 
members who may need support from a patient advocate.
    Committee Bill. Section 433 of the Committee bill would, in 
a freestanding provision, require the VA Secretary to display, 
at each VA medical facility, the purpose of the Patient 
Advocacy Program with the contact information for the 
facility's patient advocate. It would also require the VA 
Secretary to post the rights and responsibilities of patients, 
residents, and family members at VA medical facilities, 
community living centers, and other VA residential facilities. 
The section would also require that this information be 
displayed within 90 days of the enactment of the Committee bill 
and would require that the VA Secretary ensure that it is 
displayed in prominent locations where the greatest possible 
number of patients and family members can see it.
    The Committee intends that VA place a high importance on 
disseminating this key information and that VA seek additional 
ways to improve awareness of the Patient Advocacy Program and 
the services it can provide to veterans and family members. The 
Committee further intends that the VA Secretary ensure that 
this critical information would be easily visible in as many 
locations in the facility as possible.

Sec. 434. Comptroller General report on Patient Advocacy Program of 
        Department of Veterans Affairs.

    Section 434 of the Committee bill, which is derived from 
S. 1641, would require GAO to conduct a study and issue 
recommendations to Congress on improving VA's Patient Advocacy 
Program as carried out and managed by the new Office of Patient 
Advocacy established by this bill.
    Background. The Patient Advocacy Program is for all 
veterans who receive care at VHA facilities and clinics and 
their families to have someone to go to with concerns about 
patient care. The Patient Advocacy Program establishes a 
Patient Advocate at every VA medical center. The VHA Patient 
Advocacy Program Handbook provides the requirements for the 
Patient Advocacy Program including what is required from the 
service-level advocates up to what is required at the facility 
and VISN level. The Handbook establishes minimum expectations 
for the Patient Advocacy Program including that patients must 
have easy access to someone who will hear their complaint, 
patients must have their complaints addressed in a timely 
manner, advocates must utilize the Patient Advocate Tracking 
System, and the Patient Advocacy Program must be integrated 
with the Facility Veteran Customer Service and Service Recovery 
Activities. The Handbook was last updated in 2005.
    Committee Bill. Subsection (a) of section 434 of the 
Committee bill would, in a freestanding provision, require GAO 
to deliver a report on VA's Patient Advocacy Program within 3 
years of the enactment of this bill. Subsection (b) of section 
434 of the Committee bill would establish that the elements to 
be included in the report are: recommendations for improving 
the program and any other information about the program as GAO 
deems appropriate. The bill would further provide options for 
additional elements that may be included in the report: a 
description of the Patient Advocacy Program, including its 
purpose and activities; the extent to which the program is 
achieving its purpose at the time of the review; an assessment 
of the staffing of the program; an assessment of the adequacy 
of training for program staff; and a review of veteran and 
family member awareness and use of the program.
    The Committee intends for the report to provide a general 
sense of the working of the program at the time of the review 
and an assessment of its general effectiveness. The Committee 
included several potential topics that might be included, but 
intends for GAO to have the flexibility to determine the key 
elements included in the report based on what their research 
and investigation of the program uncovers. The Committee 
intends that, in addition to providing critical information 
about the current state of the program, the review and 
culminating report would serve as a baseline for future 
evaluations of the patient advocacy services provided by VA.

            SUBTITLE D--COMPLEMENTARY AND INTEGRATIVE HEALTH

Sec. 441. Expansion of research and education on and delivery of 
        complementary and integrative health to veterans.

    Section 441 of the Committee bill, which is derived from 
S. 1641, would direct VA to develop a plan to expand research 
and education on and delivery of CIH to veterans.
    Background. In recent years, VA has worked to transform the 
traditional practice of medicine to one that is patient-
centered and optimizes overall health while minimizing risk of 
harm to the patient. The approach is focused on the overall 
well-being of individuals, rather than solely disease 
management. To better meet the goals of providing patient-
centered care to veterans, VA created the OPCC&CT. The OPCC&CT 
plays a role in identifying best practices for VA care, such as 
the movement toward patient-centered care or the utilization of 
CIH services and therapies. However, further research and 
education on, and the delivery and integration of, CIH into the 
health care services provided to veterans is necessary. VA 
needs to understand the comparative effectiveness of various 
CIH therapies as well as the various approaches for integrating 
such therapies into traditional health services. Finally, 
identifying barriers to receiving or providing CIH to veterans 
will allow VA to overcome such barriers and improve delivery of 
these therapies to veterans. A variety of terms are used to 
describe therapies such as acupuncture, massage therapy, and 
guided imagery. Particular organizations and individuals have 
strong preferences and rationales for the utilization of one 
particular terminology over another. For the purposes of this 
legislation, the utilization of the term ``complementary and 
integrative health services'' to describe these therapies 
should not be construed to interject a position of this 
Committee in this debate. Rather, this terminology is utilized 
to conform to the terminology currently utilized by NIH. NIH 
currently defines complementary and integrative health services 
as ``practices and products of non-mainstream origin'' and the 
practice of incorporating complementary approaches into 
mainstream health care.
    Committee Bill. Section 441 of the Committee bill would, in 
a freestanding provision, outline requirements for VA to 
develop a plan to expand research and education on CIH. 
Subsection (a) of section 441 of the Committee bill would 
require VA, within 6 months of the effective date of that 
section, to develop a detailed plan to expand research and 
education on and the delivery and integration of CIH services 
for veterans. Subsection (b) of this section would specify that 
the plan shall outline research on the comparative 
effectiveness of various CIH services and strategies to 
integrate CIH services into other health care services provided 
by the Department. Additionally, the plan would outline 
education and training of health care professionals in the 
Department on CIH services, the appropriate uses of those 
services, and how such services would be integrated into 
existing health care services for veterans. Furthermore, the 
plan would require centers of innovation at Department medical 
centers to carry out research, education, and clinical 
activities on CIH. Finally, the plan would outline an approach 
for the identification or development of metrics and outcome 
measures to evaluate the delivery of CIH services as well as an 
approach to integrate and deliver CIH services with other 
health care services provided by the Department.
    Subsection (c) of section 441 of the Committee bill would 
require VA, in creating the plan, to consult with the Director 
of the National Center on CIH of the NIH; the Commissioner of 
Food and Drugs; institutions of higher education, private 
research institutes, and individual researchers who have 
extensive experience in CIH; nationally recognized CIH 
providers; and other officials, entities, and individuals who 
have experience in CIH as VA deems appropriate. VA would 
consult with these parties in developing the plan; identify 
specific CIH services that are promising or supported by 
research for veterans; identify barriers to the effective 
implementation and integration of CIH services; and offer 
solutions to overcome such barriers. Subsection (d) of section 
441 of the Committee bill would define the term ``complementary 
and integrative health'' to have the meaning given that term by 
the NIH. As the Committee seeks to align VA's terminology used 
to describe CIH services, VA should follow any recommendations 
and actions by NIH and the Department of Health and Human 
Services to revise said terminology.

Sec. 442. Pilot program on integration of complementary and integrative 
        health within Department of Veterans Affairs medical centers.

    Section 442 of the Committee bill, which is derived from 
S. 1641, would require VA to carry out a 3-year program to 
assess the feasibility and advisability of integrating the 
delivery of CIH services with other health care services 
provided by the Department for veterans' mental health 
diagnoses, pain management, and chronic illness.
    Background. Currently, CIH is used in VA facilities 
primarily for the purpose of pain management. Additionally, 
according to VA/DOD Clinical Practice Guidelines for Management 
of post traumatic stress, CIH therapies may be more acceptable 
to patients ``reluctant to accept mental health labels or 
interventions'' and have ``the added benefit of increasing 
socialization'' because many of these therapies are practiced 
in a group setting. CIH is also used to help individuals manage 
stress and to promote general wellness. According to the April 
2011 edition of ``VA Research Currents,'' a 2011 study 
conducted by VA's Health Care Analysis and Information Group 
showed the use of CIH has grown substantially within VA over 
the last 10 years. VA's survey noted that, out of 125 VA 
facilities nationwide that responded, only 12 percent have an 
integrated medicine clinic where CIH is provided. Integration 
of CIH services within VA's Patient Aligned Care Teams 
(hereinafter, ``PACT'') is necessary to ensuring its 
utilization in collaboration with other primary care services. 
The integration of mental health services as part of PACT is 
vital for the improved utilization of these services and the 
reduction of stigma associated with their use. CIH services may 
also benefit from such integration.
    While CIH services are not currently available at every VA 
facility, there is interest in expanding access to such 
services for veterans. Of the remaining facilities that 
participated in the 2011 survey that did not provide CIH 
services at the time, half either indicated a desire to provide 
CIH or were in the process of establishing a program. CIH 
therapies provide an alternative to veterans who do not respond 
to more conventional therapies as well as for those interested 
in avoiding the use of prescription medications. Such therapies 
could also be used in conjunction with more conventional 
therapies to maximize veterans' health and well-being. 
Additionally, CIH therapies may be utilized in the treatment of 
seriously injured veterans--such as those receiving care at 
VA's polytrauma centers--as well as veterans receiving new, 
less acute diagnoses.
    Committee Bill. Section 442 of the Committee bill would, in 
a freestanding provision, outline requirements for the pilot 
program. Subsection (a) of section 442 would require VA to 
carry out a program, through the OPCC&CT, to assess the 
feasibility and advisability of integrating CIH services with 
other health care services provided by the Department. Under 
the program, CIH services would be provided to veterans with 
mental health, chronic pain, or other chronic conditions. This 
subsection would specify that, during the development of the 
program, potential barriers to the integration of CIH services 
into VA medical centers must be identified and resolved.
    Subsections (b) and (c) of section 442 of the Committee 
bill would require the program to be carried out during a 3-
year period at no fewer than 15 separate VA medical centers. 
Subsection (c) of section 442 of the Committee bill also would 
require that at least two VA medical centers designated by VA 
as polytrauma centers be included as program sites. The medical 
centers chosen must include locations in rural areas, areas 
that are not in close proximity to an active duty military 
installation, and different geographic locations. Furthermore, 
consideration of medical centers with prescription rates of 
opioids that are in conflict with or are inconsistent with the 
standards of appropriate and safe care would be given priority. 
Subsection (d) of section 442 of the Committee bill would 
require VA to, as part of the program, provide covered CIH 
services to covered veterans. Subsection (e) of section 442 of 
the Committee bill would specify that covered veterans shall 
include any veteran who has a mental health condition diagnosed 
by a VA clinician, experiences chronic pain, or has a chronic 
illness being treated in a VA facility. Additionally, veterans 
who do not meet any of the above criteria can request to 
participate or be referred by a VA clinician.
    Subsection (f) of section 442 of the Committee bill would 
define covered services as those CIH services selected by the 
VA Secretary. Under the program, those covered CIH services 
would be administered by clinicians hired by VA who, to the 
extent possible, solely provide such services. Covered services 
must be included in the PACT initiative of the Office of 
Patient Care Services, Primary Care Program Office in 
coordination with the OPCC&CT. Covered services would be 
available to veterans for the treatment of mental health 
disorders, chronic pain, or other chronic conditions who have 
or have not received traditional treatments from VA for such 
conditions. Subsection (g) of section 442 of the Committee bill 
would specify that, in order to participate in the program, 
veterans must voluntarily elect to participate in consultation 
with a VA clinician. Subsection (h) of this section would 
require VA to report to Congress not later than 3 years after 
commencing the pilot. The reports must include the findings, 
conclusions, and recommendations with respect to the 
utilization and efficacy of CIH centers established under the 
program, an assessment of the benefits of the program, and the 
comparative effectiveness of various CIH therapies, barriers 
identified, and recommendations for continuation or expansion.

                     SUBTITLE E--FAMILY CAREGIVERS

Sec. 451(a)(1). Expansion of family caregiver program of Department of 
        Veterans Affairs.

    Section 451(a)(1) of the Committee bill, which is derived 
from S. 1085, would expand eligibility for VA's Program of 
Comprehensive Assistance for Family Caregivers.
    Background. The Caregivers and Veterans Omnibus Health 
Services Act of 2010 was signed into law on May 5, 2010. It 
established the Program of General Caregiver Support Services 
and the Program of Comprehensive Assistance for Family 
Caregivers. The Program of Comprehensive Assistance for Family 
Caregivers (hereinafter, ``the Program'') provides additional 
support services to caregivers beyond what is provided through 
the Program of General Caregiver Support Services, including a 
monthly financial stipend, health care coverage through the 
Civilian Health and Medical Program of the Department of 
Veterans Affairs (hereinafter, ``CHAMPVA''), counseling and 
mental health services, respite care, and technical assistance. 
The Program is only available to veterans who have serious 
injuries (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 September 11, 2001.
    In September 2014, GAO released a report on the Program 
entitled ``Actions Needed to Address Higher-Than-Expected 
Demand for the Family Caregiver Program.'' The report noted, 
``Caregivers enable those for whom they are caring to live 
better quality lives and can contribute to faster 
rehabilitation and recovery.'' Supporting caregiving activities 
not only ensures equity of services and benefits available to 
the caregivers of our most seriously injured veterans, it may 
further enable veterans to remain at home rather than admitting 
them to a potentially more expensive institutional setting, 
such as a nursing home.
    Prior to the Program's implementation, VA initially 
estimated that 4,000 caregivers would be approved for the 
program; however, as of December 14, 2015, 22,616 caregivers 
had been approved. GAO's 2014 report on the Program made 
specific recommendations for improvement. Among its 
recommendations, GAO recommended that VA ``expedite the process 
for identifying and implementing an [information technology 
(hereinafter, ``IT'')] system that fully supports the program 
and will enable [the Veterans Health Administration] program 
officials to comprehensively monitor the program's workload, 
including data on the status of applications, appeals, home 
visits, and the use of other support services, such as respite 
care.'' GAO also recommended that the VA Secretary direct the 
Under Secretary for Health ``to use data from the IT system, 
once implemented, as well as other relevant data to formally 
reassess how key aspects of the program are structured and to 
identify and implement modifications as needed to ensure that 
the program is functioning as envisioned so that caregivers can 
receive the services they need in a timely manner.''
    Committee Bill. Section 451(a)(1) of the Committee bill 
would amend section 1720G of title 38, U.S.C., to require VA to 
expand eligibility for the Program to all eras of veterans in 
two phases. The first phase of expanded eligibility would begin 
during the 2-year period beginning on the date on which the VA 
Secretary submits to Congress a certification that VA has fully 
implemented an IT system to support the Program. Section 
451(a)(1)(B) of the Committee bill would require VA to submit 
the certification date in the Federal Register within 30 days 
to ensure public notification. The first phase includes 
veterans with a serious injury incurred or aggravated in the 
line of duty in the active military, naval, or air service on 
or before May 7, 1975. The second phase of eligibility would 
begin 2 years after the first phase. This includes those 
injured in the line of duty after May 7, 1975, and before 
September 11, 2001.
    The eligibility criteria created an inequity between post-
9/11 veterans and pre-9/11 veterans. However, VA has 
encountered numerous challenges in implementing the program, 
and it is clear improvements are needed to ensure the program 
is meeting the needs of those currently enrolled and can 
sustain an increase in eligible veterans.
    The Program's expansion in two phases, as required by this 
section, is intended to ensure the Program does not get 
overwhelmed and continues to operate as intended, providing 
services in a timely manner, while enrolling those who have 
become newly eligible. The publication of the VA Secretary's 
certification date in the Federal Register is intended to 
ensure veterans are notified of the Program's impending 
expansion.

Sec. 451(a)(2). Expansion of needed services in eligibility criteria.

    Section 451(a)(2) of the Committee bill, which is derived 
from S. 1085, would expand the Program's eligibility criteria 
for needed services.
    Background. Current law, section 1720G of title 38, U.S.C., 
provides that veterans eligible for the Program must be in need 
of personal care services because of an inability to perform 
one or more activities of daily living, a need for supervision 
or protection based on symptoms or residuals of neurological or 
other impairment or injury, or such other matters as the VA 
Secretary considers appropriate.
    Committee Bill. Section 451(a)(2) of the Committee bill 
would amend subsection (a)(2)(C) of section 1720G of title 38, 
U.S.C., to include a need for regular or extensive instruction 
or supervision without which the ability of the veteran to 
function in daily life would be seriously impaired among the 
criteria considered for needed personal care services. It is 
the intent of the Committee to ensure the Program is 
consistently inclusive of the caregiving needs required by 
mental health conditions, traumatic brain injuries or other 
conditions with which eligible veterans may be diagnosed.

Sec. 451(a)(3). Expansion of services provided.

    Section 451(a)(3) of the Committee bill, which is derived 
from S. 1085, would expand the services provided to caregivers 
under the Program of Comprehensive Assistance for Family 
Caregivers to include legal and financial planning services.
    Background. In 2014, the RAND Corporation released a 
report, ``Hidden Heroes: America's Military Caregivers,'' which 
examined characteristics of military caregivers and services 
available to them. The report indicates that, of the military 
caregiver-specific programs identified by RAND, few provide 
long-term planning assistance, including legal and financial 
planning, for military caregivers.
    Committee Bill. Section 451(a)(3) of the Committee bill 
would amend subsection (a)(3)(A)(ii) of section 1720G of title 
38, U.S.C., to require VA to include financial planning 
services and legal services related to the needs of injured 
veterans and their caregivers as among the services provided to 
caregivers. The section makes clear that VA should provide 
these services through the use of contracts with or the 
provision of grants to public or private entities.
    While section 451(a)(3) requires that financial planning 
and legal services be offered to caregivers in the Program, it 
is the Committee's intent that VA not provide these services 
themselves, but instead partner with public or private 
entities. It is also the Committee's intent that, to the 
maximum extent practicable, VA should utilize partnerships that 
will provide the services pro bono.

Sec. 451(a)(4). Modification of stipend calculation.

    Section 451(a)(4) of the Committee bill, which is derived 
from S. 1085, would expand the number of factors VA should 
consider when determining the amount and degree of personal 
care services provided for certain veterans.
    Background. Currently, there are three levels of caregiver 
stipends based on the amount and degree of personal care 
services provided. This was established pursuant to section 
1720G of title 38, U.S.C. According to current regulations, the 
stipend payment is based on the number of hours of caregiving 
required by the veteran. The maximum stipend is based on the 
requirement of 40 hours of caregiving each week, the median 
stipend is based on the requirement of 25 hours of caregiving 
each week, and the lowest stipend is based on the requirement 
of 10 hours of caregiving each week. In order to determine the 
degree of personal care services required by the veteran, VA 
evaluates the veteran and establishes a clinical rating based 
on specific criteria regarding the ability to perform 
activities of daily living and the need for supervision or 
protection based on symptoms or residuals of neurological or 
other impairment or injury.
    Committee Bill. Section 451(a)(4) of the Committee bill 
would amend subsection (a)(3)(C) of section 1720G of title 38, 
U.S.C., to ensure VA is considering the assessment by the 
family caregiver of the needs and limitations of the veteran; 
the extent to which the veteran can function safely and 
independently in the absence of such supervision, protection, 
or instruction; and the amount of time required for the family 
caregiver to provide such supervision, protection, or 
instruction to the veteran when determining the amount and 
degree of personal care services provided for a veteran whose 
need for personal care services is based on a need for 
supervision or protection or regular instruction or supervision 
under subsection (a)(2)(C) of section 1720G of title 38, U.S.C.
    The Committee understands that these determinations are 
made at the VA Medical Center level and the intent is to ensure 
consistency by VA in determining the amount of hours of 
caregiving required by the veteran.

Sec. 451(a)(5). Periodic evaluation of need for certain services.

    Section 451(a)(5) of the Committee bill, which is derived 
from S. 1085, would require VA to periodically evaluate the 
needs of the veteran and the skills of the family caregiver to 
determine if additional instruction, preparation, training, or 
technical support is needed.
    Background. Under section 1720G of title 38, U.S.C., VA is 
required to provide instruction, preparation, and training for 
family caregivers to provide care to veterans, in addition to 
ongoing technical support to address routine, emergency, and 
specialized caregiving needs of the family caregiver.
    Committee Bill. Section 451(a)(5) of the Committee bill 
would amend subsection (a)(3) of section 1720G of title 38, 
U.S.C., to require that, in providing instruction, preparation, 
and training under subparagraph (A)(i)(I) of that section and 
technical support under subparagraph (A)(i)(II) of that section 
to each approved family caregiver, the VA Secretary 
periodically evaluate the needs of the veteran and the skills 
of the family caregiver to determine if additional instruction, 
preparation, training, or technical support is necessary.
    The requirement for periodic evaluation of this support 
will ensure that caregivers have ongoing access to resources 
and support for their unique needs as they care for veterans, 
especially given that a veteran's needs may change over time as 
well as caregiving techniques and best practices.

Sec. 451(a)(6). Use of primary care teams.

    Section 451(a)(6) of the Committee bill, which is derived 
from S. 1085, would require the VA Secretary to collaborate 
with the veteran's primary care team when evaluating 
applications for the Program, to the extent practicable.
    Background. Under subsection (a)(5) of section 1720G of 
title 38, U.S.C., when reviewing applications submitted jointly 
by the veteran and family caregiver, VA is required to evaluate 
the veteran to identify the personal care services required and 
to determine whether the requirements could be significantly or 
substantially satisfied through personal care services from a 
family member. The determination for a veteran's approval for 
the Program is a clinical decision; however, there is no 
statutory requirement that VA include the veteran's primary 
care team in the evaluation.
    Committee Bill. Section 451(a)(6) of the Committee bill 
would amend subsection (a)(5) of section 1720G of title 38, 
U.S.C., to require that the VA Secretary evaluate each 
application submitted jointly by an eligible veteran and family 
member in collaboration with the veteran's primary care team to 
the maximum extent practicable.
    Though the veteran's primary care team maintains the 
veteran's treatment once in the Program, it is the intent of 
the Committee to ensure multidisciplinary input in the initial 
evaluation process, when possible.

Sec. 451(a)(7). Assistance for family caregivers.

    Section 451(a)(7) of the Committee bill, which is derived 
from S. 1085, would authorize VA, in providing caregiver 
services required under current law, to partner with Federal 
agencies, States, and private, non-profit, and other entities 
to provide the assistance.
    Background. There are numerous public and private entities 
that provide caregiver services. According to VA's fiscal year 
2013 annual report to Congress on assistance and support 
services for caregivers, among the services VA provides under 
the Program, it contracts with a non-profit organization to 
provide the family caregivers' core curriculum training and 
with respite care providers in communities.
    Committee Bill. Section 451(a)(7) of the Committee bill 
would amend subsection (a) of section 1720G of title 38, 
U.S.C., to authorize VA to enter into contracts, provider 
agreements, and memoranda of understanding with Federal 
agencies, States, and private, non-profit, and other entities 
to provide family caregiver services required by section 1720G 
of title 38, U.S.C. The VA Secretary may provide assistance 
under this authority only if it is reasonably accessible to the 
family caregiver and is substantially equivalent or better in 
quality to similar services provided by VA. In addition, the VA 
Secretary could provide fair compensation to entities that 
provide assistance under this authority.
    The Committee recognizes that other entities provide 
services the Program is required to provide, including respite 
care, and that VA in some cases is already partnering with 
these other entities to provide services. It is the Committee's 
intent that, if appropriate in order to provide the services 
and they are equivalent or better in quality to similar 
services provided by VA, VA continues to utilize its authority 
to partner with entities. This could ensure availability of 
services and could reduce any duplication.

Sec. 451(b). Modification of definition of personal care services.

    Section 451(b) of the Committee bill, which is derived from 
S. 1085, would modify the definition of personal care services.
    Background. Subsection (d)(4) of section 1720G of title 38, 
U.S.C., defines ``personal care services'' as services that 
provide the veteran assistance with one or more independent 
activities of daily living (subsection (d)(4)(A) of section 
1720G of title 38, U.S.C.) and any other non-institutional 
extended care (subsection (d)(4)(B) of section 1720G of title 
38, U.S.C.).
    Committee Bill. Section 451(b) of the Committee bill would 
strike ``independent'' in subsection (d)(4)(A) of section 1720G 
of title 38, U.S.C., and amend subsection (d)(4) to include 
supervision or protection based on symptoms or residuals of 
neurological or other impairment or injury and regular or 
extensive instruction or supervision without which the ability 
of the veteran to function in daily life would be seriously 
impaired.
    This section is consistent with changes made by sections 
451(a)(2) and 451(a)(4) of the Committee bill, which recognize 
the need for regular or extensive instruction or supervision 
within the definition of personal care services and ensure the 
consideration of these personal care needs when determining the 
caregiver stipend.

Sec. 452. Implementation of information technology system of Department 
        of Veterans Affairs to assess and improve the family caregiver 
        program.

    Section 452 of the Committee bill, which is derived from 
S. 1085, would require VA to implement a new IT system and 
conduct ongoing monitoring and modifications after the system 
is implemented.
    Background. The requirement that VA implement a new IT 
system that can easily retrieve data that will allow all 
aspects of the Program to be assessed and comprehensively 
monitored, that can manage data, and that has the ability to 
integrate with other relevant VHA IT systems, is consistent 
with recommendations made by GAO in its September 2014 report. 
The report indicated that the IT system currently utilized, the 
Caregiver Application Tracker, was developed quickly due to 
time constraints on implementing the Program. VA initially 
expected the Program to be much smaller, and the Caregiver 
Application Tracker was not designed to manage a high volume of 
information. As a result, VA is not able to effectively monitor 
and assess the Program.
    Committee Bill. Section 452 of the Committee bill would, in 
a freestanding provision, outline requirements for implementing 
an IT system. Section 452(a) of the Committee bill would 
require VA to implement an IT system that fully supports the 
Program and allows for data assessment and comprehensive 
monitoring of the Program not later than December 31, 2016. The 
IT system would also be required to include the ability to 
easily retrieve data that will allow for comprehensive 
monitoring of all aspects of the Program and workload trends, 
in addition to the ability to manage data with respect to a 
number of caregivers that is greater than the number of 
caregivers expected to apply for the Program, and the ability 
to integrate the system with other relevant Veterans Health 
Administration IT systems. These requirements are consistent 
with the GAO recommendations, and it is the Committee's 
understanding that the process for developing the new IT system 
to support the Program is already underway.
    Section 452(b) of the Committee bill would require VA to 
use the IT system to assess key aspects of the Program within 
180 days of implementation. Section 452(c) of the Committee 
bill would require VA to also use the IT system for ongoing 
monitoring and assessment, including data on the status of 
applications and the use by caregivers of support services such 
as respite care. In addition, VA would be required to identify 
and implement necessary modifications to ensure the Program is 
functioning as intended and providing veterans and caregivers 
with services in a timely manner. These requirements are also 
consistent with the recommendations made by GAO. In order for 
expansion of the Program to begin, the VA Secretary must 
certify to the Committee on Veterans' Affairs of the Senate and 
House of Representatives and the Comptroller General that the 
IT system has been implemented. Section 452(d)(3) of the 
Committee bill would require VA to submit the certification, 
along with a description of its implementation and utilization 
for program monitoring not later than December 31, 2017.
    Section 452(d)(1) of the Committee bill would require VA, 
within 90 days of enactment, to submit a report to the 
Committee on Veterans' Affairs of the Senate and House of 
Representatives and the Comptroller General, providing an 
update on the status of the planning, development, and 
deployment of the IT system. The section would also require 
that the report include an assessment of the needs of family 
caregivers and veterans who would be eligible for the Program, 
as expanded, as well as resources needed for their inclusion.
    The intent of this requirement is to ensure proper 
preparation for the expansion. The Committee expects to be kept 
up to date on the progress of the IT system implementation and 
deployment and be informed of any changes to the timeline. By 
including GAO as a recipient of the report, GAO will have the 
opportunity to review VA's progress in implementing its 
recommendations, as required by section 452(d)(2) of the 
Committee bill. While GAO's audit quality control processes 
require GAO to at least annually follow up on, track, and 
record the extent to which GAO's recommendations have been 
implemented, the Committee expects GAO to follow up on its 
recommendations for the Program more often than annually and 
periodically inform the Committees on VA's implementation 
status until VA has taken the appropriate corrective actions to 
address GAO's findings and recommendations. The Committee also 
directs the Comptroller General to notify the Committee on 
Veterans' Affairs of the Senate and the House of 
Representatives once it has verified that the recommended 
actions have been implemented and, to the extent possible, that 
the desired outcomes are being achieved, within 45 days of that 
determination.

Sec. 453. Modifications to annual evaluation report on caregiver 
        program of Department of Veterans Affairs.

    Section 453 of the Committee bill, which is derived from 
S. 1085, would amend requirements for VA's annual evaluation 
report on VA's caregiver programs.
    Background. Pursuant to the Caregivers and Veterans Omnibus 
Health Services Act of 2010 (section 1720G note of title 38, 
U.S.C.), VA submits an annual report to the Committee on 
Veterans' Affairs of the Senate and House of Representatives. 
Currently, VA is required to report on both the Program of 
Comprehensive Assistance for Family Caregivers and the Program 
of General Caregiver Support and include information regarding 
the number of caregivers receiving assistance, the cost to VA 
to provide such assistance, a description of outcomes achieved 
by the program, an assessment of their effectiveness and 
efficiency, and recommendations for legislative or 
administrative action. For the Program of Comprehensive 
Assistance for Family Caregivers, VA is also required to report 
on outreach activities carried out, in addition to an 
assessment of the manner in which resources are expended.
    Committee Bill. Section 453 of the Committee bill would 
amend subparagraph (A)(iv) of section 101(c)(2) of the 
Caregivers and Veterans Omnibus Health Services Act of 2010 to 
require that VA's annual evaluation report on the Program of 
Comprehensive Assistance for Family Caregivers and the Program 
of General Caregiver Support include a description of any 
barriers to accessing and receiving care and services. It would 
also amend subparagraph (B) of such section to require that the 
report on the Program of Comprehensive Assistance for Family 
Caregivers also include an evaluation of the sufficiency and 
consistency of the training provided to family caregivers. The 
additional information on barriers to care and services and the 
sufficiency and consistency of training will help further 
inform the Committee on the effectiveness of the Program and 
potential issues that may need to be addressed.

Sec. 454. Advisory committee on caregiver policy.

    Section 454 of the Committee bill, which is derived from 
S. 1085, would establish a VA advisory committee on caregiver 
policy.
    Background. VA has 25 advisory committees, including 15 
that were established by statute. Advisory committees provide 
VA with the opportunity to gain insight from experts and those 
impacted by programs and policies. The recommendations and 
reports from advisory committees can be a beneficial resource 
as VA develops new programs and policies and strengthens its 
current programs and policies.
    Committee Bill. Section 454 of the Committee bill, in a 
freestanding provision, would direct VA to establish an 
advisory committee on caregiver policy to regularly review and 
recommend veteran caregiver policies to VA, to examine and 
advise the implementation of the policies, to evaluate their 
effectiveness, to recommend standards of care for caregiver 
services and respite care services provided to veterans or 
caregivers by private entities, to develop recommendations for 
legislative or administrative action to enhance and eliminate 
gaps in the provision of services to caregivers and veterans, 
and to make recommendations on coordination with state and 
local agencies and relevant non-profit organizations on 
maximizing the use and effectiveness of resources for veteran 
caregivers. The advisory committee would be required to submit 
to VA and Congress annual reports on its assessments, 
recommendations, and evaluations. The advisory committee would 
be authorized through December 31, 2021.
    The intent of the advisory committee is to not only review 
and evaluate VA policies relating to caregivers of veterans, 
but also to identify gaps and duplication in services and 
opportunities for coordination with state and local agencies 
and relevant non-profit organizations. Federal and state 
agencies, in addition to other private entities, provide 
services to caregivers, and the Committee believes there is 
potential for increased coordination to reduce duplication and 
maximize opportunities. If legislation establishing a similar 
committee that may have duplicative responsibilities is enacted 
through separate legislation, the Committee recognizes that 
this specific committee may no longer be necessary.

Sec. 455. Comprehensive study on seriously injured veterans and their 
        caregivers.

    Section 455 of the Committee bill, which is derived from 
S. 1085, would require VA to provide for the conduct of a 
comprehensive study on veterans and caregivers by an 
independent entity.
    Background. VA conducts numerous studies, through 
collaboration with public and private entities, on health care 
related issues impacting veterans. While VA is currently 
engaged in research on such issues as traumatic brain injury, 
post traumatic stress disorder, and certain aspects of 
caregiving, it is not engaged in a comprehensive study on 
veterans and caregivers.
    Committee Bill. Section 455 of the Committee bill, in a 
freestanding provision, would require VA to partner with an 
independent entity through a grant or contract to conduct a 
comprehensive study on veterans who have incurred a serious 
injury or illness, including a mental health injury or illness, 
and individuals who are acting as caregivers for veterans. 
Section 455(d) of the Committee bill would require that the 
study would begin 4 years after the expansion of the Program, 
though specific requirements for veteran or caregiver 
participation in the Program in order to be included in the 
study are not specified and left up to the independent entity. 
Section 455(b) of the Committee bill would require the study to 
include the health of the veteran, and if applicable, the 
impact of the caregiver on the health of the veteran; the 
employment status of the veteran, and if applicable, the impact 
of the caregiver on the employment status of the veteran; the 
financial status and needs of the veteran; and the veteran's 
use of benefits available through VA. Section 455(e) of the 
Committee bill would require VA to submit a report on the 
results of the study to the Committee on Veterans' Affairs of 
the Senate and House of Representatives. Additional insight 
into the impact of caregivers on veterans' health and well-
being and the needs of caregivers and the veterans for whom 
they care will help inform VA and Congress on any improvements 
or modifications that could be made.

                   SUBTITLE F--HEALTH CARE AGREEMENTS

Sec. 461. Authorization of agreements between the Department of 
        Veterans Affairs and non-Department extended care providers.

    Section 461 of the Committee bill, which is derived from 
S. 2000, would add a new section 1703A to title 38, U.S.C., to 
provide that VA may enter into agreements to provide nursing 
home care and those agreements may be entered into without 
regard to any law that would require VA to use competitive 
procedures in selecting the party with which to enter into the 
agreement. Generally, a nursing home in carrying out that 
agreement would not be subject to any law that Medicare 
providers are not subject to.
    Background. Currently, if VA cannot provide extended care 
services to veterans at a VA nursing home or community living 
center, VA may contract to provide those services in the 
community. However, the contract VA would enter into with a 
community extended care provider would be required to be 
Federal Acquisition Regulation (hereinafter, ``FAR'') based 
agreements. FAR-based agreements require reporting of employee 
and applicant data and demographics that would be burdensome to 
extended care providers, and has served as a deterrent for 
extended care providers to care for veterans. As Fred Benjamin, 
Vice President and Chief Operating Officer of Medicalodges, 
Inc., testified before the Committee on June 3, 2015, ``[f]or 
our company, and many extended care providers, FAR-based 
agreements are simply not workable, and a streamlined approach 
that still protects Veterans, taxpayers, and preserves 
oversight is desperately needed.'' Medicare and Medicaid 
providers are not considered to be Federal contractors by 
regulations developed by the Department of Labor; however, if 
those same extended care providers care for a veteran they will 
be required to enter into a FAR-based agreement.
    Committee Bill. Section 461 of the Committee bill would 
authorize VA to enter into agreements that are exempt from 
certain provisions of law to provide extended care services to 
veterans.
    Section 461(a) of the Committee bill would create a new 
section 1703A in title 38, U.S.C., which would provide VA the 
authority to enter into provider agreements to provide extended 
care services to veterans. Section 1703A(a) of title 38, 
U.S.C., would allow VA to provide extended care services to 
veterans through the use of agreements if that care cannot be 
provided at a VA facility. Section 1703A(b) defines which 
veterans would be eligible for care under a Veterans Extended 
Care Agreement and directs that VA may not direct veterans to a 
particular provider. Section 1703A(c) would define the eligible 
providers to be participants of the United States Medicare and 
Medicaid programs or other providers the VA Secretary deems 
appropriate. Section 1703A(d) would require VA to promulgate 
regulations to establish a certification process for providers. 
Section 1703A(e) would establish the terms of the Veterans 
Extended Care Agreements to specify the rates VA would 
reimburse, ensure the return of medical records to VA, ensure 
that the provider does not attempt to collect compensation from 
a third party or health care plan for extended care services 
provided under the agreements, ensure that only care authorized 
by VA would be provided under the agreement, and would 
establish a methodology for providers to submit bills to VA. 
Section 1703A(f) would establish the circumstances under which 
an agreement could be terminated.
    Section 1703A(g) would direct VA to conduct periodic 
reviews of agreements over $1,000,000 annually to determine if 
the extended care services should be provided at VA, through a 
contract, or through a sharing agreement. Section 1703A(h) 
would exclude the Veterans Extended Care Agreements from any 
law that would require VA to use competitive contracting 
procedures; however, the providers would be required to follow 
certain laws relating to ethics, fraud, integrity, or those 
laws that subject a person to civil or criminal penalties as if 
they were incorporated in the agreements. The language in 
section 1703A(h) was overwhelmingly agreed upon on a bipartisan 
basis by members of the Committee as a result of an amendment 
offered in Committee and reflects a compromise suggested by a 
Democratic Senator.
    Section 1703A(i) would direct VA to establish a procedure 
to monitor the quality of care provided through the agreements. 
Section 1703A(j) would direct VA to establish procedures for 
providers to present disputes related to the agreements.
    Section 1703A(k) would provide that this section would 
sunset 2 years after enactment of the Jason Simcakoski Memorial 
Act.
    Section 461(b) of the Committee bill would direct VA to 
promulgate an interim final rule to carry out this section no 
later than 1 year after the date of enactment.
    Section 461(c) of the Committee bill would make a clerical 
change to add section 1703A to the table of contents for 
chapter 17 of title 38, U.S.C.
    It is the Committee's intent that a Veterans Extended Care 
Agreement will not be considered a ``contract'' or ``contract-
like instrument'' as those terms are defined in Executive Order 
13658 and its implementing regulations (29 C.F.R. Part 10). Any 
Veterans Extended Care Agreement will not be treated as a 
Federal contract or subcontract for the acquisition of goods or 
services and will not be subject to any provision of law 
governing Federal contracts or subcontracts for the acquisition 
of goods or services. This section intends to ensure veterans' 
access to high-quality extended care if that care is not 
available directly from VA while ensuring providers are subject 
to robust terms and conditions that address the quality of care 
for veterans, oversight of the provision of such care, and 
protections for taxpayers.

Sec. 462. Modification of authority to enter into agreements with State 
        homes to provide nursing home care.

    Section 462 of the Committee bill, which is derived from 
S. 2000, would amend section 1745 of title 38, U.S.C., to 
provide that VA may enter into agreements to provide nursing 
home care and those agreements may be entered into without 
regard to any law that would require VA to use competitive 
procedures in selecting the party with which to enter into the 
agreement. Generally, a State home in carrying out that 
agreement would not be subject to any law that Medicare 
providers are not subject to.
    Background. Currently, VA may enter into contracts or 
agreements with State Veterans Homes to provide extended care 
services to certain veterans; however, those contracts or 
agreements would need to be FAR-based contracts. FAR-based 
agreements require reporting of employee and applicant data and 
demographics that would be burdensome to State Veterans Homes. 
Medicare and Medicaid providers are not considered to be 
Federal contractors by regulations developed by the Department 
of Labor; however, a State Veterans Home agreement or contract 
with VA would be a FAR-based agreement.
    Committee Bill. Section 462 of the Committee bill would 
amend section 1745 of title 38, U.S.C., to modify how VA enters 
into agreements exempt from certain provisions of law with 
State Veterans Homes. Section 462(a) of the Committee bill 
would amend section 1745(a) of title 38, U.S.C., by replacing 
language to provide VA the authority to enter into agreements 
with State Veterans Homes. Section 462(b) of the Committee bill 
would further amend such section to exempt the agreements from 
any law that would require competitive contracting procedures. 
Section 462(c) of the Committee bill would direct that section 
1745, as amended, would apply to agreements entered into 30 
days after the date of enactment.
    It is the Committee's intent that an agreement made under 
this section will not be considered a ``contract'' or 
``contract-like instrument'' as those terms are defined in 
Executive Order 13658 and its implementing regulations (29 
C.F.R. Part 10). Any agreement entered into will not be treated 
as a Federal contract or subcontract for the acquisition of 
goods or services and will not be subject to any provision of 
law governing Federal contracts or subcontracts for the 
acquisition of goods or services. This section intends to 
ensure veterans' access to high-quality extended care services 
if that care is not available directly from VA while ensuring 
providers are subject to robust terms and conditions that 
address the quality of care for veterans, oversight of the 
provision of such care, and protections for taxpayers.

                         TITLE V--OTHER MATTERS

Sec. 501. Extension of temporary increase in number of judges on United 
        States Court of Appeals for Veterans Claims.

    Section 501 of the Committee bill, which is derived from 
S. 1754, continues the expansion of the United States Court of 
Appeals for Veterans Claims from seven to nine authorized 
judges through January 1, 2021.
    Background. The Veterans Court is a national court of 
record established under Article I of the Constitution that 
reviews appeals from decisions rendered by VA's Board of 
Veterans' Appeals. Under section 7253(a) of title 38, U.S.C., 
the Veterans Court was originally authorized to be composed of 
not more than seven judges. In 2001, the Veterans Court was 
temporarily expanded from seven to nine authorized judges for 
the period spanning January 2002 through August 2005 by Public 
Law 107-103. In 2008, the Veterans Court was again expanded 
from seven to nine authorized judges until January 2013 by 
Public Law 110-389. By December 2012, a full complement of nine 
judges had been confirmed by the U.S. Senate. Since then, two 
judges have retired, leaving the total number of confirmed 
judges at the time of the writing of this report at seven. 
Because the most recent temporary expansion of the court has 
expired, the eighth and ninth judges cannot be replaced. In 
recent years, the Board of Veterans' Appeals has increased the 
volume of decisions it is rendering annually, suggesting there 
may be a larger volume of incoming appeals ripe for Veterans 
Court review in the coming years.
    Committee Bill. Subsection (a) of section 501 of the 
Committee bill would amend section 7253 to expand the number of 
authorized judges at the Veterans Court to nine through January 
1, 2021. Subsection (b) of section 501 of the Committee bill 
would require the chief judge of the Veterans Court to report 
to Congress not later than June 30, 2020, on the temporary 
expansion, including an assessment on the effect of the 
expansion to ensure appeals are handled in a timely manner, a 
description of the types of ways in which the complexity levels 
of appeals may vary based on appellants' eras of service, and a 
recommendation on whether the number of judges should be 
adjusted at the end of the expansion time.
    It is the view of the Committee that allowing the temporary 
expansion of the court to continue until 2021 will help allow 
the Veterans Court to address the anticipated surge in incoming 
appeals. Because the workload of the Veterans Court has varied 
over the years based on a number of factors, the temporary 
expansion coupled with the reporting requirement will allow 
Congress to again assess the appropriate size of the court 
prior to the expiration of this expansion.

Sec. 502. Repeal inapplicability of modification of basic allowance for 
        housing to benefits under laws administered by Secretary of 
        Veterans Affairs.

    Section 502 of the Committee bill, which is an original 
provision, would repeal section 604(b) of Public Law 113-291 in 
order to realign the housing allowance provided to VA 
beneficiaries using Post-9/11 GI Bill benefits so it is paid at 
the same rate as the Basic Allowance for Housing provided to 
active duty military personnel in pay grade E-5 at the ``with 
dependents'' rate.
    Background. Section 604 of the Carl Levin and Howard P. 
``Buck'' McKeon National Defense Authorization Act for Fiscal 
Year 2015 (Public Law 113-291) allowed the Secretary of Defense 
to change how basic allowance for housing is computed under 
section 403 of title 37, U.S.C. Specifically, it authorized the 
Secretary of Defense to reduce the monthly allowance rate by 1 
percent of the average national housing costs for each pay 
grade and dependent status. This provision is similar to 
section 603 of the legislative proposals for fiscal year 2015 
that the Department of Defense transmitted to Congress.
    As part of the final language agreed to by the Senate and 
the House of Representatives, subsection 604(b) of Public Law 
113-291 specified that any authorized reductions to the monthly 
rate under section 403 of title 37, U.S.C., would not apply to 
benefits paid by the VA Secretary. Instead, that subsection 
specified that benefits paid by the VA Secretary would be paid 
according to section 403 of title 37, U.S.C., as that section 
was written prior to enactment of Public Law 113-291.
    Committee Bill. Section 502 of the Committee bill repeals 
section 604(b) of the Carl Levin and Howard P. ``Buck'' McKeon 
National Defense Authorization Act for Fiscal Year 2015 (Public 
Law 113-291), removing the exception of benefits paid by the 
Secretary of Veterans Affairs from the new calculation of basic 
allowance for housing under section 403 of title 37, U.S.C. The 
repeal of section 604(b) in the Carl Levin and Howard P. 
``Buck'' McKeon National Defense Authorization Act for Fiscal 
Year 2015 (Public Law 113-291) is made effective January 1, 
2016, with the intent that housing allowance rates for benefits 
under chapters 31 and 33 of title 38, U.S.C., will match those 
prescribed according to section 403 of title 37, U.S.C., when 
those rates are adjusted on August 1, 2016.

Sec. 503. Department of Veterans Affairs program of internal audits.

    Section 503 of the Committee bill, which is derived from 
S. 1641, would establish an independent and interdisciplinary 
office in the Office of the Secretary to regularly conduct 
internal audits to improve the delivery of benefits and health 
care to veterans and their families.
    Background. In fiscal year 2016, Congress provided VA $71.2 
billion in discretionary funding, which is in addition to the 
$94.5 billion in the Department's mandatory accounts. This 
funding is vitally important for providing health care and 
benefits to our nation's veterans. However, the Department does 
not currently undertake a regular, formal audit process to 
determine whether its funds are being used for the maximum 
benefit of veterans and their families, despite the fact that 
VHA is the largest integrated health system in the country. 
Many of the nation's largest health systems, such as Emory 
Health care, have an established internal audit process to 
identify and evaluate risks to the system as well as to drive 
efforts at improving the system and protecting institutional 
resources. The ability to conduct internal audits allows large 
health care systems to monitor systemic adherence to policies 
and procedures and to address any pressing concerns within the 
organization.
    In January 2015, GAO added VHA to the GAO High Risk List, a 
designation that GAO assigns to government operations and 
programs it has identified as high risk due to vulnerability to 
fraud, waste, abuse, and mismanagement or the need to transform 
in order to address economic, efficiency, or effectiveness 
challenges. GAO concluded it was necessary to place VA on this 
list because of ambiguous policies and inconsistent processes, 
inadequate oversight and accountability, information technology 
challenges, inadequate training for staff, and unclear resource 
needs and allocation priorities within VHA. If VA is to comply 
with the recommendations GAO made in order to be removed from 
the High Risk List, then it will need to prove a sustained 
ability to allocate resources appropriately in areas of the 
highest need and to consistently implement policies across the 
health care system. In order to understand where resources are 
most needed, VA must have a better understanding of where the 
biggest problems are and an ability to determine how to address 
those problems. The ability to self-assess issues through an 
internal review process would assist VA in addressing any new 
issues before they rise to the level of threatening VA's 
ability to deliver health care or benefits.
    Section 201 of the Veterans Access, Choice, and 
Accountability Act of 2014 (Public Law 113-146) required the 
commissioning of an Independent Assessment of the Health Care 
Delivery Systems and Management Processes of the Department of 
Veterans Affairs (hereinafter, ``Independent Assessment''). The 
Independent Assessment was reported to the Committee on 
September 1, 2015, and cost approximately $68 million to 
complete. This assessment provided an important review of VHA 
programs, including those that the Committee has held hearings 
on during the past year, such as construction, the non-VA care 
program, and the addition of VA to GAO's High Risk List. One of 
the key findings from the Independent Assessment was the need 
to take a systemic approach to addressing the challenges at VA 
that were identified in the Independent Assessment.
    Enhanced internal assessment is an important tool for 
identifying opportunities early--before material weaknesses 
develop--for improvement of conditions within the Department 
that can result in financial loss or can affect care. On 
January 12, 2016, an OIG Audit of Non-VA Medical Care 
Obligations found VA facilities returned $1.9 billion to the 
Department of Treasury in fiscal year 2013 because the 
facilities did not manage their obligations appropriately. OIG 
found a reduction in the over-obligation of Non-VA Care funds 
from approximately 29 percent to 10 percent would have allowed 
an increase in approximately $358 million in direct Non-VA Care 
services to veterans. A September 28, 2015, OIG Administrative 
Investigation revealed Senior Executive Service employees were 
utilizing the relocation program and employee incentives in the 
Veterans Benefits Administration, including spending $1.8 
million for 23 reassignments from fiscal year 2013 to fiscal 
year 2015. The OIG identified an inadequate approval process 
and a lack of standardization regarding practices regarding 
annual salary increases as contributing factors to this 
excessive spending by VA. The findings in these two reports 
illustrate systematic failures within VA that might have been 
prevented before costing the agency millions of dollars in lost 
or inappropriately used resources. A more robust internal 
auditing system could uncover problems at an early stage and 
serve as an alert that intervention is needed in order to 
preserve resources and avoid fraud, waste, and abuse.
    In addition to the work done at GAO and OIG, the Committee 
plays a vital role in the ongoing oversight of VA. VA's lack of 
a consistent process and protocol regarding internal auditing 
and self-assessment impacts many of the topics the Committee's 
work covers. In fact in 2015, Committee oversight addressed 
several budget shortfalls, including cost overruns associated 
with building a new medical center in Denver and the poor 
financial forecasting that led to a $3.2 billion gap in VHA's 
non-VA care budget.
    Despite the success of the above-mentioned audits, 
investigations and Congressional inquiries, these alone cannot 
achieve the type of insight into risks, effectiveness, and 
planning that is necessary to ensure the Department's smooth 
provision of benefits and health care to veterans and their 
families. In order to demonstrate the Department's ability to 
consistently manage the funding that is provided to it for the 
care and benefits of veterans and their families, the Committee 
believes the VA Secretary must engage in regular, independent 
review across the Department's offices to better monitor the 
delivery of health care and benefits to veterans and their 
families.
    Committee Bill. Subsection (a) of section 503 of the 
Committee bill would establish a program of internal audits and 
self-analysis at VA. The Committee believes this program will 
improve the delivery of benefits and health care to veterans 
and their families. The newly-established program would be an 
independent, interdisciplinary office within the Office of the 
Secretary tasked with conducting periodic risk assessments. 
These risk assessments would then be utilized to develop a plan 
to conduct internal audits.
    The VA Secretary would be required to audit no fewer than 
five covered administrations or their functions, staff 
organizations, or staff offices each year. In determining which 
risk assessments to undertake, the VA Secretary would be 
required to prioritize administrations, such as VHA or the 
Veterans Benefits Administration and their functions, such as 
mental health and compensation and pension. Audits of staff 
organizations, including the Office of Acquisition, Logistics, 
and Construction, the Board of Veterans' Appeals, and the 
Office of Regulation Policy and Management, and staff offices, 
including the Office of the Assistant Secretary for 
Congressional and Legislative Affairs, the Office of the 
Assistant Secretary for Information and Technology, and the 
Office of Management would also be authorized.
    Subsection (b) of section 503 of the Committee bill would 
require the VA Secretary to complete the first required risk 
assessment within 180 days of enactment. When the VA Secretary 
completes an audit under the program, the VA Secretary would be 
required to submit a report on the audit to the Senate and 
House Committees on Veterans' Affairs, the Senate and House 
Committees on Appropriations, the Senate Committee on Homeland 
Security and Governmental Affairs, and the House Committee on 
Oversight and Government Reform within 90 days of completion of 
the audit. The submitted report would include a summary of the 
audit, the findings in the report, the recommendations for 
legislative or administrative action to improve the furnishing 
of benefits and health care to veterans and their families and 
the plans, including timelines, to carry out the 
recommendations that the VA Secretary can complete without 
legislative action.
    Finally, the VA Secretary would be required to submit to 
the Senate and House Committees on Veterans' Affairs, the 
Senate and House Committees on Appropriations, the Senate 
Committee on Homeland Security and Governmental Affairs, and 
the House Committee on Oversight and Government Reform by 
September 1 of each year a plan for risk assessments and audits 
to be conducted in the next fiscal year.

Sec. 504. Improvement of training for managers.

    Section 504 of the Committee bill, which is derived from 
S. 1856, would require VA to provide periodic training to its 
managers.
    Background. On June 24, 2015, the Committee held a 
legislative hearing to consider certain benefits and health 
care legislation pending before the Committee. The Partnership 
for Public Service (hereinafter, ``Partnership'')--a 
nonpartisan, non-profit organization dedicated to revitalizing 
the Federal civil service and transforming the way government 
works--testified at the hearing. In its testimony, the 
Partnership mentioned that ``the biggest contributor to the 
performance problems at the VA is the quality of the 
management, rather than the quality of the system.''\22\ The 
Partnership also mentioned that ``the process for removing or 
disciplining a Federal employee is daunting in terms of the 
time and effort required, and this discourages some managers 
from taking appropriate action.''\23\ According to the 
Partnership, often managers are not trained in handling 
disciplinary actions and administrative support to take 
action.\24\ The importance of training was also stressed during 
the Committee's legislative hearing on September 16, 2015, by 
Donald F. Kettl, a professor at the School of Public Policy at 
the University of Maryland. In his testimony in support of 
S. 1856, Professor Kettl discussed how S. 1856 would 
significantly advance the nation's efforts to care for its 
veterans for it places training at the center of the 
Department's career development network.\25\ In his testimony, 
Professor Kettl mentioned that training is the most essential 
component, for the Committee is not only trying to solve the 
serious problems that plague the Department today, but the 
Committee is also building the foundation on which its future 
service to veterans depends. According to Professor Kettl, 
``[t]he only effective way to avoid future crises is to build--
now--the capacity the Department will need tomorrow.''\26\ To 
bring greater accountability to the Department, and to build 
the capacity the Department will need in the future, the 
Department must invest in providing regular training to its 
managers.
---------------------------------------------------------------------------
    \22\Testimony of Max Stier, President and CEO of the Partnership 
for Public Service, during a hearing entitled, ``Pending Health and 
Benefits Legislation,'' before the Senate Committee on Veterans' 
Affairs, June 24, 2015, available at http://www.veterans.senate.gov/
imo/media/doc/PPS%20Stier%20Testimony%206.24.15.pdf.
    \23\Id.
    \24\Id.
    \25\Testimony of Donald F. Kettl, Professor, School of Public 
Policy University of Maryland, during a hearing entitled, ``Pending 
Health and Benefits Legislation,'' before the Senate Committee on 
Veterans' Affairs, September 16, 2015, available at http://
www.veterans.senate.gov/imo/media/doc/
D%20Kettl%20Testimony%2009.16.2015.pdf.
    \26\Id.
---------------------------------------------------------------------------
    Committee Bill. Section 504 would require VA to provide 
each employee who is in a managerial position with periodic 
training on the following: (1) the rights of whistleblowers and 
how to address a report by an employee of a hostile work 
environment, reprisal, or harassment; (2) how to effectively 
motivate, manage, and reward the employees who report to the 
manager; and (3) how to effectively manage employees who are 
performing at an unacceptable level and access assistance from 
the VA Office of Human Resources Management and the Office of 
General Counsel with respect to those employees.

                      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, decrease direct 
spending by $4.1 billion over 10 years and increase 
discretionary spending by $3.5 billion over 5 years. 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, September 9, 2016.
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 S. 425, the Veterans 
Homeless Programs, Caregiver Services, and Other Improvements 
Act of 2015.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann Futrell.
            Sincerely,
                                                Keith Hall,
                                                          Director.

  Enclosure.

S. 425--Veterans Homeless Programs, Caregiver Services, and Other 
        Improvements Act of 2015

    Summary: Enacting S. 425 would reduce benefits provided 
under certain education programs administered by the Department 
of Veterans Affairs (VA) while expanding eligibility under 
those programs for some beneficiaries. The bill also would 
increase the amount of the pension paid to Medal of Honor 
recipients. On net, those changes would decrease direct 
spending by $4.1 billion over the 2017-2026 period.
    In addition, S. 425 would make a number of changes to VA's 
health care programs, including expanding the caregivers 
program, improving benefits for homeless veterans, and 
increasing pay for medical staff. In total, CBO estimates that 
implementing those provisions would cost $3.5 billion over the 
2017-2021 period, subject to appropriation of the necessary 
amounts.
    Pay-as-you-go procedures apply because enacting the 
legislation would affect direct spending. Enacting the bill 
would not affect revenues. CBO estimates that enacting S. 425 
would not increase net direct spending or on-budget deficits in 
any of the four consecutive 10-year periods beginning in 2027.
    S. 425 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would benefit public entities, including educational 
institutions and health care providers, that provide services 
to veterans. Any costs those entities might incur would be 
incurred as conditions of participating in a voluntary federal 
program.
    Estimated cost to the Federal Government: The estimated 
budgetary effect of S. 425 is shown in Table 1. The costs of 
this legislation fall within budget function 700 (veterans 
benefits and services).

  Table 1.--Estimated Budgetary Effects of S.425, The Veterans Homeless Programs, Caregiver Services, and Other
                                            Improvements Act of 2015
----------------------------------------------------------------------------------------------------------------
                                                                By fiscal year, in millions of dollars--
                                                       ---------------------------------------------------------
                                                          2017     2018     2019     2020      2021    2017-2021
----------------------------------------------------------------------------------------------------------------
                                          DECREASES IN DIRECT SPENDINGa
 
Estimated Budget Authority............................    -13     -151     -300      -426      -453      -1,345
Estimated Outlays.....................................    -13     -151     -300      -426      -453      -1,345
 
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION
 
Estimated Authorization Level.........................     40      162      518     1,105     1,902       3,728
Estimated Outlays.....................................     33      143      482     1,040     1,808       3,507
----------------------------------------------------------------------------------------------------------------
Note: Details do not add to totals because of rounding.
aEnacting S.425 would have effects beyond 2020. CBO estimates that under the bill, direct spending would
  decrease by $4.1 billion over the 2017-2026 period.

    Basis of estimate: For this estimate, CBO assumes that 
S. 425 will be enacted at the start of fiscal 2017, that the 
estimated amounts will be appropriated each year, and that 
outlays will follow historical spending patterns for affected 
programs.

Direct spending

    S. 425 would reduce the amounts paid for certain education 
and rehabilitation benefits provided by VA and expand 
eligibility for those programs. It also would increase the 
amount of the pension the department pays to Medal of Honor 
recipients. On net, those changes would decrease direct 
spending by $4.1 billion over the 2017-2026 period (see Table 
2).
    Reduced Housing Allowances. Under the Post-9/11 GI Bill 
(Chapter 33), VA provides monthly housing allowances to certain 
beneficiaries while they are in school. Those allowances are 
set at the amount of the housing allowance paid by the 
Department of Defense (DOD) to enlisted servicemembers with 
dependents and a rank of E-5. Additionally, VA provides some 
disabled veterans enrolled in education and training for 
rehabilitation with a monthly stipend at that same rate. 
Section 502 would reduce those payments.

                                              Table 2.--Estimate of the Effects of S.425 on Direct Spending
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                        By fiscal year, in millions of dollars--
                                                              ------------------------------------------------------------------------------------------
                                                               2017   2018   2019   2020   2021   2022   2023   2024   2025   2016  2017-2021  2017-2026
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               CHANGES IN DIRECT SPENDING
Reduced Housing Allowances
  Estimated Budget Authority.................................    -8   -137   -269   -373   -387   -408   -429   -450   -468   -481    -1,174     -3,410
  Estimated Outlays..........................................    -8   -137   -269   -373   -387   -408   -429   -450   -468   -481    -1,174     -3,410
Transferred Education Benefits
  Estimated Budget Authority.................................   -10    -24    -42    -64    -80    -91   -102   -117   -131   -151      -220       -812
  Estimated Outlays..........................................   -10    -24    -42    -64    -80    -91   -102   -117   -131   -151      -220       -812
Restoration of Education Benefits
  Estimated Budget Authority.................................     3      3      4      4      5      5      5      5      6      6        19         46
  Estimated Outlays..........................................     3      3      4      4      5      5      5      5      6      6        19         46
Credit for Time in Medical Care
  Estimated Budget Authority.................................     0      3      3      3      4      4      4      4      4      5        13         34
  Estimated Outlays..........................................     0      3      3      3      4      4      4      4      4      5        13         34
Fry Scholarships
  Estimated Budget Authority.................................     2      2      2      2      3      3      3      3      3      3        11         26
  Estimated Outlays..........................................     2      2      2      2      3      3      3      3      3      3        11         26
Medal of Honor Pensions
  Estimated Budget Authority.................................     0      2      2      2      2      2      2      1      1      1         6         14
  Estimated Outlays..........................................     0      2      2      2      2      2      2      1      1      1         6         14
                                                              ------------------------------------------------------------------------------------------
  Total Changes in Direct Spending
    Estimated Budget Authority...............................   -13   -151   -300   -426   -453   -485   -517   -554   -585   -617    -1,345     -4,102
    Estimated Outlays........................................   -13   -151   -300   -426   -453   -485   -517   -554   -585   -617    -1,345     -4,102
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Details do not add to totals because of rounding.

    The Department of Defense sets its housing allowances on 
the basis of average housing costs for each locality. The 
Congress, in the National Defense Authorization Act for Fiscal 
Year 2016 (Public Law 114-92), authorized the department to 
reduce those allowances by up to 5 percent below the average. 
DOD has cut that allowance by 2 percentage points to 98 percent 
of the average for 2016. CBO expects that DOD will phase in the 
rest of the reduction by 1 percentage point a year through 
2019. Under current law, VA's housing allowances are exempt 
from those reductions. Section 502 would strike VA's exemption, 
resulting in a decrease in the allowances provided by VA.
    Based on current enrollment data, CBO estimates that about 
800,000 people will use Chapter 33 benefits in 2017, and that 
the housing allowance per beneficiary will average about $7,800 
in that year. (Many beneficiaries are not eligible to receive a 
housing allowance from VA, and most of those who do only 
receive the allowance during the 9-month academic year; thus, 
the average payment is significantly less than the 
approximately $19,500 in housing allowance that an E-5 with 
dependents would receive in 2017.) On that basis, and 
accounting for growth in the eligible population and 
incorporating annual inflation, CBO estimates that enacting 
section 502 would reduce direct spending for Chapter 33 
benefits by about $3.2 billion over the 2017-2026 period.
    About 27,000 disabled veterans enrolled in college, 
apprenticeship programs, or on-the-job training through VA's 
rehabilitation services receive the same housing stipend as 
that provided to Chapter 33 beneficiaries. Those stipends would 
be similarly affected by section 502. CBO estimates that 
cutting the stipends as described above would reduce direct 
spending for rehabilitative benefits by about $170 million over 
the 2017-2026 period.
    In total, enacting section 502 would reduce direct spending 
by $3.4 billion over the 2017-2026 period.
    Transferred Education Benefits. Servicemembers who earn 
benefits under the Post-9/11 GI Bill can use those benefits 
themselves or transfer them to their dependents. Section 202 
would modify the authorities under which servicemembers may 
make such transfers. On net, those changes would reduce direct 
spending by about $800 million over the 2017-2026 period, CBO 
estimates.
    Housing Allowance. Section 202 would reduce by half the 
monthly housing allowance paid to children who use transferred 
benefits. That reduction would apply to benefits that are 
transferred to children180 days or more after the bill is 
enacted. Based on current payment levels and adjusting for the 
effect of section 502 as discussed above and for expected 
inflation, CBO estimates that the annual payment for the 
housing allowance under the Post-9/11 GI Bill will average 
about $7,600 in 2017 and $8,500 over the 2017-2026 period. 
(That annual payment may represent an academic years' worth of 
benefits for one student or portions of an academic year for 
two or more students.)
    Based on data from DOD, CBO estimates that about 38,000 
servicemembers will transfer their education benefits to their 
children each year. Less than 10 percent of children who 
receive transferred benefits will be college-aged at the time 
of the transfer and only half will reach college age during the 
subsequent 10-year period. Thus, the reduction in the housing 
allowance would affect a small number of annual payments 
initially--about 1,700 in 2017. The number of reduced payments 
would increase over time to about 40,000 annual payments in 
2026. CBO estimates that the number of annual payments that 
would be cut in half under section 202 would total roughly 
210,000 over the 2017-2026 period, reducing direct spending by 
$940 million.
    Conditions for Transferring Benefits. Section 202 also 
would change the terms under which servicemembers may transfer 
Chapter 33 benefits to their spouses and children. Under 
current law, members must serve at least 6 years and agree to 
serve another 4 years to be eligible to transfer their 
benefits. Spouses are able to begin using those transferred 
benefits immediately, while children must wait until the member 
has completed 10 years of service. Under section 202, members 
would have to serve at least 10 years, and agree to serve an 
additional 2 years in order to transfer benefits. Spouses and 
children could begin using benefits as soon as they are 
transferred by the member.
    CBO expects that those changes would cause some 
servicemembers who, under current law, would choose to transfer 
benefits, to instead leave the military and use their benefits 
themselves. Because servicemembers would have to wait four more 
years before committing to additional military service, they 
would have more opportunities to leave the armed forces. Also, 
spouses would have to wait an additional 4 years to use 
transferred benefits, somewhat reducing their value to the 
spouse. Finally, the length of service required from the member 
would increase from 10 years to 12 years.
    Based on the rate at which personnel leave the military 
between their 6th and 10th years of service, CBO estimates that 
each year about 1,800 members who would have committed to 
additional service in order to transfer benefits under current 
law would, under this provision, leave the military and retain 
those benefits for their own use. That change would have 
several offsetting effects that would, on net, increase direct 
spending by $125 million over the 2017-2026 period, CBO 
estimates. Those effects include:

     Increased costs of $520 million for an additional 
17,000 servicemembers who would separate and use additional 
benefits;
     Increased costs of $40 million for the roughly 
1,400 additional recruits who would replace some of those 
separating servicemembers and then later separate and use 
education benefits near the end of the budget window;
     Decreased costs of $245 million because spouses 
who do receive transferred benefits would have to wait an 
additional 4 years to use them, reducing the total number of 
spouses who attend school over the next 10 years by about 
5,500;
     Decreased costs of $90 million because about 3,700 
fewer spouses would receive transferred benefits; and
     Decreased costs of $100 million because about 
14,000 fewer children would receive transferred benefits, about 
1,700 of whom would have reached college age during the next 10 
years.

    Restoration of Education Benefits. Section 201 would 
increase the education benefits that VA provides under the 
Post-9/11 GI Bill by restoring some of those benefits to 
students who attend institutions that permanently close during 
an academic term.
    Under current law, VA pays educational institutions at the 
start of the academic term for beneficiaries' tuition and fees. 
It then reduces the months of education benefits available to 
those students by the duration of that term. If a school 
permanently closes during the term, students will have been 
charged for use of the benefit, but may not have received 
academic credit. Additionally, VA discontinues payment of the 
monthly housing allowance to students at the time the school 
closes. Military personnel earn 36 months of Chapter 33 
benefits if they serve on active duty after September 11, 2001; 
however, beneficiaries may have fewer than 36 months available 
if servicemembers transfer a portion of the benefit to 
dependents or use education benefits under a different VA 
education program. The bill would direct VA to restore lost 
months of education benefits to students who do not receive 
credit for a term as a result of school closures occurring in 
2015 or thereafter.
    Restoring benefit months would increase VA's payments only 
for those students who would otherwise use every month of 
education benefit currently available to them. In addition, 
those new costs would not begin to accrue for a beneficiary 
until that individual had used each month of eligibility 
available to them under current law and continued on to use 
months newly available under this provision. Thus, CBO expects 
that additional costs resulting from closures in a particular 
year would occur over several subsequent years.
    On the basis of data from VA regarding usage rates for its 
education programs, CBO expects that roughly 900 students using 
the Post-9/11 GI Bill will be affected by school closures each 
year and that about half of those beneficiaries will use every 
month of education benefit available to them under the current 
program. Thus, CBO estimates that under section 201, about 450 
beneficiaries a year would receive about 5 months of restored 
eligibility that they would use over the succeeding years. CBO 
further estimates that the average cost of that additional 
usage would be $6,300 in 2017 and would increase with inflation 
in subsequent years. On that basis, restoring benefits under 
section 201 would increase direct spending by $28 million over 
the budget window, CBO estimates.
    Section 201 also would require VA to continue to pay the 
monthly housing allowance to beneficiaries affected by school 
closures for the lesser of 4 months or the remainder of the 
cancelled term. Under that requirement, CBO estimates that 900 
students a year would receive an average of three additional 
months of housing allowance at a cost of $1,900 per person in 
2017. After incorporating annual inflation, those additional 
payments would increase direct spending by a total of $18 
million over the 2017-2026 period, CBO estimates.
    In total, enacting section 201 would increase direct 
spending by $46 million over the 2017-2026 period.
    Credit for Time in Medical Care. Section 210 would allow 
the time a reservist serves on active duty while receiving 
medical care or undergoing a medical evaluation to count as 
qualifying service for accruing education benefits under the 
Post-9/11 GI Bill. To qualify for full benefits under Chapter 
33, veterans must serve 36 months on active duty or receive a 
disability retirement. Reduced benefits, between 40 percent and 
90 percent of the full benefit, are available to veterans who 
serve less than 36 months but at least 90 days.
    On the basis of historical data from the Department of 
Defense regarding activations for medical evaluations or care, 
CBO estimates that about 1,000 reservists will be called to 
active duty for those reasons annually, and spend an average of 
7 months in that status. That additional qualifying service 
would increase benefit payments for those reservists who would 
not qualify for full Chapter 33 benefits under current law. 
That change would apply to benefits used after 2017. On the 
basis of average benefits, CBO estimates that those reservists 
who would receive an additional $2,600 in benefits in 2018. 
That amount would increase annually to reflect the increased 
cost of higher education.
    Based on personnel data from DOD, CBO estimates that under 
section 210, about 25 percent of the reservists who are 
activated for medical care would receive and use additional 
benefits as a result of that service. Because beneficiaries 
typically attend school over several years, approximately 1,000 
people would receive a larger benefit each year. In total, the 
additional payments from VA for those benefits would increase 
direct spending by $34 million over the 2017-2026 period, CBO 
estimates.
    Fry Scholarships. The Marine Gunnery Sergeant John David 
Fry Scholarship provides 36 months of education benefits under 
the Post-9/11 GI Bill to spouses and children of servicemembers 
who died on active duty at any time after September 11, 2001. 
Section 209 would allow recipients of the Fry scholarship to 
receive additional benefits under the Yellow Ribbon GI 
Education Enhancement Program (YRP). As part of the Post-9/11 
GI Bill, that program provides additional payments for some 
students--such as those at certain private schools and out-of-
state students attending public schools--who face tuition and 
fees above what VA will typically cover. Institutions 
participating in the YRP agree to cover a portion of the 
difference between the tuition charged and the amount that VA 
would otherwise pay. VA then matches that financial assistance, 
thereby reducing or eliminating students' out-of-pocket 
expenses.
    In 2014, VA made payments averaging $5,700 for 4 percent of 
the students who were eligible for the Yellow Ribbon Program. 
About 5,600 people with Fry Scholarships will attend school 
each year, CBO estimates. Assuming the same percentage of 
students with Fry Scholarships get similar YRP benefits 
(incorporating annual inflation), those additional payments 
would increase direct spending by $26 million over the 2017-
2026 period, CBO estimates.
    Medal of Honor Pensions. Effective 1 year from the date of 
enactment, section 102 would increase the special monthly 
pension rate paid to Congressional Medal of Honor recipients 
from $1,299 per month to $3,000 per month, and adjust it 
annually thereafter for inflation. As of 2015, there were 79 
individuals receiving a special monthly pension for the Medal 
of Honor. While CBO estimates that, on average, one new living 
recipient will receive a Metal of Honor and thus a special 
monthly pension each year, expected mortality rates for the 
existing population will cause the total number of recipients 
to decline gradually over the coming years. After accounting 
for projected mortality, new recipients, and inflation, CBO 
estimates that section 102 would increase direct spending for 
those pensions by $14 million over the 2018-2026 period.

Spending subject to appropriation

    S. 425 contains a number of provisions that would enhance 
the support services provided to homeless veterans. Other 
provisions would modify VA's administration of its health care 
programs and expand eligibility and benefits for caregivers. In 
total, CBO estimates that implementing the bill would cost $3.5 
billion over the 2017-2021 period, assuming appropriation of 
the necessary amounts (see Table 3).
    Health Care Administration. Title IV would modify certain 
aspects of VA's health care program. In total CBO estimates 
implementing the provisions under title IV would cost $3.4 
billion over the 2017-2021 period.
    Expansion of Caregivers Program. The Family Caregivers 
program provides stipends, health insurance, respite care, 
training, and other forms of support to caregivers of eligible 
veterans who are enrolled in the program. Eligible veterans are 
those who require assistance in daily activities such as 
bathing, eating, or grooming as a result of injuries incurred 
during military service on or after September 11, 2001. Section 
451 would open that program, in two stages, to eligible 
veterans of any era, and would expand the benefits offered 
under the program to include legal and financial planning 
services. In total, CBO estimates that implementing this 
section would cost $2.9 billion over the 2017-2021 period.

                    Table 3.--Estimated Effects of S.425 on Spending Subject to Appropriation
----------------------------------------------------------------------------------------------------------------
                                                                  By fiscal year, in millions of dollars--
                                                          ------------------------------------------------------
                                                            2017    2018    2019     2020      2021    2017-2021
----------------------------------------------------------------------------------------------------------------
                                           Health Care Administration
Expansion of Caregivers Program
  Estimated Authorization Level..........................    10      12     310       969     1,768      3,069
  Estimated Outlays......................................     9      12     278       895     1,673      2,867
Overtime for Medical Staff
  Estimated Authorization Level..........................     1       1       1         1         1          5
  Estimated Outlays......................................     1       1       1         1         1          5
Competitive Pay for Physician Assistants
  Estimated Authorization Level..........................     0      16      16        17        17         66
  Estimated Outlays......................................     0      14      16        17        17         64
Competitive Pay for Directors
  Estimated Authorization Level..........................     0      19      22        26        27         94
  Estimated Outlays......................................     0      17      21        25        27         90
Guidelines for Opioid Therapy
  Estimated Authorization Level..........................     1       7      14        16        17         55
  Estimated Outlays......................................     1       6      13        16        17         53
Opioid Safety Measures
  Estimated Authorization Level..........................    18      20      20        21        22        101
  Estimated Outlays......................................    16      20      20        21        22         99
Pain Management Boards
  Estimated Authorization Level..........................     0       9       9         9        10         37
  Estimated Outlays......................................     0       8       9         9        10         36
Assessment of Opioid Therapy
  Estimated Authorization Level..........................     0       1       3         3         3         10
  Estimated Outlays......................................     0       1       3         3         3         10
Office of Patient Advocacy
  Estimated Authorization Level..........................     *       *       1         1         1          3
  Estimated Outlays......................................     *       *       1         1         1          3
Community Meetings
  Estimated Authorization Level..........................     *       1       1         1         1          4
  Estimated Outlays......................................     *       1       1         1         1          4
Complementary and Integrative Health
  Estimated Authorization Level..........................     0       6       7         7         0         20
  Estimated Outlays......................................     0       5       7         7         1         20
IT System
  Estimated Authorization Level..........................     1       1       *         *         *          2
  Estimated Outlays......................................     1       1       *         *         *          2
Agreements for Extended Care
  Estimated Authorization Level..........................     0       4      10         0         0         14
  Estimated Outlays......................................     0       4       9         1         0         14
State Veterans Homes
  Estimated Authorization Level..........................     0      50      80         0         0        130
  Estimated Outlays......................................     0      40      80        10         0        130
                                                          ------------------------------------------------------
  Subtotal, Health Care Administration
    Estimated Authorization Level........................    31     147     494     1,071     1,867      3,610
    Estimated Outlays....................................    28     130     459     1,007     1,773      3,397
 
                                                Homeless Veterans
Dental Care
  Estimated Authorization Level..........................     *       8      15        24        25         72
  Estimated Outlays......................................     *       7      14        23        25         69
Homeless Veterans Reintegration Program
  Estimated Authorization Level..........................     4       4       4         4         4         20
  Estimated Outlays......................................     *       3       4         4         4         15
Case Management
  Estimated Authorization Level..........................     *       1       1         1         1          4
  Estimated Outlays......................................     *       1       1         1         1          4
Legal Services for Homeless Veterans
  Estimated Authorization Level..........................     *       1       1         2         2          6
  Estimated Outlays......................................     *       1       1         2         2          6
                                                          ------------------------------------------------------
  Subtotal, Homeless Veterans
    Estimated Authorization Level........................     4      14      21        31        32        102
    Estimated Outlays....................................     *      12      20        30        32         94
 
                                                  Other Matters
Court of Appeals for Veterans Claims
  Estimated Authorization Level..........................     0       *       1         1         1          3
  Estimated Outlays......................................     0       *       1         1         1          3
Internal Audits
  Estimated Authorization Level..........................     *       1       2         2         2          7
  Estimated Outlays......................................     *       1       2         2         2          7
Training for Managers
  Estimated Authorization Level..........................     *       *       *         *         *          1
  Estimated Outlays......................................     *       *       *         *         *          1
                                                          ------------------------------------------------------
  Subtotal, Other Matters
    Estimated Authorization Level........................     *       1       3         3         3         11
    Estimated Outlays....................................     *       1       3         3         3         11
                                        Reports, Studies, and Evaluations
 
Estimated Authorization Level............................     5       *       *         *         *          5
Estimated Outlays........................................     5       *       *         *         *          5
                                                          ------------------------------------------------------
  Total Spending Subject to Appropriation
    Estimated Authorization Level........................    40     162     518     1,105     1,902      3,728
    Estimated Outlays....................................    33     143     182     1,040     1,808      3,507
----------------------------------------------------------------------------------------------------------------
Note:IT = Information Technology; details do not add to totals because of rounding; * = less than $500,000.

    Stage one of this provision would open eligibility for the 
Family Caregivers program to eligible veterans who were injured 
during service on or before May 7, 1975. That stage would begin 
within 2 years of the date of enactment (after VA develops and 
certifies a new IT system to track benefits, as required under 
section 452). The second stage would begin 2 years after stage 
one, and would open the program to the remaining eligible 
veterans--those injured during service after May 7, 1975, and 
before September 11, 2001. For the purposes of this estimate, 
CBO assumes that S. 425 will be enacted by October 2016, that 
stage one of the proposal will begin in October 2018, and that 
stage two will begin in October 2020.
    In 2015, costs for the Family Caregivers Program totaled 
$454 million, about $18,300 per participating veteran. Most of 
that cost resulted from stipends paid to caregivers. To qualify 
as a caregiver, individuals must be at least 18 years of age 
and either a member of a veteran's extended family or live with 
the veteran full time. Stipends are paid monthly and are based 
on the hours of daily care the veteran requires and the 
prevailing wage for home health aides. In 2015, stipends paid 
under the program ranged from $7,700 to $29,000 on an annual 
basis, and averaged roughly $15,600. Caregivers also are 
eligible to participate in CHAMPVA, a program run by VA that 
provides health insurance for dependents and survivors of 
certain disabled veterans. In addition, the Family Caregiver 
Program provides up to 30 days a year of respite care, as well 
as training and other support services. In 2015, costs under 
the Family Caregivers Program for CHAMPVA and the remaining 
services averaged about $2,700 per veteran.
    CBO's estimate of the cost of expanding the Caregivers 
program is based on the usage and average costs of the existing 
program, and the number of veterans with significant, service-
connected disabilities in the cohorts that would be newly 
eligible. However, to account for the advanced age of the newly 
eligible veterans, our estimate reflects the following findings 
from a recent RAND study:\1\
---------------------------------------------------------------------------
    \1\Ramchand, Rajeev, Terri Tanielian, Michael P. Fisher, Christine 
Anne Vaughan, Thomas E. Trail, Caroline Batka, Phoenix Voorhies, 
Michael Robbins, Eric Robinson and Bonnie Ghosh-Dastidar. Hidden 
Heroes: America's Military Caregivers. Santa Monica, CA: RAND 
Corporation, 2014.

     Disabled veterans rely more heavily on assistance 
for daily activities as they age,
     Older veterans tend to rely on older caregivers, 
and
     Health care costs for caregivers increase with 
age.

    For stage one, CBO estimates that about 20,000 additional 
veterans would benefit from the program in 2019, growing to 
roughly 44,000 by 2021. CBO expects that the youngest members 
of this cohort will be in their late 60s. After factoring in a 
heavier reliance on caregiver assistance for activities of 
daily living and higher health care costs for caregivers 
because of advanced age we estimate that the average cost per 
participant would be about $30,000 in 2019. However, through 
the General Caregiver Program--which provides limited support 
services to caregivers of eligible veterans from all eras--VA 
already provides respite care to assist some caregivers. 
Accounting for those current benefits in our estimate reduces 
the average added cost per participant to $29,400. After 
accounting for gradual implementation and incorporating annual 
inflation, CBO estimates that stage one of this proposal would 
cost $2.5 billion over the 2019-2021 period.
    In the second stage of expansion we estimate that about 
29,000 additional veterans would use the Family Caregivers 
program in 2021. Because veterans in this group would be 
younger than those under the initial expansion we expect they 
would have less reliance on caregiver assistance (lower stipend 
amount) and the caregivers would be younger (lower CHAMPVA 
costs). On average, in 2021, we estimate the incremental cost 
per participant would be $28,000, after accounting for existing 
benefits under the General Caregiver Program. After factoring 
in a gradual implementation for the second stage of expansion 
and incorporating annual inflation, CBO estimates additional 
costs for the Family Caregivers Program of $367 million in 
2021. Those costs would grow to be in the tens of billions of 
dollars over the 10-year window, CBO estimates.
    In addition, under this section CBO estimates that roughly 
34,000 caregivers in the current Family Caregivers Program (for 
veterans injured during service after September 11, 2001) would 
receive legal and financial support services. On the basis of 
the resources necessary to provide counseling under the 
existing program, we estimate an average annual cost of $130 
per beneficiary for legal and financial services. CBO estimates 
it would cost $23 million over the 2017-2021 period to provide 
those benefits to individuals eligible for the Family 
Caregivers Program under current law. The costs of providing 
that additional benefit for individuals newly eligible for the 
Family Caregivers Program under this provision are included in 
the above estimates of adding those individuals to the program.
    Furthermore, in anticipation of the surge of new 
applications upon expansion of the Family Caregivers Program, 
VA would need to hire and train additional staff to manage the 
program (caregiver support line, outreach activities, and 
monitoring). On the basis of the overhead costs to manage the 
existing program of $7 million in 2014 for 19,000 participants 
and incorporating annual inflation, CBO estimates staffing 
costs of $400 per participant. To handle roughly 20,000 new 
beneficiaries starting in 2018, CBO estimates additional 
overhead costs of $16 million in 2017 and 2018.
    Overtime for Medical Staff. Section 412 would allow VA to 
offer flexible work hours (above or below 80 hours on a 
biweekly basis) to physicians or physician assistants (PAs) who 
work for VA on a full-time basis, provided the total work hours 
in a calendar year did not exceed 2,080. VA reports that the 
department does not compensate physicians for overtime; 
however, it does offer overtime pay to PAs at a premium rate of 
25 percent of the employee's basic hourly rate.
    VA employs roughly 1,800 PAs on a full-time basis. Using 
the average weekly hours for PAs in the private sector (where 
overtime pay is offered) of 40.63 hours, we estimate that PAs 
will work an average of 33 hours over the calendar year at the 
overtime pay rate (about $14 above their basic hourly rate of 
$55, which includes the pay increase under section 413). After 
factoring in the time to prepare regulations, we estimate that 
implementing the section would cost $5 million over the 2017-
2021 period.
    Competitive Pay for Physician Assistants. Beginning 1 year 
after enactment, section 413 would require VA to compensate PAs 
at rates that are competitive with those paid by health care 
providers in the private sector. Currently, VA employs about 
1,850 physician assistants. On the basis of wages paid by 
private-sector providers, we estimate that the pay rate for 
those employees would increase by about 6 percent in 2018 (from 
$112,000 to $120,000) if VA paid competitive rates.
    In addition, we expect that the higher pay level would help 
ameliorate VA's current difficulties in recruiting and 
retaining physicians' assistants, and would thus increase the 
total number of PAs employed by VA. On the basis of data from 
VA on hiring and retaining nurses, who are paid at competitive 
rates, CBO estimates that under section 413 VA would employ 
roughly 2,000 physicians' assistants by 2021 (or an 8 percent 
increase above the current staffing level). On that basis, CBO 
estimates that implementing this section would cost $64 million 
over the 2018-2021 period.
    Competitive Pay for Directors. One year after enactment, 
section 415 would allow VA to offer competitive pay (based on 
compensation in the private market) to directors of regional 
and medical facilities at the department. VA employs about 130 
directors at an average compensation amount of $220,000 in 
2015. On average, compensation for medical directors in the 
private sector is about $320,000. As a result of the increase 
in salary, CBO estimates that VA would be able to fully staff 
the 140 Medical Director positions by 2021. After factoring in 
a 1-year delay and additional hiring, CBO estimates that 
implementing this provision would cost $90 million over the 
2018-2021 period.
    Guidelines for Opioid Therapy. Within 1 year of enactment 
of this bill, section 421 would require VA and DOD to jointly 
update their guidelines for managing opioid therapy for chronic 
pain. The updated guidelines would require VA to expand 
participation in the state-run Prescription Drug Monitoring 
Program (PDMPs) to include all VA medical facilities and to 
conduct both routine and random urine drug tests for patients 
receiving opioid therapy.
    On the basis of information from VA and DOD, we estimate 
minimal costs to update the VA/DOD Clinical Practice Guideline 
for Management of Opioid Therapy for Chronic Pain.
    In 2015, the PDMPs cost about $4 million to operate at 64 
percent of the VA medical facilities. CBO estimates that 
increasing the program nationwide would cost an additional $2 
million each year. After factoring in a 1-year period to update 
the guidelines, we estimate expanding the PDMPs would cost $9 
million over the 2017-2021 period.
    According to VA, about 255,000 (or 77 percent) of the 
333,000 patients being treated for pain had at least one urine 
drug screening in 2015. After accounting for the growth in the 
number of such patients, we estimate about 100,000 additional 
urine tests would need to be completed each year at an average 
cost of about $110 per test to meet the updated requirements. 
After factoring in the necessary time to update the guidelines, 
we estimate that conducting urine tests would cost $44 million 
over the 2017-2021 period.
    In total, CBO estimates that implementing this section 
would cost $53 million over the 2017-2021 period.
    Opioid Safety Measures. Section 422 would require VA to 
expand its safety measures by improving training on providing 
pain management and prescribing opioids, establishing pain 
management teams at each medical facility, and improving 
patient tracking through electronic reports.
    This provision would create pain management teams 
throughout the VA health care system. According to VA, each 
medical facility currently has its own methods to manage and 
oversee pain therapy; however, they do not always have 
designated pain management teams. Under this provision, VA 
would be required to implement a protocol for such teams. Based 
on information from VA, we expect that establishing and 
implementing such protocols at roughly 1,000 medical facilities 
would require very little additional work and would have an 
annual cost of roughly $6,500 per facility. On that basis, CBO 
estimates that establishing the pain management teams 
nationwide would cost $33 million over the 2017-2021 period.
    Section 422 also would require VA to expand the nationwide 
availability of certain treatments such as Naloxone kits for 
opioid overdose. According to VA, it currently has roughly 
55,000 patients with opioid-use disorder and roughly 28,000 
Naloxone kits in its inventory. CBO estimates that it would 
cost roughly $14 million each year to ensure the availability 
of kits (at a cost of about $400 per kit) for those 55,000 
patients who have the greatest potential risk of overdose. On 
that basis, CBO estimates it would cost $66 million over the 
2017-2021 period to expand the availability of such treatments.
    This section also would require VA to enhance the ability 
of the electronic Opioid Therapy Risk Report (OTRR) to access 
information on prescribed drugs through the Prescription Drug 
Monitoring Programs. According to VA, such modifications to the 
OTRR would require minimal analyst and programming support. CBO 
estimates that implementing that requirement would cost less 
than $500,000 over the 2017-2021 period.
    In total, CBO estimates that implementing section 422 would 
cost $99 million over the 2017-2021 period.
    Pain Management Boards. One year after enactment of this 
bill, section 424 would require VA to establish Pain Management 
Boards in each of the 21 VA health care regions to do the 
following:

     Consult with patients and family members,
     Oversee use of best practices in managing pain and 
issue recommendations for treating difficult cases, and
     Host educational and public events.

    Under this provision, CBO expects that the regional 
boards--whose members might be spread across multiple states--
would usually hold regular board meetings via phone or virtual 
conferencing. However, face-to-face meetings may be needed on 
occasion; thus, CBO estimates annual per diem and travel costs 
of $250 for 315 individuals (based on 15 board members in each 
of the 21 VA health care regions). CBO also expects VA would 
hire roughly 60 support staff (or 3 support staff per board) 
with an average compensation of $120,000. After factoring in a 
1-year delay, CBO estimates that implementing this section 
would cost $36 million over the 2017-2021 period.
    Assessment of Opioid Therapy. Under section 425, within 2 
years of enactment of the bill, VA would be required to enter 
into a contract with an independent entity to assess and report 
on opioid prescribing practices at VA medical facilities. 
Beginning no later than 1 year after enactment, this section 
also would require VA to collect and analyze data on 
prescription rates of opioids and usage of opioid therapy at 
all VA medical facilities and to provide annual reports to the 
Congress on those matters. CBO estimates that implementing 
those requirements would cost about $1 million each year for 
data collection and coordination at all medical facilities.
    On the basis of information from VA and independent 
entities who worked on similar studies, CBO estimates an 
independent review would take 3 years and cost $2 million each 
year, beginning in 2019. In total, CBO estimates it would cost 
$10 million over the 2017-2021 period to implement section 425.
    Office of Patient Advocacy. Within a year of enactment, 
section 431 would establish a new Office of Patient Advocacy 
under the Undersecretary of Health at VA. According to VA, the 
department has already established a Client Services Response 
Team (CSRT) that reports directly to the Undersecretary of 
Health's office. We expect this provision would mostly codify 
existing practice; however, we think VA would hire two 
additional support staff and a director (with an average 
compensation level of $200,000 for each new employee) to assist 
the CSRT's efforts. After factoring in the time to hire the new 
staff, we estimate it would cost $3 million over the 2017-2021 
period to implement this section.
    Community Meetings. Section 432 would require VA Medical 
Centers and Community Based Outpatient Clinics to host 
community meetings on an annual and quarterly basis, 
respectively. Those meetings would be open to the public. VA 
currently hosts town hall meetings to get feedback from 
veterans, their family members and other community 
stakeholders. On the basis of information from VA, CBO 
estimates that VA would need to hold an additional 500 such 
meetings a year to meet the requirements of this provision.
    Based on costs in the private sector, we estimate VA would 
spend roughly $1,500 per meeting for audio visual equipment, 
staff time, and supplies. In total, CBO estimates implementing 
this provision would cost $4 million over the 2017-2021 period.
    Complementary and Integrative Health. Section 442 would 
require VA to operate a 3-year program at 15 VA Medical Centers 
to assess the feasibility of integrating complementary and 
alternative medicine with traditional care. On the basis of 
VA's implementation of other pilot programs of similar scope 
(such as using meditation for veterans with Post Traumatic 
Stress Disorder), CBO expects that developing and operating the 
program would require two additional medical practitioners at 
each of the 15 facilities to provide nontraditional care, as 
well as two additional employees at each facility to engage in 
research, training, and assessment of the program.
    The use of complementary and alternative medicine also 
would partially displace the use of traditional care (emergency 
care, primary care, and physical therapy) but would lead to 
greater use of medical services on balance, than under current 
law. Specifically, CBO estimates that the net cost to deliver 
medical services, after adjusting for the expected reduction in 
usage of traditional health care services would be roughly 
$66,000 per medical provider, resulting in costs of roughly $2 
million annually during the 3-year pilot program.
    On the basis of information from VA, CBO further estimates 
that the annual cost per person for the research and training 
personnel was $127,000 in 2015. Thus, in total, implementing 
section 442 would cost $20 million over the 2018-2021 period, 
CBO estimates.
    IT System. By December 31, 2016, section 452 would require 
VA to develop and implement an IT system to track and assess 
data of the Family Caregiver Program. VA reports that it is 
currently working on enhancing its existing IT system, the 
Caregivers Application Tracker system, to allow for an easier 
application process, as well as tracking stipend awards and 
other benefits. As a result, we estimate this requirement would 
mostly codify existing practice and would have no budgetary 
effect. However, the provision also includes assessment and 
reporting requirements that CBO estimates would cost $2 million 
over the 2017-2021 period.
    Agreements for Extended Care. Section 461 would 
temporarily--through 2019--exempt VA from the requirements of 
the Federal Acquisition Regulation (FAR) for the purposes of 
entering into agreements to provide long-term care to veterans 
in private facilities. The FAR is a set of rules that governs 
the conditions under which most federal agencies may purchase 
goods and services. VA has faced continuing challenges securing 
access to certain long-term care facilities because of the high 
cost of the contractual requirements (mostly related to 
reporting, compensation, and fringe benefits) under the FAR. 
Under this provision, CBO expects that VA will be able to 
contract for long-term care for more veterans than is possible 
under current law. This section also would require VA to 
develop a system, similar to that used by Medicare, to monitor 
the care provided to veterans in such extended care facilities.
    According to VA, there are a total of 150 extended care 
facilities that have terminated their contracts with VA due to 
the strict requirements of the FAR. After factoring in the time 
for VA to place veterans, CBO estimates that by 2018 VA would 
enter into non FAR agreements with about 30 of those 
facilities. Based on information from VA, we estimate that, on 
average, veterans would occupy three beds at each of those 
facilities at a per diem rate of $280--with an average length 
of stay of 113 days. Based on information from the department, 
we expect that after the authority provided under this section 
expires in 2019, VA would lose access to the extended stay 
facilities under non FAR agreements, and would therefore have 
to place veterans in facilities with existing contracts. Thus, 
we estimate no additional costs after 2019.
    CBO also estimates that VA would incur administrative costs 
of $1 million each year to increase its monitoring of care 
provided to veterans in extended care facilities by expanding 
its use of existing data gathered by the states and the Centers 
for Medicare and Medicaid on extended care facilities. In total 
we estimate discretionary costs of $14 million over the 2017-
2021 period.
    State Veterans' Homes. Section 462 would temporarily--
through 2019--waive the requirements of the FAR for contracts 
and agreements that VA enters into with state-run nursing homes 
for veterans. Under current law, the state veterans' homes 
(SVHs) are required to fill 75 percent of their beds with 
veterans. VA is required to pay SVHs the full cost of care for 
veterans with a service-connected disability (SCD) rating of 70 
percent or more, under a contract or agreement. For all other 
veterans, VA pays SVHs a grant based on a fixed daily 
allowance.
    According to VA, in 2015 the Department used such 
agreements to reimburse state-run nursing homes at a daily rate 
of $380 for each veteran with a SCD of 70 percent or more--at 
an annual cost of roughly $350 million (or 37 percent of the 
total reimbursements to SVHs). However, those agreements do not 
comply with the FAR, and VA does not expect to be able to enter 
into FAR agreements with any of the SVHs. In the absence of 
this legislation, CBO expects that VA will gradually phase out 
the use of such agreements as those veterans who are currently 
under that payment structure die or leave the SVHs. We expect 
those veterans would be replaced by veterans under the lower 
daily allowance rate of roughly $100 per patient. By allowing 
VA to enter into non FAR agreements, CBO estimates that this 
proposal would nearly triple VA's reimbursements to SVHs for 
veterans with severe SCDs.
    As a result, after factoring in a gradual phase out of 
using non FAR agreements, CBO estimates that enacting this 
provision would cost $130 million over the 2018-2021 period. 
The additional costs from waiving the FAR requirements would 
begin in 2017. However, appropriations have already been 
provided for such agreements in 2017, so we estimate no 
additional funding would be necessary in that year.
    Homeless Veterans. Title III would authorize VA to expand 
benefits provided to homeless veterans, such as dental care, 
employment assistance, and legal services. In total, CBO 
estimates implementing those requirements would cost $94 
million over the 2017-2021 period.
    Dental Care. One year after enactment of the bill, section 
303 would expand eligibility for dental care to veterans 
receiving certain forms of housing assistance. Under current 
law, veterans who receive short-term housing assistance through 
VA may receive limited dental care to alleviate pain, as part 
of treatment for a more severe periodontal disease, or to aid 
in getting a job. This section would provide that same out-
patient dental care to certain veterans receiving longer-term 
housing assistance through the Department of Housing and Urban 
Development-VA Supportive Housing (HUD-VASH) program and 
transitional housing through a non-VA entity.
    Based on an analysis of information from VA, CBO estimates 
about 3,700 veterans would take advantage of this benefit in 
2018, growing to about 10,000 by 2020. At an average cost of 
about $2,000 per veteran in 2018, and incorporating the effects 
of medical inflation and a 1-year delay in implementation, CBO 
estimates that providing dental care to those additional 
homeless veterans would cost $69 million over the 2018-2021 
period.
    Homeless Veterans Reintegration Program. Section 304 would 
expand the eligibility for the Homeless Veterans Reintegration 
Program (HVRP). HVRP provides grants to agencies and 
organizations that provide job placement, training, and 
vocational counseling to homeless veterans.
    This section would extend the benefits to veterans 
receiving longer-term housing assistance through HUD-VASH, 
newly released veterans who were incarcerated, and certain 
veterans who are Native Americans. According to VA, roughly 
17,000 veterans would become eligible for the HVRP program 
under this proposal. Based on the current participation levels 
for HVRP, we estimate that under section 304 about 1,800 new 
beneficiaries would seek job placement annually at an average 
cost of $2,000 in 2017. CBO estimates that implementing this 
provision would cost $15 million over the 2017-2021 period.
    Case Management. Within 1 year of enactment of the bill, 
section 306 would require VA to conduct a pilot program to 
assess the feasibility of using intensive case management 
practices for certain homeless veterans who are enrolled in the 
VA health care system. The pilot program would operate in at 
least six locations in the VA health care system and would 
include no fewer than 20 veterans at each location.
    Based on the size of the pilot program and information from 
VA, CBO expects that implementing this provision would require 
the department to hire six full-time case managers at an 
average salary of $100,000. After adjusting for projected 
salary increases for federal workers, CBO estimates a total 
cost of $4 million over the 2017-2021 period.
    Legal Services for Homeless Veterans. Section 308 would 
allow VA to collaborate with public and private entities to 
provide legal assistance (in areas such as housing, family law, 
and criminal defense) to veterans at risk of homelessness. On 
the basis of existing rates of participation in the Supportive 
Service Low Income Vets and Families program, which currently 
provides limited legal services to veterans at risk of 
homelessness, CBO estimates that roughly 15,000 veterans would 
take advantage of the proposed legal assistance.
    Further, given the number and dollar amount of stipends 
provided to the health professional trainees (which includes 
fellows, residents, and students) rotating through VA, CBO 
estimates that VA would award stipends of $20,000 
(incorporating annual inflation) to about 90 legal fellows to 
provide services to veterans. Because of the time necessary to 
write regulations and to develop partnerships, CBO expects that 
this program would not be fully implemented for several years. 
As a result, CBO estimates that implementing section 308 would 
cost $6 million over the 2017-2021 period.
    Other Matters. Title V would extend the temporary increase 
in the number of judges for the Court of Appeals for Veterans 
Claims, establish a program of internal audits within VA, and 
provide training to managers throughout VA. CBO estimates that 
implementing title V would cost $11 million over the 2017-2021 
period.
    Court of Appeals for Veterans Claims. Section 501 would 
extend, through January 1, 2021, the authority for the Court of 
Appeals for Veterans Claims (CAVC) to appoint a new judge to 
the court should a position become vacant. Previous legislation 
allowed for the court to expand from seven judges to nine in 
order to address the workload of the court. The authority to 
appoint a new judge to maintain nine judges expired on January 
1, 2013.
    According to the CAVC, the cost of a judge and his or her 
chamber is about $1 million per year. CBO expects that one 
judge will leave or retire over the next several years; thus, 
under section 501 one new judge would be appointed. Therefore, 
CBO estimates that implementing section 201 would cost $3 
million over the 2017-2021 period.
    Internal Audits. Section 503 would establish an office and 
program of internal audits--independent of other offices within 
VA--to do periodic risk assessments and analysis of various 
organizations and staff offices within the department. Based on 
information from VA, CBO expects that VA would hire 10 
additional support staff and a director (with an average 
compensation level of $200,000 per staff member) to carry out 
the internal audits. After factoring in the time to hire the 
new staff, we estimate that implementing this provision would 
cost $7 million over the 2017-2021 period.
    Training for Managers. Section 504 would require VA to 
provide training to managers in several areas. Such training 
would cover: ensuring rights of whistleblowers, effectively 
managing and motivating employees, and managing employees who 
are performing at an unacceptable level. According to VA, while 
managers are currently required to undergo training similar to 
that required by section 504, the agency would need to add new 
and updated content to meet all the requirements of the bill. 
On the basis of VA's current practices, CBO expects that VA 
would enter into a contract with a private entity to implement 
those changes at a cost of $1 million over the 2017-2021 
period.
    Reports, Studies, and Evaluations. The bill would require 
VA to produce a total of 13 reports on matters such as opioid 
therapy, patient advocacy, and benefits to caregivers of 
injured veterans. It also would require a study by the 
Government Accountability Office of programs offered to 
homeless veterans. Based on the costs of similar studies and 
reports, CBO estimates that meeting those requirements would 
cost a total of $5 million over the 2017-2021 period.
    Pay-As-You-Go Considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget-reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. The net changes in outlays that are subject to those 
pay-as-you-go procedures are shown in the following table.

     Table 4.--CBO Estimate of Pay-As-You-Go Effects for S.425 as ordered reported by the Senate Committee on Veterans' Affairs on December 9, 2015
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                     By fiscal year, in millions of dollars--
                                                        ------------------------------------------------------------------------------------------------
                                                         2016  2017   2018   2019   2020   2021   2022   2023   2024   2025   2026  2016-2021  2016-2026
--------------------------------------------------------------------------------------------------------------------------------------------------------
 
                                                       NET INCREASE OR DECREASE (-) IN THE DEFICIT
Statutory Pay-As-You-Go Impact.........................     0   -13   -151   -300   -426   -453   -485   -517   -554   -585   -617    -1,345     -4,102
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Increase in Long-Term Direct Spending and Deficits: CBO 
estimates that enacting S. 425 would not increase net direct 
spending or on-budget deficits in any of the four consecutive 
10-year periods beginning in 2026.
    Intergovernmental and private-sector impact: S. 425 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would benefit public entities, including 
educational institutions and health care providers, that 
provide services to veterans. Any costs those entities might 
incur would be incurred as conditions of participating in a 
voluntary federal program.
    Previous cost estimates: On June 3, 2015, CBO transmitted a 
cost estimate for S. 1376, the National Defense Authorization 
Act for Fiscal Year 2016, as ordered reported by the Senate 
Committee on Armed Services on May 19, 2015. Section 605 of 
that bill is similar to section 502 of S. 425. The estimates 
differ because other legislation has been enacted in the 
interim that changed costs under current law and because VA 
provided additional information on how it would implement the 
provision.
    On November 19, 2015, CBO transmitted a cost estimate for 
H.R. 3016, the Veterans Employment, Education, and Healthcare 
Improvement Act, as ordered reported by the House Committee on 
Veterans' Affairs on September 17, 2015. Section 301 of that 
bill is similar to section 202 of S. 425. The costs of section 
202 are higher because of interactive effects with other 
provisions of the bill. Section 302 of that earlier bill also 
would increase benefits under the Fry Scholarships in a more 
expansive manner than would section 209 of S. 425, thus, the 
costs in this estimate are lower. Section 210 of S. 425 is 
similar to section 307 of H.R. 3016 and section 103 of H.R. 475 
the GI Bill Processing Improvement and Quality Enhancement Act 
of 2015, as ordered reported by the House Committee on 
Veterans' Affairs on May 21, 2015. Section 210 would credit 
military service before the date of enactment of the bill; the 
previous bills would not. However, the estimate for the 
proposal has been updated for new information. Thus, on net, 
the cost of section 210 is less than the previous estimates.
    On May 4, 2016, CBO transmitted a cost estimate for 
H.R. 4063, the Promoting Responsible Opioid Management and 
Incorporating Scientific Expertise Act, as ordered reported by 
the House Committee on Veterans' Affairs on February 25, 2016. 
Sections 102 and 201 of that bill are similar to sections 422 
and 432 respectively of S. 425, and the estimated costs for 
those provisions are the same. Section 302 of H.R. 4063 is 
similar to section 442 of S. 425, but would be effective 1 year 
later. The estimated costs for those provisions differ only 
because of that timing effect.
    Estimate prepared by: Federal Costs: Ann E. Futrell, David 
Newman, and Dwayne M. Wright; Impact on State, Local, and 
Tribal Governments: Jon Sperl; Impact on the Private Sector: 
Paige Piper/Bach.
    Estimate approved by: H. Samuel Papenfuss, 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 December 9, 2015, meeting. One 
amendment by Senator Isakson was adopted by voice vote; Senator 
Brown and Senator Hirono requested to be recorded as voting no 
on the amendment. S. 425 as amended, and as subsequently 
amended during the Committee meeting, was agreed to by voice 
vote, without dissent, and ordered favorably reported to the 
Senate.

                             Agency Report

    On May 13, 2015, David R. McLenachen, Acting Deputy Under 
Secretary for Disability Assistance, Veterans Benefits 
Administration; on June 3, 2015, Dr. Thomas Lynch, Assistant 
Deputy Under Secretary for Health Clinical Operations, Veterans 
Health Administration; on June 24, 2015, Dr. Rajiv Jain, 
Assistant Deputy Under Secretary for Health for Patient Care 
Services, Veterans Health Administration; on September 16, 
2015, Thomas Lynch, Assistant Deputy Under Secretary for Health 
Clinical Operations, Veterans Health Administration; on October 
6, 2015, Thomas Lynch, Assistant Deputy Under Secretary for 
Health Clinical Operations, Veterans Health Administration; and 
on November 18, 2015, Curtis L. Coy, Deputy Under Secretary for 
Economic Opportunity, Veterans Benefits Administration, from 
the Department of Veterans Affairs appeared before the 
Committee on Veterans' Affairs and submitted testimony on 
various bills incorporated into the Committee bill. In 
addition, on July 15, 2015; September 4, 2015; and December 8, 
2015, VA provided views on various bills incorporated into the 
Committee bill. Excerpts from these statements are reprinted 
below:

  STATEMENT OF DAVID R. MCLENACHEN, ACTING DEPUTY UNDER SECRETARY FOR 
     DISABILITY ASSISTANCE, VETERANS BENEFITS ADMINISTRATION, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

    Good afternoon, Mr. Chairman and Members of the Committee. 
I am pleased to be here today to provide the views of the 
Department of Veterans Affairs (VA) on pending legislation 
affecting VA's programs, including the following: S. 270, 
S. 602, S. 627, the ``21st Century Veterans Benefits Delivery 
Act,'' the ``Veterans' Compensation Cost-of-Living Adjustment 
Act of 2015,'' and a draft bill concerning VA small business 
contracting, Veterans benefits, and burial matters. We will 
separately provide views on the following bills: S. 681; 
sections 202, 203 and 206 of the ``21st Century Veterans 
Benefits Delivery Act;'' the bill associated with legislative 
proposals from the Report of the Military Compensation and 
Retirement Modernization Commission; the bill associated with 
legislative proposals from the Department of Defense (DOD); and 
sections 201 and 206 of the consolidated bill related to bills 
from the 113th Congress. Accompanying me this afternoon is 
Renee Szybala, Assistant General Counsel.

           *       *       *       *       *       *       *

                                 S. 602

    S. 602, the ``GI Bill Fairness Act of 2015,'' would amend 
the term ``active duty'' under chapter 33 of title 38, to 
include certain time spent receiving medical care from DOD as 
qualifying active duty service performed by members of the 
Reserve and National Guard. Under this bill, individuals 
ordered to active duty under section 12301(h) of title 10, 
United States Code, to receive authorized medical care; to be 
medically evaluated for disability or other purposes; or to 
complete a required DOD health care study, would receive credit 
for this service under the Post-9/11 GI Bill.
    S. 602 would apply as if it were enacted immediately after 
the enactment of the Post-9/11 Veterans Educational Assistance 
Act of 2008, Public Law 110-252.
    VA defers to DOD regarding the change to qualifying active 
duty service under the Post-9/11 GI Bill, with the observation 
that a similar proposal was submitted by the Administration for 
inclusion with the 2016 NDAA, with an exception that this bill 
would be retroactive. Currently, individuals with qualifying 
active duty service of at least 30 continuous days who are 
honorably discharged due to a service-connected disability 
become eligible for 100 percent of the Post-9/11 GI Bill 
benefit. Because service under 10 U.S.C. Sec. 12301(h) does not 
meet the current definition of active duty, Guard and Reserve 
members with such service who are discharged under these 
circumstances do not automatically qualify for 100 percent of 
the benefit. If enacted, this change would allow for an 
increase in benefits from the 40-90 percent benefit tier up to 
the 100 percent level, and the change would be retroactive to 
as early as August 1, 2009.
    The proposed change to the eligibility criteria under the 
Post-
9/11 GI Bill would require VA to make changes to the type of 
data that are exchanged between DOD and VA through the VA/DOD 
Identity Repository (VADIR) and displayed in the Veteran 
Information System (VIS). In addition, new rules would need to 
be programmed into the Post-9/11 GI Bill Long Term Solution 
(LTS) in order to calculate eligibility based on service under 
section 12301(h) and to allow for benefit payments retroactive 
to 2009. VA estimates that it would need 1 year from enactment 
of S. 602 to complete these changes.
    VA estimates that administrative cost requirements 
associated with the enactment of S. 602 would be insignificant. 
The Department is still evaluating benefit and resource costs 
related to this legislation.
                                ------                                

 STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR 
   HEALTH CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

    Good morning Chairman Isakson, Ranking Member Blumenthal, 
and Members of the Committee. Thank you for inviting us here 
today to present our views on several bills that would affect 
VA benefits programs and services. Joining us today is Maureen 
McCarthy, M.D., VHA's Deputy Chief Patient Care Services 
Officer and Susan Blauert, Deputy Assistant General Counsel in 
VA's Office of General Counsel.
    We do not yet have cleared views on sections 2 and 4 of 
S. 297, S. 471, the draft bill on Joint VA-DOD formulary for 
pain and psychiatric medications, and the draft bill Veterans 
Health Act of 2015. We will forward the views to the Committee 
as soon as they are available.

           *       *       *       *       *       *       *

 S. 425, HOMELESS VETERANS' REINTEGRATION PROGRAMS REAUTHORIZATION ACT 
                                OF 2015

    S. 425 would extend the authorization of appropriations for 
the Department of Labor's Homeless Veteran Reintegration 
Programs (HVRP) and the Homeless Women Veterans and Homeless 
Veterans with Children Reintegration Grant Program from 2015 to 
2020. The bill would further expand the population eligible to 
receive services under HVRP to include not only homeless 
Veterans but also Veterans who are participating in the 
Department of Housing and Urban Development-VA Supportive 
Housing (HUD-VASH) program, receiving assistance under the 
Native American Housing Assistance and Self-Determination Act 
of 1996, or transitioning from incarceration.
    VA defers to the Department of Labor for views and costs on 
S. 425; however, we offer that this bill would provide 
additional services for homeless and at-risk Veterans in the 
critical area of employment, which is a key factor in achieving 
and maintaining stability in permanent housing. Veterans 
transitioning from incarceration often face multiple barriers 
to successful reentry, and expanding HVRP eligibility to this 
population would help address the employment-related needs of a 
population of Veterans who are often at high risk of becoming 
homeless. It would also be especially helpful for Veterans 
transitioning from incarceration who may not be eligible for VA 
services.

            S. 684, HOMELESS VETERANS PREVENTION ACT OF 2015

    Section 2 of S. 684 would amend 38 U.S.C. Sec. 2012(a)(2) 
to increase the per diem payments for Veterans who are 
participating in the VA's Homeless Provider Grant and Per Diem 
(GPD) Program through a ``transition in place'' (TIP) grant. 
The per diem payments under GPD TIP would be increased to 150 
percent of the VA State Home rate for domiciliary care, 
compared to the current payment which is the lesser of 100 
percent of the VA State Home rate for domiciliary care or the 
daily cost of care minus other sources of payments to the per 
diem recipient for furnishing services to homeless veterans.
    VA supports section 2. This new provision would facilitate 
and provide support for Veterans moving from transitional to 
permanent housing. Supporting Veterans' transition from 
homelessness to permanent housing is a strategy VA believes 
will be effective in our efforts to end homelessness among 
Veterans. By allowing Veterans to ``transition in place'' to 
permanent housing, the Department would provide a valuable 
alternative for Veterans who may not need or be interested in 
participating in the HUD-VASH program.
    Section 3 would amend 38 U.S.C. Sec. 2012(a) to permit a 
grantee receiving per diem payments under the GPD Program to 
use part of these payments for the care of a dependent of a 
homeless Veteran who is receiving services covered by the GPD 
grant. This authority would be limited to the time period 
during which the Veteran is receiving services under the grant.
    VA supports the intent of section 3, conditioned on the 
availability of additional resources to implement this 
provision. We feel that this authority is needed to fully reach 
the entire homeless population. However, full implementation of 
the legislation would require additional funding to avoid 
diminished services in VA's full complement of programs for 
homeless Veterans.
    Section 4 would authorize the Secretary to enter into 
partnerships with public or private entities to provide general 
legal services to Veterans who are homeless or at risk of 
homelessness. The language further specifies that VA is only 
authorized to fund a portion of the cost of legal services.
    VA supports section 4 as legal services remain a crucial 
but largely unmet need for homeless and at-risk Veterans, but 
respectfully recommends technical amendments to the bill 
language. The Supportive Services for Veteran Families Program 
currently allows for grantees to enter into partnerships with 
legal service providers to address legal needs that pose 
barriers to housing stability. However, this is not a required 
service under the SSVF regulations and, therefore, is not 
provided to Veterans through all SSVF programs. Rather than 
authorizing VA to enter into ``partnerships,'' section 4 should 
authorize VA to provide grants to ensure the language reflects 
a funding mechanism that VA could use to execute it. 
Furthermore, VA recommends removing the phrase ``a portion of'' 
from the proposed section 2022A(a). This change would allow VA 
to fund a portion or the entirety of the legal services 
provided under the partnership, thereby providing VA greater 
flexibility to support these efforts. Finally, VA would like to 
work with the Committee to make additional minor improvements 
to section 4.
    Section 5 would extend dental benefits under 38 U.S.C. 
Sec. 2062 to a Veteran enrolled in the VA health care system 
who is also receiving for a period of 60 consecutive days 
assistance under the HUD-VASH program, or care under title 38 
authority in one of the following settings: a domiciliary, 
therapeutic residence, community residential care, or a GPD 
program. For purposes of the 60-day requirement, it would 
permit breaks in the continuity of assistance or care for which 
the Veteran is not responsible.
    VA appreciates the intent of section 5 to expand 
eligibility for VA dental care, but cannot support it under a 
realistic assumption of future funding availability. VA 
believes these services would be especially valuable for this 
group of Veterans, and we welcome further discussion with the 
Committee.
    VA supports section 6, which would provide permanent 
authority for VA's Veterans Justice Outreach (VJO) and Health 
care for Reentry Veterans (HCRV) Programs. VJO's goal is to 
avoid the unnecessary criminalization of mental illness and 
extended incarceration among Veterans by ensuring that eligible 
Veterans involved with the criminal justice system have timely 
access to VA's mental health and substance use services when 
clinically indicated, and other VA services and benefits as 
appropriate. Similarly, designed to address the community 
reentry needs of incarcerated Veterans, HCRV's goals are to 
prevent homelessness, reduce the impact of medical, 
psychiatric, and substance abuse problems upon community 
readjustment, and decrease the likelihood of re-incarceration 
for those leaving prison. This permanent authority would 
recognize the crucial role these programs play in preventing 
and ending Veteran homelessness.
    Section 7 would amend 38 U.S.C. Sec. 2044(e) to authorize 
the use of $500 million from VA's FY 2016 Medical Services 
appropriation for the Supportive Services for Veteran Families 
(SSVF) Program, and to extend the existing $1 million 
appropriation authority for training and technical assistance 
to SSVF grantees through FY 2015.
    While the $500 million level of this authorization is above 
the level proposed in VA's budget, we nevertheless support an 
authorization level that provides flexibility should VA 
determine that additional funding is necessary and the 
Department is in a position to dedicate higher amounts to the 
program. VA thus supports the intent of section 7, but believes 
that in order to ensure the provision of quality services to 
Veteran families and the efficient execution of such additional 
funds; this increased flexibility should be accompanied by an 
increased proportional authorization in technical assistance 
for SSVF providers.
    Section 8 would require the Secretary to assess and measure 
the capacity of programs receiving grants under 38 U.S.C. 
Sec. 2011, or per diem payments under 38 U.S.C. Sec. 2012 or 
2061.
    VA believes the intent of section 8 is satisfied by 
existing VA's Homeless Providers Grant and Per Diem Program 
monitoring practices. VA's GPD Program regularly monitors 
capacity and performance in grantees' programs, so section 8 
would impose a new and potentially duplicative reporting 
requirement. Although VA expects that compliance with section 8 
would require time and effort from VA employees, the reporting 
requirements are not unduly burdensome and would result in 
minimal costs to VA. Therefore, VA does not object to section 
8.
    Section 9 would require the U.S. Comptroller General to 
conduct an assessment of VA programs serving homeless Veterans 
to determine whether these programs are meeting Veterans' 
needs, and recent efforts to improve the privacy, safety, and 
security of female Veterans receiving assistance under these 
programs. VA supports the intent of section 9, but believes its 
goals have been accomplished by recent reviews of VA homeless 
programs conducted by the Government Accountability Office and 
by VA's annual assessment of homeless Veterans' service needs 
and the availability of responsive VA and community services. 
Since its inception in 1994, VA's Project CHALENG (Community 
Homelessness Assessment, Local Education and Networking Groups) 
has surveyed participants (homeless and formerly homeless 
Veterans, as well as VA and community service providers) on the 
needs of homeless Veterans in their local communities, and the 
extent to which these are addressed by existing VA and 
community services. The results not only drive the development 
of new local partnerships, but also generate a national picture 
of male and female homeless Veterans' met and unmet service 
needs, as identified by homeless Veterans themselves and the 
service providers who work with them directly.
    Section 10 would remove the requirement that VA report to 
the Senate and House of Representatives Committees on Veterans' 
Affairs on the activities of the Department during the calendar 
year preceding the report under programs of the Department for 
the provision of assistance to homeless veterans.
    VA supports section 10. Removing this time consuming 
reporting function would free up VA resources that could be 
better used to internally asses the programs and implement 
changes to enhance the benefits and services provided to 
homeless Veterans. Furthermore, VA remains committed to 
providing timely data reporting to the Committees upon request. 
Removing this annual reporting requirement would recognize that 
VA, on its own initiative, conducts ongoing data analysis of VA 
homeless programs.

    DRAFT BILL--DEPARTMENT OF VETERAN AFFAIRS PURCHASED HEALTH CARE 
                   STREAMLINING AND MODERNIZATION ACT

    This draft bill is similar to legislation requested by the 
Administration to reform the authorities VA uses to purchase 
hospital care, medical services, and extended care when that 
care is not feasibly available at a VA facility, or through 
contracts or sharing agreements entered into under other 
authorities. We sincerely appreciate the Committee placing it 
on the agenda today, and look forward to working with you on 
this critical aspect of ensuring Veterans' timely access to 
health care.
    Section 2 would amend chapter 17 of title 38, U.S.C., by 
adding a new section, ``1703A. Veterans Care Agreements with 
certain health care providers.''
    Subsection (a) of 1703A would provide that if VA is not 
feasibly able to furnish hospital care, medical services, or 
extended care within the Department or through the exercise of 
other authority to enter into contracts or sharing agreements, 
VA may enter into ``Veterans Care Agreements'' (VCA) with 
eligible providers who are certified under subsection (c) of 
the new 1703A. Eligibility for care would be determined in the 
same manner as if the care or services were furnished directly 
by a VA facility.
    Subsection (b) would define eligible providers to include 
Medicare and Medicaid providers; an Aging or Disability 
Resource Center, an area agency on aging, or a State agency as 
defined in section 102 of the Older Americans Act; a center for 
independent living as defined in section 702 of the 
Rehabilitation Act; and other providers the Secretary 
determines to be appropriate.
    Subsection (c) would require the Secretary to establish a 
process for the certification and re-certification of eligible 
providers. This process must include procedures for screening 
providers according the risk of fraud, waste, and abuse and 
must require the denial of applications from providers excluded 
from certain Federal programs. VA notes that this provision 
would require VA to certify all eligible providers, including 
those participating in Medicare or Medicaid. In VA's 
legislative proposal, VA would establish a separate 
certification process for those eligible providers that are not 
under the certification regimes of Medicare and Medicaid. VA 
suggests this approach to avoid subjecting providers to 
duplicative certification processes, which could dissuade 
providers from entering VCAs.
    Subsection (d) would require the inclusion of specific 
terms in VCAs, including payment rates that are, to the extent 
practicable, in accordance with the rates paid by the United 
States in the Medicare program. Other requirements of VCAs 
would include restricting care to that authorized by VA, 
prohibiting third-party billing by providers, and submitting 
medical records to the Department.
    Subsection (e) would specify the terms and conditions under 
which VA or the provider may terminate a VCA.
    Subsection (f) would require the Secretary to review VCAs 
of material size every 2 years to determine whether it is 
feasible or advisable to provide the necessary care at 
facilities of the Department or through contract or sharing 
agreements entered into under other authorities.
    Subsection (g) would specify that VCAs under section 1703A 
are exempt from certain provisions of law governing Federal 
contracting. Specifically, VCAs would be awarded without regard 
to competitive procedures and would not subject an eligible 
provider to certain laws that providers and suppliers of health 
care services through the Medicare program are not subject to. 
Providers entering into VCAs would be subject to all laws 
regarding integrity, ethics, fraud, or that subject a person to 
civil or criminal penalties, as well as all laws prohibiting 
employment discrimination on the basis of race, color, national 
origin, religion, gender, sexual orientation, gender identity, 
disability, or status as a Veteran.
    Subsection (h) would require the Secretary to establish a 
system or systems to monitor the quality of care and services 
provided to Veterans under section 1703A and to assess the 
quality of care and services for purposes determining whether 
to renew a VCA.
    Subsection (i) would require the Secretary to establish 
administrative procedures for providers to present disputes 
arising under or related to VCAs. It would further require that 
providers exhaust these administrative procedures before 
seeking judicial review under the Contract Disputes Act.
    Subsection (j) would direct the Secretary to prescribe 
regulations to carry out section 1703A.
    Section 3 of the draft bill would amend 38 U.S.C. Sec. 1745 
to permit VA to enter into agreements with State Veterans Homes 
that are exempt from certain provisions of law governing 
Federal contracting. Specifically, an agreement could be 
awarded without regard to competitive procedures and would not 
subject a State Home to certain laws that providers and 
suppliers of health care services through the Medicare program 
are not subject to. An agreement would be subject to all laws 
regarding integrity, ethics, fraud, or that subject a person to 
civil or criminal penalties, as well as all laws prohibiting 
employment discrimination on the basis of race, color, national 
origin, religion, gender, sexual orientation, gender identity, 
disability, or status as a Veteran. In addition, subsection (c) 
would establish a separate effective date for the amendments 
made by section 3 based on the effective date of implementing 
VA regulations.
    Although section 3 would eliminate the word ``contract'' in 
section 1745, it would authorize VA to enter into 
``agreements'' which VA believes would include contracts based 
on the Federal Acquisition Regulation (FAR) contracts. VA thus 
does not interpret this amendment to prohibit VA from using 
FAR-based contracts if a State home requests it.
    Similar to the legislation proposed by the Administration, 
the draft bill would not result in additional costs and thus 
would be budget neutral.
    This bill is a critical reform that will address 
deficiencies in current law, as well as provide a comprehensive 
framework and foundation for the purchase of non-VA care in 
those circumstances where it is not feasibly available from VA 
or through contracts or sharing agreements. We strongly support 
its enactment, which we believe is essential to maintaining 
Veterans' access to care in every part of the country.

    Mr. Chairman, thank for the opportunity to present the 
Department's views on these bills and we will be glad to 
respond to the Committee's questions.
                                ------                                

   STATEMENT OF DR. RAJIV JAIN, ASSISTANT DEPUTY UNDER SECRETARY FOR 
HEALTH FOR PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

    Good morning Chairman Isakson, Ranking Member Blumenthal, 
and Members of the Committee. Thank you for inviting us here 
today to present our views on several bills that would affect 
VA benefits programs and services. Joining us today is 
Catherine Mitrano, Deputy Assistant Secretary for Resolution 
Management, and Jennifer Gray, Staff Attorney in VA's Office of 
General Counsel.
    We do not yet have cleared views on the Draft Biological 
Implant Tracking and Veteran Safety Act of 2015 or on S. 1117, 
the Ensuring Veteran Safety Through Accountability Act of 2015. 
Additionally, we do not have cleared views on sections 203, 
205, 208, and 209(b) of S. 469, sections 3 through 8 of 
S. 1085, section 2 of the draft bill referred to on the agenda 
as ``Discussion Draft'' or sections 101-106, 204, 205, 403 and 
501 of The Jason Simcakoski Memorial Opioid Safety Act. We will 
be glad to work with the Committee on prioritization of those 
views and cost estimates not included in our statement.

           *       *       *       *       *       *       *

  S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF 
                                  2015

    The Caregivers and Veterans Omnibus Health Services Act of 
2010, Public Law 111-163, signed into law on May 5, 2010, 
provided expanded support and benefits for caregivers of 
eligible and covered Veterans. While the law authorized certain 
support services for caregivers of covered Veterans of all 
eras, other benefits were authorized only for qualified family 
caregivers of eligible Veterans who incurred or aggravated a 
serious injury in the line of duty on or after September 11, 
2001. These new benefits for approved family caregivers, 
provided under the Program of Comprehensive Assistance for 
Family Caregivers, include a monthly stipend paid directly to 
designated primary family caregivers and medical care under 
CHAMPVA for designated primary family caregivers who are not 
eligible for TRICARE and not entitled to care or services under 
a health-plan contract.
    Section 2 of S. 1085, the Military and Veteran Caregiver 
Services Improvement Act of 2015, would remove ``on or after 
September 11, 2001'' from the statutory eligibility criteria 
for the Program of Comprehensive Assistance for Family 
Caregivers, and thereby expand eligibility under the program to 
Veterans of all eras who otherwise meet the applicable 
eligibility criteria. Family caregivers could not receive 
assistance under this expanded eligibility until Fiscal Years 
2016, 2018, or 2020 depending on the monthly stipend tier for 
which their eligible Veteran qualifies. Section 2 would also 
add ``or illness'' to the statutory eligibility criteria, and 
thereby expand eligibility to include those Veterans who 
require a caregiver because of an illness incurred or 
aggravated in the line of duty. In addition, the bill would 
expand the bases upon which a Veteran could be deemed to be in 
need of personal care services, to include ``a need for regular 
or extensive instruction or supervision without which the 
ability of the Veteran to function in daily life would be 
seriously impaired.''
    The bill would also expand the assistance available to 
primary family caregivers under the Program of Comprehensive 
Assistance for Family Caregivers to include child care 
services, financial planning and legal services ``relating to 
the needs of injured and ill veterans and their caregivers,'' 
and respite care that includes peer-oriented group activities. 
The bill would ensure that in certain circumstances VA accounts 
for the family caregiver's assessment and other specified 
factors in determining the primary family caregiver's monthly 
stipend amount. In addition, the bill would require VA to 
periodically evaluate the needs of the eligible Veteran and the 
skills of the family caregiver to determine if additional 
instruction, preparation, training, or technical support is 
needed, and it would require certain evaluation be done in 
collaboration with the Veteran's primary care team to the 
maximum extent practicable.
    Section 2 of S. 1085 would also authorize VA, in providing 
assistance under the Program of Comprehensive Assistance for 
Family Caregivers, to ``enter into contracts, provider 
agreements, and memoranda of understanding with Federal 
agencies, States, and private, nonprofit, and other entities'' 
in certain circumstances. It would expand the definition of 
family member to include a non-family member who does not 
provide care to the Veteran on a professional basis, and it 
would amend the definition of ``personal care services.'' The 
bill would also end the Program of General Caregiver Support 
Services on October 1, 2020, but would ensure that all of its 
activities are carried out under the Program of Comprehensive 
Assistance for Family Caregivers. Finally, the bill would amend 
the annual reporting requirements for the Program of 
Comprehensive Assistance for Family Caregivers.
    In September 2013, VA sent a report to the Committees on 
Veterans' Affairs of the Senate and House of Representatives 
(as required by Section 101(d) of the Public Law 111-163) on 
the feasibility and advisability of expanding the Program of 
Comprehensive Assistance for Family Caregivers to family 
caregivers of Veterans who incurred or aggravated a serious 
injury in the line of duty before September 11, 2001. In that 
report, VA noted that expanding the Program of Comprehensive 
Assistance for Family Caregivers would allow equitable access 
to seriously injured Veterans from all eras (who otherwise meet 
the program's eligibility criteria) and their approved family 
caregivers.
    In the report, however, VA noted difficulties with making 
reliable projections of the cost effect of opening the Program 
of Comprehensive Assistance for Family Caregivers to eligible 
Veterans of all eras, but estimated a population range of 
32,000 to 88,000 additional Veterans in the first year 
(estimated for FY 2014), at a cost of $1.8 billion to $3.8 
billion in the first year (estimated for FY 2014). After VA 
provided this report to Congress, the RAND Corporation 
published a report titled, ``Hidden Heroes: America's Military 
Caregivers,'' which estimates a significantly larger eligible 
population (1.5 million) that may be eligible if the program 
were expanded to caregivers of pre-9/11 Veterans. VA's 
estimates in the 2013 report did not account for expansion to 
eligible Veterans with an illness incurred or aggravated in the 
line of duty, other Veterans who would become eligible for the 
program based on the amendments in section 2 of S. 1085, or the 
additional assistance that would become available to primary 
family caregivers under the bill.
    VA cannot responsibly provide a position in support of 
expanding the Program of Comprehensive Assistance for Family 
Caregivers without a realistic consideration of the resources 
necessary to carry out such an expansion, including an analysis 
of the future resources that must be available to fund other 
core direct-to-Veteran health care services. That consideration 
includes the budget levels included in the fiscal year 2016 
budget resolution adopted by Congress, S. Con. Res 11, as well 
as the fiscal year 2016 Military Construction/VA appropriations 
measures passed in the House and awaiting action in the Senate 
(H.R. 2029). This is especially true as VA presses to 
strengthen mental health services and ensure the fullest 
possible access to care across the system.
    While VA has not provided views on section 7 of S. 1085, 
the Department of Justice advises that it has constitutional 
concerns with that provision, which it will provide to the 
Committee under separate cover.
    We wish to make it very clear that VA believes an expansion 
of those benefits that are currently limited by era of service 
would result in equitable access to the Program of 
Comprehensive Assistance for Family Caregivers for long-
deserving caregivers of those who have sacrificed greatly for 
our Nation. However, VA cannot endorse this measure before 
further engaging with Congress on these fiscal constraints, 
within the context of all of VA health care programs. VA 
welcomes further discussion of these issues with the Committee.

           *       *       *       *       *       *       *

             DRAFT LEGISLATION--JASON SIMCAKOSKI MEMORIAL 
                           OPIOID SAFETY ACT

    Section 201 would establish within the Office of the Under 
Secretary for Health an office to be known as the ``Office of 
Patient Advocacy.'' The Office would carry out the Patient 
Advocacy Program of VA. This section would also establish the 
responsibilities of patient advocates at VA medical facilities.
    VHA currently has a Patient Advocacy program established to 
ensure that all Veterans and their families served in VHA 
facilities and clinics have their complaints addressed in a 
convenient and timely manner. The program operates under a 
philosophy of Service Recovery, whereby patient complaints are 
identified, resolved, classified, and utilized to improve 
overall services to Veterans.
    As health care continues to evolve, so does the role of the 
Patient Advocate. The role of the advocate in VHA has 
traditionally been more reactive, i.e. responding to issues as 
they arise, hearing and reacting to patient complaints as they 
bring them forward. With a heightened awareness of the 
importance of a positive, patient experience, VHA is on the 
pathway to transform the program including the role of the 
Patient Advocate to focus on a more proactive approach by all 
staff that would result in a more positive patient experience.
    Earlier this month, to maintain the highest standard for 
responding to patient issues while continually improving the 
advocacy program, VHA established the Client Services Response 
Team (CSRT), reporting directly to the Office of the Under 
Secretary for Health. The CSRT is charged to centralize and 
streamline internal processes to improve VHA's overall 
responsiveness to the concerns of Veterans, employees and other 
key stakeholders.
    The proposed bill reflects the existing Patient Advocacy 
program but does not account for the strategy to transform the 
Patient Advocate role to keep pace with private sector advances 
in patient experience. The model has been successfully 
demonstrated in VHA pilots and private sector health care 
systems\27\ and is consistent with VA's vision of providing 
world-class customer service. This vision will engage staff 
from across the organization as well as Veterans to be actively 
involved in the transformation process. VA is thus very 
supportive of the concept in section 201, but has concerns that 
detailed statutory directives could restrict the evolution and 
breadth of the Patient Advocacy program.
---------------------------------------------------------------------------
    \27\Merlino, J (2015). Service fanatics: how to build a superior 
patient experience the Cleveland Clinic way. New York, NY: McGraw-Hill 
Education.
---------------------------------------------------------------------------
    VA supports section 202 which would require VA Medical 
Centers and Community Based Outpatient Clinics to host 
community meetings, open to the public, on improving health 
care from the Department. This section is consistent with 
current practices of hosting Town Hall meetings to hear from 
Veterans, families, and other stakeholders.
    Section 203 would require VA display at each VA medical 
facility the purposes of the Patient Advocacy Program, contact 
information for the patient advocate, and the rights and 
responsibilities of patients and family members. VA supports 
increasing the awareness of the Patient Advocacy Program and 
the Rights and Responsibilities of Veterans and family members. 
This section is consistent with current practices of posting 
this information in medical facilities and would only require 
the addition of posting the Patient Advocacy Program's purpose.
    VA supports the intent of title III which seeks to expand 
research, education and delivery of complementary and 
integrative health (CIH) to Veterans. VA is committed to 
expanding the research, education and delivery of complementary 
and integrative health services to Veterans. Aligning with VA's 
Blueprint for Excellence VHA leadership identified as its 
number one strategic goal ``to provide Veterans personalized, 
proactive, patient-driven health care.'' This approach to 
health care prioritizes the Veteran and their values, and 
partners with them to create a personalized strategy to 
optimize their health, healing, and well-being. Many of the 
strategies that may be of benefit extend beyond what is 
conventionally addressed or provided by the health system and 
includes CIH. To this end, VA is establishing the Integrative 
Health Coordinating Center within the Office of Patient 
Centered Care and Cultural Transformation (OPCC&CT).
    OPCC&CT, along with Patient Care Services, deployed a 
national survey on CIH to better understand the evolution of 
how these services are being provided across the system and to 
advance further implementation. The survey was deployed to all 
VA parent medical facilities with a 100 percent completion 
rate. This report is being finalized this month for review by 
VHA and VA leadership.
    VA is preparing the current workforce through a focus on 
education of the clinical staff. OPCC&CT developed the Whole 
Health Clinical Education Program which is designed to educate 
clinicians in providing a proactive, whole person approach. 
This includes learning how to effectively integrate CIH 
approaches. This inter-professional training includes VA 
physicians, nurses, dietitians, chaplains and other clinical 
staff. The core curriculum was designed and launched in 2014 
and targets traditional health care providers across VHA.
    The evaluation demonstrated that clinicians had improved 
attitudes towards Integrative Health, as well as changes in 
intentions to integrate mindful awareness in interactions with 
Veterans, encourage the use of self-care strategies, encourage 
the use of integrative health strategies during clinical 
encounters, and to co-manage patients with practitioners 
outside their own medical paradigm.
    To implement safe and effective management of pain, VHA's 
National Pain Program office oversees several work groups and a 
National Pain Management Strategy Coordinating Committee 
representing the VHA offices of nursing, pharmacy, mental 
health, primary care, anesthesia, education, integrative 
health, and physical medicine and rehabilitation. Working with 
the field, these groups develop, review and communicate strong 
pain management practices to VHA clinicians and clinical teams.
    VHA has multiple projects, coordinated under the National 
Pain Program office, to support and educate clinicians and 
Veterans about safe and effective stepped pain management, 
including use of opioids. Programs such as the Opioid Safety 
Initiative (OSI), the Joint Pain Education and Training Project 
(JPEP) with Department of Defense (DOD), the Tiered Acupuncture 
Training Across Clinical Settings (ATACS) with DOD, the Pain 
Mini-residency, Pain Specialty Care Access Network (SCAN ECHO), 
asynchronous Web-based training, and Community of Practice 
calls all reach across the VHA to train primary care providers 
in all settings in the assessment and treatment of pain and in 
the use of patient education in self-management, the use of 
multiple modalities such as behavioral, integrative medicine 
(Complementary and Alternative Medicine, or CAM), and physical 
therapies and the use of consultant specialists in pain, mental 
health, and CAM.
    For example, on the topic of opioids safety, all the 
education programs listed above, except ATACS which is focused 
on acupuncture skill training, have presentations on universal 
precautions and risk management in opioid therapy for pain, 
including clinical evaluation, written informed consent, 
screening such as urine drug monitoring, use of state 
monitoring programs, and safe tapering. Related specifically to 
safe opioid prescribing, the VHA has implemented the Opioid 
Safety Initiative, a mandatory academic detailing program that 
identifies targets of risky practices (e.g., high opioid doses, 
co-prescribed benzodiazepines, use of urine drug screens) and 
universally monitors these practices in VHA at the provider and 
facility/VISN level through appointed VISN and facility OSI and 
Pain Management Point of Contact, or POCs. A POC is a clinician 
appointed and supported at the VISN level who is an 
appropriately trained, experienced and credentialed in pain 
medicine, pain management, or another credential appropriate to 
the clinical discipline. These individuals identify targets of 
risky practices through regular monthly and `on-demand' 
progress reports, and provide education and counseling for 
facilities and prescribers whose patterns of prescribing and 
pain management practices require remediation.
    To provide clinical education and resource support to 
providers and facilities for successful OSI implementation, the 
National Pain Program office established the interdisciplinary 
OSI Toolkit Task Force to systematically peer-review and 
standardize clinical education and patient education materials 
for distribution throughout VHA. The OSI Toolkit Task force has 
completed peer-review, revision and approval of the below 
trainings and materials and meets regularly to peer-review, 
revise, and publish new ``strong practices'' that are 
identified in VHA.
    Most recently, in March 2015, the National Pain Management 
launched the new Opioid Therapy Risk Report tool which provides 
detailed information on the risk status of Veterans taking 
opioids to assist VA primary care clinicians with pain 
management treatment plans. This tool is a core component of a 
reinvigorated focus on patient safety and effectiveness.
    In 2014, VA's Office of Academic Affiliations in 
conjunction with Physical Medicine and Rehabilitation Services 
launched a national VA Chiropractic residency program. The VA 
Chiropractic program has been engaged in chiropractic education 
and training for a decade. Since 2004 over 1,500 chiropractic 
students have completed clinical rotations at 24 VA facilities. 
The VA chiropractic residency program focuses on Integrated 
Clinical Practice, with training emphasizing the provision of 
chiropractic care in an integrated health care system, 
collaborating with primary care Patient Aligned Care Teams 
(PACTs), specialty care, and other medical and associated 
health providers and trainees. Individual residencies are 
administered by the respective local VA facilities. Each VA 
facility partners with its affiliated Council on Chiropractic 
Education accredited chiropractic school in conducting the 
program.
    VA Research is actively engaged with the community of 
scientists in establishing the evidence base for complementary 
and integrative health treatments for physical and mental 
conditions, the latter including examining the benefit of CIH 
therapy for PTSD, suicide prevention, and mood disorders. As 
these studies are completed, results will be evaluated to 
determine potential impact on Clinical Practice Guidelines. The 
VA Evidence-based Synthesis Program in conjunction with OPCC&CT 
and Patient Care Services has examined the scientific 
literature on various CAM services and have presented the 
findings in the form of ``evidence maps.'' An evidence review 
and map in acupuncture, yoga, Tai Chi and mindfulness has been 
completed. The findings from these reviews are helping to 
inform decisions on how to best use CAM within VA and identify 
areas for further research.
    Section 401 would require that as part of the hiring 
process VA reach out to state medical boards to ascertain 
whether a prospective employee has any violations over the past 
twenty years, or has entered into a settlement agreement 
related to the employee's practice of medicine. VA does not 
feel that additional legislation is needed to accomplish this. 
VHA policy, already in place, requires the verification of all 
current and previously held licenses for all licensed health 
care providers. At the time of initial appointment all current 
and previously held licenses are verified with the state 
licensing board issuing the license. Verification requires 
querying the state licensing board for not only the issue date 
and expiration date, but also any pending or previous adverse 
actions. If an adverse action is identified, the verification 
requires obtaining all documentation available associated with 
such action, including but not limited to copies of any 
agreements. At the time of expiration of a license as well as 
at the time of reappraisal, VHA policy requires querying the 
state licensing board to confirm renewal of the license as all 
as whether or not there have been any new pending or previous 
adverse actions. If the license is not renewed, VHA policy 
requires confirmation that the license expired in good standing 
and if not, what was not in good standing.
    At the time of initial appointment, all health care 
providers are queried through the National Practitioner Data 
Bank (NPDB). The NPDB is a national flagging system that serves 
as a resource for hospitals and other health care entities 
during the provider credentialing process. The NPDB provides 
information about past adverse actions of health care 
providers. VHA also enrolls all independent, privileged 
providers in the NPDB's Continuous Query program for ongoing 
monitoring of not only adverse actions taken against a 
credential, but also paid malpractice. VHA receives 
notification of a new report within 24 hours of the report 
being filed with the NPDB.
    Additionally, at the time of initial appointment, all 
physicians are queried through the Federation of State Medical 
Boards (FSMB) Federation Physician Data Center, a nationally 
recognized system for collecting, recording and distributing to 
state medical boards and other appropriate agencies data on 
disciplinary actions taken against licensees by the boards and 
other governmental authorities. The report returned from the 
FSMB Physician Data Center not only identifies if there are any 
adverse actions recorded against a physician's license but also 
lists all of the physician's known licenses, current or 
previously held, serving as double-check that the physician 
reported all licenses during the credentialing process. In 
addition, the licenses of all physicians are monitored through 
a contract with the FSMB's Disciplinary Alert Service (DAS). 
Through this contract, all physicians are enrolled in the DAS 
which offers ongoing monitoring of physician licensure. If a 
new action against a physician's license is reported to the 
FSMB DAS, VHA receives a notification of the report within 24 
hours. The staff at the physician's facility then contacts the 
reporting state licensing board to obtain the details of the 
action.
    If the facility learns of an adverse action taken against a 
provider license, the staff at the facility must obtain 
information from the provider against whom the action was taken 
and consider it as well as the information obtained from the 
state licensing board. This review is documented to include the 
reasons for the review, the rationale for the conclusions 
reached, and the recommended action for consideration and 
appropriate action by the facility.
    Section 402 would require VA to provide the relevant state 
medical board detailed information about any health care 
provider of VA that has violated a requirement of their medical 
license. We also believe in this case additional legislation is 
not required. VA has broad authority to report to state 
licensing boards those employed or separated health care 
professionals whose behavior or clinical practice so 
substantially failed to meet generally-accepted standards of 
clinical practice as to raise reasonable concern for the safety 
of patients. The authority to report those professionals is 
derived from VA's long-standing statutory authority, contained 
in 38 U.S.C. 7401-7405, which authorizes the Under Secretary 
for Health, as head of VHA, to set the terms and conditions of 
initial appointment and continued employment of health care 
personnel, as may be necessary, for VHA to operate medical 
facilities. This authority includes requiring health care 
professionals to obtain and maintain a current license, 
registration, or certification in their health care field.
    The Veterans Administration Health-Care Amendments of 1985, 
Public Law 99-166, and Part B of Title IV of Public Law 99-660, 
the Health Care Quality Improvement Act of 1986, are Acts 
require VHA to strengthen quality assurance and reporting 
systems to promote better health care. Pursuant to section 204 
of Public Law 99-166, VA established a comprehensive quality 
assurance program for reporting any licensed health care 
professional to state licensing boards who:

          (1) Was fired or who resigned following the 
        completion of a disciplinary action relating to such 
        professional's clinical competence;
          (2) Resigned after having had such professional's 
        clinical privileges restricted or revoked; or
          (3) Resigned after serious concerns about such 
        professional's clinical competence had been raised, but 
        not resolved.

    The statutory provisions of 38 U.S.C. 7401-7405, augmented 
by Public Laws 99-166 and 99-660, provide VHA ample authority 
to make reports to state licensing boards when exercised 
consistent with Privacy Act requirements for release of 
information. VHA policy requires the VA medical facility 
Director to ensure that within seven calendar days of the date 
a licensed health care professional leaves VA employment, or, 
information is received suggesting that a current employee's 
clinical practice has met the reporting standard, an initial 
review of the individual's clinical practice is conducted to 
determine if there may be substantial evidence that the 
individual so substantially failed to meet generally-accepted 
standards of clinical practice as to raise reasonable concern 
for the safety of patients.
    Usually this review is conducted and documented by first 
and second level supervisory officials. When the initial review 
suggests that there may be substantial evidence that the 
licensed health care professional so failed to meet generally-
accepted standards of clinical practice as to raise reasonable 
concern for the safety of patients, the medical facility 
Director is responsible for immediately initiating a 
comprehensive review to determine whether there is, in fact, 
substantial evidence that this reporting standard has been met. 
This review involves the preparation of a state licensing board 
Reporting File. VHA policy defines the process for collecting 
evidence; notifying the provider of the intent to report which 
affords the provider the opportunity to respond in writing to 
the allegations; and then the review process to assure that VHA 
has complied with the Privacy Act prior to reporting.
    It is VA's policy to cooperate whenever possible with an 
inquiry by a state licensing board. VA medical facilities must 
provide reasonably complete, accurate, timely, and relevant 
information to a state licensing board in response to 
appropriate inquiries.
    Mr. Chairman, thank you for the opportunity to present our 
views on the legislation today and we will be glad to answer 
any questions you or other Members of the Committee may have.
                                ------                                

 STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR 
   HEALTH CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

    Good afternoon Chairman Isakson, Ranking Member Blumenthal, 
and Members of the Committee. Thank you for inviting us here 
today to present our views on several bills that would affect 
VA benefits programs and services. Joining me today are Robert 
Worley, Director of the Education Service in the Veterans 
Benefits Administration, Catherine Mitrano, Deputy Assistant 
Secretary for Resolution Management, and Susan Blauert and Kim 
McLeod, who are both Deputy Assistant Counsels in VA's Office 
of General Counsel

           *       *       *       *       *       *       *

  S. 1450, DEPARTMENT OF VETERANS AFFAIRS EMERGENCY MEDICAL STAFFING 
                     RECRUITMENT AND RETENTION ACT

    S. 1450 would allow VA to arrange flexible physician and 
physician assistant work schedules to allow for the hiring and 
full implementation of a hospitalist physician system and to 
accommodate the unusual work schedule requirements for 
Emergency Medicine (EM) Physicians.
    VA supports increased flexibility for critical medical 
personnel. Hospitalist physicians and EM physicians specialize 
in the care of patients in the hospital, often working 
irregular work schedules to accommodate the need for continuity 
of efficient hospital care. VA believes that increased 
scheduling flexibility would align VA practice with the private 
sector, facilitating the recruitment, retention of emergency 
physicians and the recruitment, retention and operation of a 
hospitalist physician system at VA medical centers (VAMC). We 
note concerns that the Office of Personnel Management will 
provide in its statement for the record with respect to certain 
of the bill's provisions. The Administration looks forward to 
working with the Congress and our agency partners to finalize 
language on these provisions.
    VA believes S. 1450 would be cost neutral in terms of 
impact on salaries as it merely authorizes flexibility in 
physician and physician assistant work schedules to allow for 
the hiring and full implementation of a hospitalist physician 
system and improvements in EM physician coverage and enhanced 
ability to recruit EM trained and experienced physicians.

            S. 1451, VETERANS' SURVIVORS CLAIMS PROCESSING 
                         AUTOMATION ACT OF 2015

    S. 1451, the ``Veterans' Survivors Claims Processing 
Automation Act of 2015,'' would authorize VA to pay benefits to 
a survivor of a Veteran who has not filed a formal claim if the 
record contains sufficient evidence to establish the survivor's 
entitlement to such benefits. The bill would specify that the 
date on which a survivor notifies VA of the Veteran's death 
would be treated as the date of receipt of the survivor's 
application for benefits. S. 1451 would be applicable to claims 
based on a death occurring on or after the date of enactment of 
this legislation.
    VA supports S. 1451. The Department submitted a similar 
legislative proposal for the Fiscal Year (FY) 2016 Budget. 
Under 38 U.S.C. 5101(a), a claimant must file a formal claim as 
a condition of receiving benefits. However, when a survivor of 
a Veteran files a claim for VA benefits based upon the 
Veteran's death, the information and evidence necessary to 
decide the claim is often contained in the Veteran's claims 
file. As a result, it is not necessary from a practical 
standpoint for a claimant to file a formal claim in such 
circumstances. Elimination of the formal-claim requirement 
would automate the delivery of uninterrupted benefits to 
qualifying survivors.
    VA has one technical comment. VA would prefer to change the 
language from ``the date on which a survivor of a Veteran 
notifies the Secretary of the death of the Veteran,'' to ``the 
date on which the Secretary is notified of the Veteran's 
death.'' The modified language would allow VA to be more 
liberal when providing benefits in instances where the survivor 
is not the individual notifying VA of the Veteran's death.
    VA estimates that there would be no benefit or general 
operating expenses (GOE) associated with S. 1451.

            S. 1460, FRY SCHOLARSHIP ENHANCEMENT ACT OF 2015

    S. 1460 would allow recipients of the Marine Gunnery 
Sergeant John David Fry Scholarship to be eligible for the 
Yellow Ribbon program under the Post-9/11 GI Bill. The Yellow 
Ribbon program is currently available to Veterans and most 
transfer-of-entitlement recipients receiving Post-9/11 GI Bill 
benefits at the 100 percent benefit level attending 
institutions of higher learning. The program provides payment 
for up to half of the tuition-and-fee-charges that are not 
covered by the Post-9/11 GI Bill, such as charges that exceed 
an academic year cap or out-of-state charges, if the 
institution enters into an agreement with VA to pay or waive an 
equal amount of the charges that exceed Post-9/11 GI Bill 
coverage. This bill would take effect for the academic year 
(August 1) beginning after the date of enactment.
    VA does not object to S. 1460, subject to Congress 
identifying acceptable offsets for the additional benefit 
costs. VA would need to make modifications to its existing 
information technology (IT) systems to implement this 
legislation. Specifically, VA would need to modify the Benefits 
Delivery Network (BDN), the VA-Online Certification of 
Enrollment (VA-ONCE), and the Post-9/11 GI Bill Long-Term 
Solution (LTS), to calculate eligibility and award Yellow 
Ribbon program payments for Fry Scholarship beneficiaries. VA 
estimates that it would require 1 year from the date of 
enactment to make the IT system changes necessary to implement 
the proposed legislation.
    VA estimates the benefit costs associated with enactment of 
the bill to be $492,000 in FY 2016, $2.7 million over 5 years, 
and $6.2 million over 10 years. Although VBA administrative 
costs are estimated to be insignificant, IT costs are estimated 
to be $5 million. This IT estimate consists of the design, 
development, testing, and deployment of the new functionality 
that would be needed to meet the requirements of this 
legislation.

S. 1856, VA EQUITABLE EMPLOYEE ACCOUNTABILITY ACT OF 2015

           *       *       *       *       *       *       *

    Section 6 of S. 1856 would require VA to provide all 
managers with periodic training on whistleblower rights and 
managing and motivating employees. VA already offers managers 
the training discussed in section 6. Moreover, some training, 
such as whistleblower rights and protections, is already 
required for all managers. Nevertheless, VA is committed to the 
principles of section 6 of S. 1856 and supports this section.

           *       *       *       *       *       *       *

           S. 1938, CAREER READY STUDENT VETERANS ACT OF 2015

    S. 1938, the ``Career-Ready Student Veterans Act of 2015,'' 
would amend title 38, United States Code, to improve the 
approval of certain VA programs of education for purposes of 
educational assistance.
    This bill would amend 38 U.S.C. 3676(c), pertaining to the 
approval of non-accredited courses, by adding new requirements 
to the criteria that must be met for State approving agencies 
to approve institutions' written applications for approval of 
non-accredited courses. First, in the case of a program 
designed to prepare an individual for licensure or 
certification in a State, the program would need to meet any 
instructional curriculum licensure or certification 
requirements of that State. Second, in the case of a program 
designed to prepare an individual for employment pursuant to 
standards developed by a board or agency of a State in an 
occupation that would require approval or licensure, the 
program would need to be approved or licensed by such board or 
agency of the State.
    The bill also would add subsection (f) to section 3676 to 
permit VA to waive the aforementioned requirements in the case 
of a program of education offered by an educational institution 
if VA determined:

     The educational institution was accredited by an 
agency or association recognized by the Department of 
Education;
     The program did not meet the requirements at any 
time during the 2-year period preceding the date of the waiver;
     The waiver furthers the purposes of the 
educational assistance programs administered by VA or would 
further the education interests of individuals eligible for 
assistance under such programs;
     The educational institution does not provide any 
commission, bonus, or other incentive payment based directly or 
indirectly on success in securing enrollments or financial aid 
to any persons or entities engaged in any student recruiting or 
admission activities or in making decisions regarding the award 
of student financial assistance, except for the recruitment of 
foreign students residing in foreign countries who are not 
eligible to receive Federal student assistance.

    Subsection (d) of the proposed legislation would add a new 
subsection to section 3679 of title 38 to require VA to 
disapprove a non-accredited course of education designed to 
prepare an individual for licensure or certification in a State 
or for employment pursuant to standards developed by a board or 
agency of a State in an occupation that requires approval or 
licensure, if the educational institution providing the course 
of education does not publicly disclose any conditions or 
additional requirements, including training, experience, or 
exams, required to obtain the license, certification, or 
approval for which the course of education is designed to 
provide preparation.
    Subsection (e) of this bill would amend section 
3672(b)(2)(A)(i) to include the new approval requirements for 
non-accredited courses in the approval requirements for 
``deemed approved'' accredited programs.
    The bill would also amend 38 U.S.C. 3675, to apply the new 
requirements in section 3676(c), to the approval conditions for 
accredited courses offered by private for-profit institutions.
    VA supports the intent behind this bill. However, we do not 
support the bill as currently drafted for a number of reasons.
    If enacted, the bill would ensure that non-accredited 
courses pursued by GI Bill beneficiaries meet all of the State 
requirements for licensure or certification in a given 
occupation or career field and would be approved by the State 
board or agency that developed the standards. VA does not 
oppose the concept of additional criteria for the approval of 
non-accredited courses. However, we note that, as written, the 
bill would not allow the Secretary to waive the requirement for 
non-accredited courses, as the institution must be accredited 
in order to meet the criteria for a waiver. VA is unclear as to 
the reason why an accreditation requirement would be inserted 
in the approval criteria for non-accredited programs. In 
general, an institution's accreditation applies to all of the 
courses offered by the institution, and accredited courses have 
different approval requirements.
    Additionally, the bill would ensure that accredited courses 
at private, for-profit institutions meet all State requirements 
for certification and licensure. VA supports efforts to ensure 
that Veterans and other GI Bill beneficiaries are well-trained 
and adequately equipped to obtain employment and achieve 
economic success. However, we note that the proposed licensure 
and certification requirements would not be applied to similar 
programs at public and private, not-for-profit institutions. 
Consequently, the bill does not ensure that all Veterans and 
beneficiaries would receive all of the training required for 
licensure or certification in their chosen occupational fields.
    VA also has concerns about the language in the new section 
3679(d), which would require the disapproval of waived programs 
if the educational institution does not publicly disclose the 
additional conditions or requirements needed in order to meet 
licensing or certification requirements. VA believes ``the 
Secretary or the appropriate State approving agency'' should be 
substituted for ``the Secretary,'' as the State approving 
agencies are responsible for the approval of non-accredited 
courses. As State employees, they have subject matter expertise 
with regard to the specific State requirements for licensure or 
certification and, consequently, are better-positioned to 
determine the gaps in training or conditions that must be 
publicized. In addition, to be consistent with approval 
authorities in other sections of chapter 36, VA believes that 
both the Secretary and the SAA should have this authority.
    VA is unclear as to the intent underlying the proposed 
amendment to 3672(b)(2)(A)(i). As written, it could be 
interpreted to include non-accredited programs in a ``deemed 
approved'' category. However, if the intent is to make the 
proposed paragraphs (14) and (15) of section 3676(c) apply to 
accredited programs at public and proprietary not-for-profit 
institutions of higher learning as well, then it should be 
reworded to read, ``Subject to paragraphs (14) and (15) of 
section 3676(c) of this title, an accredited.'' In addition, we 
note that, as currently drafted, the licensure and 
certification requirements could not be waived for these 
programs. VA believes that the waiver authority should apply to 
accredited programs at public and proprietary not-for-profit 
institutions of higher learning as well as to accredited 
courses at private, for-profit institutions and non-accredited 
programs.
    VA estimates that there would be no additional mandatory or 
discretionary cost requirements associated with the enactment 
of this bill.

      DRAFT BILL REGARDING IMPROVEMENTS IN EDUCATIONAL ASSISTANCE

    Section 1 of the proposed legislation would add a new 
section (3326) under subchapter III of chapter 33, title 38 
U.S.C. Specifically, this section proposes to recodify the 
provisions of Public Law (Pub. L.) 110-252, section 5003(c), to 
bring those requirements into title 38, and it proposes a few 
amendments to those requirements.
    The Post-9/11 GI Bill (or chapter 33) requires individuals 
to relinquish eligibility to some other VA education benefit, 
as applicable, in order to receive the chapter 33 benefits.
    Subsection (a) of the proposed 38 U.S.C. 3326 would define 
the eligibility requirements for individuals to elect chapter 
33 educational benefits. Individuals would be able to elect to 
receive chapter 33 benefits if, as of August 1, 2009, they were 
entitled to the MGIB-AD, MGIB-Selected Reserve (SR), or the 
Reserve Educational Assistance Program, and had some or all of 
their entitlement remaining under those programs. Individuals 
would be able also to elect chapter 33 if they are making 
contributions to receive MGIB-AD, or previously declined 
participation in the MGIB-AD program.
    Subsection (b) of the proposed 38 U.S.C. 3326 would call 
for the cessation of contributions toward MGIB-AD if an 
individual elects to receive chapter 33 while still making 
contributions to MGIB-AD. The obligation to make contributions 
would cease the first month after the individual elects chapter 
33 benefits.
    Subsection (c) of the proposed 38 U.S.C. 3326 would address 
the revocation of remaining entitlement transferred to a 
dependent under MGIB-AD, if the individual who transferred the 
benefit elects to receive chapter 33 benefits instead. The 
proposed legislation would allow the transferor to revoke any 
unused benefits that have been transferred to a dependent. If 
the transferor revoked the transferred benefits from his or her 
dependent, then the remaining entitlement would be available 
for the transferor to use under chapter 33. If the transferor 
did not elect to revoke the transferred MGIB-AD benefits, then 
those benefits would remain available to the dependent under 
MGIB-AD.
    Subsection (d) of the proposed 38 U.S.C. 3326 would state 
that individuals who make an election would be eligible for 
benefits under chapter 33, rather than under the relinquished 
benefit. It also would state that if individuals elected to 
receive chapter 33 in lieu of MGIB-AD, and had previously used 
entitlement under MGIB-AD, they would have eligibility under 
chapter 33 for the number of months of entitlement that were 
remaining under MGIB-AD, plus any entitlement that was revoked 
from a dependent in accordance subsection (c).
    Subsection (e) of the proposed 38 U.S.C. 3326 would allow 
individuals who elect to receive educational assistance under 
chapter 33 to receive payments at the rate available under the 
relinquished benefit if their educational pursuit is authorized 
under the relinquished benefit, but not under chapter 33. Any 
entitlement used would be charged against chapter 33 in the 
same manner as it would be charged against the relinquished 
benefit.
    Subsection (f) of the proposed 38 U.S.C. 3326 would outline 
additional chapter 33 assistance for members who made 
contributions toward the MGIB-AD program. A refund of MGIB-AD 
contributions would be issued to a qualifying Veteran as an 
increase to the last monthly housing stipend when benefit 
entitlement is exhausted. The amount of the refund would be 
calculated by taking the remaining months of entitlement under 
MGIB-AD, at the time of the chapter 33 election, plus the 
number of months, if any, of entitlement under chapter 30 that 
were revoked by the individual and dividing that number by 36. 
The result would be multiplied by the dollar amount that the 
Veteran contributed toward the MGIB-AD, and the resulting 
amount would be issued in conjunction with the final monthly 
housing stipend. This proposed legislation would also change 
the corresponding language currently contained in section 
5003(c) of Pub. L. 110-252 by also authorizing refunds to 
individuals pursuing programs at non-degree granting 
institutions.
    Subsection (g) of the proposed 38 U.S.C. 3326 would provide 
for continued entitlement to additional assistance for critical 
skills, specialty, and/or service (i.e., a college fund or 
kicker) to which an individual was entitled under MGIB-AD or 
MGIB-SR prior to relinquishing one of those benefits and 
establishing eligibility under chapter 33. The additional 
assistance would be paid in conjunction with the individual's 
monthly housing stipend.
    Subsection (h) of the proposed 38 U.S.C. 3326 would provide 
VA with the authority to make an alternative election for an 
individual if the election submitted by the applicant is not in 
his or her best interest. If an individual elected to receive a 
benefit that would be clearly not in his or her best interest 
on or after January 1, 2016, VA would be able to change the 
election and would be required to notify the individual of the 
change within 7 days. The individual would be allowed 30 days 
from the date he or she received the VA notification to modify 
or revoke the election made by VA. In addition, VA would notify 
the individual of the change of election by electronic means 
whenever possible. These provisions are not included in section 
5003(c) of Pub. L. 110-252; therefore, they would constitute a 
new authority.
    Subsection (i) of the proposed 38 U.S.C. 3326 would provide 
that any election made under section 3326 would be irrevocable.
    Finally, this section would repeal subsection (c) of 
section 5003 of the Post-9/11 Veterans Educational Assistance 
Act of 2008 (Pub. L. 110-252; 38 U.S.C. 3301 note).
    VA does not object to (a) through (g) of the proposed 38 
U.S.C. 3326 because these provisions are, generally, identical 
to those that were enacted in section 5003(c) of Pub. L. 110-
252, with the exception of one minor change in the proposed 
section 3326(f), which would also authorize refunds of MGIB-AD 
contributions to individuals receiving monthly stipend payments 
for pursuit of non-degree programs under 38 U.S.C. 3313(g).
    However, VA has concerns with subsection (h) of the 
proposed 38 U.S.C. 3326, which would allow VA to make an 
alternative election on behalf of the Veteran that VA 
determines is in his or her best interests. As individuals' 
situations are different, elections made in the best interest 
of a Veteran would be highly subjective. While one claims 
examiner might view an election option as being the best, 
another might disagree. Therefore, VA recommends specific 
criteria for an election be added to the legislation that would 
eliminate subjectivity. For example, in some instances, a 
Veteran elects to relinquish MGIB-AD to receive chapter 33 
benefits when he or she has only a few months of MGIB-AD 
entitlement remaining. If the individual has more than one 
qualifying period of service, it may be in that individual's 
best interest to finish 36 months of entitlement under MGIB-AD 
before beginning to receive chapter 33 benefits--the individual 
could then receive up to 12 months of entitlement under chapter 
33. If this situation met the criteria in the legislation as 
enacted, the Veteran's claim would be processed under the 
chapter 30 program until his or her entitlement under that 
program ends.
    VA also recommends that the proposed legislation include 
language to allow VA to make an election in cases where a 
Veteran or Servicemember applies for chapter 33 benefits and 
does not elect to relinquish any benefit. This would allow VA 
to maximize automation, improve processing times, and obviate 
the need to contact the Veteran for an election.
    Further, VA has concerns with the impact this subsection 
would have on the automation of original claims using LTS. If 
VA has to make an alternative election under chapter 33 when a 
Veteran is eligible for more than one benefit, claims' 
examiners would have to review the majority of chapter 33 
original claims. The need for this review would limit the 
number of original claims that could be automated through LTS 
without human intervention, increasing the length of time that 
Veterans would be waiting to receive their benefits.
    VA estimates the cost of this section would be 
insignificant because subsections (a) through (g) of the 
proposed 38 U.S.C. 3326 are provisions that are already in 
place under section 5003(c) of Pub. L. 110-252 and, therefore, 
would result in no additional cost. In some cases, subsection 
(h) may result in a Veteran receiving a better benefit that 
would increase costs to VA. However, due to VA's current 
outreach efforts, such as the GI Bill Comparison Tool, and the 
amount of information available to assist Veterans in making 
informed decisions on education benefits, VA does not 
anticipate making a significant number of alternative 
elections. Therefore, anticipated costs to the readjustment 
benefits account are insignificant.
    Section 2 would amend 38 U.S.C. 3684(a) to define the term 
``educational institution'' to include a group, district, or 
consortium of separately accredited educational institutions 
located in the same State, and which are organized in a manner 
that facilitates the centralized reporting of their 
enrollments. This legislation would also amend section 3684(a) 
to include individuals enrolled under chapters 32 and 33.
    The proposed legislation would apply to any reports of 
enrollment submitted on or after the date of enactment.
    VA supports section 2. This legislation would allow each 
institution in a district/consortium to certify a student's 
enrollment regardless of where the student is matriculated. 
Furthermore, since school certifying officials at ``District'' 
institutions have access to student records and all courses 
have universal numbering, VA compliance visits could be done at 
any institution and records would be available for students who 
attend any of the institutions included in the group, district, 
or consortium.
    There would be no additional cost for implementing this 
provision because the reporting fees would be paid to the 
school that is certifying the enrollment, regardless of the 
location of the institution.
    Section 3 would amend subsection 38 U.S.C. 3313(c)(1)(A) to 
limit the benefits paid for pursuit of certain degree programs 
at a public institution of higher learning (IHL). It would 
limit the amount of tuition and fees payable for certain 
programs at IHLs, specifically those that involve a contract or 
agreement with an entity (other than another public IHL) to 
provide a program of education or a portion of a program of 
education, to the same amount per academic year that applies to 
programs at private or foreign IHLs. This section would be 
effective the first day of a quarter, semester, or term 
(whatever is applicable) after the legislation's enactment.
    VA supports legislation that would limit the amount of 
tuition and fee payments at public IHLs that involve contracted 
training. VA is concerned about high tuition and fee payments 
for enrollment in degree programs involving flight training at 
public IHLs. Education benefit payments for these types of 
programs have increased tremendously with the implementation of 
P.L. 111-377, and in some cases, public institutions seem to be 
targeting Veterans for their flight-related training programs.
    There has been a significant increase in flight training 
centers, specifically those that offer helicopter training, 
that have contracted with public IHLs to offer flight-related 
degrees. Sometimes these programs charge higher prices than 
those that would be charged if the student had chosen to attend 
the vocational flight school for the same training.
    Additionally, VA has also noticed a growing number of VA 
beneficiaries are taking flight courses as electives. VA allows 
for ``rounding out,'' whereby non-required courses may be taken 
to bring a student's course load up to full-time status in the 
student's last term. Based on anecdotal evidence, some schools 
are enrolling students in these very expensive flight courses 
when ``rounding out'' is applicable. In most cases, these 
courses are not specifically required for the Veteran's degree.
    VA is still determining the costs associated with this 
provision.
    Section 4 would add a new section 3699 to title 38, U.S.C., 
requiring VA to make available to educational institutions 
information about the amount of educational assistance to which 
a Veteran or other individual is entitled under chapter 30, 32, 
33, or 35. This information would be provided to the 
educational institution through a secure information technology 
system accessible by the educational institution and updated 
regularly to reflect any amounts used by the Veteran or other 
individual.
    VA supports the intent behind providing educational 
institutions with the number of months of educational 
assistance to which a Veteran is entitled. Currently, VA 
provides the amount of a Veteran's entitlement (original and 
remaining) and other information (i.e., the delimiting date) to 
the educational institution through the VA Online Certification 
of Enrollment (VA-ONCE) system. The educational institution in 
which the student is enrolled can view this information for 
individuals training under chapters 30, 1606, and 1607 after VA 
processes an award for education benefits. This functionality 
is not currently available for Veterans or other individuals 
training under chapters 32, 33, or 35; therefore, VA would need 
to make programming changes to VA-ONCE in order to make this 
information available as well.
    VA recommends removing the requirement to provide 
information for individuals training under chapter 32 from the 
proposed legislation. Chapter 32 usage has decreased from 560 
beneficiaries in FY 2008 to 2 beneficiaries for fiscal year 
2015 through June 30, 2015. Because eligibility for chapter 32 
ends 10 years after an individual's release from active duty, 
the majority of those with remaining entitlement are likely 
also eligible for benefits under chapter 33.
    VA estimates the administrative costs for developing the 
functional requirements of this section to be $500,000, and the 
information technology (IT) costs associated with this section 
to be $5 million to make enhancements to VA-ONCE to provide 
newly required information to educational institutions.
    Section 5 would amend 38 U.S.C. 3672(b)(2)(A) to authorize 
State Approving Agencies (SAA) to determine if a program of 
education is deemed to be approved for purposes of this chapter 
if the program is one of the following:

     An accredited standard college degree program 
offered at a public or not-for-profit proprietary educational 
institution that is accredited by an agency or association 
recognized for that purpose by the Secretary of Education.
     A flight training course approved by the Federal 
Aviation Administration (FAA) that is offered by a certified 
pilot school that possesses a valid FAA pilot school 
certificate.
     An apprenticeship program registered with the 
Office of Apprenticeship, Employment Training Administration, 
Department of Labor; or a State apprenticeship agency 
recognized by the Office of Apprenticeship pursuant to the Act 
of August 16, 1937 (popularly known as the ``National 
Apprenticeship Act;'' 29 U.S.C. 50, et seq.).
     A program leading to a secondary school diploma 
offered by a secondary school approved in the state in which it 
is operating.
     A licensure test offered by a Federal, state, or 
local government.

    This legislation also would amend 38 U.S.C. 3675(a)(1) to 
substitute ``A State approving agency, or the Secretary when 
acting in the role of a State approving agency'' for ``the 
Secretary or a State approving agency.'' Further, this 
legislation proposes to amend section 3675 to expand the 
approval of other courses by authorizing an SAA, or the 
Secretary when acting in the role of a SAA, to approve 
accredited programs (including non-degree accredited programs) 
not covered by section 3672 of title 38.
    VA supports the clarification of the approval requirements 
codified in 38 U.S.C. 3672(b)(2)(A), as detailed in section 
2(a) of the proposed legislation. To be ``deemed approved,'' 
accredited programs must meet the requirements of a number of 
provisions in chapter 36 of title 38. Consequently, compliance 
with those provisions must be verified, which the proposed 
change will make more explicit. However, to be consistent with 
approval authorities in other sections of chapter 36, VA 
believes that both the Secretary and the SAA should have 
approval authority.
    VA also supports the proposed change to 38 U.S.C. 3675 in 
section 5(b) of the bill, to make those approval provisions 
apply to accredited non-degree programs at public and private 
non-profit IHLs that are not covered by section 3672 or by any 
of the approval requirements currently contained in chapter 36 
of title 38. However, VA does not support modifying the current 
language that grants approval authority to both the Secretary 
and the SAA. The Secretary was granted authority under P.L. 
111-377 to approve those programs, if necessary. While VA has 
no plans to take over approvals of all educational programs, it 
does appreciate this flexibility of authority.
    VA estimates there are no costs associated with this 
section.
    Section 6 would amend 38 U.S.C. 3676(c)(14) as it pertains 
to the criteria used to approve non-accredited courses. Under 
the proposed legislation, VA, in consultation with the SAA and 
pursuant to regulations, would determine if additional criteria 
may be deemed necessary for the SAA to approve an institution's 
written application for a course of education. VA and the SAA 
must treat public, private, and private for-profit educational 
institutions equitably.
    The legislation would also amend 38 U.S.C. 3675(b)(3) to 
include this requirement as part of the approval conditions for 
accredited courses offered by private for-profit institutions.
    This change would apply with respect to criteria developed 
pursuant to 38 U.S.C. 3676(c)(14) on or after January 1, 2013, 
and an investigation conducted under 38 U.S.C. 3676(c) that is 
covered by a reimbursement of expense paid by VA to a state, 
pursuant to 38 U.S.C. 3674, on or after October 1, 2015.
    While VA agrees with the intent underlining section 6, that 
the approval requirements for non-accredited courses should be 
applied equitably regardless of the type of institution 
providing the training, VA does not believe that it should be 
interjected into the SAA approval requirements applicable to 
educational institutions located in the state over which the 
SAA has jurisdiction. VA is not aware of any widespread 
concerns regarding unfair practices or unequal treatment with 
respect to additional SAA approval requirements. VA is 
concerned about the amount of resources that could potentially 
be involved in regulating the process, reviewing the SAA 
requirements, and making determinations regarding necessity and 
equity. In this instance, VA would have to coordinate with all 
50 States, territories, and institutions of higher learning 
regarding policy and procedure changes. At this time, VA cannot 
quantify the level of effort required for coordination of this 
scope. Consequently, VA recommends adding the requirement that 
any additional criteria treat public, private, and proprietary 
for-profit educational institutions equitably, without 
requiring a formal process and a VA decision on each additional 
requirement. This would ensure the consistent application of 
additional SAA approval requirements, allow states to 
promulgate additional requirements for educational institutions 
located within their borders, and avoid the potentially 
burdensome administrative process proposed in this section.
    At this time, VA cannot quantify the costs and level of 
effort required for coordination of this scope.
    Section 7 would amend 38 U.S.C. 3693 by inserting a new 
subsection (a) that would require VA to conduct an annual 
compliance survey of educational institutions and training 
establishments offering one or more courses approved for 
enrollment of eligible Veterans or individuals, if at least 20 
such Veterans or individuals are enrolled. VA would be 
responsible for:

     Designing the compliance surveys to ensure that 
such institutions or establishments, as the case may be, and 
approved courses are in compliance with all applicable 
provisions of chapters 30 through 36 of title 38;
     Surveying each of these educational institutions 
and training establishments not less than once during every 2-
year period; and
     Assigning not fewer than one education compliance 
specialist to work on compliance surveys in any year for each 
40 compliance surveys required to be made under this section 
for such year.

    Additionally, VA, in consultation with the SAAs, would 
annually determine the parameters of the surveys, and not later 
than September 1 of each year, make available to the SAAs a 
list of the educational and training establishments that would 
be surveyed during the fiscal year following the date of making 
such list available.
    VA supports this section as it would improve the compliance 
survey process. VA recognizes the importance of compliance work 
in ensuring timely and accurate payments to Veterans and their 
families. As such, VA and the National Association of State 
Approving Agencies formed a joint committee, the Compliance 
Survey Redesign Working Group, to streamline and enhance the 
compliance survey process.
    Currently, there are approximately 16,000 approved domestic 
and international IHLs and non-college degree institutions. Of 
the 16,000 institutions, there were 11,260 active institutions 
in calendar year 2013. During FY 2013 and FY 2014, VA and SAAs 
completed well over 10,000 surveys, with just over 5,000 
surveys completed in FY 2014. VA anticipates completing a 
similar number of reviews in 2015. This work will be split 
roughly in half between VA and SAAs, as it has been for the 
last few years.
    The statute requires VA to conduct annual surveys at 100 
percent of schools with greater than 300 beneficiaries and non-
college degree programs. Schools with high numbers of 
beneficiaries are more likely to have one or more full-time 
school certifying officials and may not need a visit annually. 
Institutions with a smaller number of beneficiaries are more 
likely to have school certifying officials who have other 
duties, and these institutions may not be as well-versed in 
school certifying official requirements, especially as they 
relate to the Post-9/11 GI Bill program.
    This section would also create a new provision that would 
require the Secretary to consult with SAAs when determining the 
parameters of which institutions would receive a compliance 
survey each year. VA believes this provision is unnecessary as 
VA already consults with SAAs when determining where surveys 
will be conducted. With the implementation of section 203 of 
P.L. 111-377 (Post-9/11 Veterans Educational Assistance 
Improvements Act of 2010), VA was granted the authority to 
utilize SAAs to assist VA in conducting compliance surveys at 
GI Bill-approved institutions. Although VA can use the services 
of SAAs, VA continues to be ultimately responsible for 
conducting compliance surveys.
    There are no mandatory costs associated with section 7, and 
there would be only minimal administrative costs associated 
with this provision.

    Mr. Chairman, thank you for the opportunity to present our 
views on the legislation today and we will be glad to answer 
any questions you or other members of the Committee may have.
                                ------                                

 STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR 
   HEALTH CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. 
                     DEPARTMENT OF VETERANS AFFAIRS

    Good afternoon Chairman Isakson, Ranking Member Blumenthal, 
and Members of the Committee. Thank you for inviting us here 
today to present our views on several bills that would affect 
VA benefits programs and services. Joining me today are Vince 
Kane, Special Assistant to the Secretary and Jennifer Gray, 
Staff Attorney in VA's Office of General Counsel
    We do not have cleared views on sections 5 and 8 of 
S. 1885. We also do not have cleared views on S. 1676, a bill 
to increase the number of graduate medical education positions 
treating veterans, to improve the compensation of health care 
providers, medical directors, and directors of Veterans 
Integrated Service Networks, and for other purposes. We will be 
glad to work with the Committee on prioritization of those 
views and cost estimates not included in our statement.

           *       *       *       *       *       *       *

         S. 1754, VETERANS COURT OF APPEALS SUPPORT ACT OF 2015

    S. 1754 would amend section 7253(a) of title 38, United 
States Code, by permanently increasing the maximum number of 
judges presiding over the United States Court of Appeals for 
Veterans Claims (Veterans Court) from seven to nine. Because 
the bill would primarily affect the Veterans Court and would 
not affect the operation of VA, we defer to the Veterans Court 
as to whether S. 1754 should be enacted.

             S. 1885, VETERAN HOUSING STABILITY ACT OF 2015

    Section 2 of S. 1885 would expand the definition of 
``homeless Veteran'' to include those Veterans fleeing domestic 
violence and interpersonal violence (DV/IPV), aligning VA's 
definition with that of the Department of Housing and Urban 
Development (HUD). VA supports section 2. Since Veterans 
fleeing from DV/IPV are considered at high risk for 
homelessness, they are already served in VA's homeless programs 
when it is clinically appropriate.
    Section 3 would require VA to create a new program to 
provide intensive case management interventions to homeless 
Veterans in at least six locations selected by VA based on 
criteria which is described in the bill. VA would also be 
required to prepare a report for Congress on the outcomes of 
the program. VA does not believe section 3 is necessary, as VA 
is already authorized to provide intensive case management 
through the HUD-VASH program. HUD-VASH is similarly already 
authorized to provide flexible team-based care management and 
thus does not require the proposed program to provide such 
services.
    Section 4 would require VA to award grants for the 
provision of case management services for Veterans who are 
transitioning to permanent housing and those who are at risk 
for homelessness. This would help address a current gap in case 
management service delivery. The Homeless Providers Grant and 
Per Diem (GPD) program, for example, lacks the authority to 
provide funding for case management services once a Veteran 
exits a GPD-funded transitional housing program. However, such 
services may be currently provided by grantees in VA's 
Supportive Services for Veteran Families (SSVF) program.
    Section 4 would also require the Secretary to prioritize 
for grant funding those organizations that would voluntarily 
stop receiving per diem payments under the GPD program (38 
U.S.C. Section 2012) or Special Need awards (38 U.S.C. Section 
2061), and be willing to use their transitional housing 
facility for permanent housing. VA supports this section of the 
bill. Currently there are nearly 9,000 transitional housing 
beds developed through VA investment of capital in partnership 
with community organizations. As the number of homeless 
Veterans decreases, the need for some of this transitional 
housing will diminish, but there will be a continued need for 
permanent housing interventions like rapid re-housing and 
permanent supportive housing. This grant funding could enable 
VA to help fill this need for permanent housing interventions, 
consistent with the VA's Housing First approach to assisting 
homeless Veterans.
    VA supports section 6, which would require VA and HUD to 
collaboratively provide outreach to public housing authorities, 
tribally designated housing entities, realtors, landlords, 
property management companies, developers, and other relevant 
audiences to educate them about the housing needs of Veterans 
and encourage them to rent to Veterans. VA and HUD currently 
collaborate on such efforts.
    VA supports section 7, which would codify the role of the 
VA National Center on Homelessness Among Veterans as a center 
of research, evaluation, and dissemination of best practices 
regarding services for homeless Veterans.

           *       *       *       *       *       *       *

         S. 2022, SPECIAL PENSION OF MEDAL OF HONOR RECIPIENTS

    S. 2022 would amend section 1562(a) of title 38, United 
States Code, by increasing the monthly rate for the Medal of 
Honor Pension to $3,000. VA administers the Medal of Honor 
Pension, a special pension benefit that is not based on income 
level, need, or disability, to recipients of the Medal of 
Honor. For reference, the monthly Medal of Honor Pension rate 
established pursuant to 38 U.S.C. Sec. 1562 is currently 
$1,299.61.
    The bill would be effective either (1) 180 days after the 
date of enactment, or (2) if the date 180 days after the date 
of enactment does not fall on the first day of a month, the 
first day of the first month beginning after the date that is 
180 days after the date of enactment. If the increased rate for 
the Medal of Honor Pension is effective prior to December 1, 
2016, the monthly rate would not be increased by a cost of 
living adjustment (COLA) for FY 2017. Annual COLA increases 
would resume beginning on December 1, 2017.
    VA supports S. 2022, subject to Congress identifying 
acceptable offsets for the additional benefit costs. This 
legislation would be consistent with Congress' original intent 
for the Medal of Honor Pension, which was to serve as a 
``recognition of superior claims on the gratitude of the 
country'' and to ``reward * * * in a modest way startling deeds 
of individual daring and audacious heroism in the face of 
mortal danger when war is on.''
    VA estimates that benefit costs to the appropriation for 
compensation and pension would be $788,000 in FY 2016, $7.2 
million over 5 years, and $16.1 million over 10 years.
                                ------                                

    STATEMENT OF CURTIS L. COY, DEPUTY UNDER SECRETARY FOR ECONOMIC 
   OPPORTUNITY, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF 
                            VETERANS AFFAIRS

    Good morning, Mr. Chairman and Members of the Committee. I 
am pleased to be here today to provide the views of the 
Department of Veterans Affairs (VA) on pending legislation 
affecting VA's programs, including the following: S. 2106, 
S. 2134, S. 2170, S. 2253, and a draft bill regarding 
whistleblower complaints. At this time, VA is unable to develop 
cost estimates for the ``Department of Veterans Affairs 
Veterans Education Relief and Restoration Act of 2015;'' 
however, we will provide these to you as soon as they are 
available. Accompanying me this morning are Maureen McCarthy, 
Acting Assistant Deputy Under Secretary for Health for Patient 
Care Services, Veterans Health Administration and Meghan Flanz, 
Deputy General Counsel, Legal Operations & Accountability.

           *       *       *       *       *       *       *

                                S. 2134

    S. 2134, the ``Grow Our Own Directive: Physician Assistant 
Employment and Education Act of 2015,'' would establish a pilot 
program to provide educational assistance to certain former 
members of the Armed Forces for education and training as 
physician assistants within the VA. While VA supports the 
concept, the cost associated with the legislation would cause 
concern within our available resources.
    S. 2134 would require the Secretary to provide information 
on the pilot program to eligible individuals. An eligible 
individual would be defined as an individual who: (1) has 
medical or military health experience while serving as a member 
of the Armed Forces; (2) has received a certificate, associate 
degree, baccalaureate degree, master's degree, or post-
baccalaureate training in a science related to health care; (3) 
has participated in the delivery of health care services or 
related medical services; and (4) does not have a degree of 
doctor of medicine, doctor of osteopathy, or doctor of 
dentistry.
    S. 2134 would also require the Secretary to select no less 
than 250 eligible individuals to participate in the program 
with a minimum of 35 scholarship participants per year. 
Priority would be given to: individuals who participated in the 
Intermediate Care Technician Pilot Program of the Department 
that was carried out by the Secretary between January 2011 and 
February 2015, and individuals who agree to be employed as a 
physician assistant for VHA in a community designated as a 
medically underserved population and in a State with a per 
capita Veteran population of more than 9 percent. Although VA 
supports the minimum requirement of scholarship participants, 
VA is concerned that the applicant pool of eligible individuals 
may be insufficient to meet the required number.
    S. 2134 would also require the Secretary, in carrying out 
the pilot program, to provide educational assistance to 
individuals participating in the program to cover the costs to 
the individuals of obtaining a master's degree in physician 
assistant studies or a similar master's degree. The legislation 
would call for the use of the Health Professionals Educational 
Assistance Program (HPEAP) and other educational assistance 
programs the Secretary considers appropriate, to administer a 
5-year pilot program.
    S. 2134 would also require each individual participating in 
the pilot program to enter into an obligated service agreement 
with the Secretary to be employed as a physician assistant with 
VHA for a period of time that is either specified in the HPEAP 
or other educational assistance program or, if the individual 
is participating through a program where an obligated service 
period is not specified, a period of at least 3 years or such 
other period as the Secretary considers appropriate.
    The bill would also provide that where an individual who 
participates in the pilot program fails to satisfy the period 
of obligated service, he or she shall be liable to the United 
States, in lieu of the obligated service, for the amount that 
has been paid or is payable to or on behalf of the individual 
under the pilot program, reduced by the proportion that the 
number of days the individual served for completion of the 
period of obligated service years to the total number of days 
in the period of obligated service of such individual.
    The bill would also require the Secretary to ensure that a 
physician assistant mentor or mentors are available for 
individuals participating in the pilot program at each facility 
of VHA at which a participant in the pilot program is employed.
    The bill would require the Secretary to seek to partner 
with not less than
    15 institutions of higher education that offer a master's 
degree program in physician assistant studies or a similar area 
of study accredited by the Accreditation Review Commission on 
Education for the Physician Assistant. These institutions would 
also agree to guarantee seats in such master's degree program 
for pilot program participants, and to provide pilot program 
participants with information on admissions criteria and 
process. VA recommends that it be granted flexibility with the 
final number of partnerships/affiliates as less than 15 
institutions may be sufficient to meet these requirements.
    The bill would also require four new employees to 
administer the pilot program: a Deputy Director of Education 
and Career Development of Physician Assistants; a Deputy 
Director of Recruitment and Retention; a recruiter; and an 
administrative assistant. All positions would be aligned with 
VHA's Office of Physician Assistant Services.
    This pilot program would require scholarship recipients to 
complete a service obligation at a VA health care facility 
after graduation and licensure/certification. VHA has had 
difficulty recruiting and retaining physician assistants for 
several years. Additionally, VHA Workforce Succession Strategic 
Plan and Reports have listed physician assistants in the top 
ten critical occupations, and VA's Office of Inspector 
General's Critical Occupation Staffing Shortage Report has 
listed physician assistants in the top five most critical 
occupations shortages.
    The total cost of the Health Professional Scholarship 
Program for 450 awards over 5 years would be $56,573,810.
    The total cost associated with administering the pilot 
program over 5 years would be $2,764,667.
    The total cost associated with establishment of pay grades 
for physician assistants and the requirement of providing 
competitive pay would be $374,921,436 over 10 years

           *       *       *       *       *       *       *

 S. 2253--DEPARTMENT OF VETERANS AFFAIRS VETERANS EDUCATION RELIEF AND 
                        RESTORATION ACT OF 2015

    This bill would amend title 38, U.S.C., to provide Veterans 
affected by school closures with certain relief and restoration 
of education benefits. The bill would add a new subsection (d) 
to section 3312 of title 38, U.S.C., to allow for the 
restoration of entitlement to educational assistance and 
provide other relief for Veterans affected by a school closure. 
More specifically, no payment of educational assistance would 
be charged against an individual's entitlement to educational 
assistance under the Post-9/11 GI Bill, or counted against the 
aggregate period for which an individual may receive 
educational assistance under two or more programs, if VA finds 
that the individual was forced to discontinue a course or 
courses as a result of a permanent school closure and did not 
receive credit, or lost training time, toward completion of the 
program of education being pursued at the time the school 
closed.
    S. 2253 also would amend section 3680(a) of title 38, 
U.S.C., authorizing VA to prescribe regulations allowing VA to 
continue a monthly housing allowance stipend under the Post-9/
11 GI Bill during a temporary school closure or for a limited 
period following a permanent school closure. The housing 
allowance would be payable until the end of the term, quarter, 
or semester during which the school closure occurred, or 4 
months after the date of the school closure, whichever is 
sooner.
    VA supports S. 2253, as it would allow VA to restore 
entitlement and continue monthly housing allowance stipend 
payments to Post-9/11 GI Bill beneficiaries impacted by school 
closures. While VA currently has authority to continue payments 
to beneficiaries when schools are temporarily closed due to an 
emergency or under an established policy based on an Executive 
Order of the President, there is no similar statutory authority 
upon which to continue benefit payments in the event of a 
permanent school closure. Furthermore, regardless of whether a 
school closure is temporary or permanent, there is no statutory 
authority that allows VA to restore entitlement for a term, 
quarter, or semester for which a beneficiary fails to receive 
credit toward program completion due to such a closure. VA 
would interpret the bill to apply only to a course or courses 
in which an individual was enrolled in FY 2015, and all current 
or future enrollments. VA would also interpret the bill as 
currently written to provide that the portion of a course or 
courses that a beneficiary has participated in through the time 
of the school's closure (e.g., the portion of an incomplete 
college semester that has already passed at the time of a 
school closure) is not charged against the beneficiary's 
entitlement. We note that there appears to be a discrepancy 
between the new subsection (d)(2), which applies to an 
individual who meets the criteria of both (A) and (B) of that 
subsection, and the applicability provision in section 2(a)(2) 
of the bill, which describes new subsection (d) as applying if 
the criteria of either paragraph (A) or paragraph (B) of 
subsection (d)(2) are met.
    The closure of educational institutions while GI Bill 
beneficiaries are actively pursuing approved programs of 
education or training negatively impacts Veterans and eligible 
dependents in a number of ways. First, their monthly housing 
benefits are suddenly and unexpectedly discontinued in the 
middle of the term. In many cases, these payments are the 
primary (or sole) source of funds for paying for housing, food, 
utilities, and other basic necessities while attending school. 
Second, while VA can pay benefits for the term, quarter, or 
semester up to the time of the school's closure, the student is 
still charged entitlement for that period, even though he/she 
does not earn any credit toward program completion. In some 
instances, this could result in a beneficiary exhausting his/
her entitlement before being able to complete his/her program 
at another institution.
    We will be pleased to provide for the record an estimate of 
the cost of enactment of this bill.
                                ------                                

                            Department of Veterans Affairs,
                                     Washington, DC, July 15, 2015.
Hon. Johnny Isakson,
Chairman,
Senate Committee on Veterans' Affairs
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The agenda for the Senate Committee on 
Veterans' Affairs' June 3, 2015, and June 24, 2015, legislative 
hearings included a number of bills that the Department of 
Veterans Affairs (VA) was unable to address in our testimony. 
We are aware of the Committee's interest in receiving our views 
and cost estimates for those bills.
    By this letter, we are providing the following remaining 
views and cost estimates for the following bills from the 
June 3, 2015, legislative hearing: S. 471, the Women Veterans 
Access to Quality Care Act of 2015; and sections 4(b)-(c) and 5 
of the draft Veterans Health Act of 2015.
    We are also providing views and costs on the following 
bills from the June 24, 2015, legislative hearing: the Draft 
Biological Implant Tracking and Veteran Safety Act of 2015; on 
S. 1117, the Ensuring Veteran Safety Through Accountability Act 
of 2015; sections 203, 205, 208, and 209(b) of S. 469, the 
Women Veterans and Families Health Services Act of 2015; 
sections 3 through 8 of S. 1085, the Military and Veteran 
Caregiver Services Improvement Act of 2015; section 2 of the 
draft bill referred to on the agenda as ``Discussion Draft;'' 
and sections 101-106, 204, 205, 403 and 501 of the draft Jason 
Simcakoski Memorial Opioid Safety Act.
    In the time requested for transmittal of follow up views, 
VA was not able to include in this letter the following views: 
sections 2 and 4 of S. 297, the Frontlines to Lifelines Act of 
2015; the draft bill on establishing a joint VA-Department of 
Defense (DOD) formulary for systemic pain and psychiatric 
medications; sections 2, 3, and 5 of the draft Veterans Health 
Act of 2015, sections 203, 208, and 209(b) of S. 469, the Women 
Veterans and Families Health Services Act of 2015; sections 
4(b) and 8 of S. 1085, the Military and Veteran Caregiver 
Services Improvement Act of 2015; and sections 105, 205, 403, 
and 501 of the Jason Simcakoski Memorial Opioid Safety Act. The 
remaining views can be forwarded in a separate and final 
follow-up views letter.
    We appreciate this opportunity to comment on this 
legislation and look forward to working with you and the other 
Committee Members on these important legislative issues.
            Sincerely,
                                        Robert A. McDonald,
                                                         Secretary.

  Enclosure.

           *       *       *       *       *       *       *

           S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES 
                        IMPROVEMENT ACT OF 2015

    Section 3 of this bill proposes to add a new section 3319A 
to title 38 to authorize individuals who are eligible for and 
participating in a program of comprehensive assistance for 
family caregivers under 38 U.S.C. 1720G(a) the opportunity to 
transfer their unused Post-9/11 GI Bill education benefits to 
their dependents. Veterans may complete the transfer of 
entitlement any time during the 15-year period beginning on the 
date of their last discharge or release from active duty. 
Transferees would be subject to the same rules in place for 
individuals who receive transferred benefits under 38 U.S.C. 
3319. However, there is no length of service requirement, and 
the monthly rate of educational assistance would be the same 
rate payable to the individual making the transfer. The 
Secretary would be authorized to prescribe regulations to carry 
out this section.
    Currently, DOD determines eligibility for transfer of 
entitlement. If enacted, the proposed legislation would require 
VA to develop procedures to receive requests to transfer 
entitlement for certain individuals, determine eligibility, and 
award benefits for the transfer of entitlement program. Because 
the transfer of entitlement provisions of the Post-9/11 GI Bill 
were established as a recruitment and retention tool for the 
uniformed services, VA defers to DOD on this section of the 
bill. However, VA notes that Congress would need to identify 
appropriate offsets for the cost of this legislation, which we 
are unable to estimate at this time.
    Section 4(a) would amend 37 U.S.C. 439, providing for 
special compensation for members of the uniformed services with 
catastrophic injuries or illnesses requiring assistance in 
everyday living, by amending the definition of covered members 
to include those Servicemembers who have a serious injury or 
illness that was incurred or aggravated in the line of duty, 
are in need of personal care services as a result of the 
injury, and who would require hospitalization, nursing home 
care, or other residential care in the absence of such personal 
care services. Section 4(b) would further amend section 439 by 
requiring VA to provide family caregivers of a Servicemember in 
receipt of monthly special compensation assistance available to 
family caregivers of eligible veterans under 38 U.S.C. 
1720G(a)(3)(A), other than the monthly caregiver stipend. VA 
would provide assistance under this subsection in accordance 
with a memorandum of understanding (MOU) between VA and DOD, 
and an MOU between VA and the Secretary of Homeland Security. 
Section 4(c) would define the term ``serious injury or 
illness,'' which would replace the term ``catastrophic injury 
or illness,'' to mean an injury, disorder, or illness that (1) 
renders the afflicted person unable to carry out one or more 
activities of daily living; (2) renders the afflicted person in 
need of supervision or protection due to the manifestation by 
such person of symptoms or residuals of neurological or other 
impairment or injury; (3) renders the afflicted person in need 
of regular or extensive instruction or supervision in 
completing two or more instrumental activities of daily living; 
or (4) otherwise impairs the afflicted person in such manner as 
the Secretary of Defense or Homeland Security prescribes.
    VA defers to DOD and the Department of Homeland Security 
regarding amendments sections 4(a) and 4(c).
    VA is still analyzing section 4(b) and would be glad to 
provide views at a later time.
    Section 5 would authorize the Office of Personnel 
Management (OPM) to promulgate regulations under which a 
covered employee, which would include a caregiver defined in 38 
U.S.C. 1720G or a caregiver of an individual receiving 
compensation under 37 U.S.C. 439, to use a flexible schedule or 
compressed schedule or to telework.
    VA defers to OPM on this section.
    Section 6 would amend the Public Health Service Act (42 
U.S.C. 300ii), which governs lifespan respite care, to amend 
the definition of ``adult with special need'' to include a 
veteran participating in the family caregiver program under 38 
U.S.C. 1720G. It would also amend the definition of ``family 
caregiver'' to include family caregivers under 38 U.S.C. 1720G. 
Furthermore, in awarding grants or cooperative agreements to 
eligible State agencies to furnish lifespan respite care, the 
HHS would be required to work in cooperation with the 
interagency working group on policies relating to caregivers of 
Veterans established under section 7 of this bill. Section 6 
would also authorize appropriations of $15 million for fiscal 
years 2016 through 2020 for these grants.
    VA defers to HHS on this section.
    Section 7 would establish an interagency working group on 
policies relating to caregivers of Veterans and Servicemembers. 
The working group would be composed of a chair selected by the 
President, and representatives from VA, DOD, HHS (including the 
Centers for Medicare & Medicaid Service), and the Department of 
Labor. The working group would be authorized to consult with 
other advisors as well. The working group's duties would 
include regularly reviewing policies relating to caregivers of 
Veterans and Servicemembers, coordinating and overseeing the 
implementation of policies relating to these caregivers, 
evaluating the effectiveness of such policies, developing 
standards of care for caregiver and respite services, and 
others. Not later than December 31, 2015, and annually 
thereafter, the working group would be required to submit to 
Congress a report on policies and services relating to 
caregivers of Veterans and Servicemembers.
    VA generally supports a working group that would provide a 
forum for analyzing and evaluating different issues that family 
caregivers of Veterans and Servicemembers face. Such a working 
group would be ideally suited to considering in depth the types 
of issues other provisions of this bill are intended to 
address, and would also be able to evaluate emerging issues.
    The Department of Justice advises, however, that it 
believes the method for selecting members of the working group 
raises Appointment Clause concerns, which DOJ will convey in 
greater detail under separate cover.
    Section 8(a) would require VA to conduct a longitudinal 
study on Servicemembers who began their service after September 
11, 2001. VA would be required to award a grant to or enter 
into a contract with an appropriate entity unaffiliated with VA 
to conduct the study. Within 1 year of the date of the 
enactment of the Act, VA would be required to submit to the 
Committees on Veterans' Affairs a plan for the conduct of the 
study. Not later than October 1, 2019, and not less frequently 
than once every 4 years thereafter, VA would be required to 
submit to the Committees on Veterans' Affairs a report on the 
results of the study. Section 8(b) would require VA to provide 
for the conduct of a comprehensive study on Veterans who have 
incurred a serious injury or illness and individuals who are 
acting as caregivers for Veterans. VA would be required to 
award a grant to or enter into a contract with an appropriate 
entity unaffiliated with VA to conduct the study. The study 
would be required to include the health of the Veteran and the 
impact of the caregiver on the health of the Veteran, the 
employment status of the Veteran and the impact of the 
caregiver on that status, the financial status and needs of the 
Veteran, the use by the Veteran of VA benefits, and any other 
information VA considers appropriate. Not later than 2 years 
after the date of the enactment of this Act, VA would be 
required to submit to the Committees on Veterans' Affairs a 
report on the results of this study.
    VA is still analyzing this section and would be glad to 
provide views at a later time.

           *       *       *       *       *       *       *

      DRAFT BILL, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

    Section 101 would require, within 1 year of the date of the 
enactment of the Act, VA and DOD to jointly update the VA/DOD 
Clinical Practice Guideline for Management of Opioid Therapy 
for Chronic Pain. The guidelines would have to include 
guidelines for safely prescribing opioids for the treatment of 
chronic, non-cancer pain in outpatient settings; enhanced 
guidance with respect to absolute contraindications for opioid 
therapy; enhanced guidance with respect to the treatment of 
patients with behaviors or comorbidities, or a history of 
substance abuse or addiction, that require consultation or co-
management of opioid therapy with one or more specialists; 
enhanced guidance with respect to the conduct by health care 
providers of an effectiveness assessment for patients receiving 
opioid therapy; requirements that each VA and DOD provider, 
before initiating opioid therapy, use VA's Opioid Therapy Risk 
Report tool to assess the risk for adverse outcomes; guidelines 
to govern the methodologies used by VA and DOD providers to 
taper opioid therapy when adjusting or discontinuing opioid 
therapy; guidelines with respect to appropriate case management 
for patients receiving opioid therapy who transition between 
inpatient and outpatient settings; enhanced recommendations on 
the use of routine and random urine drug tests for all patients 
before and during opioid therapy; and guidance that health care 
providers discuss with patients before initiating opioid 
therapy other options for pain management therapies. Before 
updating these guidelines, VA and DOD would be required to 
jointly consult with the working group on pain management and 
opioid therapy established under section 3 of this bill. Within 
1 year of the date of enactment of this Act, GAO would be 
required to submit to the Committees on Veterans' Affairs a 
report on the implementation of the updated guidelines by each 
VA medical facility and the compliance of each medical facility 
with these guidelines.
    VA appreciates the intent of this thoughtful and 
comprehensive bill, and agrees that more needs to be done to 
support clinicians with clearer guidance and training on 
prescribing medications for pain management. VA, because of its 
central role in training physicians across the country, can 
provide leadership by training clinicians in pain management 
and supporting a team approach to care. There are cases where 
the use of opioids is clinically indicated, albeit closely 
controlled and monitored, to control pain when nothing else 
does. We have a number of recommendations to improve the bill, 
and would be glad to meet with the Committee to discuss these 
further. For example, the requirement in section 101(b) that VA 
and DOD jointly consult the working group on pain management 
and opioid therapy established in section 103 of the bill would 
be redundant, as the VA/DOD Health Executive Council (HEC) 
already has a Pain Management Work Group whose focus is on 
improving pain management practices in the two Departments.
    Section 102(a) would require VA, within 180 days of 
enactment, to expand the Opioid Safety Initiative to include 
all VA medical facilities.
    Section 102(b) would require VA to ensure all providers 
responsible for prescribing opioids to receive education and 
training on pain management and safe opioid prescribing 
practices. The education and training would have to cover a 
number of identified areas, and in providing the training, VA 
would be required to use the Interdisciplinary Chronic Pain 
Management Training Team Program.
    Section 102(c) would require each VA medical facility to 
identify and designate a pain management team of health care 
professionals responsible for coordinating and overseeing 
therapy at the facility for patients experiencing acute and 
chronic pain that is not related to cancer. Each VISN Director 
would be responsible for establishing protocols for the 
designation of a pain management team at each VA medical 
facility in the VISN, and the protocols would need to ensure 
that any health care provider without expertise in prescribing 
analgesics or who has not completed required training not 
prescribe opioids, with limited exceptions. Within 1 year of 
enactment of this Act, each VA medical facility would be 
required to submit to the VISN Director a report identifying 
the health care professionals that have been designated as 
members of the pain management team at the facility.
    Section 102(d) would require, within 18 months of the date 
of the enactment of the Act, that VA provide for real time 
tracking and access to data on the use of opioids and 
prescribing practices. VA also would be required to ensure 
access by VA health care providers to information on controlled 
substances prescribed by community providers through State 
prescription drug monitoring programs. Within 180 days of the 
enactment of this Act, VA would be required to submit to 
Congress a report on the implementation of these improvements.
    Section 102(e) would require VA to increase the 
availability of opioid receptor antagonists, such as naloxone, 
to veterans and for use by VA health care providers treating 
Veterans. Within 90 days of enactment of this Act, VA would be 
required to equip each VA medical facility with opioid receptor 
antagonists approved by FDA. VA notes that other opioid 
receptor antagonists approved by FDA exist, but only one type 
(naloxone) is approved for overdose reversal. This section also 
directs VA to enhance training of providers on distributing 
such antagonists, and to expand the Overdose Education and 
Naloxone Distribution program to ensure all Veterans in receipt 
of health care who are at risk of opioid overdose (as defined 
by the bill) have access to opioid receptor antagonists and 
training on their proper administration. Within 120 days of the 
date of the enactment of this Act, VA would be required to 
submit to the Committees on Veterans' Affairs a report on 
compliance with this requirement.
    Section 102(f) would require that VA include in the Opioid 
Therapy Risk Report tool information on the most recent time 
the tool was accessed by a VA health care provider with respect 
to each Veteran and information on the results of the most 
recent urine drug test for each Veteran. VA would also be 
required to determine if a provider prescribed opioids without 
checking the information in this tool first.
    Section 102(g) would require VA to modify VA's Computerized 
Patient Record System (CPRS) to ensure that any health care 
provider that accesses the record of a Veteran will be 
immediately notified whether the Veteran is receiving opioid 
therapy and has a history of substance use disorder or prior 
instances of overdose, has a history of opioid abuse, or is at 
risk of becoming an opioid abuser.
    VA agrees that additional training for providers is 
necessary. Clinicians want to help Veterans and Servicemembers, 
but often do not have the skills and resources to do so. A 
well-trained physician and clinical team will know how to 
evaluate comprehensively a patient with pain, including making 
clinical diagnoses and how to develop a goal oriented 
management plan for pain, as well as how to engage the 
particular resource needs of each patient. Regarding other 
parts of section 102, VA is currently taking steps to fulfill 
the intent of many of these provisions. For example, section 
102(e) would require VA to increase the availability of opioid 
receptor antagonists approved by the FDA, and VA is currently 
exploring ways to increase the availability of these life-
saving medications. Similarly, section 102(g) would require VA 
to modify the Computerized Patient Record System to ensure 
providers will be immediately notified about opioid risks for 
each patient. VA's electronic health record already has real-
time mechanisms in place to alert VA health care providers of 
existing opioid prescriptions to prevent prescribing of 
additional opioids to Veterans who receive all their healthcare 
and prescriptions through the VA system. These mechanisms 
include real-time order checks that alert providers of 
prescriptions with potential problems with duplication, drug 
interactions, and doses in excess of the maximum recommended 
amount. In some facilities, VA health care providers also can 
check the State Prescription Drug Monitoring program databases 
to determine if a Veteran has an opioid prescription outside of 
VA.
    Section 103 would establish within the VA-DOD Joint 
Executive Committee (JEC) a working group on pain management 
and opioid therapy for individuals receiving health care from 
either VA or DOD. The working group would cover the prescribing 
practices of health care providers in both Departments, the 
ability of each Department to manage acute and chronic pain, 
the use of complementary and integrative health in treating 
such individuals, the concurrent use of opioids and 
prescription drugs to treat mental health disorders, the 
practice of prescribing opioids, the coordination in coverage 
and consistent access to medications for patients receiving 
care from VA and DOD, and the ability of each Department to 
identify and treat substance use disorders. The working group 
would be required to coordinate with other working groups 
established under 38 U.S.C. 320, consult with other Federal 
agencies, and review and comment on the VA/DOD Clinical 
Practice Guideline for Management of Opioid Therapy for Chronic 
Pain. The Secretaries of VA and DOD would be required to 
jointly ensure that the working group is able to consult 
meaningfully with respect to the updated guideline required by 
section 101 of this bill within 1 year of the date of the 
enactment of this Act.
    As noted previously, the VA-DOD HEC already has a pain 
management work group, so to that extent, we think VA and DOD 
are already meeting the intent of section 103.
    Section 104 would add a new section 7309A to title 38, 
which would require VA to establish in each VISN a Pain 
Management Board. These Boards would have a series of defined 
duties, including consulting with health care professionals and 
other VA employees in the VISN about resources and best 
practices for pain management, overseeing compliance and 
providing oversight of professionals using pain management 
practices, and carrying out educational forums and public 
hearings on best practices on pain management. The Boards would 
be able to provide treatment recommendations for patients in 
some situations. Each Board would be required to submit an 
annual report to the Under Secretary for Health on pain 
management practices within the VISN and recommended best 
practices. VA would be required to submit an annual report to 
Congress that contains comprehensive information from the 
reports submitted by the Boards.
    VA appreciates the intent of this provision, but is 
concerned that the time it would take to participate in this 
admittedly very important activity would be time these 
professionals are not able to furnish direct clinical care and 
treat patients. In particular, the clinicians who would be best 
qualified to serve on such boards are also those likely to be 
treating the most complex patients. If additional resources 
were available to ensure that patient care would not suffer as 
a result of implementing these Boards, this concern would be 
alleviated. We note that the bill is unclear in terms of the 
appointment of non-Federal employees to the Pain Management 
Boards and the implications of such appointments under other 
laws.
    Section 105 would require VA to conduct a study on the 
feasibility and advisability of carrying out a pharmacy lock-in 
program under which veterans at risk for abuse of prescription 
drugs would be permitted to receive prescription drugs only 
from certain specified VA pharmacies. VA would be required to 
report to the Committees on Veterans' Affairs within 1 year on 
this study.
    VA is still analyzing this section and would be glad to 
provide views at a later time.
    Section 106 would require the Comptroller General, within 2 
years of the date of the enactment of this Act, to submit to 
the Committees on Veterans' Affairs, a report on the Opioid 
Safety Initiative and the opioid prescribing practices of VA 
health care professionals. The report would include 
recommendations for improvement, and VA would be required to 
report to the Committees on Veterans' Affairs on a quarterly 
basis on the actions taken by VA to address any outstanding 
findings and recommendations from the Comptroller General.
    We defer to GAO on this provision.
    Section 106 would also require VA to conduct an annual 
report and investigation on opioid therapy, and to submit this 
report to the Committees on Veterans' Affairs. This report 
would include information on patient populations and 
prescribing patterns for opioids. Facilities that are among the 
top 10 percent in prescription rates would be subject to a full 
investigation by the Office of the Medical Inspector, and VA 
would be required to notify the Committees on Veterans' Affairs 
and the senators and representatives from the area in which the 
facility is located.
    Section 204 would require the Comptroller General to submit 
to the Committees on Veterans' Affairs a report on VA's Patient 
Advocacy Program, including recommendations and proposals for 
modifying the program and other information the Comptroller 
General considers appropriate.
    We defer to GAO on this provision.
    Section 205 would require VA, within 180 days of the date 
of the enactment of this Act, to submit to the Committees on 
Veterans' Affairs a report on the transitions undergone by 
Veterans in receiving health care in different health care 
settings. The report would have to include an evaluation of 
VA's standards for facilitating and managing the transitions 
undergone by veterans in receiving health care in different 
settings, an assessment of the case management services that 
are available, an assessments of the coordination in coverage 
of and consistent access to medications, and such 
recommendations to improve transitions, including coordination 
of drug formularies between VA and DOD.
    VA is still analyzing this section and would be glad to 
provide views at a later time.
    Section 403 would require, within 2 years of the date of 
the enactment of this Act, VA to submit a report on its 
compliance with VA's policy to conduct a review of each health 
care provider who transfers to another VA medical facility or 
leaves VA to determine whether there are any concerns, 
complaints, or allegations of violations relating to the 
medical practice of the health care provider, and to take 
appropriate action with respect to any such concern, complaint, 
or allegation.
    VA is still analyzing this section and would be glad to 
provide views at a later time.
    Section 501 would add a new section 527A to title 38 
requiring VA to carry out a program of internal audits and 
self-analysis to improve the furnishing of benefits and health 
care to veterans and their families. The Secretary would be 
required to establish an office within the Office of the 
Secretary to carry out these audits. The office would conduct 
periodic risk assessments, develop plans in response to these 
assessments, and conduct internal audits. At least five covered 
administrations, staff organizations, or staff offices would 
have to be audited each year. Within 90 days of completing an 
audit, the Secretary would be required to submit to Committees 
on Veterans' Affairs, the House Committee on Oversight and 
Government Reform, and the Senate Committee on Homeland 
Security and Government Affairs a report on the audit. The 
first audit would have to be completed within 180 days of the 
date of the enactment of this Act.
    VA is still analyzing this section and would be glad to 
provide views at a later time.
    Overall, VA understands the bill is a well-intentioned 
effort to combat a national public health problem, as outlined 
in a 2011 study by the Institute of Medicine (IOM).
                                ------                                

                            Department of Veterans Affairs,
                                 Washington, DC, September 4, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The agenda for the Senate Committee on 
Veterans' Affairs' June 3, 2015, and June 24, 2015, legislative 
hearings included a number of bills that the Department of 
Veterans Affairs (VA) was unable to address in our testimony or 
in our prior correspondence with you on July 15, 2015. By this 
letter, we are providing the final remaining views and cost 
estimates on the following bills from the June 3, 2015, 
legislative hearing: sections 2 and 4 of S. 297, the Frontlines 
to Lifelines Act of 2015; the draft bill on establishing a 
joint VA-Department of Defense (DOD) formulary for systemic 
pain and psychiatric medications; and sections 2, 3, and 5 of 
the draft bill, Veterans Health Act of 2015.
    We are also providing the final remaining views and cost 
estimates on the following bills from the June 24, 2015, 
legislative hearing: sections 203, 208, and 209(b) of S. 469, 
Women Veterans and Families Health Services Act of 2015; 
sections 4(b) and 8 of S. 1085, Military and Veteran Caregiver 
Services Improvement Act of 2015; and sections 105, 205, 403, 
and 501 of the Jason Simcakoski Memorial Opioid Safety Act.
    We appreciate this opportunity to comment on this 
legislation and look forward to working with you and the other 
Committee Members on these important legislative issues.
            Sincerely,
                                        Robert A. McDonald,
                                                         Secretary.

  Enclosure.

           *       *       *       *       *       *       *

           S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES 
                        IMPROVEMENT ACT OF 2015

    Section 4(b) of S. 1085 would amend 37 U.S.C. 439 by 
requiring VA to provide family caregivers of a Servicemember in 
receipt of monthly special compensation assistance under 37 
U.S.C. 439(a) the assistance that is currently provided to 
family caregivers of eligible Veterans under 38 U.S.C. 
1720G(a)(3)(A), other than the monthly caregiver stipend. VA 
would provide assistance under this subsection in accordance 
with a memorandum of understanding (MOU) between VA and DOD and 
an MOU between VA and the Secretary of Homeland Security.
    VA does not support section 4(b). DOD already provides many 
of the services and supports available under VA's Program of 
Comprehensive Assistance for Family Caregivers including health 
care coverage, mental health services, and respite care. 
Requiring VA to furnish these services as well would result in 
a duplication of benefits.
    Section 8(a) would require VA to conduct a longitudinal 
study on Servicemembers who began their service after September 
11, 2001. VA would be required to award a grant to or enter 
into a contract with an appropriate entity unaffiliated with VA 
to conduct the study. Within 1 year of the date of the 
enactment of the Act, VA would be required to submit to the 
Committees on Veterans' Affairs a plan for the conduct of the 
study. Not later than October 1, 2019, and not less frequently 
than once every 4 years thereafter, VA would be required to 
submit to the Committees on Veterans' Affairs a report on the 
results of the study. Section 8(b) would require VA to provide 
for the conduct of a comprehensive study on Veterans who have 
incurred a serious injury or illness and individuals who are 
acting as caregivers for Veterans. VA would be required to 
award a grant to or enter into a contract with an appropriate 
entity unaffiliated with VA to conduct the study. The study 
would be required to include the health of the Veteran and the 
impact of the caregiver on the health of the Veteran; the 
employment status of the Veteran and the impact of the 
caregiver on that status; the financial status and needs of the 
Veteran; the use by the Veteran of VA benefits; and any other 
information VA considers appropriate. Not later than 2 years 
after the date of the enactment of this Act, VA would be 
required to submit to the Committees on Veterans' Affairs a 
report on the results of this study.
    We do not believe this section is necessary. Currently, VA 
researchers are seeking new ways to address the mental health 
issues of Iraq and Afghanistan Veterans, including PTSD. They 
are also researching Traumatic Brain Injury (TBI) and its 
treatment and are developing and testing prostheses that will 
allow Veterans with amputations or other issues to live as 
independently as possible. One major effort is the Marine 
Resiliency Study (MRS), involving some 2,600 Marines who 
deployed to Iraq and Afghanistan. Beginning in 2008, the 
research team conducted clinical interviews on Marine bases and 
collected psychological, social, and biological data before 
deployment and then multiple times after deployment. 
Researchers are analyzing the data to identify risk and 
resilience factors for combat-related PTSD. The team recently 
published two articles in JAMA Psychiatry. One shows 
deployment-related brain injury to be a significant risk factor 
for PTSD. Another implicates high levels of inflammation in the 
body as a PTSD risk factor. VA is also conducting a 
longitudinal study of the neuropsychological and mental 
outcomes of Veterans of the Iraq war (CSP #566). VA will soon 
have large datasets to characterize health status and changes 
over time for Vietnam, Iraq, and Afghanistan Veterans, which 
will be a rich resource for researchers.
    In addition, VA researchers are already studying the impact 
of caregivers on the health of Veterans. For example, one 
recently initiated randomized study is examining the 
effectiveness of an innovative caregiver skills training 
program and whether it can help Veterans to have increased days 
at home, reduced total health care costs, and higher 
satisfaction with VHA health care compared to Veterans in usual 
care; it will also examine if caregivers in the program have 
lower depressive symptoms than caregivers who do not receive 
the training. Another ongoing project is studying an 
intervention aimed at dementia patients with pain, assessing 
whether it decreases incidence of aggression, pain, caregiver 
burden, injuries, use of antipsychotic medication, and nursing 
home use. Another study is seeking to understand better how 
war-related psychiatric symptoms of Operation Enduring Freedom/
Operation Iraqi Freedom Veterans may interfere with family 
reintegration and negatively affect family functioning; this 
study is testing whether difficulties with family reintegration 
account for the impact of psychiatric symptoms on overall 
family functioning over time. Another current study is 
examining whether a brief, inexpensive intervention to foster 
end-of-life preparation and completion improves quality of life 
and health utilization for Veterans with serious illness and 
improves outcomes for caregivers of these Veterans at the end 
of life.
    Additionally, VA works closely with other Federal research 
agencies to ensure effective use of scarce taxpayer resources 
in executing its research mission. We carry out joint 
programmatic reviews with DOD and NIH to ensure that our 
research efforts are complementary and not duplicative. Under 
the auspices of the President's National Research Action Plan, 
VA has worked with DOD to create two research consortia for TBI 
and PTSD, at a combined investment of $107 million over 5 
years. This tight coordination has become routine for all three 
agencies, with benefits that accrue to Veterans and the 
American public at large.

      DRAFT BILL, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

    Section 105 would require VA to conduct a study on the 
feasibility and advisability of carrying out a pharmacy lock-in 
program under which Veterans at risk for abuse of prescription 
drugs would be permitted to receive prescription drugs only 
from certain specified VA pharmacies. VA would be required to 
report to the Committees on Veterans' Affairs within 1 year on 
this study.
    VA has numerous concerns with section 105. We believe a 
pharmacy lock-in program, under which Veterans at risk for 
abuse of prescription drugs are permitted to receive 
prescription drugs only from certain specified VA pharmacies, 
will lead to negative patient outcomes. For example, Veterans 
who are traveling or require emergent/urgent medical care from 
a VA facility may need to receive a prescription from another 
VA facility's pharmacy to treat the Veteran's emergent/urgent 
condition. The pharmacy lock-in program would prevent 
medically-necessary drugs from being dispensed to Veterans. VA 
health care providers receive duplicate order checks from other 
VA facilities at the point of prescribing. These duplicate 
order checks would notify the provider and pharmacist in real-
time that the Veteran is receiving similar medications at 
another VA facility. Therefore we do not believe a study on a 
pharmacy lock-in program would yield useful information.
    Section 205 would require VA, within 180 days of the date 
of the enactment of this Act, to submit to the Committees on 
Veterans' Affairs a report on the transitions undergone by 
Veterans in receiving health care in different health care 
settings. The report would have to include an evaluation of 
VA's standards for facilitating and managing the transitions 
undergone by Veterans in receiving health care in different 
settings, an assessment of the case management services that 
are available, an assessments of the coordination in coverage 
of and consistent access to medications, and such 
recommendations to improve transitions, including coordination 
of drug formularies between VA and DOD.
    VA does not support Section 205 because its requirements 
would duplicate multiple GAO investigations regarding the 
health care transition of Servicemembers and Veterans, most 
notably a November 2012 report, Recovering Servicemembers and 
Veterans: Sustained Leadership Attention and Systematic 
Oversight Needed to Resolve Persistent Problems Affecting Care 
and Benefits. In response, DOD and VA are enhancing care 
coordination and case management to improve transitions across 
health care settings, including the development of an 
Interagency Comprehensive Plan for Servicemembers and Veterans 
requiring complex care coordination as well as a Lead 
Coordinator to align and standardize care coordination 
processes, roles, and responsibilities and to reduce confusion, 
duplication, and frustration.
    In addition, GAO is currently conducting a study, 
Engagement on Care Transitions and Medication Management for 
Post-Traumatic Stress Disorder and Traumatic Brain Injury (GAO 
code 291282). GAO is interviewing DOD and VA officials, as well 
as staff in the field. Thus far, GAO has conducted interviews 
at the Washington, DC VA Medical Center, at Fort Hood, Texas, 
and at Fort Carson, Colorado. VA looks forward to their 
objective, third-party assessment.
    Section 403 would require VA, within 2 years of the date of 
the enactment of this Act, to submit a report on its compliance 
with VA's policy to conduct a review of each health care 
provider who transfers to another VA medical facility or leaves 
VA to determine whether there are any concerns, complaints, or 
allegations of violations relating to the medical practice of 
the health care provider and to take appropriate action with 
respect to any such concern, complaint, or allegation.
    VA does not support section 403 because reporting systems 
are already in place. VA has broad authority to report employed 
or separated health care professionals to state licensing 
boards when their behavior or clinical practice so 
substantially failed to meet generally accepted standards of 
clinical practice as to raise reasonable concern for the safety 
of patients. VA medical facility Directors are required to 
ensure that a review is conducted of the clinical practice of a 
licensed health care professional who leaves VA employment or 
when information is received suggesting that a current 
employee's clinical practice has met the reporting standard. VA 
has established a comprehensive quality assurance program for 
reporting any licensed health care professional to state 
licensing boards who was fired or resigned following the 
completion of a disciplinary action relating to such 
professional's clinical competence, resigned after having had 
such professional's clinical privileges restricted or revoked, 
or resigned after serious concerns about such professional's 
clinical competence had been raised but not resolved. When a 
report is made to a state licensing board, a copy of that 
letter is also forwarded to VA Central Office. VA would be 
happy to provide this information upon request, but we do not 
believe a statutory requirement to submit this information is 
warranted.
    Section 501 would add a new section 527A to title 38 
requiring VA to carry out a program of internal audits and 
self-analysis to improve the furnishing of benefits and health 
care to Veterans and their families. The Secretary would be 
required to establish an office within the Office of the 
Secretary to carry out these audits. The office would conduct 
periodic risk assessments, develop plans in response to these 
assessments, and conduct internal audits. At least five covered 
administrations, staff organizations, or staff offices would 
have to be audited each year. Within 90 days of completing an 
audit, the Secretary would be required to submit to the 
Committees on Veterans' Affairs, the House Committee on 
Oversight and Government Reform, and the Senate Committee on 
Homeland Security and Governmental Affairs a report on the 
audit. The first audit would have to be completed within 180 
days of the date of the enactment of this Act.
    VA understands the intent of this section, but is concerned 
about creating an entirely new structure that would in essence 
duplicate efforts of other organizations, such as the Inspector 
General or the Office of the Medical Inspector. We are also 
concerned that legislation directing VA to create certain 
offices or functions could produce conflict with the 
Department-wide restructuring effort underway through the MyVA 
initiative. VA recommends against further consideration of this 
section until VA's MyVA restructuring plans are more advanced 
so we can ensure that any new offices and functions are 
properly aligned and do not overlap with the missions of other 
organizations.
                                ------                                

                         The Secretary of Veterans Affairs,
                                  Washington, DC, December 8, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: By this letter, we are providing the 
remaining views and cost estimates for the following bills from 
the Committee's October 6, 2015, legislative hearing: S. 1676 
and sections 5 and 8 of S. 1885.
    We appreciate this opportunity to comment on this 
legislation and look forward to working with you and the other 
Committee Members on these important legislative issues.
            Sincerely,
                                        Robert A. McDonald.

  Enclosure.

 S. 1676, DELIVERING OPPORTUNITIES FOR CARE AND SERVICES FOR VETERANS 
                              ACT OF 2015

    Section 101 of S. 1676 would amend the Social Security Act 
to direct the Secretary of Health and Human Services to not 
take into account any resident within the field of allopathic 
or osteopathic medicine who counts towards the obligation of 
the Secretary of Veterans Affairs under section 301 (b)(2) of 
the Veterans Access, Choice, and Accountability Act of 2014 
(Public Law 113-146; 38 United States Code (U.S.C.) 7302 note) 
(VACAA) when applying the limitations regarding the total 
number of full-time equivalent residents in a hospital's 
approved medical residency training program. The Secretary 
would disregard such residents for cost reporting periods 
beginning on or after July 1, 2016.
    VA appreciates this effort to increase VA's ability to 
expand graduate medical education (GME), including expanding 
into underserved communities by allowing other community 
partners to assist in GME development. Since VA does not 
sponsor its own physician residency programs, it relies on its 
academic affiliates to select and sponsor residents who then 
receive a portion (typically around a quarter of their time) of 
their clinical training in a VA facility. This arrangement can 
help ensure that residents receive a well-rounded educational 
experience. The current cap on residency positions funded by 
the Centers for Medicare & Medicaid Services (CMS) limits the 
ability of potential partners to sponsor new VACAA residency 
positions in collaboration with VA.
    This provision, however, would have a budget impact on CMS 
and VA that could be significant, which makes support for this 
provision contingent on the availability of resources for both 
CMS and VA for its implementation. Still, however, VA believes 
that a partnership with CMS on the VA GME Expansion could 
assist with addressing known inequities in physician workforce, 
including the increasing specialization of physicians and the 
geographic maldistribution. VA's GME Expansion specifically 
targets Primary Care and Mental Health, and focuses on GME 
development in smaller and rural communities. A partnership 
with CMS on this initiative could create significant and 
beneficial change in the physician workforce for the nation.
    Section 102 would amend section 301 (b) of the VACAA to 
extend from 5 years to 10 years the time period provided for 
the Secretary of Veterans Affairs to increase the number of GME 
residency positions to 1,500; and extend by 5 years the time 
period during which the Secretary must file annual reports to 
Congress on residency positions at VA medical facilities. VA 
supports section 102. This legislation would provide additional 
time for VA to build the infrastructure needed to successfully 
create the required new residency positions. VA estimates that 
enactment of section 102 would be cost neutral.
    Section 103(a) would require the Secretary of Veterans 
Affairs and the Secretary of Health and Human Services to 
jointly conduct a 6-year pilot program to establish not less 
than three GME residency programs in behavioral medicine in 
underserved areas in the United States. Section 103(b) would 
require each residency program to provide participating 
residents the opportunity to work with diverse patient 
populations through rotations between medical facilities of VA, 
the Indian Health Service, and facilities participating under 
the Medicare program; provide education in the field of 
behavioral medicine; be carried out in a manner consistent with 
other residency programs supported and funded by VA and the 
Department of Health and Human Services; and be located in a 
community that is designated as a medically under-served area 
under 42 U.S.C. 254b(b)(3)(A), in a state with a per capita 
population of Veterans of more than 9 percent according to the 
National Center for Veterans Analysis and Statistics and the 
United States Census Bureau, and be within 100 miles of a 
Reservation as defined in 25 U.S.C. 1452.
    Section 103(c) would require the Secretary of Veterans 
Affairs and Secretary of Human Health and Services to provide 
to Congress at least annually a joint report containing certain 
specified elements regarding implementation of the pilot 
program.
    VA appreciates the goals behind section 103 but does not 
support these provisions. The extremely narrow criteria for the 
location of the three pilot sites would make the pilot program 
difficult to implement. For example, large states such as 
California and New York would be disqualified from 
consideration because of the per capita Veteran population 
requirement. Also, the requirement that each pilot site be 
located within 100 miles of a reservation would exclude many VA 
facilities from participation. In addition, the extremely 
limited residency training opportunities within the Indian 
Health Service would create a challenge when seeking to provide 
residents rotations through the Indian Health Service. Finally, 
the requirement for detailed annual joint reports from the 
Secretary of Veterans Affairs and the Secretary of Health and 
Human Services would be unduly burdensome given the relatively 
small portion of the GME workload these pilot sites would 
represent. VA estimates that the reporting requirement in 
section 103(c) would cost $260,000 annually and $1.56 million 
over the course of the pilot program.
    Section 104(a) would require the Secretary of Veterans 
Affairs to include in the education and training program 
required under section 7302(a)(1) of title 38 U.S.C., education 
and training of marriage and family therapists (MFT) and 
licensed professional mental health counselors (LPMHC). VA 
supports the goal behind section 104(a) but does not believe 
that section 104(a) is necessary as VA is presently providing 
this training and will continue to do so.
    Section 104(b) would require the Secretary to apportion 
funding equally among the professions included in the education 
and training program. VA does not support section 104 and has a 
technical concern. It is unclear to which professions the 
requirement for equal apportionment of funding would apply. If 
the intent is to require equal funding among all professions, 
VA does not support such a requirement. Presently, trainee 
funding is allocated in accordance with future hiring needs and 
capacity to support training programs at VA facilities. If the 
intent is to provide equal funding for LPMHC and MFT training 
programs, this would be problematic as well. VA has attempted 
to provide equal funding for these two professions. 
Nonetheless, internships are conducted in partnership with 
academic affiliate programs and under principles ensuring a 
quality educational experience and in the context of state 
licensing laws governing the credentials of supervisors. We 
have been able to rapidly expand LPMHC internships, but for the 
MFT internships, the supervisory requirements do not allow 
equally rapid expansion. A legislative requirement for equal 
funding might actually result in curtailing training for one 
profession, so that training for one profession does not exceed 
funding for another.
    Section 105 would amend section 7402(b)(11)(A) of title 38 
to expand eligibility for appointment within VA as a LPMHC to 
specifically include persons who hold a doctoral degree. VA 
supports section 105. VA estimates that there would be no cost 
associated with implementation of section 105.
    Section 201 would amend section 7451(a)(2) of title 38 to 
include physician assistants as ``covered positions'' to which 
the competitive pay provisions of that section apply. 
Presently, only registered nurses and certain positions as the 
Secretary may determine upon recommendation of the Under 
Secretary for Health are covered positions under section 7451.
    While VA supports the intent of Section 201, VA's support 
is conditioned on Congress providing the additional funding 
necessary to support these costs. VA also believes that the 
following health care professionals should also be added as 
``covered positions'' to this section of the law to apply these 
same competitive pay provisions to physical therapists, 
occupational therapists, physical therapy assistants, and 
occupational therapy assistants.
    Recruitment and retention of physical and occupational 
therapy professionals has been a longstanding challenge for VA. 
A major recruitment and retention barrier for these disciplines 
is the significant pay disparity between private sector market 
pay and VA pay schedules for these therapies. Although special 
pay rate authority exists at the local medical center level to 
address these disparities, such authority is not consistently 
utilized and is ineffective in many cases because special 
salary rates are below the full performance level salary.
    VA estimates that the cost of enactment of section 201 for 
PAs would be $33.2 million in FY 2016, $129 million over 5 
years, and $241 million over 10 years. In addition, VA 
estimates that expansion of the cost of applying the 
competitive pay provisions of section 7511 to physical 
therapists, occupational therapists, physical therapy 
assistants, and occupational therapy assistants would be $42.8 
million in FY 2016, $220 million over 5 years, and $458 million 
over 10 years.
    Section 202 would amend section 7681 of title 38 to require 
that not less than 30 percent of the amount of debt reduction 
payments paid under the Education Debt Reduction Program (EDRP) 
each year be paid to individuals who practice medicine in a 
rural area or highly rural area or demonstrate a commitment to 
practice medicine in such an area. Section 202 would define 
``highly rural area'' to mean an area located in a county or 
similar community that has less than seven individuals residing 
in that county or community per square mile, ``rural area'' to 
mean an area that is not an urbanized area or a highly rural 
area, and ``urbanized area'' to have the meaning given that 
term by the Director of the Bureau of the Census. VA does not 
support section 202. VA recognizes the intent of the 
legislation is to ensure use of EDRP for recruitment and 
retention in rural and highly rural areas. However, the 
proposed legislation would negatively impact the ability of 
local facilities to effectively use EDRP by restricting the 
flexibility that exists in the current process and seriously 
misaligning funding with respect to relative representation of 
clinical staff and vacancies.
    EDRP is designed for recruitment and retention of health 
care providers who are in difficult to recruit/retain health 
care positions and who are providing direct patient care 
services or services incident to direct patient care. Local 
facilities prioritize hard-to-recruit-and-retain occupations 
based on facility needs. Each VA medical facility receives EDRP 
funding allocation to recruit and retain health care providers. 
Many VA facilities, including both urban and rural facilities, 
are in fierce competition with the private sector. In fact, 
some of the hardest to recruit/retain facilities are in urban 
areas where the cost of living is extremely high and where VA 
has a harder time competing with the salaries offered by the 
private sector.
    Currently, the percentage of EDRP funding is on par with 
the percentage of rural and highly rural facilities and 
providers at those facilities. Rural and highly rural 
facilities make up 12.6 percent of VA facilities, and employ 
only 6 percent of VA's clinical providers and support staff. In 
FY 2015, 11 percent of facilities receiving EDRP were rural or 
highly rural, and employees at those facilities received 8 
percent of the total EDRP funds distributed, commensurate with 
their representation in the workforce. Furthermore, a review of 
current recruitment activity rates indicates that only 5.4 
percent of clinical vacancies are in rural and highly rural 
facilities.
    Requiring 30 percent of all EDRP funding be awarded to 
rural facilities would create a significant disparity in 
overall program funding for other sites, preventing facilities 
with critical provider shortages from filling EDRP-eligible 
positions. Restricting usage of nearly one-third of all EDRP 
funding for rural areas would negatively impact the flexibility 
afforded to local facilities to determine their specific health 
care provider needs. Finally, past efforts to set aside EDRP 
funds for various hiring initiatives have indicated that funds 
set aside for special uses, such as this, are frequently under-
used because the employees hired at those sites or for those 
positions simply do not have eligible student loan debt. It is 
imperative that flexibility not be restricted for use of these 
funds in a way that has unintended consequences, and 
potentially limits the use of the funding all together. VA 
estimates that there would be no cost associated with 
implementation of section 202.
    Section 203(a) would require the Secretary of Veterans 
Affairs to submit to Congress a report on the medical workforce 
of the Department not later than 120 days after the date of 
enactment of the Act. Section 203(b) would require the report 
to include specific elements. Specifically, section 203(b)(1) 
would require the report to include how many LPMHCs and MFTs 
are enrolled in the mental health professionals trainee program 
of the Department; how many are expected to enroll in the 
mental health professionals trainee program of the Department 
during the 180-day period beginning on the date of submittal of 
the report; a description of the eligibility criteria for such 
counselors and therapists compared to other behavioral health 
professions in the Department; a description of the objectives, 
goals, and timing of the Department regarding increasing the 
representation of such counselors and therapists in the 
behavioral health workforce of the Department; and a 
description of the actions taken by the Secretary, in 
consultation with the Director of the Office of Personnel 
Management (OPM), to create an occupational series for such 
counselors and therapists and a timeline for the creation of 
such an occupational series.
    Section 203(b)(2) would require the report to include a 
specific breakdown of spending by the Department in connection 
with EDRP, as well as descriptions of how the Department 
prioritizes such spending and the actions taken by the 
Secretary to increase the effectiveness of such spending for 
the purposes of recruitment of health care providers. Section 
203(b)(3) would require the report to include a description of 
any impediments to the delivery of telemedicine services to 
Veterans and any actions taken by the Department to address 
such impediments, including with respect to certain specified 
issues.
    Section 203(b)(4) would require the report to include an 
update on the efforts of the Secretary to offer training 
opportunities in telemedicine to medical residents in medical 
facilities of the Department that use telemedicine, consistent 
with medical residency program requirements established by the 
Accreditation Council for Graduate Medical Education, as 
required by the Honoring America's Veterans and Caring for Camp 
Lejeune Families Act of 2012 (Public Law 112-154; 38 U.S.C. 
7406 note). Section 203(b)(5) would require the report to 
include an assessment of the development and implementation by 
the Secretary of succession planning policies to address the 
prevalence of vacancies in the Veterans Health Administration 
(VHA) of more than 180 days, including development of an 
enterprise position management system to more effectively 
identify, track, and resolve such vacancies.
    Section 203(b)(6) would require the report to include a 
description of the actions taken by the Secretary, in 
consultation with the Director of OPM, to address any 
impediments to the timely appointment and determination of 
qualifications for Directors of Veterans Integrated Service 
Networks (VISN) and Medical Directors of the Department.
    VA does not believe that the reporting requirements in 
section 203 are necessary and the actions and initiatives 
addressed by section 203 are already deployed or being pursued 
within VHA. VA estimates that the costs associated with 
enactment of section 203 would not be significant.
    Section 301 would amend section 7306(a)(4) of title 38 to 
add VISN Directors to the list of personnel who comprise the VA 
Office of the Under Secretary for Health and remove the 
requirement that Medical Directors be doctors of medicine, 
dental surgery, or dental medicine.
    Section 302 would amend chapter 74 of title 38 to add a new 
subchapter VII and section 7481 regarding compensation for 
Medical Directors and VISN Directors. Section 302 would 
establish the elements of pay for Directors appointed under 
section 7306(a)(4) of title 38 to include basic pay as 
determined under section 7404(a) of title 38 and market pay as 
determined under the new section 7481. Section 302 would 
require the Secretary to evaluate the amount of market pay 
payable to a Director not less frequently than once every 2 
years and may adjust market pay as a result of such evaluation. 
Section 302 require the Secretary not less than once every 2 
years to set forth a Department-wide total annual pay minimum 
and maximum which must be published in the Federal Register. 
Section 302 would prohibit the Secretary from delegating the 
authority to determine the Department-wide minimum and maximum 
total annual pay.
    VA supports sections 301 and 302, and the latter provision 
matches a proposal put forward in February 2015 in VA 's Fiscal 
Year 2016 budget submission. VA believes that there are three 
primary factors that warrant a separate compensation system for 
Medical Directors and VISN Directors. First, existing pay 
compression within the current Senior Executive Service (SES) 
pay system and the closely proximate rates of pay for direct 
reports to Medical Center Directors and VISN Directors have 
resulted in declining Director applicant pools. Second, a high 
number of existing (an estimated 84 percent by FY 2018) 
Directors are or will soon be eligible for retirement. Third, 
private sector pay for health care leadership positions is 
highly competitive.
    In addition, there are limited pay incentives for 
experienced Medical Center Directors and VISN Directors to 
voluntarily move to fill more demanding positions. Due to the 
SES pay compression between experienced Medical Center 
Directors and VISN Directors, the small pay raise, if any, that 
VHA is able to offer in a reassignment may cause the candidate 
to be disadvantaged financially. The most significant cost 
disparities occur due to housing costs and in some cases, 
higher tax rates (e.g., New York, California). With current 
executive pay authorities, a move for the good of the 
organization most of the time means a move to the financial 
detriment of the Director and their family. On average, it has 
taken over 6 months to fill Medical Center Director and VISN 
Director positions, with many being re-announced multiple times 
for positions in both rural and major metropolitan areas. The 
reluctance on the part of these senior leaders to relocate is 
understandable. It is imperative that VHA have the ability to 
implement pay to retain eligible leaders, reward mobility, and 
ensure knowledge transfer to the next generation of Medical 
Center Directors and VISN Directors. VA estimates that 
enactment of section 301 would involve no cost and that 
enactment of section 302 would cost $8.8 million in FY 2016, 
$46 million over 5 years, and $93.2 million over 10 years.
    Section 401(a) would require the Secretary, not later than 
1 year after the date of enactment of the Act, to conduct a 2-
year pilot program to assess the feasibility and advisability 
of implementing in rural areas and highly rural areas with a 
large percentage of Veterans a nurse advice line to furnish to 
Veterans medical advice, appointment and cancellation services, 
and information on the availability of benefits from VA.
    Section 401(b) would require the pilot program to establish 
a nurse advice line that operates free of charge, is based on 
and improves upon the Department of Defense TRICARE advice 
line, complies with call center requirements set forth by URAC, 
uses a process for determinations of caller eligibility, allows 
for information sharing between VA and the nurse advise line, 
and maintains quality controls to ensure calls are answered by 
a customer service representative within 30 seconds with an 
abandonment rate of less than 5 percent.
    Section 401(c) would require the nurse advice line to 
provide an array of services including: medical advice from 
licensed registered nurses who assess the caller's symptoms 
using a proprietary clinical algorithm meeting specified 
criteria, information to address basic questions regarding 
eligibility for VA benefits, and use of an appointment clerk to 
facilitate scheduling of appointments for health care from the 
Department.
    Section 401(d) would require, not later than 120 days after 
the date of completion of the pilot program, the Secretary to 
submit to Congress a report providing specified information 
regarding the pilot program.
    VA does not support section 401 as VA already provides 
telephone services for clinical care. Specifically, VHA 
Directive 2007-033, Telephone Service for Clinical Care, 
requires telephone services for clinical care to be made 
available to all Veterans receiving care at VHA facilities to 
include 24/7 telephone access to clinical staff trained to 
provide health care advice and information. Each facility is 
responsible for providing access for Veteran clinical concerns 
consistent with VHA Directive 2007-033. Veteran telephone 
access to clinical care during business hours is facility 
based, managed, and resourced. Veterans are able to call their 
local facility and speak with clinical staff to address and 
manage their concerns. VA staff members working with Veterans 
are responsible for following evidence-based guidance including 
during in-person and telephone contact. VA estimates that 
enactment of section 401 would cost $75 million in FY 2016, 
$385 million over 5 years, and $770 million over 10 years.

            S. 1885, VETERANS HOUSING STABILITY ACT OF 2015

    Section 5 of S. 1885 would amend section 2041 of title 38 
U.S.C. to expand eligibility for the services provided under 
that section as well as the scope of services provided. Under 
section 2041, VA may enter into agreements to sell, lease, or 
donate real property acquired by the Secretary as a result of a 
default on a loan made, insured, or guaranteed by VA to 
qualified nonprofit organizations or state or local governments 
that agree to use the properties to shelter homeless Veterans 
and their families. Section 5 would permit such entities to 
continue assisting homeless Veterans and their families, as 
under current section 2041, but would also expand section 2041 
to include Veterans and their families who are at risk of 
becoming homeless and very low-income Veteran families (as 
defined in section 2044(f) of title 38). Rather than limiting 
the entities' assistance to shelter, as is currently the case, 
the entities would also be able to assist such Veterans and 
their families in acquiring and transitioning to permanent 
housing, and in maintaining occupancy in permanent housing. 
Section 5 would also require the entity to expand the range of 
services it provides to the Veterans that it houses by ensuring 
that such Veterans receive referrals for the benefits and 
services to which the Veterans may be entitled or eligible 
under title 38.
    VA does not object to section 5 but has a technical 
concern. Section 5(a)(2)(C) would amend subsection (a)(3)(B) of 
section 2041 to strike ``solely as a shelter primarily for 
homeless Veterans and their families'' and insert ``to provide 
permanent or transitional housing for Veterans and families 
described in paragraph (1).'' By striking ``shelter,'' section 
5(a)(2)(C) would require the entity to agree to use the 
property in a manner more narrow than the overall purpose of 
the bill as expressed in section 5(a)(2)(A), which includes 
assisting eligible individuals ``in acquiring shelter.'' 
Therefore, VA recommends that line 2 of page 12 of the draft 
bill be revised to include ``shelter or'' before ``permanent or 
transitional housing.'' VA estimates that enactment of section 
5 would result in new benefit loan subsidy costs of $16.6 
million for FY 2016. The provision would expire at the end of 
2016. VA estimates that enactment would not increase general 
operating expenses costs.
    Section 8 would amend section 2012 of title 38 to require 
VA to annually review each Homeless Provider Grant and Per Diem 
(GPD) program grant recipient and eligible entity that received 
a per diem payment and evaluate each grantee's success in 
assisting Veterans to obtain, transition into, and retain 
permanent housing and increasing Veteran income through 
obtaining employment or income-related benefits. VA would only 
be able to continue providing per diem to the grantee if VA 
determines that the grantee's performance merits continuation 
of the per diem. Section 8 would also require VA to establish 
uniform performance targets for all GPD grantees in order to 
conduct its review and evaluation.
    VA supports section 8 and has a minor technical concern. 
Currently, the GPD program has in place an annual inspection 
protocol which includes an evaluation of certain performance 
metrics established by VA. When grantees fail to meet the 
annual inspection requirements the GPD program begins 
corrective action process that can lead to stopping per diem if 
corrections are not implemented. VA believes the current annual 
inspections process could be changed to incorporate the 
criteria specified in, and new uniform performance targets 
required by, section 8. These changes would further help VA to 
tie continued per diem payment to grantee performance. VA's 
minor technical concern relates to lines 5 and 6 of page 16 of 
the bill, which state that VA would evaluate performance with 
respect to success ``in assisting Veterans obtain, transition 
into, and retain permanent housing.'' VA recommends inserting 
the word ``to'' before the word ``obtain.'' VA estimates that 
the enactment of section 8 would be cost neutral.
                                ------                                

    On May 13, 2015, Anthony Kurta, Deputy Assistant Secretary 
of Defense, Military Personnel Policy, Department of Defense, 
appeared before the Committee on Veterans' Affairs and 
submitted testimony on various bills incorporated into the 
Committee bill. An excerpt from that testimony is reprinted 
below:

  STATEMENT OF ANTHONY KURTA, DEPUTY ASSISTANT SECRETARY OF DEFENSE, 
         MILITARY PERSONNEL POLICY, U.S. DEPARTMENT OF DEFENSE

    Good afternoon, Chairman Isakson, Ranking Member 
Blumenthal, and esteemed members of the Committee. I am pleased 
to appear before you today to discuss pending benefits 
legislation.
    Per the agenda for today's hearing, the committee requested 
the Department of Defense's view on a series of bills and 
proposals. Since both funding and administration of the Post-9/
11 GI Bill fall under the purview of the Department of Veterans 
Affairs, I will focus my comments only on those proposals that 
will affect the Department of Defense and generally defer to 
the Departments of Labor and Veterans Affairs to provide 
responses on those with no significant DOD impacts. This 
statement will follow the order on the printed agenda.

                  S. 602, GI BILL FAIRNESS ACT OF 2015

    The committee asked for comments on S. 602, ``GI Bill 
Fairness Act of 2015,'' a bill that would consider active duty 
performed under the authority of title10, United States Code, 
section 12301(h), as qualifying active duty for the purposes of 
Post-9/11 GI Bill Education Benefits. Reserve component members 
wounded in combat are often given orders to active duty under 
this provision to receive authorized medical care; to be 
medically evaluated for disability; or to complete a required 
health care study. However, as currently written, section 
3301(1)(B), of title 38, United States Code, does not include 
active duty performed under 12301(h) as qualifying active duty 
for purposes of Post-9/11 GI Bill educational assistance.
    Currently, when a member of the Reserve Component on active 
duty sustains an injury due to military operations, the 
Servicemember is not discharged, but remains in the Selected 
Reserve on active duty under 12301(h), title 10, United States 
Code. None of the time spent in recovery under this status is 
qualifying time for purposes of the Post-9/11 GI Bill. In this 
case, the Servicemember would return to Selected Reserve status 
with less qualifying time than those who served an entire 
period of active duty without an intervening injury. As a 
result, the Servicemember would not receive an educational 
benefit equivalent to the other members of his or her cohort. 
In effect, the Servicemember is being penalized for having 
being wounded or injured in theater. This legislation would 
correct this inequity by simply extending eligibility for the 
Post-9/11 GI Bill to service under 12301(h).
    DOD recognizes the inequity of not including this active 
duty time for purposes of Post-9/11 GI Bill benefits, and has 
included a provision similar to this bill in our FY 2016 
legislative proposal package as section 514. However, the DOD 
proposal would include only active duty performed after 
enactment. In contrast, S. 602 would be retroactive; 
categorizing all duty performed under 12301(h) since September 
11, 2001, as qualifying active duty for purposes of the Post-9/
11 GI Bill. We estimate that approximately 5,000 Reserve 
Component members performed active duty under 12301(h) each 
year since September 11, 2001. Accordingly, we believe that 
S. 602 would generate an additional cost to the Department of 
Veterans Affairs. Given that both the funding and 
administration of the Post-9/11 GI Bill fall under the purview 
of the Department of Veterans Affairs, we would defer to that 
agency to determine the costs and effects of the bill on their 
Department.

           *       *       *       *       *       *       *

                                ------                                

    On October 6, 2015, Hon. Lawrence B. Hagel, Chief Judge of 
the U.S. Court of Appeals for Veterans Claims submitted the 
following written testimony:

STATEMENT OF HON. LAWRENCE B. HAGEL, CHIEF JUDGE, U.S. COURT OF APPEALS 
                          FOR VETERANS CLAIMS

    Mr. Chairman and Distinguished Members of the Committee: 
Thank you for the opportunity to comment on S. 1754, a bill 
that would amend 38 U.S.C. Sec. 7253(a), to make permanent the 
authorization for an increase in the number of judges on the 
U.S. Court of Appeals for Veterans Claims (Court), from seven 
to nine. Succinctly stated, the Court supports this legislation 
and urges its passage.
    The decision by Congress several years ago to expand the 
Court temporarily to nine judges came in response to a 
significant increase in the Court's caseload, and a perception 
that the rise was not simply a spike but in fact a trend. 
Effective December 31, 2009, authorization permitted the Court 
to grow to nine active judges, and we reached that full 
complement in December 2012. We were fortunate to operate with 
nine judges for almost three years until the retirement of one 
of our colleagues one month ago. With full staffing the Court 
has been able to conduct effective, efficient, and expeditious 
judicial review. Your support in providing the resources to 
handle our heavy caseload is very much appreciated.
    Under current law we will operate with eight judges until 
the next retirement, and then we revert to seven judges, our 
current permanent authorization. The reality is that two 
judges' terms expire within days of each other in 
December 2016, so absent legislation the Court will dip to six 
judges at that time. With the unpredictability of the judicial 
nomination and appointment process, and another retirement 
likely in 2017, there is a very real possibility that the Court 
will shrink to five judges just two years from now. Passage of 
S. 1754 would permit a judicial appointment now to bring us 
back up to nine judges, and would prevent the Court from 
dropping to a critically low number of judges in the near 
future.
    Since its creation in 1988, the Court has become one of the 
Nation's busiest Federal courts based on the numbers of appeals 
filed and decided per judge. Up until about ten years ago the 
Court received roughly 2,200 appeals annually. That number 
began to rise significantly starting in FY 2005, reaching over 
4,700 appeals filed in FY 2009. Since that time, annual appeals 
filed have not fallen below 3,500 and although we are still 
tabulating FY 2015 numbers, we estimate that over 4,400 appeals 
were filed. This is double the number of appeals filed annually 
during the Court's first 15 years from 1989 to 2004.
    For cases decided, the Court terminated in the neighborhood 
of 4,400 appeals in FY 2015. That is in addition to acting on 
nearly 3,000 applications for attorney fees, hundreds of 
petitions for extraordinary relief, and thousands of procedural 
motions. We continue to be one of the busiest national courts, 
but we are efficiently handling this formidable caseload. 
Generally speaking, appeals filed at the Court come from 
veterans who are dissatisfied with a decision of the Board of 
Veterans' Appeals (Board). Much emphasis and financial support 
has been placed toward increasing the numbers of personnel at 
the Department of Veterans Affairs, and toward improving claims 
processing times. Up from 41,910 decisions in FY 2013, the 
Board issued 55,532 decisions in FY 2014, and the Board 
estimates that it will decide at least the same number in FY 
2015. Although it is difficult to predict with certainty what 
our caseload will be in the future, it seems likely, 
considering the number of claims filed annually with VA and the 
increased productivity by the Board, that the number of appeals 
filed at the Court will also rise further and stay high.
    Over the past several years the Court has striven to create 
efficiencies in how we conduct judicial review of veterans' 
appeals. We have adopted an electronic case filing and 
management system. We are constantly improving our pre-briefing 
mediation program to resolve cases earlier in the process, to 
hone the issues on appeal, and to stretch our judicial 
resources to the greatest extent possible. We have an active 
bar, and we engage frequently with our practitioners to discuss 
ways to further improve our process. Everyone involved in 
judicial review of veterans' appeals shares a common goal of 
wanting to honor our veterans and provide full, fair, and 
prompt decisions on their appeals. Authorization for nine 
active judges would be a significant factor in furthering that 
goal.

    In closing, on behalf of the Court, I express my 
appreciation for your past and continued support, and for the 
opportunity to provide this statement.

  SUPPLEMENTAL VIEWS OF HON. RICHARD BLUMENTHAL, RANKING MEMBER, HON. 
PATTY MURRAY, HON. BERNIE SANDERS, HON. SHERROD BROWN, HON. JON TESTER, 
                        AND HON. MAZIE K. HIRONO

    On December 9, 2015, the Senate Committee on Veterans' 
Affairs (hereinafter, ``the Committee'') voted, by voice vote, 
to approve S. 425, as amended, a bill to provide for a five-
year extension to the homeless veterans reintegration programs 
of the Department of Veterans Affairs (hereinafter, ``VA'' or 
``Department'') and to provide clarification regarding 
eligibility for services under such programs. We strongly 
support the Committee's intent, expressed on December 9, 2015 
that employment discrimination on the basis of race, color, 
religion, sex, sexual orientation, gender identity, national 
origin, disability, veteran status, or other protected category 
or activity has no place in the health care that VA provides. 
We reaffirm in these supplemental views our expectation that 
all entities providing health care to veterans will meet the 
highest standards of nondiscrimination, civil rights 
protections and equality of employment opportunity.
    Section 461(a) of the bill would add a new Sec. 1703A to 38 
U.S.C. chapter 17. That section includes a provision, 
Sec. 1703A(h)(2)(A), which was modified during the Committee 
meeting to fully exempt extended-care providers that enter into 
``Veterans Extended Care Agreements'' from laws to which 
providers under Medicare are not subject. Similarly, 
Sec. 462(b) of the bill adds a new subparagraph 4(B) to 38 
U.S.C. Sec. 1745(a), which ensures similar status for state 
veterans homes that provide nursing-home care by agreement with 
VA. The Veterans Extended Care Agreements authorized by this 
bill arrange for eligible extended-care providers to provide 
direct health care services for veterans for which VA will 
reimburse the providers for those services. This is distinct 
from the arrangement under Medicare and Medicaid, where the 
Federal Government provides financial assistance to the 
individuals to whom health-care providers furnish services. It 
is also different from the arrangement used by the Department 
of Defense (hereinafter, ``DOD'') through the TRICARE health 
system, whereby health-care providers do not directly contract 
with DOD but rather are part of health-care networks 
administered by Managed Care Support Contractors.
    This bill exempts extended-care providers from complying 
with the Vietnam Era Veterans' Readjustment Assistance Act of 
1974, as amended, section 4212 of title 38 U.S.C. (hereinafter, 
``VEVRAA''). VEVRAA is the only Federal statute that promotes 
employment opportunities for protected veterans who work for or 
apply to work for covered Federal contractors and 
subcontractors that have at least $150,000 in contracts. The 
VEVRAA regulations provide explicit, comprehensive protection 
from discrimination in all aspects of the employment 
relationship--including advertising and recruitment, the 
application process and initial hiring, training opportunities, 
performance evaluations, promotions, benefits, compensation, 
discharge, and all other terms and conditions of employment. 
For Federal contractors that have at least 50 employees, VEVRAA 
also requires that they measure progress toward achieving equal 
employment opportunity for veterans against an established 
benchmark, periodically review their personnel processes to 
ensure that they do not stereotype protected veterans in a way 
that limits their access to all jobs for which they are 
qualified; and periodically assess any qualification standards 
that tend to screen out qualified veterans to ensure the 
standards are job-related for the position in question and 
consistent with business necessity. The Office of Federal 
Contract Compliance Programs (hereinafter, ``OFCCP'') within 
the Department of Labor (hereinafter, ``DOL'') enforces VEVRAA. 
If OFCCP finds that a covered contractor has engaged in 
unlawful discrimination against a protected veteran, it can 
require the contractor to provide ``make-whole relief'' to the 
veteran, including back pay and an offer of employment. A 
covered contractor that refuses to comply with the statute and 
its regulations may be subject to disbarment from future 
contracts.
    A consequence of enactment of this bill would mean 
extended-care providers who enter into agreements during the 
two years for which they are authorized will not have to file 
annual Federal Contractor Veterans' Employment Reports. The 
information from these reports is valuable for contractors, the 
public, and policymakers who want to assess contractors' 
progress in hiring veterans. In 2012, Congress amended VEVRAA 
in 2012 to require DOL to make this data public further 
indicating the value of this information. As DOL has explained 
in its Annual Report from Federal Contractors in 2014----

          Information on the total number and proportion of 
        protected veterans employed and newly hired in Federal 
        contractor workforces from year to year will show 
        trends in the employment of protected veterans, and 
        analyses of those trends can be used to assess the 
        extent to which Federal contractors are providing 
        employment opportunities to protected veterans.

    In addition to VEVRAA, two other key civil rights 
protections would no longer protect employees who work for 
providers with Veterans Extended Care Agreements under this 
bill:

     Executive Order (hereinafter, ``E.O.'') 11246, 
which prohibits contractors with more than $10,000 in Federal 
contracts from discriminating against employees or applicants 
because of race, color, religion, sex, sexual orientation, 
gender identity, or national origin, or because they inquired 
about, discussed or disclosed information about compensation, 
and requires contractors to take affirmative action to ensure 
equal employment opportunity; and
     Section 503 of the Rehabilitation Act of 1973 
(``Section 503''), which prohibits contractors with more than 
$10,000 in Federal contracts from discriminating in employment 
on the basis of disability and requires them to take 
affirmative action to ensure equal employment opportunity for 
individuals with disabilities.

    Like VEVRAA, these two laws and their implementing 
regulations were adopted to ensure that Federal dollars 
establish reasonable standards for contractors by requiring not 
only that they not discriminate in their employment practices, 
but also that they take positive steps to ensure equal 
employment opportunity. These requirements include assigning 
responsibility and accountability for the implementation of 
equal employment opportunity to an official who has the 
authority, resources, support of and access to top management 
to ensure effective implementation; sending notices of 
contractors' equal employment opportunity obligations to each 
labor union with which they have a collective bargaining 
agreement; and reviewing personnel activity to eliminate 
unnecessary causes of disparities.
    Section 503 requirements are particularly useful for 
veterans with disabilities as they require contractors with 50 
or more employees and a contract of $50,000 or more to 
undertake appropriate outreach activities that are reasonably 
designed effectively to recruit qualified individuals with 
disabilities. These activities include reaching out to the 
Veterans' Service Organizations and the disabled veterans' 
outreach program specialists in the American Jobs Center 
nearest the contractor's establishment. This bill would exempt 
the extended-care providers who often provide health care and 
rehabilitation services to veterans with disabilities so that 
they can return to the civilian workforce, from having to take 
at least the same steps to employ veterans with disabilities 
who are able to work as other Federal contractors do.
    E.O. 11246 and Section 503 are important because they 
provide protection from discrimination on the bases of race, 
religion, sex, sexual orientation, gender identity, national 
origin, and disability. Indeed, the commitment to civil rights 
protections that they embody is consistent with VA's long 
history of embracing the diversity that has made our Nation 
great.
    OFCCP plays a vital role and unique role in combating 
unlawful employment discrimination by Federal contractors on 
the basis of sex, race, national origin, color, sexual 
orientation, gender identity and disability; as well as 
requiring non-discrimination and affirmative action for special 
and disabled veterans of war in which a campaign badge has been 
authorized. Notably, no other applicable anti-discrimination 
law requires contractors to ensure they have a workforce that 
includes protected veterans and qualified individuals with 
disabilities. No other Federal law explicitly makes it unlawful 
for employers to discriminate in employment on the basis of 
sexual orientation. Finally, no other anti-discrimination law 
carries with it the possibility--albeit remote--that a 
contractor will be debarred from future Federal contracts if it 
engages in ongoing, repeated, and egregious discrimination.
    We are gravely concerned that claims made about the burdens 
of compliance, suggesting it will undermine the ability of 
providers that enter into Veterans Extended Care Agreements to 
deliver high-quality, timely, and efficient care to veterans, 
are devoid of evidence-based data. Many health-care facilities, 
including extended-care facilities, have been subject to these 
laws for years and have succeeded in complying with them. 
Despite these concerns, we support the temporary use of 
Veterans Extended Care Agreements under this bill as an interim 
step to promote quick delivery of much-needed extended health 
care to veterans as VA and Congress work together to reform 
care delivered by VA. However, more permanent contractual 
agreements that VA enters into with health-care providers 
should restore employee protections unless the concerns, 
outlined in these Supplemental Views, are alleviated by a 
strong showing using fact-based evidence that the costs of 
complying with VEVRAA, Section 503, and E.O. 11246 would make 
it impossible for extended care providers to provide care to 
veterans unless they were exempted from these laws.

           *       *       *       *       *       *       *

                        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

           *       *       *       *       *       *       *

Chapter 5. Authority and Duties of The Secretary

           *       *       *       *       *       *       *

                   SUBCHAPTER I. GENERAL AUTHORITIES

Sec.

           *       *       *       *       *       *       *

SUBCHAPTER II. SPECIFIED FUNCTIONS

           *       *       *       *       *       *       *

527. Evaluation and data collection.
527A. Program of internal audits.

           *       *       *       *       *       *       *

Subchapter II. Specified Functions

           *       *       *       *       *       *       *

SEC. 527A. PROGRAM OF INTERNAL AUDITS

    (a) Program Required.--(1) The Secretary shall carry out a 
program of internal audits and self-analysis to improve the 
furnishing of benefits and health care to veterans and their 
families.
    (2) The Secretary shall carry out the program required by 
paragraph (1) through an office the Secretary shall establish 
for purposes of the program within the office of the Secretary 
that is interdisciplinary and independent of--
          (A) the other offices within the office of the 
        Secretary; and
          (B) the covered administrations (or functions of such 
        administrations), staff organizations, and staff 
        offices identified under subsection (b)(1)(A).
    (b) Program Requirements.--(1) In carrying out the program 
required by subsection (a), the Secretary shall--
          (A) conduct periodic risk assessments of the 
        Department to identify those covered administrations 
        (or functions of such administrations), staff 
        organizations, and staff offices of the Department the 
        audit of which would lead towards the greatest 
        improvement in the furnishing of benefits and health 
        care to veterans and their families;
          (B) develop plans that are informed by the risk 
        assessments conducted under paragraph (1) to conduct 
        internal audits of the covered administrations (or 
        functions of such administrations), staff 
        organizations, and staff offices identified under 
        subparagraph (A); and
          (C) conduct internal audits in accordance with the 
        plans developed pursuant to subparagraph (B).
    (2) The Secretary shall carry out under the program 
required by subsection (a) an audit of not fewer than five 
covered administrations (or functions of such administrations), 
staff organizations, or staff offices of the Department each 
year.
    (3) In identifying covered administrations (or functions of 
such administrations), staff organizations, and staff offices 
of the Department under paragraph (1)(A), the Secretary shall 
accord priority to the covered administrations and functions of 
such administrations.
    (4)(A) For purposes of this subsection, the covered 
administrations of the Department are the following:
          (i) The National Cemetery Administration.
          (ii) The Veterans Benefits Administration.
          (iii) The Veterans Health Administration.
    (B) For purposes this subsection, the covered staff 
organizations of the Department are the following:
          (i) The Office of Acquisition, Logistics, and 
        Construction.
          (ii) The Advisory Committee Management Office.
          (iii) The Board of Veterans' Appeals.
          (iv) The Center for Faith-Based and Neighborhood 
        Partnerships.
          (v) The Center for Minority Veterans.
          (vi) The Center for Women Veterans.
          (vii) The Office of General Counsel.
          (viii) The Office of Regulation Policy and 
        Management.
          (ix) The Office of Employment Discrimination 
        Complaint Adjudication.
          (x) The Office of Interagency Care and Benefits 
        Coordination.
          (xi) The Office of Small and Disadvantaged Business 
        Utilization.
          (xii) The Office of Survivors Assistance.
          (xiii) The Veterans' Service Organizations Liaison.
    (C) For purposes of this subsection, the covered staff 
offices of the Department are the following:
          (i) The office of the Assistant Secretary for 
        Congressional and Legislative Affairs.
          (ii) The office of the Assistant Secretary for Human 
        Resources and Administration.
          (iii) The office of the Assistant Secretary for 
        Information and Technology.
          (iv) The Office of Management.
          (v) The office of the Assistant Secretary for 
        Operations, Security, and Preparedness.
          (vi) The office of the Assistant Secretary for Policy 
        and Planning.
          (vii) The office of the Assistant Secretary for 
        Public and Intergovernmental Affairs.
    (c) Reports.--(1)(A) Not later than 90 days after 
completing an audit under the program required by subsection 
(a), the Secretary shall submit to the appropriate committees 
of Congress a report on the audit.
    (B) Each report submitted under subparagraph (A) with 
respect to an audit shall include the following:
          (i) A summary of the audit.
          (ii) The findings of the Secretary with respect to 
        the audit.
          (iii) Such recommendations as the Secretary may have 
        for legislative or administrative action to improve the 
        furnishing of benefits and health care to veterans and 
        their families.
          (iv) Plans to carry out the recommendations submitted 
        under clause (iii), including timelines for completion 
        of such plans.
    (2)(A) Not later than September 1 of each year, the 
Secretary shall submit to the appropriate committees of 
Congress a report on the administration of this section.
    (B) Each report submitted under subparagraph (A) shall 
include the following:
          (i) A detailed description of each matter for which a 
        recommendation was submitted under clause (iii) of 
        paragraph (1)(B) and with respect to which plans that 
        were submitted under clause (iv) of such paragraph have 
        not been completed.
          (ii) A plan for the conduct of audits under this 
        section during the first fiscal year beginning after 
        the fiscal year in which the report is submitted, which 
        shall include the following:
                  (I) A description of any risk assessments the 
                Secretary plans to conduct in such fiscal year.
                  (II) A summary of each audit the Secretary 
                plans to conduct in such fiscal year, including 
                a description of the subject matter of the 
                audit and identification of the administration, 
                office, or function to be audited.
    (3) In this subsection, the term ``appropriate committees 
of Congress'' includes--
          (A) the Committee on Veterans' Affairs, the Committee 
        on Appropriations, and the Committee on Homeland 
        Security and Governmental Affairs of the Senate; and
          (B) the Committee on Veterans' Affairs, the Committee 
        on Appropriations, and the Committee on Oversight and 
        Government Reform of the House of Representatives.

           *       *       *       *       *       *       *

Part II. General Benefits

           *       *       *       *       *       *       *

 Chapter 15. Pension for Non-Service-Connected Disability or Death or 
for Service

           *       *       *       *       *       *       *

 Subchapter IV. Army, Navy, Air Force, and Coast Guard Medal of Honor 
                                  Roll

SEC. 1562. SPECIAL PROVISIONS RELATING TO PENSION

    (a) The Secretary shall pay monthly to each living person 
whose name has been entered on the Army, Navy, Air Force, and 
Coast Guard Medal of Honor Roll, and a copy of whose 
certificate has been delivered to the Secretary under 
subsection (d) of section 1134a of title 10, a special pension 
at the rate of [$1,000] $3,000, as adjusted from time to time 
under subsection (e), beginning as of the date on which the 
person's name is entered on the Army, Navy, Air Force, and 
Coast Guard Medal of Honor Roll under subsection (b) of such 
section.

           *       *       *       *       *       *       *

   Chapter 17. Hospital, Nursing Home, Domiciliary, and Medical Care

                         SUBCHAPTER I. GENERAL

Sec.

           *       *       *       *       *       *       *

1703. Contracts for hospital care and medical services in non-
            Department facilities.
1703A. Veterans Extended Care Agreements with certain health care 
            providers.

           *       *       *       *       *       *       *

Subchapter I. General

           *       *       *       *       *       *       *

SEC. 1703A. VETERANS EXTENDED CARE AGREEMENTS WITH CERTAIN HEALTH CARE 
                    PROVIDERS

    (a) Agreements to Furnish Extended Care.--(1) In addition 
to the authority of the Secretary under this chapter to furnish 
extended care at facilities of the Department and under 
contracts or sharing agreements entered into under authorities 
other than this section, the Secretary may furnish extended 
care through the use of agreements entered into under this 
section. An agreement entered into under this section may be 
referred to as a ``Veterans Extended Care Agreement''.
    (2) The Secretary may enter into agreements to furnish 
extended care under this section with eligible providers that 
are certified under subsection (d) if the Secretary is not 
feasibly able to furnish extended care at facilities of the 
Department.
    (3) An eligible provider, at its discretion, may opt to 
enter into an agreement under this section instead of a 
contract or sharing agreement under authorities other than this 
section.
    (b) Receipt of Extended Care.--(1) Eligibility of a veteran 
for extended care under this section shall be determined as if 
such care were furnished in a facility of the Department and 
provisions of this title applicable to veterans receiving 
extended care in a facility of the Department shall apply to 
veterans receiving such care under this section.
    (2) In carrying out this section, the Secretary--
          (A) may not direct veterans seeking extended care to 
        health care providers that have entered into contracts 
        or sharing agreements under authorities other than this 
        section; and
          (B) shall ensure that veterans have the option to 
        determine whether to receive extended care from a 
        health care provider described in subparagraph (A) or 
        an eligible provider that has entered into an agreement 
        under this section.
    (c) Eligible Providers.--For purposes of this section, an 
eligible provider is one of the following:
          (1) A provider of services that has enrolled and 
        entered into a provider agreement under section 1866(a) 
        of the Social Security Act (42 U.S.C. 1395cc(a)).
          (2) A physician or supplier that has enrolled and 
        entered into a participation agreement under section 
        1842(h) of such Act (42 U.S.C. 1395u(h)).
          (3) A provider of items and services receiving 
        payment under a State plan under title XIX of such Act 
        (42 U.S.C. 1396 et seq.) or a waiver of such a plan.
          (4) A provider that is--
                  (A) an Aging and Disability Resource Center, 
                an area agency on aging, or a State agency (as 
                defined in section 102 of the Older Americans 
                Act of 1965 (42 U.S.C. 3002)); or
                  (B) a center for independent living (as 
                defined in section 702 of the Rehabilitation 
                Act of 1973 (29 U.S.C. 796a)).
          (5) Such other health care providers as the Secretary 
        considers appropriate for purposes of this section.
    (d) Certification of Eligible Providers.--(1) The Secretary 
shall establish a process for the certification of eligible 
providers under this section that shall, at a minimum, set 
forth the following.
          (A) Procedures for the submittal of applications for 
        certification and deadlines for actions taken by the 
        Secretary with respect to such applications.
          (B) Standards and procedures for approval and denial 
        of certification, duration of certification, revocation 
        of certification, and recertification.
          (C) Procedures for assessing eligible providers based 
        on the risk of fraud, waste, and abuse of such 
        providers similar to the level of screening under 
        section 1866(j)(2)(B) of the Social Security Act (42 
        U.S.C. 1395cc(j)(2)(B)) and the standards set forth 
        under section 9.104 of title 48, Code of Federal 
        Regulations, or any successor regulation.
    (2) The Secretary shall deny or revoke certification to an 
eligible provider under this subsection if the Secretary 
determines that the eligible provider is currently--
          (A) excluded from participation in a Federal health 
        care program (as defined in section 1128B(f) of the 
        Social Security Act (42 U.S.C. 1320a-7b(f))) under 
        section 1128 or 1128A of the Social Security Act (42 
        U.S.C. 1320a-7 and 1320a-7a); or
          (B) identified as an excluded source on the list 
        maintained in the System for Award Management, or any 
        successor system.
    (e) Terms of Agreements.--Each agreement entered into with 
an eligible provider under this section shall include 
provisions requiring the eligible provider to do the following:
          (1) To accept payment for extended care furnished 
        under this section at rates established by the 
        Secretary for purposes of this section, which shall be, 
        to the extent practicable, the rates paid by the United 
        States for such care to providers of services and 
        suppliers under the Medicare program under title XVIII 
        of the Social Security Act (42 U.S.C. 1395 et seq.).
          (2) To accept payment under paragraph (1) as payment 
        in full for extended care furnished under this section 
        and to not seek any payment for such care from the 
        recipient of such care.
          (3) To furnish under this section only the extended 
        care authorized by the Department under this section 
        unless the eligible provider receives prior written 
        consent from the Department to furnish extended care 
        outside the scope of such authorization.
          (4) To bill the Department for extended care 
        furnished under this section in accordance with a 
        methodology established by the Secretary for purposes 
        of this section.
          (5) Not to seek to recover or collect from a health-
        plan contract or third party, as those terms are 
        defined in section 1729 of this title, for any extended 
        care for which payment is made by the Department under 
        this section.
          (6) To provide medical records for veterans furnished 
        extended care under this section to the Department in a 
        time frame and format specified by the Secretary for 
        purposes of this section.
          (7) To meet such other terms and conditions, 
        including quality of care assurance standards, as the 
        Secretary may specify for purposes of this section.
    (f) Termination of Agreements.--(1) An eligible provider 
may terminate an agreement with the Secretary under this 
section at such time and upon such notice to the Secretary as 
the Secretary may specify for purposes of this section.
    (2) The Secretary may terminate an agreement with an 
eligible provider under this section at such time and upon such 
notice to the eligible provider as the Secretary may specify 
for purposes of this section, if the Secretary--
          (A) determines that the eligible provider failed to 
        comply substantially with the provisions of the 
        agreement or with the provisions of this section and 
        the regulations prescribed thereunder;
          (B) determines that the eligible provider is--
                  (i) excluded from participation in a Federal 
                health care program (as defined in section 
                1128B(f) of the Social Security Act (42 U.S.C. 
                1320a-7b(f))) under section 1128 or 1128A of 
                the Social Security Act (42 U.S.C. 1320a-7 and 
                1320a-7a); or
                  (ii) identified as an excluded source on the 
                list maintained in the System for Award 
                Management, or any successor system;
          (C) ascertains that the eligible provider has been 
        convicted of a felony or other serious offense under 
        Federal or State law and determines that the continued 
        participation of the eligible provider would be 
        detrimental to the best interests of veterans or the 
        Department; or
          (D) determines that it is reasonable to terminate the 
        agreement based on the health care needs of a veteran 
        or veterans.
    (g) Periodic Review of Certain Agreements.--(1) Not less 
frequently than once every two years, the Secretary shall 
review each Veterans Extended Care Agreement of material size 
entered into during the two-year period preceding the review to 
determine whether it is feasible and advisable to furnish the 
extended care furnished under such agreement at facilities of 
the Department or through contracts or sharing agreements 
entered into under authorities other than this section.
    (2)(A) Subject to subparagraph (B), a Veterans Extended 
Care Agreement is of material size as determined by the 
Secretary for purposes of this section.
    (B) A Veterans Extended Care Agreement entered into after 
September 30, 2016, is of material size if the purchase of 
extended care under the agreement exceeds $1,000,000 annually. 
The Secretary may adjust such amount to account for changes in 
the cost of health care based upon recognized health care 
market surveys and other available data and shall publish any 
such adjustments in the Federal Register.
    (h) Exclusion of Certain Federal Contracting Provisions.--
(1) An agreement under this section may be entered into without 
regard to any law that would require the Secretary to use 
competitive procedures in selecting the party with which to 
enter into the agreement.
    (2)(A) Except as provided in subparagraph (B) and unless 
otherwise provided in this section or regulations prescribed 
pursuant to this section, an eligible provider that enters into 
an agreement under this section is not subject to, in the 
carrying out of the agreement, any law that providers of 
services and suppliers under the Medicare program under title 
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) are 
not subject to.
    (B) Notwithstanding subparagraph (A), an eligible provider 
that enters into an agreement under this section shall be 
subject to all laws regarding integrity, ethics, fraud, or that 
subject a person to civil or criminal penalties as if such laws 
were incorporated into its provider agreements.
    (i) Quality of Care.--The Secretary shall establish through 
regulation a system or systems for--
          (1) monitoring the quality of extended care furnished 
        to veterans under this section; and
          (2) assessing the quality of extended care furnished 
        by an eligible provider under this section prior to the 
        renewal of a Veterans Extended Care Agreement with the 
        eligible provider.
    (j) Dispute Resolution.--(1) The Secretary shall establish 
administrative procedures for eligible providers with which the 
Secretary has entered an agreement under this section to 
present any dispute arising under or related to the agreement.
    (2) Before using any dispute resolution mechanism under 
chapter 71 of title 41 with respect to a dispute arising under 
an agreement under this section, an eligible provider must 
first exhaust the administrative procedures established by the 
Secretary under paragraph (1).
    (k) Sunset.--The Secretary may not furnish extended care 
through the use of an agreement entered into under this section 
after the date that is two years after the date of the 
enactment of the Jason Simcakoski Memorial Act.

           *       *       *       *       *       *       *

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

           *       *       *       *       *       *       *

SEC. 1720G. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS

    (a) Program of Comprehensive Assistance for Family 
Caregivers.--(1)(A) The Secretary shall establish a program of 
comprehensive assistance for family caregivers of eligible 
veterans.
    (B) * * *
    (2) * * *
          (A) * * *
          [(B) 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 
        September 11, 2001; and]
          (B) for assistance provided under this subsection--
                  (i) before the date on which the Secretary 
                submits to Congress a certification that the 
                Department has fully implemented the 
                information technology system required by 
                section 452(a) of the Jason Simcakoski Memorial 
                Act, 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 September 11, 2001;
                  (ii) during the two-year period beginning on 
                the date specified in clause (i), 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--
                          (I) on or before May 7, 1975; or
                          (II) on or after September 11, 2001; 
                        or
                  (iii) after the date that is two years after 
                the date specified in clause (i), 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; and
          (C) * * *
                  (i) * * *
                  (ii) a need for supervision or protection 
                based on symptoms or residuals of neurological 
                or other impairment or injury[; or] ;
                  (iii) a need for regular or extensive 
                instruction or supervision without which the 
                ability of the veteran to function in daily 
                life would be seriously impaired; or
                  (iv) [(iii)] such other matters as the 
                Secretary considers appropriate.
    (3)(A) * * *
          (i) * * *

           *       *       *       *       *       *       *

          (ii) * * *

           *       *       *       *       *       *       *

                  (IV) medical care under section 1781 of this 
                title[; and] ;
                  (V) a monthly personal caregiver stipend[.] ; 
                and
                  (VI) through the use of contracts with, or 
                the provision of grants to, public or private 
                entities--
                          (aa) financial planning services 
                        relating to the needs of injured 
                        veterans and their caregivers; and
                          (bb) legal services, including legal 
                        advice and consultation, relating to 
                        the needs of injured veterans and their 
                        caregivers.
    (C)(i) * * *

           *       *       *       *       *       *       *

    (iii) In determining the amount and degree of personal care 
services provided under clause (i) with respect to an eligible 
veteran whose need for personal care services is based in whole 
or in part on a need for supervision or protection under 
paragraph (2)(C)(ii) or regular instruction or supervision 
under paragraph (2)(C)(iii), the Secretary shall take into 
account the following:
          (I) The assessment by the family caregiver of the 
        needs and limitations of the veteran.
          (II) The extent to which the veteran can function 
        safely and independently in the absence of such 
        supervision, protection, or instruction.
          (III) The amount of time required for the family 
        caregiver to provide such supervision, protection, or 
        instruction to the veteran.
    (iv) [(iii)] If personal care services are not available 
from a commercial home health entity in the geographic area of 
an eligible veteran, the amount of the monthly personal 
caregiver stipend payable under the schedule required by clause 
(i) with respect to the eligible veteran shall be determined by 
taking into consideration the costs of commercial providers of 
personal care services in providing personal care services in 
geographic areas other than the geographic area of the eligible 
veteran with similar costs of living.
    (D) In providing instruction, preparation, and training 
under subparagraph (A)(i)(I) and technical support under 
subparagraph (A)(i)(II) to each family caregiver who is 
approved as a provider of personal care services for an 
eligible veteran under paragraph (6), the Secretary shall 
periodically evaluate the needs of the eligible veteran and the 
skills of the family caregiver of such veteran to determine if 
additional instruction, preparation, training, or technical 
support under those subparagraphs is necessary.

           *       *       *       *       *       *       *

    (5) For each application submitted jointly by an eligible 
veteran and family member, the Secretary shall evaluate (in 
collaboration with the primary care team for the eligible 
veteran to the maximum extent practicable)--

           *       *       *       *       *       *       *

    (11)(A) In providing assistance under this subsection to 
family caregivers of eligible veterans, the Secretary may enter 
into contracts, provider agreements, and memoranda of 
understanding with Federal agencies, States, and private, 
nonprofit, and other entities to provide such assistance to 
such family caregivers.
    (B) The Secretary may provide assistance under this 
paragraph only if such assistance is reasonably accessible to 
the family caregiver and is substantially equivalent or better 
in quality to similar services provided by the Department.
    (C) The Secretary may provide fair compensation to Federal 
agencies, States, and other entities that provide assistance 
under this paragraph.

           *       *       *       *       *       *       *

    (d) Definitions.--In this section:

           *       *       *       *       *       *       *

          (4) * * *
                  (A) Assistance with one or more [independent] 
                activities of daily living.
                  (B) Supervision or protection based on 
                symptoms or residuals of neurological or other 
                impairment or injury.
                  (C) Regular or extensive instruction or 
                supervision without which the ability of the 
                veteran to function in daily life would be 
                seriously impaired.
                  (D) [(B)] Any other non-institutional 
                extended care (as such term is used in section 
                1701(6)(E) of this title).

           *       *       *       *       *       *       *

Subchapter V. Payments to State Homes

           *       *       *       *       *       *       *

SEC. 1745. NURSING HOME CARE AND MEDICATIONS FOR VETERANS WITH SERVICE-
                    CONNECTED DISABILITIES

    (a)(1) The Secretary shall enter into [a contract (or 
agreement under section 1720(c)(1) of this title)] an agreement 
with each State home for payment by the Secretary for nursing 
home care provided in the home, in any case in which such care 
is provided to any veteran as follows:

           *       *       *       *       *       *       *

    (2) Payment under each [contract (or agreement)] agreement 
between the Secretary and a State home under paragraph (1) 
shall be based on a methodology, developed by the Secretary in 
consultation with the State home, to adequately reimburse the 
State home for the care provided by the State home under the 
[contract (or agreement)] agreement.
    (3) * * *
    (4)(A) An agreement under paragraph (1) may be entered into 
without regard to any law that would require the Secretary to 
use competitive procedures in selecting the party with which to 
enter into the agreement.
    (B)(i) Except as provided in clause (ii) and unless 
otherwise provided in this section or regulations prescribed 
pursuant to this section, a State home that enters into an 
agreement under paragraph (1) is not subject to, in the 
carrying out of the agreement, any law that a provider 
described in subparagraph (C) is not subject to under the 
original Medicare fee-for-service program under parts A and B 
of title XVIII of the Social Security Act (42 U.S.C. 1395 et 
seq.) or the Medicaid program under title XIX of such Act (42 
U.S.C. 1396 et seq.).
    (ii) Notwithstanding clause (i), a State home that enters 
into an agreement under paragraph (1) shall be subject to all 
laws regarding integrity, ethics, fraud, or that subject a 
person to civil or criminal penalties as if such laws were 
incorporated into its provider agreements.
    (C) A provider described in this subparagraph is one of the 
following:
          (i) A provider of services that has enrolled and 
        entered into a provider agreement under section 1866(a) 
        of the Social Security Act (42 U.S.C. 1395cc(a)).
          (ii) A physician or supplier that has enrolled and 
        entered into a participation agreement under section 
        1842(h) of such Act (42 U.S.C. 1395u(h)).
          (iii) A provider of items and services receiving 
        payment under a State plan under title XIX of such Act 
        (42 U.S.C. 1396 et seq.) or a waiver of such a plan.
    (5) The Secretary may not furnish nursing home care under 
an agreement entered into under paragraph (1) after the date 
that is two years after the date of the enactment of the Jason 
Simcakoski Memorial Act.

           *       *       *       *       *       *       *

               Chapter 20. Benefits for Homeless Veterans

       SUBCHAPTER I. PURPOSE; DEFINITIONS; ADMINISTRATIVE MATTERS

Sec.

           *       *       *       *       *       *       *

             SUBCHAPTER II. COMPREHENSIVE SERVICE PROGRAMS

2011. Grants.
2012. Per diem payments.
2013. Program to improve retention of housing by formerly 
            homeless veterans and veterans at risk of becoming 
            homeless.
2014 [2013]. Authorization of appropriations.

SUBCHAPTER III. TRAINING AND OUTREACH

           *       *       *       *       *       *       *

2022. Coordination of outreach services for veterans at risk of 
            homelessness.
2022A. Partnerships with public and private entities to provide 
            legal services to homeless veterans and veterans at 
            risk of homelessness.

           *       *       *       *       *       *       *

SUBCHAPTER VII. OTHER PROVISIONS

           *       *       *       *       *       *       *

[2065. Annual report on assistance to homeless veterans.]
2066. Advisory Committee on Homeless Veterans.
2067. National Center on Homelessness Among Veterans.

Subchapter I. Purpose; Definitions; Administrative Matters

           *       *       *       *       *       *       *

SEC. 2002. DEFINITIONS

    In this chapter:
          (1) The term ``homeless veteran'' means a veteran who 
        is homeless (as that term is defined [in section 103(a) 
        of the McKinney-Vento Homeless Assistance Act (42 
        U.S.C. 11302(a))] in subsection (a) or (b) of section 
        103 of the McKinney-Vento Homeless Assistance Act (42 
        U.S.C. 11302)).

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Subchapter II. Comprehensive Service Programs

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SEC. 2012. PER DIEM PAYMENTS

    (a) Per Diem Payments for Furnishing Services to Homeless 
Veterans.--(1) Subject to the availability of appropriations 
provided for such purpose and except as otherwise provided in 
this section, the Secretary, pursuant to such criteria as the 
Secretary shall prescribe, shall provide to a recipient of a 
grant under section 2011 of this title (or an entity eligible 
to receive a grant under that section which after November 10, 
1992, establishes a program that the Secretary determines 
carries out the purposes described in that section) per diem 
payments for services furnished to any homeless veteran--

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    (2)(A) [The rate] Except as otherwise provided in 
subparagraph (B), the rate for such per diem payments shall be 
the daily cost of care estimated by the grant recipient or 
eligible entity adjusted by the Secretary [under subparagraph 
(B). In no case may the rate determined under this paragraph 
exceed the rate authorized for State homes for domiciliary care 
under subsection (a)(1)(A) of section 1741 of this title, as 
the Secretary may increase from time to time under subsection 
(c) of that section.] under subparagraph (C).
    (B)(i) Except as provided in clause (ii), in no case may 
the rate determined under this paragraph exceed the rate 
authorized for State homes for domiciliary care under 
subsection (a)(1)(A) of section 1741 of this title, as the 
Secretary may increase from time to time under subsection (c) 
of that section.
    (ii) In the case of services furnished to a homeless 
veteran who is placed in housing that will become permanent 
housing for the veteran upon termination of the furnishing of 
such services to such veteran, the maximum rate of per diem 
authorized under this section is 150 percent of the rate 
described in clause (i).
    (C) [(B)] The Secretary shall adjust the rate estimated by 
the grant recipient or eligible entity under subparagraph (A) 
to exclude other sources of income described [in subparagraph 
(D)] in subparagraph (E) that the grant recipient or eligible 
entity certifies to be correct.
    (D) [(C)] Each grant recipient or eligible entity shall 
provide to the Secretary such information with respect to other 
sources of income as the Secretary may require to make the 
adjustment [under subparagraph (B)] under subparagraph (C).
    (E) [(D)] The other sources of income referred to [in 
subparagraphs (B) and (C)] in subparagraphs (C) and (D) are 
payments to the grant recipient or eligible entity for 
furnishing services to homeless veterans under programs other 
than under this subchapter, including payments and grants from 
other departments and agencies of the United States, from 
departments or agencies of State or local government, and from 
private entities or organizations.

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    (e) Review and Conditional Renewal.--(1) Each year, the 
Secretary shall review each grant recipient and eligible entity 
that received a per diem payment under this section for a 
service furnished to a veteran during the one-year period 
preceding the review to evaluate the performance of the grant 
recipient or eligible entity during that period with respect 
to--
          (A) the success of the grant recipient or eligible 
        entity in assisting veterans to obtain, transition 
        into, and retain permanent housing; and
          (B) increasing the income of veterans, whether by 
        helping veterans obtain employment or by helping 
        veterans obtain income-related benefits to which such 
        veterans may be eligible or entitled.
    (2) For any grant recipient or eligible entity whose 
performance was evaluated for a year under paragraph (1), the 
Secretary may only provide per diem under this section to that 
grant recipient or eligible entity in the following year if the 
Secretary determines that such performance merits continued 
receipt of per diem under this section.
    (3) The Secretary shall establish uniform performance 
targets throughout the United States for all grant recipients 
and eligible entities that receive per diem payments under this 
section for purposes of evaluating the performance of each such 
grant recipient and eligible entity under this subsection.

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SEC. 2013. PROGRAM TO IMPROVE RETENTION OF HOUSING BY FORMERLY HOMELESS 
                    VETERANS AND VETERANS AT RISK OF BECOMING HOMELESS

    (a) Program Required.--The Secretary shall carry out a 
program under which the Secretary shall provide case management 
services to improve the retention of housing by veterans who 
were previously homeless and are transitioning to permanent 
housing and veterans who are at risk of becoming homeless.
    (b) Grants.--(1) The Secretary shall carry out the program 
through the award of grants.
    (2)(A) In awarding grants under paragraph (1), the 
Secretary shall give priority to organizations that demonstrate 
a capability to provide case management services as described 
in subsection (a), particularly organizations that are 
successfully providing or have successfully provided 
transitional housing services using amounts provided by the 
Secretary under sections 2012 and 2061 of this title.
    (B) In giving priority under subparagraph (A), the 
Secretary shall give extra priority to an organization 
described in such subparagraph that--
          (i) voluntarily stops receiving amounts provided by 
        the Secretary under sections 2012 and 2061 of this 
        title; and
          (ii) converts a facility that the organization used 
        to provide transitional housing services into a 
        facility that the organization uses to provide 
        permanent housing that meets housing quality standards 
        established under section 8(o)(8)(B) of the United 
        States Housing Act of 1937 (42 U.S.C. 1437f(o)(8)(B)).
    (C) In any case in which a facility, with respect to which 
a person received a grant for construction, rehabilitation, or 
acquisition under section 2011 of this title, is converted as 
described in subparagraph (B)(ii), such conversion shall be 
considered to have been carried out pursuant to the needs of 
the Department and such person shall not be considered in non-
compliance with the terms of such grant by reason of such 
conversion.

SEC. 2014 [2013]. AUTHORIZATION OF APPROPRIATIONS

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                 Subchapter III. Training and Outreach

SEC. 2021. HOMELESS VETERANS REINTEGRATION PROGRAMS

    (a) In General.--Subject to the availability of 
appropriations provided for such purpose, the Secretary of 
Labor shall conduct, directly or through grant or contract, 
such programs as the Secretary determines appropriate to 
provide job training, counseling, and placement services 
(including job readiness and literacy and skills training) to 
expedite the [reintegration of homeless veterans into the labor 
force.] reintegration into the labor force of--
          (1) homeless veterans;
          (2) veterans participating in the Department of 
        Veterans Affairs supported housing program for which 
        rental assistance is provided pursuant to section 
        8(o)(19) of the United States Housing Act of 1937 (42 
        U.S.C. 1437f(o)(19));
          (3) Indians who are veterans and receiving assistance 
        under the Native American Housing Assistance and Self 
        Determination Act of 1996 (25 U.S.C. 4101 et seq.); and
          (4) veterans who are transitioning from being 
        incarcerated.

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SEC. 2022A. PARTNERSHIPS WITH PUBLIC AND PRIVATE ENTITIES TO PROVIDE 
                    LEGAL SERVICES TO HOMELESS VETERANS AND VETERANS AT 
                    RISK OF HOMELESSNESS

    (a) Partnerships Authorized.--Subject to the availability 
of funds for that purpose, the Secretary may enter into 
partnerships with public or private entities to fund a portion 
of the general legal services specified in subsection (c) that 
are provided by such entities to homeless veterans and veterans 
at risk of homelessness.
    (b) Locations.--(1) The Secretary shall ensure that, to the 
extent practicable, partnerships under this section are made 
with entities equitably distributed across the geographic 
regions of the United States, including rural communities, 
tribal lands of the United States, Native Americans, and tribal 
organizations.
    (2) In this subsection, the terms ``Native American'' and 
``tribal organization'' have the meanings given such terms in 
section 3765 of this title.
    (c) Legal Services.--Legal services specified in this 
subsection include legal services provided by public or private 
entities that address the needs of homeless veterans and 
veterans at risk of homelessness, such as the following:
          (1) Legal services related to housing, including 
        eviction defense and representation in landlord-tenant 
        cases.
          (2) Legal services related to family law, including 
        assistance in court proceedings for child support, 
        divorce, and estate planning.
          (3) Legal services related to income support, 
        including assistance in obtaining public benefits.
          (4) Legal services related to criminal defense, 
        including defense in matters symptomatic of 
        homelessness, such as outstanding warrants, fines, and 
        driver's license revocation, to reduce recidivism and 
        facilitate the overcoming of reentry obstacles in 
        employment or housing.
    (d) Consultation.--In developing and carrying out 
partnerships under this section, the Secretary shall, to the 
extent practicable, consult with public and private entities--
          (1) for assistance in identifying and contacting 
        organizations described in subsection (c); and
          (2) to coordinate appropriate outreach relationships 
        with such organizations.
    (e) Reports.--The Secretary may require entities that have 
entered into partnerships under this section to submit to the 
Secretary periodic reports on legal services provided to 
homeless veterans and veterans at risk of homelessness pursuant 
to such partnerships.

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Subchapter VII. Other Provisions

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SEC. 2062. DENTAL CARE

    (a) * * *

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    [(b) Eligible Veterans.--Subsection (a) applies to a 
veteran--
          [(1) who is enrolled for care under section 1705(a) 
        of this title; and
          [(2) who, for a period of 60 consecutive days, is 
        receiving care (directly or by contract) in any of the 
        following settings:
                  [(A) A domiciliary under section 1710 of this 
                title.
                  [(B) A therapeutic residence under section 
                2032 of this title.
                  [(C) Community residential care coordinated 
                by the Secretary under section 1730 of this 
                title.
                  [(D) A setting for which the Secretary 
                provides funds for a grant and per diem 
                provider.
          [(3) For purposes of paragraph (2), in determining 
        whether a veteran has received treatment for a period 
        of 60 consecutive days, the Secretary may disregard 
        breaks in the continuity of treatment for which the 
        veteran is not responsible.]
    (b) Eligible Veterans.--(1) Subsection (a) applies to a 
veteran who--
          (A) is enrolled for care under section 1705(a) of 
        this title; and
          (B) for a period of 60 consecutive days, is 
        receiving--
                  (i) assistance under section 8(o) of the 
                United States Housing Act of 1937 (42 U.S.C. 
                1437f(o)); or
                  (ii) care (directly or by contract) in any of 
                the following settings:
                          (I) A domiciliary under section 1710 
                        of this title.
                          (II) A therapeutic residence under 
                        section 2032 of this title.
                          (III) Community residential care 
                        coordinated by the Secretary under 
                        section 1730 of this title.
                          (IV) A setting for which the 
                        Secretary provides funds for a grant 
                        and per diem provider.
    (2) For purposes of paragraph (1), in determining whether a 
veteran has received assistance or care for a period of 60 
consecutive days, the Secretary may disregard breaks in the 
continuity of assistance or care for which the veteran is not 
responsible.

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[SEC. 2065. ANNUAL REPORT ON ASSISTANCE TO HOMELESS VETERANS

    [(a) Annual Report.--Not later than June 15 of each year, 
the Secretary shall submit to the Committees on Veterans' 
Affairs of the Senate and House of Representatives a report on 
the activities of the Department during the calendar year 
preceding the report under programs of the Department under 
this chapter and other programs of the Department for the 
provision of assistance to homeless veterans.
    [(b) General Contents of Report.--Each report under 
subsection (a) shall include the following:
          [(1) The number of homeless veterans provided 
        assistance under the programs referred to in subsection 
        (a).
          [(2) The cost to the Department of providing such 
        assistance under those programs.
          [(3) The Secretary's evaluation of the effectiveness 
        of the programs of the Department in providing 
        assistance to homeless veterans, including--
                  [(A) residential work-therapy programs;
                  [(B) programs combining outreach, community-
                based residential treatment, and case-
                management; and
                  [(C) contract care programs for alcohol and 
                drug-dependence or use disabilities.
          [(4) The Secretary's evaluation of the effectiveness 
        of programs established by recipients of grants under 
        section 2011 of this title and a description of the 
        experience of those recipients in applying for and 
        receiving grants from the Secretary of Housing and 
        Urban Development to serve primarily homeless persons 
        who are veterans.
          [(5) Information on the efforts of the Secretary to 
        coordinate the delivery of housing and services to 
        homeless veterans with other Federal departments and 
        agencies, including--
                  [(A) the Department of Defense;
                  [(B) the Department of Health and Human 
                Services;
                  [(C) the Department of Housing and Urban 
                Development;
                  [(D) the Department of Justice;
                  [(E) the Department of Labor;
                  [(F) the Interagency Council on Homelessness;
                  [(G) the Social Security Administration; and
                  [(H) any other Federal department or agency 
                with which the Secretary coordinates the 
                delivery of housing and services to homeless 
                veterans.
          [(6) Any other information on those programs and on 
        the provision of such assistance that the Secretary 
        considers appropriate.
    [(c) Health Care Contents of Report.--Each report under 
subsection (a) shall include, with respect to programs of the 
Department addressing health care needs of homeless veterans, 
the following:
          [(1) Information about expenditures, costs, and 
        workload under the program of the Department known as 
        the Health Care for Homeless Veterans program (HCHV).
          [(2) Information about the veterans contacted through 
        that program.
          [(3) Information about program treatment outcomes 
        under that program.
          [(4) Information about supported housing programs.
          [(5) Information about the Department's grant and per 
        diem provider program under subchapter II of this 
        chapter.
          [(6) The findings and conclusions of the assessments 
        of the medical needs of homeless veterans conducted 
        under section 2034(b) of this title.
          [(7) Other information the Secretary considers 
        relevant in assessing those programs.
    [(d) Benefits Content of Report.--Each report under 
subsection (a) shall include, with respect to programs and 
activities of the Veterans Benefits Administration in 
processing of claims for benefits of homeless veterans during 
the preceding year, the following:
          [(1) Information on costs, expenditures, and workload 
        of Veterans Benefits Administration claims evaluators 
        in processing claims for benefits of homeless veterans.
          [(2) Information on the filing of claims for benefits 
        by homeless veterans.
          [(3) Information on efforts undertaken to expedite 
        the processing of claims for benefits of homeless 
        veterans.
          [(4) Other information that the Secretary considers 
        relevant in assessing the programs and activities.]

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SEC. 2067. NATIONAL CENTER ON HOMELESSNESS AMONG VETERANS

    (a) In General.--(1) The Secretary shall establish and 
operate a center to carry out the functions described in 
subsection (b).
    (2) The center established under paragraph (1) shall be 
known as the ``National Center on Homelessness Among 
Veterans''.
    (3) To the degree practicable, the Secretary shall operate 
the center established under paragraph (1) independently of the 
other programs of the Department that address homelessness 
among veterans.
    (b) Functions.--The functions described in this subsection 
are as follows:
          (1) To carry out and promote research into the causes 
        and contributing factors to veteran homelessness.
          (2) To assess the effectiveness of programs of the 
        Department to meet the needs of homeless veterans.
          (3) To identify and disseminate best practices with 
        regard to housing stabilization, income support, 
        employment assistance, community partnerships, and such 
        other matters as the Secretary considers appropriate 
        with respect to addressing veteran homelessness.
          (4) To integrate evidence-based and best practices, 
        policies, and programs into programs of the Department 
        for homeless veterans and veterans at risk of 
        homelessness and to ensure that the staff of the 
        Department and community partners can implement such 
        practices, policies, and programs.
          (5) To serve as a resource center for, and promote 
        and seek to coordinate the exchange of information 
        regarding, all research and training activities carried 
        out by the Department and by other Federal and non-
        Federal entities with respect to veteran homelessness.

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Part III. Readjustment and Related Benefits

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              Chapter 33. Post-9/11 Educational Assistance

                       SUBCHAPTER I. DEFINITIONS

Sec.

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SUBCHAPTER III. ADMINISTRATIVE PROVISIONS

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3326. Election to receive educational assistance.

                       Subchapter I. Definitions

SEC. 3301. DEFINITIONS

    In this chapter:
          (1) * * *
                  (A) * * *
                  (B) In the case of members of the reserve 
                components of the Armed Forces, service on 
                active duty under a call or order to active 
                duty under section 688, 12301(a), 12301(d), 
                12301(g), 12301(h), 12302, or 12304 of title 10 
                or section 712 of title 14.

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Subchapter II. Educational Assistance

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SEC. 3312. EDUCATIONAL ASSISTANCE: DURATION.

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    (d) Discontinuation of Education Due to Closure of 
Educational Institution.--
          (1) In general.--Any payment of educational 
        assistance described in paragraph (2) shall not--
                  (A) be charged against any entitlement to 
                educational assistance of the individual 
                concerned under this chapter; or
                  (B) be counted against the aggregate period 
                for which section 3695 of this title limits the 
                individual's receipt of educational assistance 
                under this chapter.
          (2) Description of payment of educational 
        assistance.--Subject to paragraph (3), the payment of 
        educational assistance described in this paragraph is 
        the payment of such assistance to an individual for 
        pursuit of a course or courses under this chapter if 
        the Secretary finds that the individual--
                  (A) was forced to discontinue such course 
                pursuit as a result of a permanent closure of 
                an educational institution; and
                  (B) did not receive credit, or lost training 
                time, toward completion of the program of 
                education being pursued at the time of such 
                closure.
          (3) Period for which payment not charged.--The period 
        for which, by reason of this subsection, educational 
        assistance is not charged against entitlement or 
        counted toward the applicable aggregate period under 
        section 3695 of this title shall not exceed the 
        aggregate of--
                  (A) the portion of the period of enrollment 
                in the course or courses from which the 
                individual failed to receive credit or with 
                respect to which the individual lost training 
                time, as determined under paragraph (2)(B), and
                  (B) the period by which a monthly stipend is 
                extended under section 3680(a)(2)(B) of this 
                title.

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SEC. 3317. PUBLIC-PRIVATE CONTRIBUTIONS FOR ADDITIONAL EDUCATIONAL 
                    ASSISTANCE

    (a) Establishment of Program.--In instances where the 
educational assistance provided pursuant to section 
3313(c)(1)(A) does not cover the full cost of established 
charges (as specified in section 3313), the Secretary shall 
carry out a program under which colleges and universities can, 
voluntarily, enter into an agreement with the Secretary to 
cover a portion of those established charges not otherwise 
covered under section 3313(c)(1)(A), which contributions shall 
be matched by equivalent contributions toward such costs by the 
Secretary. The program shall only apply to covered individuals 
described [in paragraphs (1) and (2)] in paragraphs (1), (2), 
and (9) of section 3311(b).

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SEC. 3319. AUTHORITY TO TRANSFER UNUSED EDUCATION BENEFITS TO FAMILY 
                    MEMBERS

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    (b) * * *
          (1) [six years] ten years of service in the Armed 
        Forces and enters into an agreement to serve at least 
        [four more years] two more years as a member of the 
        uniformed services; or

           *       *       *       *       *       *       *

    (g) * * *
          (1) * * *
                  (A) [six years] ten years of service in the 
                Armed Forces; or

           *       *       *       *       *       *       *

    (h) * * *

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          (3) * * *
                  (A) * * *
                  (B) in the case of a child, at the same rate 
                as such entitlement would otherwise be payable 
                under this chapter to the individual making the 
                transfer as if the individual were not on 
                active duty, except that the amount of the 
                monthly stipend described in subsection 
                (c)(1)(B) or (g)(3)(A)(ii) of section 3313, as 
                the case may be, shall be payable in an amount 
                equal to 50 percent of the amount of such 
                stipend that would otherwise be payable under 
                this chapter to the individual making the 
                transfer.

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          (5) * * *

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                  (B) Primary caregivers of seriously injured 
                members of the [armed forces] Armed Forces and 
                veterans.--

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Subchapter III. Administrative Provisions

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SEC. 3326. ELECTION TO RECEIVE EDUCATIONAL ASSISTANCE

    (a) Individuals Eligible to Elect Participation in Post-9/
11 Educational Assistance.--An individual may elect to receive 
educational assistance under this chapter if such individual--
          (1) as of August 1, 2009--
                  (A) is entitled to basic educational 
                assistance under chapter 30 of this title and 
                has used, but retains unused, entitlement under 
                that chapter;
                  (B) is entitled to educational assistance 
                under chapter 107, 1606, or 1607 of title 10 
                and has used, but retains unused, entitlement 
                under the applicable chapter;
                  (C) is entitled to basic educational 
                assistance under chapter 30 of this title but 
                has not used any entitlement under that 
                chapter;
                  (D) is entitled to educational assistance 
                under chapter 107, 1606, or 1607 of title 10 
                but has not used any entitlement under such 
                chapter;
                  (E) is a member of the Armed Forces who is 
                eligible for receipt of basic educational 
                assistance under chapter 30 this title and is 
                making contributions toward such assistance 
                under section 3011(b) or 3012(c) of this title; 
                or
                  (F) is a member of the Armed Forces who is 
                not entitled to basic educational assistance 
                under chapter 30 of this title by reason of an 
                election under section 3011(c)(1) or 3012(d)(1) 
                of this title; and
          (2) as of the date of the individual's election under 
        this paragraph, meets the requirements for entitlement 
        to educational assistance under this chapter.
    (b) Cessation of Contributions Toward GI Bill.--Effective 
as of the first month beginning on or after the date of an 
election under subsection (a) of an individual described by 
paragraph (1)(E) of that subsection, the obligation of the 
individual to make contributions under section 3011(b) or 
3012(c) of this title, as applicable, shall cease, and the 
requirements of such section shall be deemed to be no longer 
applicable to the individual.
    (c) Revocation of Remaining Transferred Entitlement.--
          (1) Election to revoke.--If, on the date an 
        individual described in paragraph (1)(A) or (1)(C) of 
        subsection (a) makes an election under that subsection, 
        a transfer of the entitlement of the individual to 
        basic educational assistance under section 3020 of this 
        title is in effect and a number of months of the 
        entitlement so transferred remain unutilized, the 
        individual may elect to revoke all or a portion of the 
        entitlement so transferred that remains unutilized.
          (2) Availability of revoked entitlement.--Any 
        entitlement revoked by an individual under this 
        paragraph shall no longer be available to the dependent 
        to whom transferred, but shall be available to the 
        individual instead for educational assistance under 
        chapter 33 of this title in accordance with the 
        provisions of this section.
          (3) Availability of unrevoked entitlement.--Any 
        entitlement described in paragraph (1) that is not 
        revoked by an individual in accordance with that 
        paragraph shall remain available to the dependent or 
        dependents concerned in accordance with the current 
        transfer of such entitlement under section 3020 of this 
        title.
    (d) Post-9/11 Educational Assistance.--
          (1) In general.--Subject to paragraph (2) and except 
        as provided in subsection (e), an individual making an 
        election under subsection (a) shall be entitled to 
        educational assistance under this chapter in accordance 
        with the provisions of this chapter, instead of basic 
        educational assistance under chapter 30 of this title, 
        or educational assistance under chapter 107, 1606, or 
        1607 of title 10, as applicable.
          (2) Limitation on entitlement for certain 
        individuals.--In the case of an individual making an 
        election under subsection (a) who is described by 
        paragraph (1)(A) of that subsection, the number of 
        months of entitlement of the individual to educational 
        assistance under this chapter shall be the number of 
        months equal to--
                  (A) the number of months of unused 
                entitlement of the individual under chapter 30 
                of this title, as of the date of the election, 
                plus
                  (B) the number of months, if any, of 
                entitlement revoked by the individual under 
                subsection (c)(1).
    (e) Continuing Entitlement to Educational Assistance Not 
Available Under 9/11 Assistance Program.--
          (1) In general.--In the event educational assistance 
        to which an individual making an election under 
        subsection (a) would be entitled under chapter 30 of 
        this title, or chapter 107, 1606, or 1607 of title 10, 
        as applicable, is not authorized to be available to the 
        individual under the provisions of this chapter the 
        individual shall remain entitled to such educational 
        assistance in accordance with the provisions of the 
        applicable chapter.
          (2) Charge for use of entitlement.--The utilization 
        by an individual of entitlement under paragraph (1) 
        shall be chargeable against the entitlement of the 
        individual to educational assistance under this chapter 
        at the rate of one month of entitlement under this 
        chapter for each month of entitlement utilized by the 
        individual under paragraph (1) (as determined as if 
        such entitlement were utilized under the provisions of 
        chapter 30 of this title, or chapter 107, 1606, or 1607 
        of title 10, as applicable).
    (f) Additional Post-9/11 Assistance for Members Having Made 
Contributions Toward GI Bill.--
          (1) Additional assistance.--In the case of an 
        individual making an election under subsection (a) who 
        is described by subparagraph (A), (C), or (E) of 
        paragraph (1) of that subsection, the amount of 
        educational assistance payable to the individual under 
        this chapter as a monthly stipend payable under 
        paragraph (1)(B) of section 3313(c) of this title, or 
        under paragraphs (2) through (7) of that section (as 
        applicable), shall be the amount otherwise payable as a 
        monthly stipend under the applicable paragraph 
        increased by the amount equal to--
                  (A) the total amount of contributions toward 
                basic educational assistance made by the 
                individual under section 3011(b) or 3012(c) of 
                this title, as of the date of the election, 
                multiplied by
                  (B) the fraction--
                          (i) the numerator of which is--
                                  (I) the number of months of 
                                entitlement to basic 
                                educational assistance under 
                                chapter 30 of this title 
                                remaining to the individual at 
                                the time of the election; plus
                                  (II) the number of months, if 
                                any, of entitlement under 
                                chapter 30 revoked by the 
                                individual under subsection 
                                (c)(1); and
                          (ii) the denominator of which is 36 
                        months.
          (2) Months of remaining entitlement for certain 
        individuals.--In the case of an individual covered by 
        paragraph (1) who is described by subsection (a)(1)(E), 
        the number of months of entitlement to basic 
        educational assistance remaining to the individual for 
        purposes of paragraph (1)(B)(i)(II) shall be 36 months.
          (3) Timing of payment.--The amount payable with 
        respect to an individual under paragraph (1) shall be 
        paid to the individual together with the last payment 
        of the monthly stipend payable to the individual under 
        paragraph (1)(B) of section 3313(c) of this title, or 
        under subsections (2) through (7) of that section (as 
        applicable), before the exhaustion of the individual's 
        entitlement to educational assistance under this 
        chapter.
    (g) Continuing Entitlement to Additional Assistance for 
Critical Skills or Speciality and Additional Service.--An 
individual making an election under subsection (a)(1) who, at 
the time of the election, is entitled to increased educational 
assistance under section 3015(d) of this title, or section 
16131(i) of title 10, or supplemental educational assistance 
under subchapter III of chapter 30 of this title, shall remain 
entitled to such increased educational assistance or 
supplemental educational assistance in the utilization of 
entitlement to educational assistance under this chapter, in an 
amount equal to the quarter, semester, or term, as applicable, 
equivalent of the monthly amount of such increased educational 
assistance or supplemental educational assistance payable with 
respect to the individual at the time of the election.
    (h) Alternative Election by Secretary.--
          (1) In general.--In the case of an individual who, on 
        or after January 1, 2016, submits to the Secretary an 
        election under this section that the Secretary 
        determines is clearly against the interests of the 
        individual, or who fails to make an election under this 
        section, the Secretary may make an alternative election 
        on behalf of the individual that the Secretary 
        determines is in the best interests of the individual.
          (2) Notice.--If the Secretary makes an election on 
        behalf of an individual under this subsection, the 
        Secretary shall notify the individual by not later than 
        seven days after making such election and shall provide 
        the individual with a 30-day period, beginning on the 
        date of the individual's receipt of such notice, during 
        which the individual may modify or revoke the election 
        made by the Secretary on the individual's behalf. The 
        Secretary shall include, as part of such notice, a 
        clear statement of why the alternative election made by 
        the Secretary is in the best interests of the 
        individual as compared to the election submitted by the 
        individual. The Secretary shall provide the notice 
        required under this paragraph by electronic means 
        whenever possible.
    (i) Irrevocability of Elections.--An election under 
subsection (a) or (c)(1) is irrevocable.

           *       *       *       *       *       *       *

Chapter 36. Administration of Educational Benefits

           *       *       *       *       *       *       *

Subchapter I. State Approving Agencies

           *       *       *       *       *       *       *

SEC. 3672. APPROVAL OF COURSES

    (a) * * *
    (b)(1) * * *
    (2)(A) Subject to sections 3675(b)(1) and (b)(2), 3680A, 
3684, and 3696 of this title, [the following programs are 
deemed to be approved for purposes of this chapter:] a program 
of education is deemed to be approved for purposes of this 
chapter if a State approving agency determines that the program 
is one of the following programs:
          (i) [An accredited] Except as provided in 
        subparagraph (C), an accredited standard college degree 
        program offered at a public or not-for-profit 
        proprietary educational institution that is accredited 
        by an agency or association recognized for that purpose 
        by the Secretary of Education.

           *       *       *       *       *       *       *

    (C) A course that is described in both subparagraph (A)(i) 
of this paragraph and in paragraph (14) or (15) of section 
3676(c) of this title shall not be deemed to be approved for 
purposes of this chapter unless--
          (i) a State approving agency, or the Secretary when 
        acting in the role of a State approving agency, 
        determines that the course meets the applicable 
        criteria in such paragraphs; or
          (ii) the Secretary issues a waiver for such course 
        under section 3676(f)(1) of this title.

           *       *       *       *       *       *       *

SEC. 3675. APPROVAL OF ACCREDITED COURSES

    (a)(1) [The Secretary or a State approving agency] A State 
approving agency, or the Secretary when acting in the role of a 
State approving agency, may approve accredited programs 
(including non-degree accredited programs) [offered by 
proprietary for-profit educational institutions] not covered by 
section 3672 of this title when--

           *       *       *       *       *       *       *

    (b) As a condition of approval under this section, [the 
Secretary or the State approving agency] the State approving 
agency, or the Secretary when acting in the role of a State 
approving agency must find the following:
          (1) The educational institution keeps adequate 
        records, as prescribed by [the Secretary or the State 
        approving agency] the State approving agency, or the 
        Secretary when acting in the role of a State approving 
        agency, to show the progress and grades of the eligible 
        person or veteran and to show that satisfactory 
        standards relating to progress and conduct are 
        enforced.

           *       *       *       *       *       *       *

          (3) The educational institution and its approved 
        courses meet the criteria of paragraphs (1), (2), [and 
        (3)] (3), (14), (15), and (16) of section 3676(c) of 
        this title (or, with respect to such paragraphs (14) 
        and (15), the requirements under such paragraphs are 
        waived pursuant to subsection (f)(1) of section 3676 of 
        this title).

           *       *       *       *       *       *       *

SEC. 3676. APPROVAL OF NONACCREDITED COURSES

           *       *       *       *       *       *       *

    (c) * * *

           *       *       *       *       *       *       *

          (14) In the case of a course designed to prepare an 
        individual for licensure or certification in a State, 
        the course--
                  (A) meets any instructional curriculum 
                licensure or certification requirements of such 
                State; and
                  (B) in the case of a course designed to 
                prepare an individual for licensure to practice 
                law in a State, is accredited by an accrediting 
                agency or association recognized by the 
                Secretary of Education under subpart 2 of part 
                H of title IV of the Higher Education Act of 
                1965 (20 U.S.C. 1099b).
          (15) In the case of a course designed to prepare an 
        individual for employment pursuant to standards 
        developed by a board or agency of a State in an 
        occupation that requires approval, licensure, or 
        certification, the course--
                  (A) meets such standards; and
                  (B) in the case of a course designed to 
                prepare an individual for licensure to practice 
                law in a State, is accredited by an accrediting 
                agency or association recognized by the 
                Secretary of Education under subpart 2 of part 
                H of title IV of the Higher Education Act of 
                1965 (20 U.S.C. 1099b).
          (16) [(14)] Such additional criteria as may be deemed 
        necessary by the State approving agency if the 
        Secretary, in consultation with the State approving 
        agency and pursuant to regulations prescribed to carry 
        out this paragraph, determines such criteria are 
        necessary and treat public, private, and proprietary 
        for-profit educational institutions equitably.

           *       *       *       *       *       *       *

    (f)(1) The Secretary may waive the requirements of 
paragraph (14) or (15) of subsection (c) in the case of a 
course of education offered by an educational institution 
(either accredited or not accredited) if the Secretary 
determines all of the following:
          (A) The course did not meet the requirements of such 
        paragraph at any time during the two-year period 
        preceding the date of the waiver.
          (B) The waiver furthers the purposes of the 
        educational assistance programs administered by the 
        Secretary or would further the education interests of 
        individuals eligible for assistance under such 
        programs.
          (C) The educational institution does not provide any 
        commission, bonus, or other incentive payment based 
        directly or indirectly on success in securing 
        enrollments or financial aid to any persons or entities 
        engaged in any student recruiting or admission 
        activities or in making decisions regarding the award 
        of student financial assistance, except for the 
        recruitment of foreign students residing in foreign 
        countries who are not eligible to receive Federal 
        student assistance.
    (2) Not later than 30 days after the date on which the 
Secretary issues a waiver under paragraph (1), the Secretary 
shall submit to Congress notice of such waiver and a 
justification for issuing such waiver.

           *       *       *       *       *       *       *

SEC. 3679. DISAPPROVAL OF COURSES

           *       *       *       *       *       *       *

    (d) Notwithstanding any other provision of this chapter, 
the Secretary or the applicable State approving agency shall 
disapprove a course of education described in paragraph (14) or 
(15) of section 3676(c) of this title unless the educational 
institution providing the course of education--
          (1) publicly discloses any conditions or additional 
        requirements, including training, experience, or 
        examinations, required to obtain the license, 
        certification, or approval for which the course of 
        education is designed to provide preparation; and
          (2) makes each disclosure required by paragraph (1) 
        in a manner that the Secretary considers prominent.

                Subchapter II. Miscellaneous Provisions

SEC. 3680. PAYMENT OF EDUCATIONAL ASSISTANCE OR SUBSISTENCE ALLOWANCES

    (a) Period for Which Payment May Be Made.--[Payment of] (1) 
Except as provided in paragraph (2), payment of educational 
assistance or subsistence allowances to eligible veterans or 
eligible persons pursuing a program of education or training, 
other than a program by correspondence, in an educational 
institution under chapter 31, 34, or 35 of this title shall be 
paid as provided in this section and, as applicable, in section 
3108, 3482, 3491, or 3532 of this title. Such payments shall be 
paid only for the period of such veterans' or persons' 
enrollment in, and pursuit of, such program, but no amount 
shall be paid--
          (A) [(1)] to any eligible veteran or eligible person 
        for any period when such veteran or person is not 
        pursuing such veteran's or person's course in 
        accordance with the regularly established policies and 
        regulations of the educational institution, with the 
        provisions of such regulations as may be prescribed by 
        the Secretary pursuant to subsection (g) of this 
        section, and with the requirements of this chapter or 
        of chapter 34 or 35 of this title, but payment may be 
        made for an actual period of pursuit of one or more 
        unit subjects pursued for a period of time shorter than 
        the enrollment period at the educational institution;
          (B) [(2)] to any eligible veteran or person for 
        auditing a course; or
          (C) [(3)] to any eligible veteran or person for a 
        course for which the grade assigned is not used in 
        computing the requirements for graduation including a 
        course from which the student withdraws unless--
                  (i) [(A)] the eligible veteran or person 
                withdraws because he or she is ordered to 
                active duty; or
                  (ii) [(B)] the Secretary finds there are 
                mitigating circumstances, except that, in the 
                first instance of withdrawal (without regard to 
                withdrawals [described in subclause (A) of this 
                clause] described in clause (i)) by the 
                eligible veteran or person from a course or 
                courses with respect to which the veteran or 
                person has been paid assistance under this 
                title, mitigating circumstances shall be 
                considered to exist with respect to courses 
                totaling not more than six semester hours or 
                the equivalent thereof.
[Notwithstanding the foregoing, the Secretary may, subject to 
such regulations as the Secretary shall prescribe, continue to 
pay allowances to eligible veterans and eligible persons 
enrolled in courses set forth in clause (1) of this subsection 
during periods when schools are temporarily closed under an 
established policy based on an Executive order of the President 
or due to an emergency situation. However, the total number of 
weeks for which allowances may continue to be so payable in any 
12-month period may not exceed 4 weeks.]
    (2) Notwithstanding paragraph (1), the Secretary may, 
pursuant to such regulations as the Secretary shall prescribe, 
continue to pay allowances to eligible veterans and eligible 
persons enrolled in courses set forth in paragraph (1)(A)--
          (A) during periods when schools are temporarily 
        closed under an established policy based on an 
        Executive order of the President or due to an emergency 
        situation, except that the total number of weeks for 
        which allowances may continue to be so payable in any 
        12-month period may not exceed four weeks; or
          (B) solely for the purpose of awarding a monthly 
        housing stipend described in section 3313 of this 
        title, during periods following a permanent school 
        closure, except that payment of such a stipend may only 
        be continued until the earlier of--
                  (i) the date of the end of the term, quarter, 
                or semester during which the school closure 
                occurred; and
                  (ii) the date that is 4 months after the date 
                of the school closure.

           *       *       *       *       *       *       *

SEC. 3684. REPORTS BY VETERANS, ELIGIBLE PERSONS, AND INSTITUTIONS; 
                    REPORTING FEE

    (a)(1) Except as provided in paragraph (2) of this 
subsection, the veteran or eligible person and the educational 
institution offering a course in which such veteran or eligible 
person is enrolled under chapter 31, 32, 33, 34, 35, or 36 of 
this title shall, without delay, report to the Secretary, in 
the form prescribed by the Secretary, such enrollment and any 
interruption or termination of the education of each such 
veteran or eligible person. The date of such interruption or 
termination will be the last date of pursuit, or, in the case 
of correspondence training, the last date a lesson was serviced 
by a school.

           *       *       *       *       *       *       *

    (4) For purposes of this subsection, the term ``educational 
institution'' may include a group, district, or consortium of 
separately accredited educational institutions located in the 
same State that are organized in a manner that facilitates the 
centralized reporting of the enrollments in such group, 
district, or consortium of institutions.

           *       *       *       *       *       *       *

SEC. 3693. COMPLIANCE SURVEYS

    [(a) Except as provided in subsection (b) of this section, 
the Secretary shall conduct an annual compliance survey of each 
institution offering one or more courses approved for the 
enrollment of eligible veterans or persons if at least 300 
veterans or persons are enrolled in such course or courses 
under provisions of this title or if any such course does not 
lead to a standard college degree. Such compliance survey shall 
be designed to ensure that the institution and approved courses 
are in compliance with all applicable provisions of chapters 30 
through 36 of this title. The Secretary shall assign at least 
one education compliance specialist to work on compliance 
surveys in any year for each 40 compliance surveys required to 
be made under this section for such year.]
    (a)(1)(A) Except as provided in subsection (b), the 
Secretary shall conduct an annual compliance survey of 
educational institutions and training establishments offering 
one or more courses approved for the enrollment of eligible 
veterans or persons if at least 20 such veterans or persons are 
enrolled in any such course.
    (B) The Secretary shall--
          (i) design the compliance surveys to ensure that such 
        institutions or establishments, as the case may be, and 
        approved courses are in compliance with all applicable 
        provisions of chapters 30 through 36 of this title;
          (ii) survey each such educational institution and 
        training establishment not less than once during every 
        two-year period; and
          (iii) assign not fewer than one education compliance 
        specialist to work on compliance surveys in any year 
        for each 40 compliance surveys required to be made 
        under this section for such year.
    (2) The Secretary, in consultation with the State approving 
agencies, shall--
          (A) annually determine the parameters of the surveys 
        required under paragraph (1); and
          (B) not later than September 1 of each year, make 
        available to the State approving agencies a list of the 
        educational institutions and training establishments 
        that will be surveyed during the fiscal year following 
        the date of making such list available.
    (b) The Secretary may waive the requirement in [subsection 
(a) of this section for an annual compliance survey] subsection 
(a)(1) for a compliance survey with respect to an [institution] 
educational institution or training establishment if the 
Secretary determines, based on the [institution's demonstrated 
record of compliance] record of compliance of such institution 
or establishment with all the applicable provisions of chapters 
30 through 36 of this title, that the waiver would be 
appropriate and in the best interest of the United States 
Government.
    (c) In this section, the terms ``educational institution'' 
and ``training establishment'' have the meaning given such 
terms in section 3452 of this title.

           *       *       *       *       *       *       *

               Part IV. General Administrative Provisions

Chapter 51. Claims, Effective Dates, and Payments

           *       *       *       *       *       *       *

Subchapter I. Claims

           *       *       *       *       *       *       *

SEC. 5101. CLAIMS AND FORMS

    (a)(1) [A specific] (A) Except as provided in subparagraph 
(B), a specific claim in the form prescribed by the Secretary 
(or jointly with the Commissioner of Social Security, as 
prescribed by section 5105 of this title) must be filed in 
order for benefits to be paid or furnished to any individual 
under the laws administered by the Secretary.
    (B)(i) The Secretary may pay benefits under chapters 13 and 
15 and sections 2302, 2307, and 5121 of this title to a 
survivor of a veteran who has not filed a formal claim if the 
Secretary determines that the record contains sufficient 
evidence to establish the entitlement of the survivor to such 
benefits.
    (ii) For purposes of this subparagraph and section 5110 of 
this title, the date on which the Secretary is notified of the 
death of the veteran shall be treated as the date of the 
receipt of the survivor's application for benefits described in 
clause (i).

           *       *       *       *       *       *       *

Part V. Boards, Administrations, and Services

           *       *       *       *       *       *       *

            Chapter 72. United States Court of Appeals for 
Veterans Claims

           *       *       *       *       *       *       *

Subchapter I. Organization and Jurisdiction

           *       *       *       *       *       *       *

SEC. 7253. COMPOSITION

           *       *       *       *       *       *       *

    (i) Additional Temporary Expansion of Court.--(1) * * *
    (2) Effective as of [January 1, 2013] January 1, 2021, an 
appointment may not be made to the Court if the appointment 
would result in there being more judges of the Court than the 
authorized number of judges of the Court specified in 
subsection (a).

           *       *       *       *       *       *       *

 Chapter 73. Veterans Health Administration--Organization and Functions

                       SUBCHAPTER I. ORGANIZATION

Sec.

           *       *       *       *       *       *       *

7309A. Pain management boards.
7309B. Office of Patient Advocacy.

           *       *       *       *       *       *       *

Subchapter I. Organization

           *       *       *       *       *       *       *

SEC. 7306. OFFICE OF THE UNDER SECRETARY FOR HEALTH

    (a) * * *

           *       *       *       *       *       *       *

          (4) Such Medical Directors and Directors of Veterans 
        Integrated Service Networks as may be appointed to suit 
        the needs of the Department[, who shall be either a 
        qualified doctor of medicine or a qualified doctor of 
        dental surgery or dental medicine].

           *       *       *       *       *       *       *

SEC. 7309A. PAIN MANAGEMENT BOARDS

    (a) Establishment.--The Secretary shall establish in each 
Veterans Integrated Service Network a Pain Management Board (in 
this section referred to as a ``Board'').
    (b) Activities.--(1) Each Board may--
          (A) consult with health care professionals and other 
        employees of the Department located in the Veterans 
        Integrated Service Network covered by the Board, 
        patients who are being treated at medical facilities of 
        the Department located in such Veterans Integrated 
        Service Network, and family members of such patients 
        with respect to the pain management resources and best 
        practices of the Department;
          (B) oversee compliance by the health care 
        professionals and other employees of the Department 
        with the best practices of the Department, including by 
        issuing recommendations to improve compliance with 
        those best practices;
          (C) provide oversight of the pain management 
        practices of the pain management teams of each medical 
        facility of the Department and the health care 
        professionals and other employees of the Department 
        that are located in the Veterans Integrated Service 
        Network covered by the Board;
          (D) host educational events, as the Board considers 
        appropriate, for individuals specified in subparagraph 
        (A) on pain management and treatment that may include 
        the sharing of updated research and best practices from 
        medical experts, other health care systems, and such 
        other Federal agencies as the Board considers necessary 
        to carry out this subparagraph; and
          (E) host public events, as the Board considers 
        appropriate, during which health care professionals 
        discuss and share best practices on pain management and 
        complementary and integrative health.
    (2)(A) Each Board may provide treatment recommendations for 
patients with complex clinical pain who are being treated at a 
medical facility of the Department located in the Veterans 
Integrated Service Network covered by the Board, and assist in 
facilitating communication between such patients and their 
health care providers, regardless of whether such treatment is 
on an in-patient or out-patient basis, and for whom a request 
for such recommendations, subject to subparagraph (C), has been 
made by an individual described in subparagraph (B).
    (B) An individual described in this subparagraph is one of 
the following individuals:
          (i) The patient.
          (ii) The spouse of the patient.
          (iii) A family member of the patient or another 
        individual if such family member or individual has been 
        designated by the patient to make health care decisions 
        for the patient or to receive health care information 
        with respect to the patient.
          (iv) A physician of the patient.
          (v) An employee of the medical facility of the 
        Department described in subparagraph (A).
    (C) An individual described in subparagraph (B) may not 
request treatment recommendations under subparagraph (A) unless 
the individual--
          (i) has requested treatment recommendations from the 
        pain management team of the medical facility of the 
        Department at which the patient is receiving treatment; 
        and
          (ii) has received treatment recommendations from such 
        team and is not satisfied with those treatment 
        recommendations.
    (D) Treatment recommendations provided under subparagraph 
(A) shall assist the patient and health care provider in 
determining the best treatment plan for the patient and shall 
not dictate the treatment plan used by the health care 
provider.
    (3) Based on treatment recommendations developed under 
paragraph (2)(A), consultations conducted under paragraph 
(1)(A), and educational and public events hosted under 
subparagraphs (D) and (E) of paragraph (1), each Board may 
provide to health care professionals of the Department located 
in the Veterans Integrated Service Network covered by the Board 
recommendations on the best practices regarding pain management 
in cases of complex clinical pain.
    (4)(A) Not later than January 31 of each year, 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 comprehensive 
information from each Board (with all personally identifiable 
information of patients redacted) on pain management practices 
carried out in the Veterans Integrated Service Network covered 
by the Board.
    (B) Each report submitted by the Secretary under 
subparagraph (A) shall include, for the year preceding the 
submittal of the report--
          (i) a summary and explanation of the treatment 
        recommendations provided under paragraph 2(A) during 
        such year; and
          (ii) the recommendations for best practices provided 
        to health care professionals under paragraph (3) during 
        such year.
    (5) The Federal Advisory Committee Act (5 U.S.C. App.) 
shall not apply to any Board.
    (c) Membership.--(1) Each Board shall include the following 
individuals appointed by the Secretary:
          (A) A board certified pain medicine specialist.
          (B) A trained and qualified member of the primary 
        care team of a medical facility of the Department with 
        experience in pain care, such as a nurse practitioner.
          (C) A pain psychologist.
          (D) A pain social worker.
          (E) A clinical pharmacist.
          (F) A pain point of contact for a Veterans Integrated 
        Service Network.
          (G) A physician with addiction and psychopharmacology 
        expertise and experience.
          (H) An allied health care professional.
          (I) A clinician with expertise in complementary and 
        integrative health.
          (J) A clinical behavioral therapist.
          (K) A patient advocate.
          (L) A representative of the labor interests of 
        employees of the Department who are responsible for 
        prescribing drugs.
          (M) Two current or former clinical patients who are 
        representative of the demographic of patients served by 
        the Veterans Integrated Service Network covered by the 
        Board.
          (N) A family member of a current or former clinical 
        patient who is representative of the demographic of 
        patients served by the Veterans Integrated Service 
        Network covered by the Board.
    (2) The Secretary shall determine the terms of service of 
the members of each Board, taking into consideration the 
clinical duties of members who are employees of the Department.
    (3)(A) Members of each Board shall serve without pay and, 
except as provided in subparagraph (B), members who are full-
time officers or employees of the United States may not receive 
additional pay, allowances, or benefits by reason of their 
service on the Board.
    (B) Members may receive travel expenses, including per diem 
in lieu of subsistence, for travel in connection with their 
duties as members of the Board.
    (C)(i) Except as provided in clause (ii), any member who 
has clinical duties as an officer or employee of the United 
States shall be relieved of such duties during periods in which 
such relief is necessary for the member to carry out the duties 
of the Board.
    (ii) The Secretary shall ensure that carrying out the 
duties of the Board does not prevent any member who has 
clinical duties as an employee of the Department from 
furnishing direct clinical care as appropriate to maintain 
quality patient care.
    (d) Participation of Certain Members.--(1) In carrying out 
the activities of a Board under subsection (b), any member 
appointed under subsection (c)(1) solely based on 
qualifications under subparagraph (K), (L), (M), or (N) of 
subsection (c)(1)--
          (A) may not have access to specific information 
        identifying a patient and other confidential 
        information relating to a patient; and
          (B) except as provided in paragraph (2), may not 
        participate in providing treatment recommendations 
        under subsection (b)(2)(A).
    (2) In carrying out the activities of the Board under 
subsection (b), a member appointed under subsection (c)(1) 
solely based on qualifications under subparagraph (K) of 
subsection (c)(1) may be present during the provision of 
treatment recommendations under subsection (b)(2)(A) with the 
consent and upon the request of the patient for which such 
treatment recommendations are provided for purposes of 
representing the interests of the patient.
    (e) Employment Protections.--No adverse personnel action 
may be made against an employee of the Department in connection 
with a communication by the employee with a member of a Board 
relating to the activities of the Board under subsection (b) 
and any such communication shall be covered by the employment 
and whistleblower protections otherwise applicable to 
communications by employees of the Department.
    (f) Resources of Department.--The Secretary shall make 
available to each Board the resources and personnel of the 
Department necessary for the Board to carry out the activities 
of the Board under subsection (b), including resources and 
personnel of the General Counsel of the Department.

SEC. 7309B. OFFICE OF PATIENT ADVOCACY

    (a) Establishment.--There is established in the Department 
within the Office of the Under Secretary for Health an office 
to be known as the ``Office of Patient Advocacy'' (in this 
section referred to as the ``Office'').
    (b) Head.--(1) The Director of the Office of Patient 
Advocacy shall be the head of the Office.
    (2) The Director of the Office of Patient Advocacy shall be 
appointed by the Under Secretary for Health from among 
individuals qualified to perform the duties of the position and 
shall report directly to the Under Secretary for Health.
    (c) Function.--(1) The function of the Office is to carry 
out the Patient Advocacy Program of the Department.
    (2) In carrying out the Patient Advocacy Program of the 
Department, the Director shall ensure that patient advocates of 
the Department--
          (A) advocate on behalf of veterans with respect to 
        health care received and sought by veterans under the 
        laws administered by the Secretary;
          (B) carry out the responsibilities specified in 
        subsection (d); and
          (C) receive training in patient advocacy.
    (d) Patient Advocacy Responsibilities.--The 
responsibilities of each patient advocate at a medical facility 
of the Department are the following:
          (1) To resolve complaints by veterans with respect to 
        health care furnished under the laws administered by 
        the Secretary that cannot be resolved at the point of 
        service or at a higher level easily accessible to the 
        veteran.
          (2) To present at various meetings and to various 
        committees the issues experienced by veterans in 
        receiving such health care at such medical facility.
          (3) To express to veterans their rights and 
        responsibilities as patients in receiving such health 
        care.
          (4) To manage the Patient Advocate Tracking System of 
        the Department at such medical facility.
          (5) To compile data at such medical facility of 
        complaints made by veterans with respect to the receipt 
        of such health care at such medical facility and the 
        satisfaction of veterans with such health care at such 
        medical facility to determine whether there are trends 
        in such data.
          (6) To ensure that a process is in place for the 
        distribution of the data compiled under paragraph (5) 
        to appropriate leaders, committees, services, and staff 
        of the Department.
          (7) To identify, not less frequently than quarterly, 
        opportunities for improvements in the furnishing of 
        such health care to veterans at such medical facility 
        based on complaints by veterans.
          (8) To ensure that any significant complaint by a 
        veteran with respect to such health care is brought to 
        the attention of appropriate staff of the Department to 
        trigger an assessment of whether there needs to be a 
        further analysis of the problem at the facility-wide 
        level.
          (9) To support any patient advocacy programs carried 
        out by the Department.
          (10) To ensure that all appeals and final decisions 
        with respect to the receipt of such health care are 
        entered into the Patient Advocate Tracking System of 
        the Department.
          (11) To understand all laws, directives, and other 
        rules with respect to the rights and responsibilities 
        of veterans in receiving such health care, including 
        the appeals processes available to veterans.
          (12) To ensure that veterans receiving mental health 
        care, or the surrogate decision makers for such 
        veterans, are aware of the rights of veterans to seek 
        representation from systems established under section 
        103 of the Protection and Advocacy for Mentally Ill 
        Individuals Act of 1986 (42 U.S.C. 10803) to protect 
        and advocate the rights of individuals with mental 
        illness and to investigate incidents of abuse and 
        neglect of such individuals.
          (13) To fulfill requirements established by the 
        Secretary with respect to the inspection of controlled 
        substances.
          (14) To document potentially threatening behavior and 
        report such behavior to appropriate authorities.
    (e) Training.--In providing training to patient advocates 
under subsection (c)(2)(C), the Director shall ensure that such 
training is consistent throughout the Department.
    (f) Controlled Substance Defined.--In this section, the 
term ``controlled substance'' has the meaning given that term 
in section 102 of the Controlled Substances Act (21 U.S.C. 
802).

           *       *       *       *       *       *       *

         Chapter 74. Veterans Health Administration--Personnel

                       SUBCHAPTER I. APPOINTMENTS

Sec.

           *       *       *       *       *       *       *

  SUBCHAPTER VII. PAY FOR MEDICAL DIRECTORS AND DIRECTORS OF VETERANS 
                      INTEGRATED SERVICE NETWORKS

7481. Pay for Medical Directors and Directors of Veterans 
            Integrated Service Networks.

           *       *       *       *       *       *       *

Subchapter II. Collective Bargaining and Personnel Administration

           *       *       *       *       *       *       *

SEC. 7423. PERSONNEL ADMINISTRATION: FULL-TIME EMPLOYEES

    (a)(1) Except as provided in paragraph (2), the hours [(a) 
The hours] of employment in carrying out responsibilities under 
this title of any employee who is appointed in the 
Administration under any provision of this chapter on a full-
time basis in a position listed in section 7421(b) of this 
title (other than an intern or resident appointed pursuant to 
section 7406 of this title) and who accepts responsibilities 
for carrying out professional services for remuneration other 
than those assigned under this title shall consist of not less 
than 80 hours in a biweekly pay period (as that term is used in 
section 5504 of title 5).
    (2) The Secretary may modify the hours of employment for a 
physician or physician assistant appointed in the 
Administration under any provision of this chapter on a full-
time basis to be more than or less than 80 hours in a biweekly 
pay period if the total hours of employment for such employee 
in a calendar year does not exceed 2,080 hours.

           *       *       *       *       *       *       *

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

    (a)(1) * * *
    (2) * * *
          (A) Registered nurse.
          (B) Physician assistant.
          (C) [(B)] Such positions referred to in paragraphs 
        (1) and (3) of section 7401 of this title (other than 
        the positions of physician, dentist, [and registered 
        nurse] registered nurse, and physician assistant) as 
        the Secretary may determine upon the recommendation of 
        the Under Secretary for Health.

           *       *       *       *       *       *       *

  Subchapter VII. Pay For Medical Directors and Directors of Veterans 
                      Integrated Service Networks

SEC. 7481. PAY FOR MEDICAL DIRECTORS AND DIRECTORS OF VETERANS 
                    INTEGRATED SERVICE NETWORKS

    (a) Elements of Pay.--Pay for a Medical Director or 
Director of a Veterans Integrated Service Network appointed 
under section 7306(a)(4) of this title (in this section 
referred to as a ``Director'') shall consist of basic pay set 
forth under section 7404(a) of this title and market pay 
determined under subsection (b).
    (b) Market Pay.--(1) Each Director is eligible for market 
pay determined under this subsection.
    (2) The amount of market pay payable to a Director under 
this section shall be determined by the Secretary on a case-by-
case basis and shall consist of pay intended to reflect needs 
of the Department with respect to the recruitment and retention 
(as determined by the Secretary) of such Director.
    (3) In determining the amount of market pay payable to a 
Director under this section, the Secretary shall--
          (A) consult not less than two national surveys on pay 
        for hospital directors, medical facility directors, or 
        other similar positions, whether prepared by private, 
        public, or quasi-public entities, to make a general 
        assessment of the range of potential pay for the 
        Director; and
          (B) take into account--
                  (i) the experience of the Director in 
                managing facilities or program offices of the 
                Department, including the complexity of such 
                facilities or offices;
                  (ii) the complexity of the facility or 
                facilities to be managed by the Director;
                  (iii) the labor market, in such geographic 
                area as the Secretary considers relevant, for 
                hospital directors, medical facility directors, 
                and other similar positions;
                  (iv) the experience of the Director in 
                managing medical facilities for other Federal 
                agencies, private entities, or non-profit 
                entities; and
                  (v) such other considerations as the 
                Secretary considers appropriate.
    (4)(A) The Secretary shall evaluate the amount of market 
pay payable to a Director under this section not less 
frequently than once every two years and may adjust the market 
pay payable to such Director as a result of such evaluation.
    (B) A Director whose market pay is evaluated under 
subparagraph (A) shall receive written notice of the results of 
such evaluation.
    (c) Requirements and Limitations on Total Pay.--(1) Not 
less frequently than once every two years, the Secretary shall 
set forth a Department-wide minimum and maximum amount for 
total annual pay under subsection (a) that may be paid to a 
Director and shall publish each such amount in the Federal 
Register.
    (2) The minimum and maximum amounts set forth under 
paragraph (1) shall take effect not earlier than the date that 
is 60 days after the publication of such amounts under such 
paragraph.
    (3) The sum of the basic pay set forth under section 
7404(a) of this title and market pay determined under 
subsection (b) for a Director for a calendar year--
          (A) may not be less than the most recent minimum 
        amount set forth under paragraph (1) before the 
        beginning of such calendar year; and
          (B) may not be more than the most recent maximum 
        amount set forth under such paragraph before the 
        beginning of such calendar year.
    (4) The total amount of compensation paid to a Director 
under this title in any calendar year may not exceed the amount 
of annual compensation (excluding expenses) of the President 
under section 102 of title 3.
    (5) The Secretary may not delegate to an officer or 
employee of the Department the requirement of the Secretary to 
set forth a Department-wide minimum and maximum amount under 
paragraph (1).
    (d) Treatment of Pay.--Pay under this section shall be 
considered pay for all purposes, including retirement benefits 
under chapters 83 and 84 of title 5 and other benefits.
    (e) Ancillary Effects of Decreases in Pay.--(1) A decrease 
in pay of a Director resulting from an adjustment in the amount 
of market pay of the Director under subsection (b) shall not be 
treated as an adverse action.
    (2) A decrease in the amount of pay of a Director resulting 
from an involuntary reassignment in connection with a 
disciplinary action taken against the Director is not subject 
to appeal or judicial review.

           *       *       *       *       *       *       *

Carl Levin and Howard P. ``Buck'' McKeon National Defense Authorization 
                        Act For Fiscal Year 2015

(Public Law 113-291; 37 U.S.C. 403 note)

           *       *       *       *       *       *       *

Division A--Department of Defense Authorizations

           *       *       *       *       *       *       *

          Title VI--Compensation and Other Personnel Benefits

Subtitle A--Pay and Allowances

           *       *       *       *       *       *       *

SEC. 604. MODIFICATION OF COMPUTATION OF BASIC ALLOWANCE FOR HOUSING 
                    INSIDE THE UNITED STATES.

    (a) * * *
    [(b) Special Rule.--Any reduction authorized by paragraph 
(3) of subsection (b) of section 403 of title 37, United States 
Code, as amended by subsection (a), shall not apply with 
respect to benefits paid by the Secretary of Veterans Affairs 
under the laws administered by the Secretary, including 
pursuant to sections 3108 and 3313 of title 38, United States 
Code. Such benefits that are determined in accordance with such 
section 403 shall be subject to paragraph (3) of such section 
as such paragraph was in effect on the day before the date of 
the enactment of this Act.]

           *       *       *       *       *       *       *

      Caregivers and Veterans Omnibus Health Services Act of 2010

(Public Law 111-163; 38 U.S.C. 1720G note)

           *       *       *       *       *       *       *

                       Title I. Caregiver Support

SEC. 101. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS.

           *       *       *       *       *       *       *

    (c) Annual Evaluation Report.--

           *       *       *       *       *       *       *

          (2) * * *
                  (A) With respect to the program of 
                comprehensive assistance for family caregivers 
                required by subsection (a)(1) of such section 
                1720G and the program of general caregiver 
                support services required by subsection (b)(1) 
                of such section--

           *       *       *       *       *       *       *

                          (iv) an assessment of the 
                        effectiveness and the efficiency of the 
                        implementation of such programs, 
                        including a description of any barriers 
                        to accessing and receiving care and 
                        services under such programs; and

           *       *       *       *       *       *       *

                  (B) With respect to the program of 
                comprehensive assistance for family caregivers 
                required by such subsection (a)(1)--
                          (i) a description of the outreach 
                        activities carried out by the Secretary 
                        under such program[; and] ;
                          (ii) an assessment of the manner in 
                        which resources are expended by the 
                        Secretary under such program, 
                        particularly with respect to the 
                        provision of monthly personal caregiver 
                        stipends under paragraph (3)(A)(ii)(v) 
                        of such subsection (a)[.] ; and
                          (iii) an evaluation of the 
                        sufficiency and consistency of the 
                        training provided to family caregivers 
                        under such program in preparing family 
                        caregivers to provide care to veterans 
                        under such program.

           *       *       *       *       *       *       *

         Post-9/11 Veterans Educational Assistance Act of 2008

(Public Law 110-252; 38 U.S.C. 3301 note)

           *       *       *       *       *       *       *

SEC. 5003.

    (a) Educational Assistance Authorized.--

           *       *       *       *       *       *       *

    [(c) Applicability to Individuals Under Montgomery Gi Bill 
Program.--
          [(1) Individuals Eligible to Elect Participation in 
        Post-9/11 Educational Assistance.--An individual may 
        elect to receive educational assistance under chapter 
        33 of title 38, United States Code (as added by 
        subsection (a)), if such individual--
                  [(A) as of August 1, 2009--
                          [(i) is entitled to basic educational 
                        assistance under chapter 30 of title 
                        38, United States Code, and has used, 
                        but retains unused, entitlement under 
                        that chapter;
                          [(ii) is entitled to educational 
                        assistance under chapter 107, 1606, or 
                        1607 of title 10, United States Code, 
                        and has used, but retains unused, 
                        entitlement under the applicable 
                        chapter;
                          [(iii) is entitled to basic 
                        educational assistance under chapter 30 
                        of title 38, United States Code, but 
                        has not used any entitlement under that 
                        chapter;
                          [(iv) is entitled to educational 
                        assistance under chapter 107, 1606, or 
                        1607 of title 10, United States Code, 
                        but has not used any entitlement under 
                        such chapter;
                          [(v) is a member of the Armed Forces 
                        who is eligible for receipt of basic 
                        educational assistance under chapter 30 
                        of title 38, United States Code, and is 
                        making contributions toward such 
                        assistance under section 3011(b) or 
                        3012(c) of such title; or
                          [(vi) is a member of the Armed Forces 
                        who is not entitled to basic 
                        educational assistance under chapter 30 
                        of title 38, United States Code, by 
                        reason of an election under section 
                        3011(c)(1) or 3012(d)(1) of such title; 
                        and
                  [(B) as of the date of the individual's 
                election under this paragraph, meets the 
                requirements for entitlement to educational 
                assistance under chapter 33 of title 38, United 
                States Code (as so added).
          [(2) Cessation of Contributions Toward Gi Bill.--
        Effective as of the first month beginning on or after 
        the date of an election under paragraph (1) of an 
        individual described by subparagraph (A)(v) of that 
        paragraph, the obligation of the individual to make 
        contributions under section 3011(b) or 3012(c) of title 
        38, United States Code, as applicable, shall cease, and 
        the requirements of such section shall be deemed to be 
        no longer applicable to the individual.
          [(3) Revocation of Remaining Transferred 
        Entitlement.--
                  [(A) Election to revoke.--If, on the date an 
                individual described in subparagraph (A)(i) or 
                (A)(iii) of paragraph (1) makes an election 
                under that paragraph, a transfer of the 
                entitlement of the individual to basic 
                educational assistance under section 3020 of 
                title 38, United States Code, is in effect and 
                a number of months of the entitlement so 
                transferred remain unutilized, the individual 
                may elect to revoke all or a portion of the 
                entitlement so transferred that remains 
                unutilized.
                  [(B) Availability of revoked entitlement.--
                Any entitlement revoked by an individual under 
                this paragraph shall no longer be available to 
                the dependent to whom transferred, but shall be 
                available to the individual instead for 
                educational assistance under chapter 33 of 
                title 38, United States Code (as so added), in 
                accordance with the provisions of this 
                subsection.
                  [(C) Availability of unrevoked entitlement.--
                Any entitlement described in subparagraph (A) 
                that is not revoked by an individual in 
                accordance with that subparagraph shall remain 
                available to the dependent or dependents 
                concerned in accordance with the current 
                transfer of such entitlement under section 3020 
                of title 38, United States Code.
          [(4) Post-9/11 Educational Assistance.--
                  [(A) In general.--Subject to subparagraph (B) 
                and except as provided in paragraph (5), an 
                individual making an election under paragraph 
                (1) shall be entitled to educational assistance 
                under chapter 33 of title 38, United States 
                Code (as so added), in accordance with the 
                provisions of such chapter, instead of basic 
                educational assistance under chapter 30 of 
                title 38, United States Code, or educational 
                assistance under chapter 107, 1606, or 1607 of 
                title 10, United States Code, as applicable.
                  [(B) Limitation on entitlement for certain 
                individuals.--In the case of an individual 
                making an election under paragraph (1) who is 
                described by subparagraph (A)(i) of that 
                paragraph, the number of months of entitlement 
                of the individual to educational assistance 
                under chapter 33 of title 38, United States 
                Code (as so added), shall be the number of 
                months equal to--
                          [(i) the number of months of unused 
                        entitlement of the individual under 
                        chapter 30 of title 38, United States 
                        Code, as of the date of the election, 
                        plus
                          [(ii) the number of months, if any, 
                        of entitlement revoked by the 
                        individual under paragraph (3)(A).
          [(5) Continuing Entitlement to Educational Assistance 
        Not Available Under 9/11 Assistance Program.--
                  [(A) In general.--In the event educational 
                assistance to which an individual making an 
                election under paragraph (1) would be entitled 
                under chapter 30 of title 38, United States 
                Code, or chapter 107, 1606, or 1607 of title 
                10, United States Code, as applicable, is not 
                authorized to be available to the individual 
                under the provisions of chapter 33 of title 38, 
                United States Code (as so added), the 
                individual shall remain entitled to such 
                educational assistance in accordance with the 
                provisions of the applicable chapter.
                  [(B) Charge for use of entitlement.--The 
                utilization by an individual of entitlement 
                under subparagraph (A) shall be chargeable 
                against the entitlement of the individual to 
                educational assistance under chapter 33 of 
                title 38, United States Code (as so added), at 
                the rate of one month of entitlement under such 
                chapter 33 for each month of entitlement 
                utilized by the individual under subparagraph 
                (A) (as determined as if such entitlement were 
                utilized under the provisions of chapter 30 of 
                title 38, United States Code, or chapter 107, 
                1606, or 1607 of title 10, United States Code, 
                as applicable).
          [(6) Additional Post-9/11 Assistance for Members 
        Having Made Contributions Toward Gi Bill.--
                  [(A) Additional assistance.--In the case of 
                an individual making an election under 
                paragraph (1) who is described by clause (i), 
                (iii), or (v) of subparagraph (A) of that 
                paragraph, the amount of educational assistance 
                payable to the individual under chapter 33 of 
                title 38, United States Code (as so added), as 
                a monthly stipend payable under paragraph 
                (1)(B) of section 3313(c) of such title, or 
                under paragraphs (2) through (7) of that 
                section (as applicable), shall be the amount 
                otherwise payable as a monthly stipend under 
                the applicable paragraph increased by the 
                amount equal to--
                          [(i) the total amount of 
                        contributions toward basic educational 
                        assistance made by the individual under 
                        section 3011(b) or 3012(c) of title 38, 
                        United States Code, as of the date of 
                        the election, multiplied by
                          [(ii) the fraction--
                                  [(I) the numerator of which 
                                is--
                                          [(aa) the number of 
                                        months of entitlement 
                                        to basic educational 
                                        assistance under 
                                        chapter 30 of title 38, 
                                        United States Code, 
                                        remaining to the 
                                        individual at the time 
                                        of the election; plus
                                          [(bb) the number of 
                                        months, if any, of 
                                        entitlement under such 
                                        chapter 30 revoked by 
                                        the individual under 
                                        paragraph (3)(A); and
                                  [(II) the denominator of 
                                which is 36 months.
                  [(B) Months of remaining entitlement for 
                certain individuals.--In the case of an 
                individual covered by subparagraph (A) who is 
                described by paragraph (1)(A)(v), the number of 
                months of entitlement to basic educational 
                assistance remaining to the individual for 
                purposes of subparagraph (A)(ii)(I)(aa) shall 
                be 36 months.
                  [(C) Timing of payment.--The amount payable 
                with respect to an individual under 
                subparagraph (A) shall be paid to the 
                individual together with the last payment of 
                the monthly stipend payable to the individual 
                under paragraph (1)(B) of section 3313(c) of 
                title 38, United States Code (as so added), or 
                under paragraphs (2) through (7) of that 
                section (as applicable), before the exhaustion 
                of the individual's entitlement to educational 
                assistance under chapter 33 of such title (as 
                so added).
          [(7) Continuing Entitlement to Additional Assistance 
        for Critical Skills or Speciality and Additional 
        Service.--An individual making an election under 
        paragraph (1)(A) who, at the time of the election, is 
        entitled to increased educational assistance under 
        section 3015(d) of title 38, United States Code, or 
        section 16131(i) of title 10, United States Code, or 
        supplemental educational assistance under subchapter 
        III of chapter 30 of title 38, United States Code, 
        shall remain entitled to such increased educational 
        assistance or supplemental educational assistance in 
        the utilization of entitlement to educational 
        assistance under chapter 33 of title 38, United States 
        Code (as so added), in an amount equal to the quarter, 
        semester, or term, as applicable, equivalent of the 
        monthly amount of such increased educational assistance 
        or supplemental educational assistance payable with 
        respect to the individual at the time of the election.
          [(8) Irrevocability of Elections.--An election under 
        paragraph (1) or (3)(A) is irrevocable.]

           *       *       *       *       *       *       *

        Veterans Access, Choice, and Accountability Act of 2014

(Public Law 113-146; 38 U.S.C. 7302 note)

           *       *       *       *       *       *       *

   Title III. Health Care Staffing, Recruitment, and Training Matters

SEC. 301. TREATMENT OF STAFFING SHORTAGE AND BIENNIAL REPORT ON 
                    STAFFING OF MEDICAL FACILITIES OF THE DEPARTMENT OF 
                    VETERANS AFFAIRS.

    (a) Staffing Shortages.--

           *       *       *       *       *       *       *

    (b) Increase of Graduate Medical Education Residency 
Positions.--

           *       *       *       *       *       *       *

          (2) [Five-year] Ten-year increase.--
                  (A) In general.--In carrying out section 
                7302(e) of title 38, United States Code, as 
                added by paragraph (1), during the [5-year 
                period] 10-year period beginning on the day 
                that is 1 year after the date of the enactment 
                of this Act, the Secretary of Veterans Affairs 
                shall increase the number of graduate medical 
                education residency positions at medical 
                facilities of the Department by up to 1,500 
                positions.

           *       *       *       *       *       *       *

          (3) Report.--
                  (A) In general.--Not later than 60 days after 
                the date of the enactment of this Act, and not 
                later than October 1 each year thereafter 
                [until 2019] until 2024, 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 on graduate medical education residency 
                positions at medical facilities of the 
                Department.

           *       *       *       *       *       *       *

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