69–006 

110TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 2d Session 110–786 

VETERANS’ HEALTH CARE POLICY ENHANCEMENT ACT 

OF 2008 

JULY 29, 2008.—Committed to the Committee of the Whole House on the State of 

the Union and ordered to be printed 

Mr. FILNER, from the Committee on Veterans’ Affairs, 

submitted the following 

R E P O R T 

[To accompany H.R. 6445] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Veterans’ Affairs, to whom was referred the 

bill (H.R. 6445) to amend title 38, United States Code, to prohibit 

the Secretary of Veterans Affairs from collecting certain copayments from veterans who are catastrophically disabled, having considered the same, report favorably thereon with amendments and 

recommend that the bill as amended do pass. 

CONTENTS 

Page 

Amendment .............................................................................................................. 2 

Purpose and Summary ............................................................................................ 3 

Background and Need for Legislation .................................................................... 4 

Hearings ................................................................................................................... 9 

Subcommittee Consideration .................................................................................. 9 

Committee Consideration ........................................................................................ 9 

Committee Votes ...................................................................................................... 9 

Committee Oversight Findings ............................................................................... 10 

Statement of General Performance Goals and Objectives .................................... 10 

New Budget Authority, Entitlement Authority, and Tax Expenditures ............. 10 

Earmarks and Tax and Tariff Benefits .................................................................. 10 

Committee Cost Estimate ....................................................................................... 10 

Congressional Budget Office Estimate ................................................................... 10 

Federal Mandates Statement ................................................................................. 15 

Advisory Committee Statement .............................................................................. 15 

Constitutional Authority Statement ...................................................................... 15 

Applicability to Legislative Branch ........................................................................ 15 

Section-by-Section Analysis of the Legislation ...................................................... 15 

Changes in Existing Law Made by the Bill as Reported ...................................... 16 


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AMENDMENT

The amendments are as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE. 

This Act may be cited as the ‘‘Veterans’ Health Care Policy Enhancement Act of 

2008’’. 

SEC. 2. PROHIBITION ON COLLECTION OF CERTAIN COPAYMENTS FROM VETERANS WHO ARE 

CATASTROPHICALLY DISABLED. 

(a) PROHIBITION ON COLLECTION OF COPAYMENTS AND OTHER FEES FOR HOSPITAL

OR NURSING HOME CARE.—Section 1710 of title 38, United States Code, is amended—

(1) by redesignating subsection (h) as subsection (i); and 

(2) by inserting after subsection (g) the following new subsection (h): 

‘‘(h) Notwithstanding any other provision of this section, a veteran who is catastrophically disabled shall not be required to make any payment otherwise required 

under subsection (f) or (g) for the receipt of hospital care or nursing home care 

under this section.’’. 

(b) EFFECTIVE DATE.—Subsection (h) of section 1710 of title 38, United States 

Code, as added by subsection (a), shall apply with respect to hospital care or nursing 

home care provided after the date of the enactment of this Act. 

SEC. 3. EXPANSION OF AUTHORITY OF SECRETARY OF VETERANS AFFAIRS TO PROVIDE 

COUNSELING FOR FAMILY MEMBERS OF VETERANS RECEIVING NONSERVICE-CONNECTED TREATMENT. 

Section 1782(b) of title 38, United States Code, is amended by striking ‘‘if—’’ and 

all that follows and inserting a period. 

SEC. 4. COMPREHENSIVE POLICY ON PAIN MANAGEMENT. 

(a) COMPREHENSIVE POLICY REQUIRED.—Not later than October 1, 2008, the Secretary of Veterans Affairs shall develop and implement a comprehensive policy on 

the management of pain experienced by veterans enrolled for health care services 

provided by the Department of Veterans Affairs. 

(b) SCOPE OF POLICY.—The policy required by subsection (a) shall cover each of 

the following: 

(1) The systemwide management of acute and chronic pain experienced by 

veterans. 

(2) The standard of care for pain management to be used throughout the Department. 

(3) The consistent application of pain assessments to be used throughout the 

Department. 

(4) The assurance of prompt and appropriate pain care treatment and management by the Department, systemwide, when medically necessary. 

(5) The Department’s program of research related to acute and chronic pain 

suffered by veterans, including pain attributable to central and peripheral nervous system damage characteristic of injuries incurred in modern warfare. 

(6) The Department’s program of pain care education and training for health 

care personnel of the Department. 

(7) The Department’s program of patient education for veterans suffering 

from acute or chronic pain and their families. 

(c) UPDATES.—The Secretary shall revise the policy developed under subsection (a) 

on a periodic basis in accordance with experience and evolving best practice guidelines. 

(d) CONSULTATION.—The Secretary shall develop the policy developed under subsection (a), and revise such policy under subsection (c), in consultation with veterans 

service organizations and organizations with expertise in the assessment, diagnosis, 

treatment, and management of pain. 

(e) ANNUAL REPORT.—

(1) IN GENERAL.—Not later than 180 days after the date of the completion and 

initial implementation of the policy under subsection (a) and on October 1 of 

every fiscal year thereafter through fiscal year 2018, 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 the implementation 

of the policy developed under subsection (a). 

(2) CONTENTS.—The report required by paragraph (1) shall include the following: 

(A) A description of the policy developed and implemented under subsection (a) and any revisions to such policy under subsection (c). 


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(B) A description of the performance measures used to determine the effectiveness of such policy in improving pain care for veterans systemwide. 

(C) An assessment of the adequacy of the Department’s pain management 

services based on a survey of patients managed in Department clinics. 

(D) An assessment of the Department’s research programs relevant to the 

treatment of the types of acute and chronic pain suffered by veterans. 

(E) An assessment of the training provided to Department health care 

personnel with respect to the diagnosis, treatment, and management of 

acute and chronic pain. 

(F) An assessment of the Department’s pain care-related patient education programs. 

(f) VETERANS SERVICE ORGANIZATION DEFINED.—In this section, the term ‘‘veterans service organization’’ means any organization recognized by the Secretary for 

the representation of veterans under section 5902 of title 38, United States Code. 

SEC. 5. ESTABLISHMENT OF CONSOLIDATED PATIENT ACCOUNTING CENTERS. 

(a) ESTABLISHMENT OF CENTERS.—Chapter 17 of title 38, United States Code, is 

amended by inserting after section 1729A the following: 

‘‘§ 1729B. Consolidated patient accounting centers 

‘‘(a) IN GENERAL.—Not later than 5 years after the date of enactment of this section, the Secretary of Veterans Affairs shall establish not more than seven consolidated patient accounting centers for conducting industry-modeled regionalized billing and collection activities of the Department. ‘‘(b) FUNCTIONS.—The centers shall carry out the following functions: ‘‘(1) Reengineer and integrate all business processes of the revenue cycle of 

the Department. ‘‘(2) Standardize and coordinate all activities of the Department related to the 

revenue cycle for all health care services furnished to veterans for nonserviceconnected medical conditions. ‘‘(3) Apply commercial industry standards for measures of access, timeliness, 

and performance metrics with respect to revenue enhancement of the Department. 

‘‘(4) Apply other requirements with respect to such revenue cycle improvement as the Secretary may specify.’’. 

(b) CLERICAL AMENDMENT.—The table of sections at the beginning of such chapter 

is amended by inserting after the item relating to section 1729A the following: 

‘‘1729B. Consolidated patient accounting centers.’’. 

SEC. 6. SIMPLIFYING AND UPDATING NATIONAL STANDARDS TO ENCOURAGE TESTING OF 

THE HUMAN IMMUNODEFICIENCY VIRUS. 

Section 124 of the Veterans’ Benefits and Services Act of 1988 (38 U.S.C. 7333 

note; 102 Stat. 505) and the item relating to such section in the table of contents 

of such Act (102 Stat. 487) are repealed. 

Amend the title so as to read: 

A bill to amend title 38, United States Code, to prohibit the Secretary of Veterans Affairs from collecting certain copayments from veterans who are catastrophically disabled, and for other purposes. 

PURPOSE AND SUMMARY

H.R. 6445 was introduced by Representative Donald J. Cazayoux, 

Jr. of Louisiana on July 9, 2008. H.R. 6445, as amended, contains 

provisions from H.R. 6439, introduced by Representative Phil Hare 

of Illinois; H.R. 6122, introduced by Representative Tim Walz of 

Minnesota; H.R. 6366, introduced by Representative Steve Buyer of 

Indiana, the Ranking Member of the Committee on Veterans’ Affairs; and H.R. 6114, introduced by Representative Mike Doyle of 

Pennsylvania. 

H.R. 6445 would modernize the Department of Veterans Affairs 

(VA) policies regarding copayments for non-service-connected Priority Group 4 veterans who are catastrophically disabled, pain care 

management programs, eligibility for counseling services for family 

members, and requirements for informed consent for HIV testing. 

Additionally, this legislation would enhance the VA’s ability to colVerDate Aug 31 2005 20:36 Jul 30, 2008 Jkt 069006 PO 00000 Frm 00003 Fmt 6659 Sfmt 6602 E:\HR\OC\HR786.XXX HR786

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lect third-party payments by requiring the VA establish not more 

than seven consolidated patient accounting centers (CPACs). 

The bill would prohibit the VA from collecting copayments from 

veterans who are catastrophically disabled (Priority Group 4) for 

hospital or nursing home care and would direct the VA to establish 

not more than seven CPACs for conducting industry-modeled regionalized billing and collection activities. 

The bill would repeal the specification that in order for family 

members of non-service-connected veterans to be eligible for counseling services the counseling must be essential to permit the discharge of the veteran from the hospital. It would direct the VA to 

develop and implement a comprehensive policy on the management 

of pain experienced by veterans enrolled for health care services 

provided by the VA and revise the policy on a periodic basis in accordance with experience and evolving best practice guidelines. The 

bill would also require VA to develop and revise the policy in consultation with veterans’ service organizations and organizations 

with expertise in the assessment, diagnosis, treatment, and management of pain. 

The bill would remove the requirement for written informed consent for HIV testing among veterans, thereby reducing existing 

barriers to the early diagnosis of HIV infection. 

BACKGROUND AND NEED FOR LEGISLATION

PROHIBITING COLLECTION OF COPAYMENTS FROM CATASTROPHICALLY

DISABLED VETERANS

The Veterans’ Health Care Eligibility Reform Act of 1996 (Public 

Law 104–262) directed the VA to establish a patient enrollment 

system to manage the provision of care and services provided to 

veterans, established seven priority groups, and directed the VA to 

enroll veterans in accordance with the priorities listed in the law. 

The Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (Public Law 107–135) subsequently added 

a new Priority Group 8 to reflect veterans with the lowest priority 

to VA health care to the existing seven priority groups. 

Veterans enrolled in Priority Groups 5 through 8, who are 

verified by the VA to be non-service connected catastrophically disabled and who have incomes above means-tested levels, may apply 

for enrollment into Priority Group 4. Those veterans who were previously subject to copayments are required to agree to pay those copayments after moving to Priority Group 4. 

Catastrophically disabled veterans are defined as having a permanent, severely disabling injury, disorder, or disease that compromises the ability to carry out the activities of daily living to 

such a degree that the individual requires personal or mechanical 

assistance to leave home or bed or requires constant supervision to 

avoid physical harm to self or others. According to the VA, approximately 25,000 catastrophically disabled veterans are enrolled in 

Priority Group 4. 

H.R. 6445 would prohibit the VA from collecting copayments 

from non-service connected veterans who are catastrophically disabled in Priority Group 4 for hospital or nursing home care. The 

very nature and severity of the disabilities experienced by these 

veterans often precludes them from being employed and may, 


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therefore, deprive them of a steady form of income. The Committee 

believes requiring catastrophically disabled veterans to pay copayments may cause these veterans undue financial hardship. 

EXPANSION OF AUTHORITY OF SECRETARY OF VETERANS AFFAIRS TO

PROVIDE COUNSELING FOR FAMILY MEMBERS OF VETERANS RECEIV- ING NON-SERVICE-CONNECTED TREATMENT

The Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (Public Law 107–135) consolidated and reorganized the authority for the VA to provide services to non-veterans. This Act created section 1782 to title 38, United States 

Code, that outlines the conditions by which the VA may provide 

counseling, training and mental health services to immediate family members. 

Under current law, all enrolled veterans receiving care for service-connected treatment are eligible for family support services to 

the extent they are necessary to the veterans’ treatment. Veterans 

being treated for non-service-connected disabilities are only eligible 

for these family support services if they are necessary in connection 

with the veteran’s treatment, initiated during the veteran’s hospitalization, and their continued provision on an outpatient basis 

is deemed essential to permit the discharge of the veteran from the 

hospital. 

Over the past decade, VA has transformed its delivery of health 

care services from an inpatient-based model to an outpatient-based 

model. According to VA, this transformation has significantly increased its efficiencies, increased veterans’ access to care, and 

aligned the VA with the health care industry at large. As a result, 

some families have become ineligible for counseling, training, and 

other family support services that are essential to the veterans’

treatment simply because their loved ones’ care was for a non-service-connected disability that was provided on an outpatient basis. 

H.R. 6445 would eliminate the requirement that family support 

services be initiated during the veteran’s hospitalization and 

deemed essential to permit the veteran’s discharge, thus making 

the eligibility criteria the same for all veterans. An enrolled veteran is eligible for any needed medical treatment, regardless of 

whether or not the condition is service-connected. The Committee 

believes it is incongruent to base eligibility for needed family support services on the service-connected nature of a veteran’s disability. If family support services are necessary in connection with 

the veteran’s treatment, it should be irrelevant whether the disability under treatment is service-connected or non-service-connected and whether the treatment is provided in a hospital setting 

or on an outpatient basis. 

H.R. 6445 would enable the VA to provide needed counseling, 

training and mental health services to immediate family members 

of these veterans. As the mental health needs of veterans continue 

to grow and the VA is authorized to provide treatment and support 

to more veterans and their families, it is likely that it will need to 

increase its mental health workforce to accommodate the increased 

demand. The Committee strongly encourages the VA to fully implement the Veterans Benefits, Health Care, and Information Technology Act of 2006 (Public Law 109–461). This Act authorized the 

VA to recognize and hire Licensed Professional Counselors and 


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Marriage and Family Therapists as mental health professionals in 

the VA. However, the VA has yet to adopt regulations and policies 

to credential and employ mental health counselors in the VA system. These qualified and licensed mental health professionals are 

willing and able to care for our nation’s veterans and their families 

and will help the VA meet the additional mental health workload 

now and into the future. 

COMPREHENSIVE POLICY ON PAIN MANAGEMENT

According to the National Center for Health Statistics, pain affects an estimated 76 million Americans, more than cancer, diabetes and heart disease combined. Uncontrolled pain is a leading 

cause of disability and reduced quality of life. It adversely affects 

every aspect of daily living. Pain patients consume health care resources at a higher rate than other groups of patients. Under-treated pain is a leading contributor to health care costs, accounting for 

more than $100 billion a year in health care expenses and lost productivity. 

The VA recognized that early assessment and pain management 

treatment is fundamental to the delivery of patient-centered medicine. In November 1996, VA appointed a Multidisciplinary Pain 

Committee to assess the appropriateness of VA pain management 

policies. This Committee found that the VA lacked a systematic 

pain management process. To address this shortcoming, VA developed a National Pain Management Strategy in November of 1998 

and in March of 1999 VA issued a guide ‘‘Pain Assessment, the 5th 

Vital Sign,’’ establishing procedures for pain assessment, treatment, and outcomes of treatments in all clinical settings to ensure 

consistent assessment of pain. 

In 2002, the VA Office of Inspector General (IG) conducted a review of VA’s Pain Management Initiative to determine whether the 

initiative had been implemented in medical and surgical settings, 

pain interventions were timely and adequate, and reflected documented follow-up pain measurements. On June 10, 2002, the IG 

issued a report (01–00026–101) that found that VA had made significant improvements over the previous five years since the initiative was established, but also found that the extent of implementation varied and more work needed to be done. Subsequently, VA 

issued VHA Directive 2003–021, establishing a Pain Management 

Strategy to make pain management a national priority. The Directive outlined the VA’s strategy as providing a system-wide VHA 

standard of care for pain management; ensuring that pain assessment is performed in a consistent manner; ensuring that pain assessment is prompt and appropriate to include patients and families as active participants in pain management; providing for an 

interdisciplinary, multi-modal approach to pain management; and, 

ensuring that clinicians practicing in the VA health care system 

are adequately prepared to assess and manage pain effectively. 

This Directive expired on May 31, 2008. 

H.R. 6445 would require VA to develop and implement a comprehensive policy on the management of pain experienced by veterans. It would require the VA to develop the policy in consultation 

with veterans service organizations and organizations with expertise in the assessment, diagnosis, treatment, and management of 

pain. 


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CONSOLIDATED PATIENT ACCOUNTING CENTERS

Current law authorizes the VA to bill veterans’ insurance companies (third-party collections) for non-service-connected care provided to veterans enrolled in the VA health care system. Public 

Law 105–33 gave VA the authority to retain these funds in the 

Medical Care Collections Fund (MCCF). VA can use the MCCF for 

providing medical services to veterans. In 2005, VA created the 

Mid-Atlantic CPAC in Asheville, North Carolina to help maximize 

its collections by using a private-sector model that is tailored to 

VA’s billing and collection needs. 

Conference Report 109–305, accompanying Public Law 109–114, 

directed VA to establish a Revenue Improvement Demonstration to 

advance revenue performance and develop a model that could be leveraged systemwide. Due to their complementary missions, VA established the Revenue Improvement Demonstration Project at the 

Mid-Atlantic CPAC. Approximately $12 million for fiscal year 2007 

in additional collections was generated as a result of this Revenue 

Improvement Demonstration Project in coordination with the 

CPAC initiatives. 

A June 2008 report from the Government Accountability Office 

(GAO) estimated that $1.2 to $1.4 billion dollars are going uncollected by VA. GAO reiterated its previous findings from 2001 and 

2004 that VA has challenges in collecting from third-party payers, 

to include improper coding, delays in billing, and collections followup. These challenges prevent VA from maximizing its potential revenue from third-party insurance companies. However, in its 2008 

report, GAO noted that the Mid-Atlantic CPAC achieved better billing performance and has been able to reduce billing times. GAO 

concluded that VA needs to establish standardized processes and 

procedures to improve timely and accurate billing and enhance collections. Effective management oversight and implementation will 

be key to the success of these initiatives. 

The Committee believes using the best practices from the CPAC 

and Revenue Improvement Demonstration Project would provide 

systemwide improvement for VA’s collection processes. H.R. 6445 

would require the VA to establish, within five years, no more than 

seven CPACs modeled after the existing CPAC and Revenue Improvement Demonstration Project in Asheville, North Carolina. The 

Committee expects VA to move quickly to implement these provisions in order to have the facilities operational in a timely manner. 

SIMPLIFYING AND UPDATING NATIONAL STANDARDS TO ENCOURAGE

TESTING OF THE HUMAN IMMUNODEFICIENCY VIRUS

According to the Center for Disease Control (CDC), human immunodeficiency virus (HIV) is the virus that causes acquired immunodeficiency syndrome (AIDS). HIV attacks the immune system 

and destroys its ability to fight disease. As HIV progresses to 

AIDS, the body becomes increasingly susceptible to life-threatening 

opportunistic infections. CDC estimates 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS at the end 

of 2003 and approximately 40,000 persons become infected with 

HIV annually. Approximately 16 to 22 million persons in the 

United States are tested for HIV every year. Although 38 percent 

to 44 percent of all adults had been tested for HIV by 2002, CDC 


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estimates that approximately 252,000 to 320,000 persons are unaware of their HIV infection. 

The VA is the largest single provider of HIV/AIDS care in the 

United States. As of fiscal year 2005, there were 22,800 patients 

with HIV/AIDS in the VA. According to the VA’s Public Health 

Strategic Working Group, 50 percent of HIV positive veterans had 

already suffered significant damage to their immune system by the 

time they were diagnosed as HIV positive. These patients had, on 

average, 3.7 years of VA care before diagnosis, indicating that 

there were missed opportunities to make a diagnosis at a stage 

when HIV treatment could have prevented many of the complications experienced by these patients. 

The Veterans’ Benefits and Services Act of 1988 (Public Law 

100–322), requires the VA to obtain a patient’s written consent before being tested for HIV. Since the enactment of Public Law 100– 322, HIV testing has entered a new era. Lawmakers and public 

health officials are making changes to ensure that more people 

know their HIV status—an important consideration for maintaining their health and reducing the spread of the virus. 

In September 2006, CDC released the Revised Recommendations 

for HIV Testing of Adults, Adolescents, and Pregnant Women in 

Health-Care Settings which recommends that diagnostic HIV testing be a part of routine clinical care in all health care settings in 

the United States and recommends that separate written consent 

for HIV screening should no longer be required. The revised recommendations contend that people who are infected with HIV but 

not aware of it are not able to take advantage of the therapies that 

can keep them healthy and extend their lives, nor do they have the 

knowledge to protect their sex or drug-use partners from becoming 

infected. 

Knowing whether one is positive or negative for HIV may influence healthy decision making. Cohort studies have demonstrated 

that many infected persons decrease high risk behaviors once they 

become aware of their positive HIV status. HIV-infected persons 

who are unaware of their infection do not reduce risk behaviors. 

Because of medical treatment that lowers HIV viral load might also 

reduce risk for transmission to others, early referral to medical 

care could prevent HIV transmission in communities while reducing a person’s risk for HIV-related illness and death. 

H.R. 6445 would remove the statutory requirements that a patient’s written consent be obtained before testing for HIV, and accompanied by pre-and post-test documented counseling. This will 

enable the VA to update its procedures to conform to current standard of care and afford VA the flexibility to update their screening 

standards. 

This provision is identical to VA’s legislative request in its fiscal 

year 2009 budget submission to update VA’s HIV Testing Policy in 

accordance with CDC Testing Recommendations. The American 

Medical Association, the HIV Medicine Association, the American 

Academy of HIV Medicine, the American Academy of Pediatrics, 

the National Medical Association, and the National Association of 

Community Health Centers have endorsed the CDC recommendations. The Committee believes that these recommendations are appropriate for VA to implement. However, we recognize that these 

recommendations might change over time. 


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The Committee recognizes that VA is a leader in responding to 

the challenges of the HIV/AIDS epidemic. The Committee urges VA 

to continue to ensure that veterans with HIV infection receive the 

highest quality clinical care and preventative services and that 

those veterans at risk also receive appropriate counseling, assistance and preventive services to lower their risk of acquiring the infection. 

HEARINGS

On June 26, 2008, the Subcommittee on Health held a legislative 

hearing on a number of bills introduced in the 110th Congress, including the discussion drafts of a number of provisions included in 

H.R. 6445, as amended. The following witnesses testified: Mr. Carl 

Blake, National Legislative Director, Paralyzed Veterans of America; Mr. Christopher Needham, Senior Legislative Associate, National Legislative Service, Veterans of Foreign Wars of the United 

States; Gerald M. Cross, M.D., FAAFP, Principal Deputy Under 

Secretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs, accompanied by Walter A. Hall, Assistant General Counsel, U.S. Department of Veterans Affairs and 

Gary M. Baker, Chief Business Officer, Veterans Health Administration, U.S. Department of Veterans Affairs. Those submitting 

statements for the record included: Mr. Joseph L. Wilson, Assistant 

Director, Veterans Affairs and Rehabilitation Commission, The 

American Legion; Mr. Raymond C. Kelley, National Legislative Director, American Veterans (AMVETS); Mr. Adrian M. Atizado, Assistant National Legislative Director, Disabled American Veterans; 

and, Ms. Barbara F. West, Executive Director, National Association 

of Veterans’ Research and Education Foundation 

SUBCOMMITTEE CONSIDERATION

On July 10, 2008, the Subcommittee on Health met in open 

markup session and ordered favorably forwarded to the full Committee H.R. 6445 by voice vote. 

COMMITTEE CONSIDERATION

On July 16, 2008, the full Committee met in an open markup 

session, a quorum being present, and ordered H.R. 6445 as amended, favorably reported to the House of Representatives, by voice 

vote. During consideration of the bill the following amendment was 

considered: 

An amendment in the nature of a substitute by Mr. Michaud of 

Maine that incorporated provisions of H.R. 6439, H.R. 6122, H.R. 

6366, and H.R. 6114, was agreed to by voice vote. 

COMMITTEE VOTES

Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list the record votes on the motion 

to report the legislation and amendments thereto. There were no 

record votes taken on amendments or in connection with ordering 

H.R. 6445 reported to the House. A motion by Mr. Buyer of Indiana 

to order H.R. 6445, as amended, reported favorably to the House 

of Representatives was agreed to by voice vote. 


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COMMITTEE OVERSIGHT FINDINGS

In compliance with clause 3(c)(1) of rule XIII and clause (2)(b)(1) 

of rule X of the Rules of the House of Representatives, the Committee’s oversight findings and recommendations are reflected in the 

descriptive portions of this report. 

STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

In accordance with clause 3(c)(4) of rule XIII of the Rules of the 

House of Representatives, the Committee’s performance goals and 

objectives are reflected in the descriptive portions of this report. 

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

In compliance with clause 3(c)(2) of rule XIII of the Rules of the 

House of Representatives, the Committee adopts as its own the estimate of new budget authority, entitlement authority, or tax expenditures or revenues contained in the cost estimate prepared by 

the Director of the Congressional Budget Office pursuant to section 

402 of the Congressional Budget Act of 1974. 

EARMARKS AND TAX AND TARIFF BENEFITS

H.R. 6445 does not contain any congressional earmarks, limited 

tax benefits, or limited tariff benefits as defined in clause 9(d), 9(e), 

or 9(f) of rule XXI of the Rules of the House of Representatives. 

COMMITTEE COST ESTIMATE

The Committee adopts as its own the cost estimate on H.R. 6445 

prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974. 

CONGRESSIONAL BUDGET OFFICE COST ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House 

of Representatives, the following is the cost estimate for H.R. 6445 

provided by the Congressional Budget Office pursuant to section 

402 of the Congressional Budget Act of 1974: 

U.S. CONGRESS, 

CONGRESSIONAL BUDGET OFFICE, 

Washington, DC, July 28, 2008. 

Hon. BOB FILNER, Chairman, Committee on Veterans’ Affairs, 

House of Representatives, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 6445, the Veterans 

Health Care Policy Enhancements Act of 2008. 

If you wish further details on this estimate, we will be pleased 

to provide them. The CBO staff contact is Sunita D’Monte. 

Sincerely, 

ROBERT A. SUNSHINE

(For Peter R. Orszag, Director). 

Enclosure. 


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H.R. 6445—Veterans Health Care Policy Enhancements Act of 2008 

Summary: H.R. 6445 would: 

• Allow the Department of Veterans Affairs (VA) to increase 

testing for human immunodeficiency virus (HIV) infection in the 

population of veterans who use VA health care facilities, 

• Require VA to establish up to seven regional accounting centers to consolidate all VA billing and collection functions related to 

health care, 

• Prohibit VA from collecting copayments and fees from certain 

catastrophically disabled veterans, 

• Authorize VA to provide certain mental health services to the 

family members and housemates of veterans being treated for a 

nonservice-connected condition, and 

• Require VA to develop and implement a comprehensive policy 

on pain care. 

In total, CBO estimates that implementing H.R. 6445 would cost 

$995 million over the 2009–2013 period, assuming appropriation of 

the estimated amounts. Enacting the bill would not affect direct 

spending or revenues. 

H.R. 6445 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA) 

and would impose no costs on state, local, or tribal governments. 

Estimated cost to the Federal Government: The estimated budgetary impact of H.R. 6445 is shown in the following table. The costs 

of this legislation fall within budget function 700 (veterans benefits 

and services). 

By fiscal year, in millions of dollars— 

2009 2010 2011 2012 2013 2009– 

2013 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Testing for Human Immunodeficiency Virus: 

Estimated Authorization Level ............................................. 43 114 188 265 343 953 

Estimated Outlays ............................................................... 38 107 181 257 335 918 

Patient Accounting Centers: 

Estimated Authorization Level ............................................. 7 24 4 0 0 35 

Estimated Outlays ............................................................... 6 22 6 ¥4 ¥6 24 

Copayments for the Catastrophically Disabled: 

Estimated Authorization Level ............................................. 6 6 6 6 6 30 

Estimated Outlays ............................................................... 6 6 6 6 6 30 

Counseling for Family Members: 

Estimated Authorization Level ............................................. 4 5 5 5 5 24 

Estimated Outlays ............................................................... 4 4 5 5 5 23 

Total Changes: 

Estimated Authorization Level ............................................. 60 149 203 276 354 1,042 

Estimated Outlays ............................................................... 54 139 198 264 340 995 

Basis of estimate: CBO assumes that the legislation will be enacted near the end of fiscal year 2008, that the estimated amounts 

will be appropriated each year, and that outlays will follow historical spending patterns for similar programs. 

TESTING FOR HIV

Section 6 would eliminate a rule prohibiting VA from conducting 

widespread testing for HIV infection in the population of veterans 

who use VA health care facilities. It also would eliminate current 


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1 Ronald O. Valdiserri, Fred Rodriguez, and Mark Holodniy, ‘‘Frequency of HIV Screening in 

the Veterans Health Administration: Implications for Early Diagnosis of HIV Infection,’’ AIDS 

Education and Prevention, vol. 20, no. 3 (2008), pp. 258–264; and Douglas K. Owens and others, ‘‘Prevalence of HIV Infection Among Inpatients and Outpatients in Department of Veterans Affairs Health Care Systems: Implications for Screening Programs for HIV,’’ American Journal of 

Public Health, vol. 97, no. 12 (2007), pp. 2173–2178. 

requirements for separate written consent for HIV tests and preand post-test counseling. 

Based on data from VA, CBO estimates that under section 6, the 

number of HIV tests administered by VA would increase significantly, from the current annual level of about 125,000 tests to 

200,000 in 2009 and to 250,000 a year over the 2010–2013 period. 

Based on studies of veterans enrolled in VA health care, CBO expects that increased testing would lead to an increase in the number of newly diagnosed veterans and that those veterans would be 

identified earlier in the course of the disease.1 We expect that people who are tested for HIV at, and receive general care in, VA 

health care facilities would prefer to maintain continuity of care 

with VA health care providers, and thus would be treated by VA 

for HIV disease. Based on data from VA and the Kaiser Family 

Foundation, CBO estimates that the average cost of treatment in 

2009 would be $18,000 per patient in the early stages of HIV infection, and $35,000 per patient in the advanced stages of the disease. 

CBO estimates that under the bill, VA would start providing 

comprehensive HIV treatment to an additional 1,600 newly diagnosed veterans in 2009 at an average cost of $27,000 per person. 

By 2013, CBO estimates that the number of additional veterans 

being treated for HIV would grow to about 12,000. Because an increasing proportion of those veterans would be diagnosed in the 

early stages of the disease when treatment is less expensive, the 

average cost of treatment, before considering the effects of inflation, would decrease over time. Adjusting for inflation, CBO estimates that implementing section 6 would cost about $920 million 

over the 2009–2013 period, assuming appropriation of the necessary funds. 

PATIENT ACCOUNTING CENTERS

Section 5 would require VA to establish up to seven consolidated 

patient accounting centers (CPACs) within the next five years. 

CPACs would be required to apply commercial industry standards 

to coordinate and standardize billing and collections related to 

health care. In total, CBO estimates that implementing this section 

would cost $24 million over the 2009–2013 period, assuming appropriation of the estimated amounts. 

In 2006, VA established a CPAC in North Carolina, and the 

agency plans to expand the area it serves in 2008 and 2009. Based 

on information from VA, CBO expects that VA would begin establishing three CPACs in 2009, one in 2010, and the remaining two 

in 2011, and that all CPACs would be fully operational by the end 

of 2013. CBO also expects that there would be no net change in the 

overall number of employees working in billing and collection activities; some existing employees would move to CPACs, other existing employees would transition to different functions at their 

current location, and some new employees would be hired. 


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CBO estimates that VA would require additional appropriations 

to retain those current employees who would transition to other 

functions at the facilities where they are employed, and that this 

period of transition would take nine months. Based on information 

from VA and assuming appropriation of the estimated amounts, 

CBO estimates that the total salary costs for those employees 

would be $12 million in 2009 and would grow to $25 million in 

2012, before declining to $13 million in 2013, when most CPACs 

would be operational. CBO estimates that other one-time costs of 

implementing CPACs—such as training, leases and start-up costs 

for office space, and information technology—would have a similar 

trend; initial costs would be $18 million in 2009, grow to $43 million in 2011 and 2012, and decline to $22 million in 2013, assuming 

appropriation of the estimated amounts. 

In addition to CPACs, CBO expects that VA would require a 

small office at the VA headquarters in Washington, D.C., to oversee 

the regional CPACs. Based on information from VA, CBO estimates 

that the office would require 10 additional staff in 2009 at a cost 

of $1 million but that staff would grow as CPACs become operational to about 33 people by 2013 with recurring costs of $4 million a year, assuming appropriation of the estimated amounts. 

Based on VA data on the growth in medical care collections (collections from third parties, copayments, and other fees) from the 

existing CPAC, CBO estimates that under the bill VA would collect 

an additional $30 million in 2009, which would rise to about $175 

million in 2013. Under current law, those collections may be retained by the department and used to provide medical care and to 

offset expenses related to billing and collections. Thus, CBO estimates that much of the five-year costs of implementing CPACs 

would be offset by the resulting increase in collections; in the initial years implementation costs would exceed the additional collections, but starting in 2012 these collections would exceed the implementation costs. Assuming appropriation of the estimated amounts, 

CBO estimates that implementing CPACs would have net costs of 

$24 million over the 2009–2013 period. 

COPAYMENTS FOR THE CATASTROPHICALLY DISABLED

Section 2 would prohibit the collection of copayments and other 

fees from catastrophically disabled veterans who receive medical or 

nursing home care from VA. Catastrophically disabled veterans are 

those who have a permanent, severely disabling condition that 

compromises their ability to carry out the activities of daily living 

to such a degree that they require assistance to leave their homes 

or require constant supervision to avoid physical harm to themselves or others. 

Data from VA show that, in 2006, the department collected about 

$6 million in medical care and nursing home fees from catastrophically disabled veterans who are priority category 4 veterans because their disabilities are not related to military service. Because 

those copayments and fees are fixed and the population of those 

veterans has been relatively stable over the past several years, 

CBO estimates that implementing this provision would decrease 

collections by $6 million per year. Such collections are offsets to 

discretionary appropriations. As part of the annual appropriations 

process, the Congress gives VA authority to spend those collections. 


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Therefore, maintaining the same level of health care services for 

veterans would necessitate additional funding each year to make 

up for the loss of copayments under this bill. Thus, CBO estimates 

that implementing this provision would cost $30 million over the 

2009–2013 period. 

COUNSELING FOR FAMILY MEMBERS

Section 3 would expand VA’s authority to provide consultations, 

professional counseling, training, and other necessary mental 

health services to the family members or housemates of certain veterans being treated for nonservice-connected conditions. Under current law, such services are only authorized if they began during the 

veteran’s hospitalization and are necessary on an outpatient basis 

to permit the veteran’s discharge from the hospital. The bill would 

strike those restrictions and allow VA to provide such services on 

the same basis to all veterans, regardless of whether the condition 

being treated is service-connected or not. 

In 2007, the VA provided services to about 5,000 family members 

or housemates of roughly 2.15 million veterans (a rate of 0.23 percent) at a cost of about $3 million. Another 2.65 million veterans 

were treated in 2007 for nonservice-connected conditions, but their 

family members or housemates were not eligible for mental health 

services. CBO expects that under the bill, the currently ineligible 

family members or housemates would require such services at the 

same rate they are being provided to those who are currently eligible. 

After adjusting for inflation and growth in the number of veterans requiring treatment, CBO estimates that under the bill VA 

would provide mental health services to an additional 6,700 people 

a year at an annual cost of almost $5 million, on average, over the 

2009–2013 period. CBO estimates that implementing this provision would cost $23 million over the 2009–2013 period, assuming appropriation of the estimated amounts. 

COMPREHENSIVE POLICY ON PAIN MANAGEMENT

Section 4 would require VA to develop and implement a comprehensive policy on pain care at all VA health care facilities, 

under which VA would assess and appropriately treat acute and 

chronic pain. The department also would be required to make annual reports on the policy to the Congress. VA reports that it has 

implemented appropriate pain assessment and management protocols at its medical facilities. Thus, CBO estimates that implementing the provision would cost less than $500,000 over the 

2009–2013 period for the production of annual reports, assuming 

availability of appropriated amounts. 

Intergovernmental and private-sector impact: H.R. 6445 contains 

no intergovernmental or private-sector mandates as defined in 

UMRA and would impose no costs on state, local, or tribal governments. 

Previous CBO estimate: On January 15, 2008, CBO transmitted 

a cost estimate for S. 2160 as ordered reported by the Senate Committee on Veterans’ Affairs on November 14, 2007. Section 3 of that 

bill is similar to section 4 of H.R. 6445 and CBO estimated it would 

have no costs, but the House bill would impose reporting requirements that CBO estimates would have small annual costs. 


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On August 23, 2007, CBO transmitted a cost estimate for S. 1233 

as ordered reported by the Senate Committee on Veterans’ Affairs 

on June 27, 2007. Section 303 of that bill is similar to section 2 of 

H.R. 6445. Their estimated costs over a five-year period are identical, except that CBO assumes a later enactment date for H.R. 

6445. 

Estimate prepared by: Federal Costs: Sunita D’Monte and Alexis 

Miller; Impact on State, Local, and Tribal Governments: Lisa Ramirez-Branum; Impact on the Private Sector: Daniel Frisk. 

Estimate approved by: Theresa Gullo, Deputy Assistant Director 

for Budget Analysis. 

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimate of Federal mandates regarding H.R. 6445 prepared by the Director of the Congressional Budget Office pursuant to section 423 of the Unfunded Mandates Reform Act. 

ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the 

Federal Advisory Committee Act would be created by H.R. 6445. 

CONSTITUTIONAL AUTHORITY STATEMENT

Pursuant to clause 3(d)(1) of rule XIII of the Rules of the House 

of Representatives, the Committee finds that the Constitutional authority for H.R. 6445 is provided by Article I, section 8 of the Constitution of the United States. 

APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that the legislation does not relate to the 

terms and conditions of employment or access to public services or 

accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Short title 

This section would provide the short title of H.R. 6445 as the ‘‘Veterans’ Health Care Policy Enhancement Act of 2008.’’

Section 2. Prohibition on collection of certain copayments from veterans who are catastrophically disabled 

This section would add a new subsection to section 1710 of chapter 17 of title 38, United States Code, which would prohibit the VA 

from collecting copayments from veterans who are non-service connected catastrophically disabled (Priority Group 4) for hospital and 

nursing home care. 

Section 3. Expansion of authority of Secretary of Veterans Affairs to 

provide counseling for family members of veterans receiving 

non-service-connected treatment 

This section would repeal the requirement currently in subsection (b) of section 1782, United States Code, that in order for 

family members of non-service-connected veterans to be eligible for 


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counseling services, the counseling must be essential to permit the 

discharge of the veteran from the hospital. 

Section 4. Comprehensive policy on pain management 

This section would direct the VA to develop and implement a 

comprehensive policy on the management of pain experienced by 

veterans enrolled for health care services provided by the VA. It 

further directs the VA to revise the policy on a periodic basis in accordance with experience and evolving best practice guidelines. The 

VA should develop and revise the policy in consultation with veterans service organizations and other organizations with expertise 

in the assessment, diagnosis, treatment, and management of pain. 

In addition, this section requires the VA to submit a report on the 

implementation of the policy to the Committee not later than 180 

days after the date of the completion and initial implementation of 

the policy and on October 1 of every fiscal year thereafter through 

fiscal year 2018. 

Section 5. Establishment of consolidated patient accounting centers 

This section would add a new section, 1729B to title 38, United 

States Code, which would require the VA to establish not more 

than seven consolidated patient accounting centers for conducting 

industry-modeled regionalized billing and collection activities not 

later than 5 years after the enactment of this act. 

Section 6. Simplifying and updating national standards to encourage testing of the Human Immunodeficiency Virus 

This section would repeal section 124 of the Veterans’ Benefits 

and Services Act of 1988 (Public Law 100–322) to remove the requirement for written informed consent for HIV testing among veterans. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, 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, UNITED STATES CODE 

* * * * * * * 

PART II—GENERAL BENEFITS 

* * * * * * * 

CHAPTER 17—HOSPITAL, NURSING HOME, 

DOMICILIARY, AND MEDICAL CARE 

SUBCHAPTER I—GENERAL 

Sec. 

1701. Definitions. 

* * * * * * * 


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SUBCHAPTER III—MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL 

AND NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS 

* * * * * * * 

1729B. Consolidated patient accounting centers. 

* * * * * * * 

SUBCHAPTER II—HOSPITAL, NURSING HOME, OR 

DOMICILIARY CARE AND MEDICAL TREATMENT 

§ 1710. Eligibility for hospital, nursing home, and domiciliary care 

(a) * * * 

* * * * * * * 

(h) Notwithstanding any other provision of this section, a veteran 

who is catastrophically disabled shall not be required to make any 

payment otherwise required under subsection (f) or (g) for the receipt 

of hospital care or nursing home care under this section. 

ø(h)¿ (i) Nothing in this section requires the Secretary to furnish 

care to a veteran to whom another agency of Federal, State, or 

local government has a duty under law to provide care in an institution of such government. 

* * * * * * * 

SUBCHAPTER III—MISCELLANEOUS PROVISIONS RELATING 

TO HOSPITAL AND NURSING HOME CARE AND MEDICAL 

TREATMENT OF VETERANS 

* * * * * * * 

§ 1729B. Consolidated patient accounting centers 

(a) IN GENERAL.—Not later than 5 years after the date of enactment of this section, the Secretary of Veterans Affairs shall establish 

not more than seven consolidated patient accounting centers for conducting industry-modeled regionalized billing and collection activities of the Department. 

(b) FUNCTIONS.—The centers shall carry out the following functions: 

(1) Reengineer and integrate all business processes of the revenue cycle of the Department. 

(2) Standardize and coordinate all activities of the Department related to the revenue cycle for all health care services furnished to veterans for nonservice-connected medical conditions. 

(3) Apply commercial industry standards for measures of access, timeliness, and performance metrics with respect to revenue enhancement of the Department. 

(4) Apply other requirements with respect to such revenue 

cycle improvement as the Secretary may specify. 

* * * * * * * 

SUBCHAPTER VIII—HEALTH CARE OF PERSONS OTHER 

THAN VETERANS 

* * * * * * * 


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§ 1782. Counseling, training, and mental health services for 

immediate family members 

(a) * * * 

(b) COUNSELING FOR FAMILY MEMBERS OF VETERANS RECEIVING

NON-SERVICE-CONNECTED TREATMENT.—In the case of a veteran 

who is eligible to receive treatment for a non-service-connected disability under the conditions described in paragraph (1), (2), or (3) 

of section 1710(a) of this title, the Secretary may, in the discretion 

of the Secretary, provide to individuals described in subsection (c) 

such consultation, professional counseling, training, and mental 

health services as are necessary in connection with that treatment 

øif—

ø(1) those services were initiated during the veteran’s hospitalization; and 

ø(2) the continued provision of those services on an outpatient basis is essential to permit the discharge of the veteran 

from the hospital¿. 

* * * * * * * 

VETERANS’ BENEFITS AND SERVICES ACT OF 1988 

SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

(a) * * * 

(b) TABLE OF CONTENTS.—The table of contents for this Act is as 

follows: 

Sec. 1. Short title; table of contents. 

* * * * * * * 

øSec. 124. Restriction on testing for infection with the human immunodeficiency 

virus.¿ 

* * * * * * * 

TITLE I—HEALTH-CARE PROGRAMS 

* * * * * * * 

PART C—MATTERS RELATING TO AIDS 

* * * * * * * 

øSEC. 124. RESTRICTION ON TESTING FOR INFECTION WITH THE 

HUMAN IMMUNODEFICIENCY VIRUS. 

ø(a) GENERAL RULE.—Except as provided in subsection (b), the 

Secretary of Veterans Affairs may not during any fiscal year conduct a widespread testing program to determine infection of humans with the human immunodeficiency virus unless funds have 

been appropriated to the Department of Veterans Affairs Department of Veterans Affairs specifically for such a program during 

that fiscal year. 

ø(b) VOLUNTARY TESTING.—(1) The Secretary shall provide for a 

program under which the Department of Veterans Affairs offers 

each patient to whom the Department is furnishing health care or 

services and who is described in paragraph (2) the opportunity to 

be tested to determine whether such patient is infected with the 

human immunodeficiency virus. 

ø(2) Patients referred to in paragraph (1) are—


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ø(A) patients who are receiving treatment for intravenous 

drug abuse, 

ø(B) patients who are receiving treatment for a disease associated with the human immunodeficiency virus, and 

ø(C) patients who are otherwise at high risk for infection 

with such virus. 

ø(3) Subject to the consent requirement in paragraph (4) and unless medically contraindicated, the test shall be administered to 

each patient requesting to be tested for infection with such virus. 

ø(4) A test may not be conducted under this subsection without 

the prior informed and separate written consent of the patient tested. The Secretary shall provide pre- and post-test counseling regarding the acquired immune deficiency syndrome and the test to 

each patient who is administered the test.¿ 

* * * * * * * 

Æ 


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