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[Senate Report 111-175]
[From the U.S. Government Publishing Office]

                                                       Calendar No. 360
111th Congress                                                   Report
                                 SENATE
 2d Session                                                     111-175

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

 
  HOMELESS VETERANS AND OTHER VETERANS HEALTH CARE AUTHORITIES OF 2010

                                _______
                                

                 April 29, 2010.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                         [To accompany S. 1237]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (S. 1237), to 
amend title 38, United States Code, to expand the grant program 
for homeless veterans with special needs to include male 
homeless veterans with minor dependents and to establish a 
grant program for reintegration of homeless women veterans and 
homeless veterans with children, and for other purposes, 
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 June 9, 2009, Senator Murray introduced S. 1237, the 
proposed ``Homeless Women Veterans and Homeless Veterans with 
Children Act of 2009.'' S. 1237, as introduced, would expand 
the grant program for homeless veterans with special needs to 
include male homeless veterans with minor dependents and would 
establish a grant program for reintegration of homeless women 
veterans and homeless veterans with children. Senators Baucus, 
Byrd, Johnson, Merkley, Reed and Specter are cosponsors.
    Earlier, on May 21, 2009, Senator Collins introduced 
S. 1155, to amend title 38, United States Code (hereinafter 
``U.S.C.''), to establish the position of Director of Physician 
Assistant Services within the office of the Under Secretary of 
Veterans Affairs for Health. Senators Burris, Feingold, Harkin, 
Inouye and Tester are cosponsors.
    On June 8, 2009, Senator Murray introduced S. 1204, the 
proposed ``Chiropractic Care Available to All Veterans Act of 
2009.'' S. 1204 would amend the Department of Veterans Affairs 
Health Care Programs Enhancement Act of 2001 to require the 
provision of chiropractic care and services to veterans at all 
Department of Veterans Affairs medical centers. Senators 
Begich, Brown, Brownback, Burris, Grassley, Isakson, Lincoln, 
and Whitehouse are cosponsors.
    On June 18, 2009, Senator McConnell introduced S. 1302, the 
proposed ``Veterans Health Care Improvement Act of 2009.'' This 
bill would provide for the introduction of pay-for-performance 
compensation mechanisms into contracts of the Department of 
Veterans Affairs with community-based outpatient clinics for 
the provision of health care services.
    On July 9, 2009, Senator Wyden introduced S. 1427, the 
proposed ``Department of Veterans Affairs Hospital Quality 
Report Card Act of 2009.'' S. 1427 would establish a Hospital 
Quality Report Card Initiative to report on health care quality 
in Department of Veterans Affairs Medical Centers. Senator 
Johanns is a cosponsor.
    On July 21, 2009, Senator Klobuchar introduced S. 1483, to 
designate the Department of Veterans Affairs outpatient clinic 
in Alexandria, Minnesota, as the ``Max J. Beilke Department of 
Veterans Affairs Outpatient Clinic.'' Senator Franken is a 
cosponsor.
    On July 29, 2009, Senator Pryor introduced S. 1531, the 
proposed ``Department of Veterans Affairs Reorganization Act of 
2009.'' S. 1531 would establish within the Department of 
Veterans Affairs the position of Assistant Secretary for 
Acquisition, Logistics, and Construction.
    On July 30, 2009, Senator Reed introduced S. 1547, the 
proposed ``Zero Tolerance for Veterans Homelessness Act of 
2009.'' S. 1547 would enhance and expand the assistance 
provided by the Department of Veterans Affairs and the 
Department of Housing and Urban Development to homeless 
veterans and veterans at risk of homelessness. Senators Baucus, 
Begich, Bond, Burris, Byrd, Cantwell, Durbin, Johnson, Kerry, 
Lautenberg, Leahy, Lincoln, Merkley, Mikulski, Murray, Specter, 
Tester, Udall of New Mexico, and Whitehouse are cosponsors.
    On October 14, 2009, Senator Bayh introduced S. 1779, the 
proposed ``Health Care for Veterans Exposed to Chemical Hazards 
Act of 2009.'' S. 1779 would provide health care to veterans 
exposed in the line of duty to occupational and environmental 
health chemical hazards. Senators Byrd, Dorgan, Lugar, Merkley, 
Rockefeller, Specter, and Wyden are cosponsors.
    On October 21, 2009, the Committee held a hearing on the 
above referenced bills and other pending health and benefits 
legislation. Testimony was offered by: Gerald M. Cross, MD, 
FAAFP, Acting Under Secretary for Health, Veterans Health 
Administration, Department of Veterans Affairs; Robert Jackson, 
Assistant Director, National Legislative Service, Veterans of 
Foreign Wars; Ian de Planque, Assistant Director for Claims 
Service, The American Legion; John Driscoll, President and CEO, 
National Coalition for Homeless Veterans; Rick McMichael, DC, 
President, American Chiropractic Association; and William Fenn, 
Ph.D., PA, Vice President, American Academy of Physician 
Assistants.

                           Committee Meeting

    After carefully reviewing the testimony from the forgoing 
hearing, the Committee met in open session on January 28, 2010, 
to consider, among other legislation, an amended version of 
S. 1237, consisting of S. 1237 as introduced, provisions 
derived from other legislation noted above, and freestanding 
provisions adopted as amendments at the Committee meeting. The 
Committee voted unanimously to report favorably S. 1237, as 
amended.

                     Summary of S. 1237 as Reported

    S. 1237, as reported (hereinafter, ``the Committee bill''), 
would provide for enhancements to services for homeless 
veterans, make expansions to the Department of Veterans Affairs 
(hereinafter, ``VA'') health care and services and would amend 
the title of the original bill.

                   TITLE I--HOMELESS VETERANS MATTERS

    Section 101 would enhance VA's homeless veterans' 
Comprehensive Services Program by broadening the pool of 
potential applicants to those who propose to use mixed 
financing to provide supportive housing.
    Section 102 would establish a grant program for 
reintegration of homeless women veterans and homeless veterans 
with children into the labor force.
    Section 103 would expand the number of eligible providers 
of programs for homeless veterans with special needs and for 
purposes of eligibility, classify male homeless veterans with 
minor dependants as homeless veterans with special needs
    Section 104 would establish a program within VA to prevent 
veteran homelessness.
    Section 105 would require VA, the Department of Housing and 
Urban Development (hereinafter, ``HUD'') and the Interagency 
Council on Homelessness to establish a method for accurately 
counting the number of homeless veterans nationwide, as well as 
tracking demographic information and type of assistance 
received.
    Section 106 would authorize the phase-in of up to 60,000 
HUD and VA Supported Housing Program (hereinafter, ``HUD-
VASH'') vouchers by 2013 and describe the types of help VA case 
managers are expected to provide homeless veterans receiving 
rental assistance.
    Section 107 would create the position of Special Assistant 
for Veterans Affairs within HUD who would ensure that veterans 
have access to HUD's housing and homelessness assistance 
programs and also serve as a liaison with VA.
    Section 108 would require the Secretary of VA to develop a 
comprehensive plan within one year of the bill's enactment for 
ending homelessness among veterans.

                  TITLE II--TOXIC SUBSTANCES EXPOSURE

    Section 201 would extend eligibility to health care for 
veterans with disabilities who served in the Persian Gulf War.

                     TITLE III--HEALTH CARE MATTERS

    Section 301 would establish within VA an Assistant 
Secretary for Acquisition, Logistics, and Construction and 
increase the authorized number of Deputy Assistant Secretaries.
    Section 302 would establish a Director of Physician 
Assistant Services within the Veterans Health Administration 
(hereinafter, ``VHA") Office of Patient Care Services.
    Section 303 would require VA to establish a Medical Center 
Report Card to ensure public view of performance comparisons 
between VA facilities and between VA and non-VA sites.
    Section 304 would require VA to submit to Congress a report 
on the advisability and feasibility of pay-for-performance 
mechanisms in VA health care contracts at Community Based 
Outpatient Clinics (hereinafter ``CBOCs'').
    Section 305 would direct VA to enable State veterans' homes 
to admit parents who had a child die while serving in the Armed 
Forces.
    Section 306 would provide for the automatic enrollment of 
eligible demobilizing members of the National Guard and Reserve 
in health care and dental care programs of the Department of 
Veterans Affairs.
    Section 307 would require VA to develop, implement, and 
fund a comprehensive policy on the provision of chiropractic 
services.
    Section 308 would designate the VA outpatient clinic in 
Alexandria, Minnesota, as the ``Max J. Beilke Department of 
Veterans Affairs Outpatient Clinic.''

                        TITLE IV--OTHER MATTERS

    Section 401 would direct unobligated funds appropriated for 
medical services in fiscal years 2009 and 2010 and carried over 
into subsequent fiscal years to be available for purposes of 
carrying out provisions contained in the Committee bill.

                       Background and Discussion

                   TITLE I--HOMELESS VETERANS MATTERS

Sec. 101. Enhancement of comprehensive service programs.

    Section 101 of the Committee bill, which is derived from 
S. 1547, would enhance VA's homeless veterans' Comprehensive 
Service Programs by broadening the pool of potential applicants 
for that program to those entities who propose to use mixed 
financing to provide supportive housing and make other changes 
designed to improve the overall program.
    Background. Public Law 102-590, the Homeless Veterans 
Comprehensive Service Programs Act of 1992, established VA's 
Homeless Providers Grant and Per Diem Program (hereinafter, 
``GPD.'') The purpose of the grant program was to assist public 
and nonprofit private entities in establishing new programs and 
service centers to furnish supportive services and housing for 
homeless veterans through grants that may be used to acquire, 
renovate or alter facilities. The purpose of the per diem 
program was to provide per diem payments, or in-kind assistance 
in lieu of per diem payments, to eligible entities which 
established programs after November 10, 1992, that provide 
supportive services and housing for homeless veterans.
    Over the years since it was established, the GPD has 
changed as more is learned about the needs of homeless 
veterans. In testimony before the Committee on October 21, 
2009, the National Coalition for Homeless Veterans stated that, 
``[f]or years service providers have suggested a system that 
reflects the actual cost of providing services to veterans with 
multiple barriers to recovery rather than a `per diem' rate 
based on reimbursements paid to state veterans' homes.'' They 
believe that, as successful as the GPD has been, it would be 
more so with less restrictions.
    Section 2011 of title 38 sets forth the authority, 
criteria, and various requirements for VA's grant program so as 
to achieve its intended purpose to furnish and expand or modify 
existing programs for furnishing, outreach, rehabilitation 
services, vocational counseling and training, and transitional 
housing assistance for homeless veterans. The law requires the 
Secretary to establish criteria and requirements for grants 
awarded under this section. Eligible entities for these grants 
are restricted to public or nonprofit private entities with the 
capacity to administer the grant effectively. An eligible 
entity must also demonstrate that adequate financial support 
will be available to carry out the project for which the grants 
is sought consistent with the plans, specifications, and 
schedule submitted by the applicant. An eligible entity must 
also agree to meet, as well as have the capacity to meet, the 
applicable criteria and requirements established by the 
Secretary. Currently, the specifications as to the kinds of 
projects for which the grants are available do not include new 
construction of facilities. In addition, the grants may not be 
used to support operational costs and the amount of the grant 
may not exceed 65 percent of the estimated cost of the project 
concerned.
    VA's Advisory Committee on Homeless Veterans (hereinafter, 
``Advisory Committee'') established pursuant to section 2066 of 
title 38, provides advice and makes recommendations to the 
Secretary of VA on the provision of benefits and services to 
homeless veterans. In the Advisory Committee's 2005 Report, it 
first recommended that the authorization for appropriations for 
the GPD be increased to $200 million. Although that amount has 
been increased over the last five years and currently is $150 
million, raising the amount to $200 million would better allow 
for continued growth in the program. The GPD has proven to be a 
vital part of VA's services for homeless veterans. In response 
to this Advisory Committee recommendation, VA stated that it 
believes that increased funding for GPD ``should be deliberate 
and systematic to provide the support systems and 
administration infrastructure that are necessary to manage the 
program with appropriate levels of oversight and assurance of 
quality of care.''
    Committee Bill. Section 101 of the Committee bill would 
amend subchapter II of chapter 20 of title 38 to make a number 
of improvements. It would amend section 2011(b)(1)(A), the 
provision which sets forth the criteria for grants, to include 
new construction of facilities as a type of program for which 
the grants are available. It would amend section 2011(c), the 
provision which sets forth funding limitations on grantees so 
as to specify that the Secretary may not deny an application 
from an entity under this program solely on the basis that the 
entity proposes to use other funding sources as long as such 
entity has oversight and site control over the project. In 
connection with this change, the Committee bill would add a 
definition of a ``private nonprofit organization.'' It is the 
Committee's expectation that these changes will modernize the 
GPD to allow for the utilization of innovative project funding 
strategies--including the use of low-income housing tax credits 
and matching funds from other government sources to facilitate 
and hasten project development.
    With respect to the issue of the per diem payments, the 
Committee bill, in a freestanding provision, would require the 
Secretary of VA to study the method of reimbursing GPD 
community providers for their program expenses and report to 
Congress, within one year, VA's recommendations for revising 
the payment system. The Committee believes that since VA plans 
to continue to develop the GPD, long term commitment to funding 
and modifying the program appropriately is critical to service 
providers and the veterans they assist. As these programs are 
improved and increased, VA needs to look more closely at the 
effectiveness of how it makes payments and reimbursements and 
to whom reimbursements are made.
    The Committee bill would amend section 2013 of title 38 by 
increasing the annual GPD authorization to $200 million in FY 
2010 and to such sums as necessary for each of fiscal years 
2011 through 2014. The Committee believes this will help VA's 
goal to assist every eligible homeless veteran willing to 
accept services.
    Finally, the Committee bill would require the Secretary to 
ensure that not less than five percent of the aggregate of the 
grant amounts awarded under section 2011 of title 38 is awarded 
to eligible entities located in rural areas. While the issues 
of homeless tend to be associated with urban areas, the 
Committee believes that it is important to address the needs of 
veterans who may live in very rural or remote areas and are at 
risk of homelessness.

Sec. 102. Grant program for workforce reintegration of homeless women 
        veterans and homeless veterans with children.

    Section 102 of the Committee bill, which is derived from 
S. 1237, would establish a grant program for reintegration of 
homeless women veterans and homeless veterans with children 
into the labor force.
    Background. Women veterans represent an increasing 
proportion of the total veteran population. The percentage of 
women veterans is nearing eight percent and expected to rise 
substantially over the next two decades. While VA is an 
institution originally designed for and focused on serving male 
veterans, the significant increase in the number of women 
veterans indicate a crucial need for VA to adapt its programs 
to address this new demographic. For example, although the 
majority of homeless veterans programs are designed for male 
veterans, more than five percent of veterans requesting 
assistance from VA and community-based homeless veteran service 
providers are women. More than 10 percent of these women have 
dependent children. In addition, there are reports of a 
significant number of male homeless veterans who have dependent 
children as well.
    Currently, under section 2021 of title 38, the Secretary of 
Labor is required to conduct, directly or through grant or 
contract, Homeless Veterans Reintegration Programs (hereinafter 
``HVRP''). These are programs the Secretary determines are 
appropriate to provide job training, counseling, and placement 
services (including job readiness, literacy and skills 
training) to expedite the reintegration of homeless veterans 
into the labor force. HVRP is administered through the 
Assistant Secretary of Labor for Veterans' Employment and 
Training (hereinafter ``VETS''.) Since women veterans have 
represented a very small percentage of the veteran population 
for decades, most of the current programs are designed for and 
provide services to male homeless veterans. The Committee's 
intent is to increase the availability of programs which focus 
efforts toward the growing and underserved populations of women 
veterans and veterans with dependent children.
    Committee Bill. Section 102 of the Committee bill would 
amend Subchapter III of chapter 20 of title 38 by adding a new 
section 2021A, entitled ``Grant program for the reintegration 
of homeless women veterans and homeless veterans with 
children.'' This grant program would differ from the current 
HVRP grants in that it would be strictly a grant program and 
would focus specifically on providing services that will assist 
in the reintegration into the labor force of homeless women 
veterans and homeless veterans with children. Like the current 
HVRP grants, services under this new grant program would 
include job training, counseling, and job placement services, 
including job readiness, literacy, and skills training. 
Importantly, it would also include child care services to serve 
most effectively the target population.
    This new grant program would also be administered through 
the Assistant Secretary of VETS and would require that 
information be collected which is appropriate to monitor and 
evaluate the use of the amounts granted, including data on 
results or outcomes of the services provided to each homeless 
veteran under the new program. The Committee believes that 
monitoring the program in this way will provide proper feedback 
to ensure the program is accomplishing its intent or identify 
unforeseen issues that may require alterations to the program.
    While homelessness is often associated with urban areas, 
there are homeless veterans in rural areas as well. With the 
increased number of National Guard and Reserve members 
deploying as part of Operation Enduring Freedom/Operation Iraqi 
Freedom (hereinafter ``OEF/OIF'') which subsequently qualifies 
them for veteran status, the number of rural veterans is 
increasing. In order to ensure that this population has access 
to homeless veterans programs, section 102 would further 
require that at least five percent of the aggregate of the 
grant amounts awarded under this new grant program in each 
fiscal year be awarded to eligible programs and facilities 
located in rural areas.
    Section 102 would authorize appropriations of $10 million 
for each of fiscal years 2010 through 2014 for this new 
program. This amount would be in addition to any amounts 
authorized to be appropriated for the current programs under 
section 2021. The funds appropriated to carry out this new 
grant program would remain available until expended and funds 
obligated in any fiscal year to carry out this program would be 
able to be expended in that fiscal year or the succeeding 
fiscal year.
    Section 2012(d) of existing title 38 requires the Secretary 
of Labor to submit a report to Congress every two years on the 
progress of the programs conducted under section 2021. Section 
102 of the Committee bill would require that report to include 
an evaluation of this new grant program for the reintegration 
of homeless women veterans and homeless veterans with children. 
This section of the report would also be required to include an 
evaluation of the services furnished to homeless women veterans 
and homeless veterans with children, as well as an analysis of 
the information collected and used to monitor the program 
mentioned. The Committee believes that this feedback will be 
helpful in determining if this grant program is meeting its 
purpose and will be helpful to identify trends as changes occur 
in the demographics of the homeless veteran population.

Sec. 103. Expansion of grant program for homeless veterans with special 
        needs.

    Section 103 of the Committee bill, which is derived from 
S. 1237, would expand the number of eligible providers of 
programs for homeless veterans with special needs and include 
male homeless veterans who have care of minor dependants as 
homeless veterans with special needs.
    Background. Under section 2061 of title 38, VA operates a 
program of grants to encourage development of programs for 
homeless veterans with special needs. Current law provides that 
these special needs grants can only be awarded to VA health 
care facilities and to providers receiving grant and per diem 
payments under VA's Comprehensive Service Programs. Homeless 
veterans with special needs eligible for these programs are 
defined as homeless veterans who are 1) women, including women 
who have care of minor dependents; 2) frail elderly; 3) 
terminally ill; or 4) chronically mentally ill.
    Committee Bill. Subsection 103(a) of the Committee bill 
would expand the number of eligible providers who may receive 
VA grants for programs to assist homeless veterans with special 
needs to those entities eligible to receive grant and per diem 
payments, but who may not be doing so. Thus, these grants would 
no longer be limited to existing VA health care facilities and 
current grant and per diem providers, but will allow those 
eligible but not in receipt of grant and per diem payments to 
apply to the grant program for homeless veterans with special 
needs.
    Subsection 103(b) would expand the definition of homeless 
veterans with special needs to include veterans who have care 
of minor dependents as well regardless of gender.

Sec. 104. Program on prevention of veteran homelessness.

    Subsection 104 of the Committee bill, which is derived from 
S. 1547, would require the Secretary of VA to establish a 
program to prevent veteran homelessness.
    Background. In January 2010, VA estimated that 131,000 
veterans were homeless on any given night. In March 2010, this 
estimate was revised downward to 107,000, although perhaps 
twice as many experience homelessness at some point during the 
course of a year. In addition, statistics show that about one-
third of the adult homeless population has served their country 
in the armed services. This means that veterans are often at 
greater risk of becoming homeless. Some commentators suggest 
that some reasons for this may be that when they leave the 
military, they discover that the skills they have honed in 
their military service can be difficult to transfer to jobs in 
the private sector. Others may struggle with physical or mental 
wounds of war. Still others return to communities that lack 
safe, affordable housing.
    Committee Bill. Section 104 of the Committee bill would 
amend subchapter VII of chapter 20 of title 38 to add a new 
section 2067, ``Prevention of veteran homelessness.'' This new 
section would create a homelessness prevention program that 
would enable VA to keep at-risk veterans in stable housing and 
offer increased assistance to veterans who have fallen into 
homelessness. Specifically, VA could provide, directly or in 
conjunction with an existing program, short-term rental 
assistance, housing relocation and stabilization services, 
services to resolve personal credit issues, payments for 
security deposits or utility costs, assistance for moving 
costs, and referral services to programs of another department 
or agency of the Federal Government. These up-front expenses 
can be a major obstacle that puts low-income or unemployed 
veterans at risk of becoming homeless. These homelessness 
prevention and rapid re-housing techniques have been 
successfully used in many communities to reduce family 
homelessness significantly. This new authority would give VA 
the opportunity to put these strategies into practice to assist 
veterans who have been identified as homeless or are at 
imminent risk of becoming homeless.
    It is not the Committee's intent to duplicate available 
services that are already effective and successful or to permit 
a veteran to ``double dip'' by receiving the same assistance 
from a variety of sources. The language of this section would 
require the Secretary of VA to provide assistance only to the 
extent that it is not duplicating a supportive service provided 
to the veteran by an eligible entity receiving financial 
assistance under section 2044 of title 38 or by any other 
Federal, State, or local entity.
    The program established by this section is also not 
intended to be long term support for the veterans identified as 
homeless or those who are at imminent risk of becoming 
homeless. Likewise, it should not be viewed as a slush fund for 
these veterans. It is the Committee's intent to give the 
Secretary the authority to protect the program from abuse by 
allowing the Secretary to establish a limit on the number of 
times that a particular veteran may receive assistance under 
the program within a fiscal year.
    The Committee bill would authorize $50,000,000 to be 
appropriated to carry out this program for each of fiscal years 
2010 through 2014. It would also add this new program to the 
oversight and coordination responsibilities of the homeless 
veterans program coordinators under Section 2003(a) of title 
38.
    Not later than 180 days after the date of establishment of 
this program, the Secretary of VA would be required to submit a 
report on its operation to the Congress. This report would be 
required to include the types and sources of assistance 
provided under the program, as well as an assessment of the 
effectiveness of the services provided. This would allow 
Congress to determine the effectiveness of the program and 
evaluate the need for any necessary changes.

Sec. 105. Homeless Veterans Management Information System.

    Section 105 of the Committee bill, which is derived from 
S. 1547, would require VA, HUD, and the Interagency Council on 
Homelessness to establish a method for accurately counting the 
number of homeless veterans nationwide, as well as tracking 
demographic information and type of assistance received.
    Background. According to the annual VA Community 
Homelessness Assessment, Local Education, and Networking Groups 
Reports, approximately 131,000 veterans are homeless on any 
given night. However, this is an estimate. There have been few 
systematic, national efforts to count the homeless and 
particularly the number of homeless veterans. In 1996, the 
National Survey of Homeless Assistance Providers and Clients 
estimated that veterans comprised 23 percent of the homeless 
population. In 2005, HUD began organizing comprehensive, 
national counts of homeless persons, but does not capture data 
specific to homeless veterans.
    Committee Bill. Section 105 of the Committee bill would 
require the Secretary, in consultation with Special Assistant 
for Veterans Affairs of HUD (as established in Section 107 of 
the Committee bill) and the United States Interagency Council 
on Homelessness, to establish a method for the collection and 
aggregation of data on homeless veterans participating in VA 
and HUD programs. The method for the collection of data would 
be required to ensure that each veteran is only counted once to 
avoid inflation of the number of homeless veterans. The data 
collected would include, among other things, information on 
age, race, sex, disability status, 
marital status, income, employment history, and whether the 
veteran is a parent. These data would be collected and 
aggregated 
annually.
    It is the Committee's intent to establish a method that 
provides accurate data regarding the number of homeless 
veterans nationwide. Having reliable and accurate data assist 
in making better assessments about the need for and 
implementation of comprehensive and supportive services for 
homeless veterans. The Committee does not intend to burden 
homeless program providers with an overwhelming system that 
would capture data about homeless veterans that is redundant 
but rather would incorporate any new data pertaining to 
veterans with data already collected for the greater homeless 
population.

Sec. 106. Rental assistance for veterans through Department of Housing 
        and Urban Development.

    Section 106 of the Committee bill, which is derived from 
S. 1547, would authorize additional housing vouchers through 
the HUD-VASH program.
    Background. HUD-VASH is a cooperative partnership between 
HUD and VA that provides long-term case management, supportive 
services, and permanent housing support for eligible homeless 
veterans. The HUD-VASH program began in 1992 under a memorandum 
of agreement between the two departments. Congress codified the 
HUD-VASH program in Public Law 107-95, the Homeless Veterans 
Comprehensive Assistance Act of 2001. That Act also authorized 
HUD to allocate 500 additional HUD-VASH vouchers in each of 
fiscal years 2003 through 2006. Public Law 109--461, the 
Veterans Benefits, Health Care, and Information Technology Act 
of 2006 authorized HUD to allocate 500 HUD-VASH vouchers in 
fiscal year 2007 and increase the amount in increments of 500 
per fiscal year up to 2,500 in fiscal year 2011.
    The HUD-VASH program is explicitly designed to provide 
permanent supportive housing to the most vulnerable homeless 
veterans. To be eligible, a veteran must be must be homeless, 
eligible for VA health care, and need and participate in case 
management services in order to obtain and sustain permanent 
independent community housing. Eligible homeless veterans 
receive VA provided case management and supportive services to 
promote stability and recovery from physical and mental health, 
substance use, and functional concerns contributing to or 
resulting from of homelessness. The program goals include 
promoting maximal veteran recovery and independence in order to 
enable the veteran and his family to sustain permanent housing 
in the community. The case manager and the veteran set goals 
related to housing, income, employment and treatment with the 
ultimate goal of having the veteran fully reintegrate back into 
the community. To achieve this goal the case manager works on 
employment and educational goals with the veteran so that the 
veteran can be more self sufficient. There is also an annual 
review by the Public Housing Authority (hereinafter, ``PHA'') 
that evaluates income eligibility and, when the veteran exceeds 
income eligibility, both VA and local PHAs assist the veteran 
with transitioning to alternative more independent living 
arrangements.
    Comprehensive evaluation of the HUD-VASH program conducted 
by the Department of Veterans Affairs' Northeast Program 
Evaluation Center found that HUD-VASH significantly reduces 
days of homelessness for veterans with mental and addictive 
disorders, who are among those considered chronically homeless. 
According to an analysis of data by the National Alliance to 
End Homelessness, about 63,000 veterans can be classified as 
chronically homeless. In the efforts to end homelessness among 
veterans, Congress appropriated funding in 2008 and 2009 for, 
and HUD currently provides, 20,000 ``Housing Choice'' Section 8 
vouchers designated for HUD-VASH to participating PHAs to 
assist with rent payment. This influx of HUD-VASH is a good 
start, but it will not meet the needs of all homeless veterans.
    Committee Bill. Section 106 of the Committee bill would 
authorize the phase-in of up to 60,000 HUD-VASH vouchers by 
2013. It would call for not more than 30,000 vouchers for 
rental assistance to be outstanding during FY 2010, not more 
than 40,000 during FY 2011, not more than 50,000 during FY 
2012, and not more than 60,000 during FY 2013 and each fiscal 
year thereafter.
    The Committee bill would define what qualifies as a 
``public housing agency'' and also would require the Secretary 
to ensure homeless veteran case managers provide appropriate 
supportive services. It describes the types of help VA case 
managers would be expected to provide homeless veterans 
receiving rental assistance to include medical care to help to 
achieve an end to chronic homelessness.

Sec. 107. Special Assistant for Veterans Affairs in Office of Secretary 
        of Housing and Urban Development.

    Section 107 of the Committee bill, which is also derived 
from S. 1547, would establish the position of Special Assistant 
for Veterans Affairs within the Office of the Secretary of 
Housing and Urban Development.
    Background. Currently, within HUD's Office of Community 
Planning and Development, the Deputy Assistant Secretary for 
Special Needs oversees efforts to confront the housing and 
service needs of homeless persons, including veterans and their 
families. These efforts include addressing the needs of 
homeless veterans and their families. Homelessness for any 
American is difficult but for an individual who has answered 
the call to duty it is simply unacceptable. There are many 
challenges that veterans face which can lead to homelessness 
such as health concerns, including mental health problems, 
economic issues, and a lack of access to safe housing. HUD 
provides housing and services to homeless veterans through 
HUD's targeted programs for special needs populations, as well 
as through other mainstream HUD resources.
    HUD administers a variety of housing programs that can 
assist veterans. These include the Housing Choice Voucher 
Program, Public Housing, HOME Investment Partnerships, and the 
Community Development Block Grant program. These programs, by 
statute, provide great flexibility so that communities can use 
these federal resources to meet their particular local needs, 
including the needs of their veterans.
    While these efforts are commendable, the Committee believes 
that HUD should have an individual who is responsible for 
addressing the needs of homeless veterans only. This would 
ensure appropriate visibility for the needs of this 
disproportionately large segment of the homeless population.
    Committee Bill. The Committee bill would amend section 3533 
of title 42, U.S.C., to require the Secretary of HUD to appoint 
an individual to be the Special Assistant for Veterans Affairs. 
This individual would be charged with ensuring that veterans 
have access to all housing and homeless assistance offered by 
all programs carried out by HUD. In addition, the new Special 
Assistant would coordinate all programs and activities within 
the agency as they pertain to veterans.

Sec. 108. Plan to end veteran homelessness.

    Section 108 of the Committee bill, which is derived from 
S. 1547, would require the Secretary of Veterans Affairs to 
develop a comprehensive plan within one year of the bill's 
enactment for ending veterans' homelessness.
    Background. At VA's Homeless Veteran Summit: Ending 
Homelessness among Veterans in Five Years, which was held on 
November 3, 2009, Secretary Shinseki announced VA's plans to 
establish new programs and enhance existing successful efforts 
designed to end homelessness among Veterans over the next five 
years. No specifics of the plan were addressed, but many of the 
references made were to programs contained in this Committee 
bill. The Committee believes that reducing the number of 
homeless veterans is going to require efforts made by providers 
on many levels and on many fronts. But more importantly, this 
will require a well thought out plan. There are many entities 
providing services to homeless veterans. Available programs 
need to be identified and assessed so that duplicative services 
are not created and inefficiencies are corrected or eliminated.
    Committee Bill. Section 108 of the Committee bill would 
require the Secretary of VA to submit to Congress a 
comprehensive plan to end homelessness. This plan would include 
an analysis of all Federal Government agencies and department 
level programs which are designed to prevent homelessness among 
veterans and assist those veterans who are homeless. It would 
also include an evaluation of whether and how partnerships 
between these programs contribute to the Secretary's plan to 
end homelessness among veterans. Both this analysis of programs 
and evaluation of partnerships would provide support for 
recommendations for improving the current programs available, 
creating partnerships between such programs, or eliminating 
ineffective programs. If new programs are recommended, they 
should include cost estimates. The Secretary can include any 
other information he feels is necessary. The plan should 
include a time line for its implementation.
    The Committee believes that better articulation of issues 
surrounding the plan to end veteran homelessness in five years 
is called for. At the time of the Committee's January 28, 2010, 
markup, the Administration had yet to submit its views on 
legislation (S. 1547) that was largely incorporated into the 
Committee bill. Also, in response to questions asked at a March 
24, 2010, Committee hearing, a VA witness testified that no 
legislative action was necessary to bring about the Secretary's 
plan to end homelessness among veterans. Finally, the Committee 
has yet to receive answers regarding how the Administration's 
proposed Fiscal Year 2011 budget request for homeless veterans' 
programs is contingent on legislative authorizations under the 
Committee's purview. To better assist in the effort to end 
homelessness among veterans, Congress needs transparency in 
order to avoid advancing duplicative programs and also ensure 
that necessary funding authorizations are enacted. The 
Committee urges the Administration to be more forthcoming on 
these matters going forward.

                  TITLE II--TOXIC SUBSTANCES EXPOSURE

Sec. 201. Extension of eligibility for heath care for veterans with 
        disabilities who served in Persian Gulf War notwithstanding 
        lack of evidence to conclude such disabilities are associated 
        with such service.

    Section 201 of the Committee bill, which is derived from 
S. 1779, would extend eligibility for VA health care until 
December 31, 2012, in the case of certain veterans who served 
in Southwest Asia during the Persian Gulf War.
    Background. Under prior law, VA had been authorized, by 
section 1710 of title 38 to provide health care for a veteran 
for any illness if the veteran served in the Southwest Theater 
of operations during the Persian Gulf War and was exposed to a 
toxic substance, radiation, or other conditions. This authority 
applied even if there was insufficient medical evidence to 
conclude that such illness was attributable to such military 
service. This authority expired on December 31, 2002.
     Since the authority expired, veterans who have been 
exposed to an environmental hazard during military service are 
not eligible for VA health care for a disability which may be 
associated with such exposure, unless they are service-
connected for the disability, apply for VA health care within 
five years of discharge or meet one of the other eligibility 
criteria set forth in section 1710. As a result, some veterans 
who may have been exposed to environmental hazards do not 
currently have access to VA health care for disabilities which 
have not yet been associated with such exposures. This 
potentially includes veterans who provided security at the 
Qarmat Ali water treatment plant in Iraq during the spring and 
summer of 2003. During the Committee's October 8, 2009, hearing 
on VA/DOD response to certain military exposures, Dr. Herman 
Gibbs, an epidemiologist, testified that ``the symptoms 
reported by the soldiers who served at Qarmat Ali are 
consistent with significant exposure to sodium dichromate.''
    Committee Bill. Section 201 of the Committee bill would 
extend eligibility for VA health care for certain veterans who 
served on active duty in the Southwest Asia Theater of 
operations during the Persian Gulf War. Such veterans are those 
who were exposed to a toxic substance, radiation, or other 
occupational or environmental hazards and have disabilities 
which have not been demonstrated to be associated with such 
service.
    Eligibility for health care under this provision would 
begin on the date of enactment of the Committee bill and end on 
December 31, 2012.
    Section 201 would also provide a technical amendment to 
section (a)(2)(F) of section 1710 by deleting the term 
``conditions'' and insert ``occupational or environmental 
hazards'' in order to more clearly reflect the intent of the 
provision. By using the term ``occupational or environmental 
hazards'', the Committee intends that generally accepted 
guidelines such as those of the Department of Defense 
(hereinafter ``DOD'') military exposure guidelines for the 
assessment of the significance of field exposures to 
occupational and environmental health chemical hazards, 
standards promulgated by the Occupational Safety and Health 
Administration or the Environmental Protection Agency would be 
taken into consideration. The Committee believes that the use 
of such terminology is more precise than the term 
``conditions.''

                    TITLE III -- HEALTH CARE MATTERS

Sec. 301. Increase in the number of authorized Assistant Secretaries 
        and Deputy Assistant Secretaries.

    Section 301 of the Committee bill, which is derived from 
S. 1531, would establish the position of Assistant Secretary 
for Acquisition, Logistics, and Construction (hereinafter ``AS/
AL&C'') within VA. 
It would also provide for the establishment of eight additional 
Deputy Assistant Secretary (hereinafter, ``DAS'') positions 
within the Department.
    Background. VA is one of the largest and most multifaceted 
agencies within the federal government. With nearly 250,000 
employees, a budget of over $125 billion, and major facilities 
spread across the country, its operations are complex and 
varied. It has responsibility for delivery of heath care; 
compensation, pension, education, burial and other benefits; 
and memorials for those who have served in uniform.
    By law, all federal agencies are required to have four 
Chief Officers: a Chief Financial Officer (hereinafter, 
``CFO''), a Chief Information Officer, a Chief Human Capital 
Officer, and a Chief Acquisition Officer (hereinafter, 
``CAO''). The CAO position was established most recently by 
title IX of Public Law 108-136, the National Defense 
Authorization Act for Fiscal Year 2004. At the present time, VA 
has designated the Assistant Secretary for Management to serve 
as both the CFO and the CAO.
    The management of acquisition and logistics has evolved 
into a complex and specialized profession with highly 
complicated and sophisticated facets. Both the Government 
Accountability Office (hereinafter, ``GAO'') and VA's Inspector 
General have identified a number of best practices and major 
management challenges that result when responsibilities for 
acquisition and logistics are combined with other duties.
    The GAO specifically identified as a weakness situations 
where the CAO has other duties not related to acquisitions. VA 
remedied this by establishing an Office of Acquisition, 
Logistics, and Construction in October 2008. But VA does not 
have a senior level, assistant secretary to lead that office. 
In an agency of this size, with programs so diverse and in so 
many cases having complex requirements, such as building major 
medical facilities, and purchasing almost 15 billion dollars in 
goods and services annually, the need for an Assistant 
Secretary with an exclusive focus on acquisition is warranted.
    Finally, the number of DAS positions within VA is limited 
by law. Section 308(d)(1) of title 38 provides that the number 
of DAS positions within VA may not exceed 19. As originally 
enacted, the 1989 law establishing VA as a Department--as 
opposed to an agency--provided for 18 DAS positions; in 2002, 
Public Law 107-287 expanded the number of DAS positions by one.
    Over time, VA has found that the number of DAS positions 
capped by law limits the Department's ability to conduct best 
conduct business practices in the 21st century and that more 
DAS positions would support a comprehensive and improved 
mechanism for delivery of services and benefits to our Nation's 
veterans. According to VA, two additional DAS positions would 
be within the newly established AS/AL&C office and five would 
be within the Office of Information and Technology. One DAS 
would support the Office of Asset Enterprise Management.
    Committee Bill. The Committee bill would establish a new 
position for an AS/AL&C within the Department. The Committee 
believes that by creating this new position with primary 
responsibility for acquisition and logistics, the Department 
may be better able to make consistent and sound business 
decisions and would elevate the importance of critical 
functions within the agency.
    In addition, as part of on-going efforts to transform VA 
into a 21st century operation, VA has recently reorganized the 
construction functions within the Department by creating an 
Office of Construction and Facilities Management which at 
present reports directly to the Deputy Secretary. Since a large 
part of the construction process involves acquisition of 
services, consolidating responsibilities for this activity 
under the new AS/AL&C seems to offer an opportunity for better 
management practices and streamlined operations.
    Finally, the Committee bill would increase the maximum 
number of DAS positions within VA from 19 to 27. This would 
give VA more flexibility--and a cost neutral option--to meet 
best practices' needs.

Sec. 302. Establishment of Director of Physician Assistant Services in 
        Veterans Health Administration.

    Section 302 of the Committee bill, which is derived from 
S. 1155, would establish a Director of Physician Assistant 
Services within the VHA Office of Patient Care Services.
    Background. Currently there is a Physician Assistant 
(hereinafter ``PA'') Advisor to the Under Secretary of Health, 
a position that is both part-time and field-based, authorized 
under the Veterans Benefits and Health Care Improvement Act of 
2000, Public Law 106-419. The Physician Assistant Advisor 
reports to the Chief Consultant for Primary Care.
    There are nearly 1,900 PAs presently employed by VA, making 
it the largest single employer of PAs. The American Academy of 
Physician Assistants estimates that in 2008 over 257 million 
patient visits were made to PAs nationally and about 332 
million medications were prescribed or recommended by PAs.
    William Fenn, Vice President of the American Academy of 
Physician Assistants testified before the Committee on October 
21, 2009, that PAs are fully integrated into the health care 
systems of the Armed Forces and nearly all other public and 
private systems. Fenn highlighted that PAs are fully integrated 
into many public and private health care systems in many cases 
due to a Director of PA Services being employed by these 
systems. Such institutions include the Cleveland Clinic, the 
Geisinger Clinic, the University of Texas M.D. Anderson Cancer 
Center, and New Orleans' Ochsner Clinic Foundation. PAs serve 
on the frontlines of Iraq and Afghanistan, providing medical 
care to members of the Armed Forces and at all levels of 
medical facilities in the military. They also play a key role 
in providing medical care in medically underserved communities 
and, in many of these communities, they serve as the only 
health care professional available.
    VA has continually had difficulties recruiting and 
retaining qualified personnel such as physicians and nurses, as 
well as PAs. The Independent Budget (hereinafter, ``IB'') for 
fiscal year 2011, a document co-authored by AMVETS, Disabled 
American Veterans, Paralyzed Veterans of America, and the 
Veterans of Foreign Wars, and supported by numerous other 
veterans service organizations, found a five year average 
turnover rate of PAs of 14 percent, with an average loss of 125 
PAs a year. Additionally, in the final quarter of 2009, there 
was a loss of 98 PAs due to retirements and resignations. Fenn 
also stated in his October 21 testimony that VA is not 
competitive with the private sector for new PA graduates, and 
approximately 40 percent of PAs currently employed by VA are 
eligible for retirement in the next five years. Furthermore, 
according to the IB, although overall PA positions have 
increased in VA by 19 percent over the past 5 years, the 
percentage of mid-level PA providers has declined by 30 
percent.
    Considering the large scope of care provided by PAs, the 
population of PAs in VHA, and that VA is in need of non-
physician care providers to address the growing patient 
population, the Committee believes it is reasonable to afford 
PAs representation comparable to these other groups of 
providers. As such, establishing a full-time PA presence at the 
VA Central Office would both improve recruitment and retention 
of such providers and ensure PAs across all VA facilities are 
properly managed and utilized and providing sufficient and 
quality care to veterans.
    Committee Bill. Section 302 of the Committee bill would 
amend section 7306 (a) of title 38 by inserting a new paragraph 
(9) to establish a Director of Physician Assistant Services 
within the VHA Office of Patient Care Services. The Director of 
Physician Assistant Services would report to the Chief Patient 
Care Services Officer on all matters relating to education and 
training, employment, appropriate utilization, and optimal 
participation of physician assistants within the programs and 
initiatives of VHA, which conforms to the reporting structure 
for most program directors and service chief consultants in the 
VA.
    Subsection (b) of section 302 of the Committee bill would 
require new paragraph (9) of section 7306(a) to be implemented 
no later than 120 days after the date of enactment of the 
legislation.
    The Committee intends that the Director of Physician 
Assistant Services operate under conditions similar to other 
program directors and service chief consultants in VHA, 
including parallel placement within the VA organizational 
structure and parallel pay authority.

Sec. 303. Department of Veterans Affairs Medical Center Quality Report 
        Card Initiative.

    Section 303 of the Committee bill, which is derived from 
S. 1427, would require VA to establish a Medical Center Report 
Card to ensure public view of performance comparisons between 
VA facilities and between VA and non-VA sites.
    Background. VHA issued a Hospital Quality Report Card in 
both 2008 and 2009 in response to the House Appropriations 
Committee Report (No. 110-186) accompanying the Consolidated 
Appropriations Act of 2008 (Public Law 110-161). That report 
card was a facility-level report comprised of quality and 
safety data of VA medical facilities. It detailed the quality 
of care provided in inpatient and outpatient settings and 
within specific patient populations, in addition to patient 
satisfaction and outcomes. Raw data from these reports were 
published online on Data.gov to provide veterans and the 
general public with access to performance data of VA medical 
facilities.
    Committee Bill. Section 303 of the Committee bill would 
amend subchapter I of chapter 17 of title 38 by inserting a new 
section 1706A entitled ``Management of health care: Medical 
Center Quality Report Card Initiative'' which would consist of 
seven subsections.
    Subsection (a) of proposed new section 1706A would require 
the Secretary to establish and implement the Medical Center 
Quality Report Card initiative no later than 18 months after 
the enactment of the Committee bill.
    Subsection (b) of proposed new section 1706A consists of 
the following seven paragraphs as follows:

    Paragraph (1) of subsection (b) has three subparagraphs. 
Subparagraph (A) would require quality and performance data of 
VA facilities to be posted on the Hospital Compare Web site of 
the Centers for Medicare and Medicaid Services, no less 
frequently than twice a year. The parameters for quality would 
include effectiveness, safety, timeliness, efficiency, patient-
centeredness, patient satisfaction, satisfaction of health 
professionals employed at Department medical centers, and the 
equity of care provided to various patient populations.
    Subparagraphs (B) and (C) would require the Secretary to 
include quality measures that are common to the health care 
industry in addition to those listed above and to conduct focus 
groups to identify other sets of data that would be of interest 
to veterans.
    Paragraph (2) of subsection (b) would provide the Secretary 
with flexibility in making data available in order to ensure 
the quality measures reflect quality and safety trends and the 
priorities of veterans' health care. The Secretary would be 
authorized to provide supplemental information to that which is 
required, or information in lieu of the required information, 
as long as the Secretary, 15 days before the date on which the 
information is made public, explains and certifies to the 
Committees on Veterans' Affairs of the Senate and the House of 
Representatives that the additional or substituted information 
is more appropriate.
    Paragraph (3) of subsection (b) would authorize the 
Secretary to make risk adjustments to such quality measures to 
account for differences relating to facility and patient 
characteristics, but would be required to make the unadjusted 
data available as well.
    Paragraph (4) of subsection (b) would authorize the 
Secretary to verify the publication of the data to ensure 
validity and accuracy.
    Paragraph (5) of subsection (b) would require the Secretary 
to disclose the methodology, nature, and scope for the 
publication of the data to any relevant organizations and to 
each Department facility that is the subject of such data, 
prior to making the data available to the public.
    Paragraph (6) of subsection (b) would require the Secretary 
to submit a copy of each set of data made available to the 
public to the Committees on Veterans' Affairs of the Senate and 
the House of Representatives. Also, this data would be required 
to be made available to the public in both electronic and non-
electronic formats and in language that can be understood by 
non-health care professionals and individuals with low-
functional health literacy. The Secretary would be required to 
provide the data in such a form that comparisons can easily be 
made between facilities. The Secretary would also be required 
to develop a way to disseminate the data in a non-electronic 
format to the public upon request.
    Paragraph (7) of subsection (b) would require the Secretary 
to acknowledge in a notice or disclaimer the analytical 
methodologies, limitations on, and appropriate uses of the 
information sources used for the publication of the data.
    Subsection (c) of proposed new section 1706A would require 
the Secretary annually to compare quality measures submitted by 
each Department facility with those submitted in prior years to 
identify possible false or artificial improvements.
    Subsection (d) of proposed new section 1706A would require 
the Secretary to develop and implement safeguards against the 
unauthorized use or dissemination of Department facility data 
and to ensure individually identifiable patient data is not 
released to the public.
    Subsection (e) of proposed new section 1706A would require 
the Secretary to periodically submit a report to Congress on 
the effectiveness of the initiative and, if necessary, a 
description of other measures that could be taken to ensure the 
purposes of the initiative is met. Each report would be 
required to be made available to the public.
    Subsection (f) of proposed new section 1706A defines the 
term ``Department medical center.''
    Subsection (g) of proposed new section 1706A authorizes the 
appropriation of sums as may be necessary to carry out this 
initiative for each fiscal year over the period of 2010 through 
2018.

    The Committee intends for this initiative to build upon 
VHA's current program and create a more comprehensive and 
accessible comparison of quality and performance of VHA 
facilities. The Medical Center Quality Report Card would allow 
for a more thorough comparison between VA facilities and 
between VA and non-VA facilities. The Committee places a high 
priority on quality management in veterans' health care and 
believes this initiative will better assist veterans and 
consumers, health care providers, and policymakers.

Sec. 304. Report on pay-for-performance compensation under health care 
        services contracts.

    Section 304 of the Committee bill, which is derived from 
S. 1302, would require VA to submit to the Committees on 
Veterans' Affairs of the Senate and the House of 
Representatives a report on the advisability and feasibility of 
pay-for-performance mechanisms in VA health care contracts at 
Community Based Outpatient Clinics.
    Background. VA Directive 1663, issued in August 2006, 
allows VA medical centers to purchase non-VA care from 
affiliated medical schools, groups, hospitals, and other 
providers, through contracts or fee-for-service care. These 
contracts are generally allowed when a VA facility cannot 
provide a clinical service; VA cannot recruit a needed 
clinician; it is not in VA's best interest to provide such 
service; only a portion of a clinician's time is needed; it is 
determined that it is necessary to compete with the private 
sector for certain highly paid subspecialists; or it is cost-
effective to share a service or space with another entity 
rather than to develop a capacity within VA.
    Throughout VHA, many VA CBOCs deliver health care on a 
contract-basis. CBOCs typically are associated with VA medical 
centers and refer patients to those facilities when needed. In 
FY 2009, VA operated 783 CBOCs, 206 of which were operated by 
contract.
    Mary A. Curtis, Psychiatric Clinical Nurse Specialist and 
Clinical Application Coordinator at the Boise VA Medical 
Center, testified on behalf of American Federation of 
Government Employees at the September 20, 2009, Committee 
hearing on health care contracts stating that VA contract care 
is over-utilized and under-scrutinized by many VA medical 
facilities in both rural and urban areas. She further commented 
that contract care makes VA less able to control costs, quality 
of care, provider qualifications, and medical privacy, or to 
even ensure care is delivered in a timely manner. She said many 
medical center directors seeking short term fixes for patient 
overloads and staff shortages tend to use contracts without 
considering better options for both veterans and the VA health 
care system.
    The IB for Fiscal Year 2011 supports VA health care 
contracts when VA facilities are not capable of providing 
necessary care to veterans. The IB stated, however, that VA 
does not track such care, its related costs, outcomes, or 
veteran satisfaction levels.
    Committee Bill. Section 304 of the Committee bill would 
require the Secretary to submit a report on pay-for-performance 
compensation mechanisms, where providers are rewarded for 
meeting pre-established targets for delivery of health care 
services, in VA health care contracts at CBOCs. The Committee 
believes that pay-for-performance mechanisms in a workplace 
would allow for employees to attain increased levels of 
compensation by reaching specific targets.
    Subsection (a) would require the Secretary to submit a 
report to the Committees on Veterans' Affairs of the Senate and 
the House of Representatives which would be required to include 
information on VA's use of pay-for-performance mechanisms in 
contracts for health care services at CBOCs. This report would 
be required to be submitted not later than 180 days after the 
enactment of this section of the Committee bill.
    Subsection (b) would outline the elements to be included in 
the report. Such requirements would include an assessment of 
the feasibility and advisability of using pay-for-performance 
compensation mechanisms in VA health care contracts with CBOCs. 
It would also require information on the number of CBOCs 
operating under pay-for-performance compensation mechanisms at 
the date of enactment of this legislation, and the impact this 
mechanism has had in providing incentives to provide high 
quality care and to better ensure patient satisfaction.
    Subsection (c) would require the Secretary to incorporate 
the views and experiences of representatives of at least two 
private health care systems that have utilized pay-for-
performance compensation mechanisms in the operation of medical 
clinics to determine if such mechanisms had an effect on the 
delivery of quality, timely, medical care in the private 
sector.

Sec. 305. Expansion of State home care for parents of veterans who died 
        while serving in the Armed Forces.

    Section 305 of the Committee bill, which is derived from an 
amendment offered by Senator Ensign on July 14, 2009, to the 
National Defense Appropriations Act for FY 2010 [Senate 
Amendment 1521], would direct VA to modify a current regulation 
so as to enable State veterans' homes to admit the parent of a 
child who died while serving in the Armed Forces.
    Background. Under section 51.210 (d) of title 38, Code of 
Federal Regulations (hereinafter CFR), State veterans' homes 
(hereinafter, ``State homes'') must allot at least 75 percent 
of their facility beds to veterans, except for those facilities 
constructed solely with state funds which may allot only 50 
percent of facility beds for veterans. This section also 
requires that all non-veteran residents of State homes must be 
spouses of veterans or parents, all of whose children died 
while serving in the Armed Forces.
    This requirement for parents to have lost all of their 
children in order to be eligible for residency leaves out some 
parents from being able to receive care in State homes. VA 
already provides certain benefits to surviving dependent 
parents of veterans who died during military service or as the 
result of a service-connected disability. Currently, certain 
surviving parents may qualify for Dependency and Indemnity 
Compensation if they are in financial need. Additional amounts 
are payable if the parent is a patient in a nursing home, 
blind, or so significantly disabled or blind to require the 
regular aid and attendance of another person. Parents may also 
be beneficiaries of life insurance policies.
    Committee Bill. Section 305 of the Committee bill would 
direct VA, in administering section 51.210 (d) of title 38, 
CFR, to permit a State home to admit parents, any--but not 
necessarily all--of whose children died while serving in the 
Armed Forces.
    The Committee anticipates the costs of providing this care 
would be negligible. According to a recent survey conducted by 
the National Association of State Veterans Homes, as of 
February 11, 2010, only nine surviving parents were residing in 
State homes across the country. Also, VA pays no per diem for 
surviving spouses or parents of veterans residing in state 
homes. The State homes typically charge such individuals a 
private pay rate. If a surviving spouse or parent receives 
Dependency and Indemnity Compensation, the amount may be 
increased due to the need for nursing home care.

Sec. 306. Automatic enrollment of eligible demobilizing members of the 
        National Guard and Reserve in health care and dental care 
        programs of the Department of Veterans Affairs.

    Section 306 of the Committee bill, which is derived from 
S. 1798, would direct VA and DOD jointly to provide automatic 
enrollment of eligible demobilizing members of the National 
Guard and Reserve in VA's health care and dental care programs.
    Background. Currently, veterans must be enrolled in the VA 
health care system to receive health care benefits in the form 
of the comprehensive Medical Benefits Package. Eligibility for 
enrollment is dependent upon if an individual has ``veteran 
status'' which is defined as having been activated for federal 
duty and subsequently discharged or released from active 
service, under conditions other than dishonorable.
    At present, many members of the National Guard and Reserve 
fail to enroll in the VA health care and dental care programs 
during the demobilization and discharge processes or during the 
subsequent five year window of opportunity for enrollment in 
such programs. DOD's Defense Manpower Data Center reported in 
October 2009 that 1,094,502 OEF/OIF servicemembers have been 
discharged and become eligible for VA health care. More than 46 
percent have sought VA care since 2002 following a cumbersome 
and time consuming enrollment process. The percentage of 
veterans seeking VA care is expected to increase over the next 
five years.
    As discussed in the April 2010 Institute of Medicine 
report, ``Returning Home from Iraq and Afghanistan: Preliminary 
Assessment of Readjustment Needs of Veterans, Service Members, 
and Their Families,'' many OEF/OIF veterans return home with 
psychological wounds that may not manifest until months or 
years after their redeployment. Further, the RAND Corporation's 
2008 study, ``Invisible Wounds of War,'' stressed the 
importance of providing treatment for veterans with mental 
illnesses as early as possible, due to the increased severity 
of such illnesses over time if not treated.
    Committee Bill. Section 306 of the Committee bill, in a 
freestanding provision consisting of nine subsections, would 
direct VA, in consultation and coordination with DOD, to 
provide for the automatic enrollment of eligible demobilizing 
members of the National Guard and Reserve (hereinafter, 
``covered members'') in health care and dental care programs of 
the Department of Veterans Affairs.
    Subsection (a) of section 306 of the Committee bill would 
require the automatic enrollment of covered members in VA 
health care or dental care programs, no later than 180 days 
after the enactment of the legislation. Covered members would 
include any member of a reserve component of the Armed Forces 
who is discharged or released and would be eligible to 
participate in a VA health care and dental care program. This 
automatic enrollment would be required to occur during the 
demobilization process used for National Guard and Reserve 
members.
    Subsection (b) of section 306 of the Committee bill would 
require the provision of assistance in the completion of 
enrollment activities of covered members. Relevant personnel of 
the VHA and Veterans Benefits Administration would be required 
to be assigned to participate in the provision of assistance. 
This assistance would include information about VA programs, 
benefits, and services for which the covered member might be 
eligible and a list of VA medical facilities located within 100 
miles of the residence of the covered member.
    Subsection (c) of section 306 of the Committee bill would 
require VA and DOD, in consultation and coordination with 
appropriate officials of each state such as the Adjutant 
General and State Director of Veterans Affairs, to ensure the 
presence of sufficient personnel at each demobilization and 
discharge event of a covered member for the performance of any 
VA health care and dental care program enrollment activities 
and for any assistance in the performance of such activities, 
not later than 180 days after the enactment of the Committee 
bill.
    Subsection (d) of section 306 of the Committee bill would 
require DOD to ensure that the facilities and other resources 
used for the demobilization and discharge process for covered 
members are adequate for enrollment activities and assistance 
for such enrollment activities, no later than 180 days after 
the enactment of the Committee bill.
    Subsection (e) of section 306 of the Committee bill would 
require that covered members who participate in such enrollment 
activities be provided protections in regard to their privacy 
and personal information.
    Subsection (f) of section 306 of the Committee bill would 
provide any covered member the option to not enroll during the 
automatic enrollment program, as long as such covered member 
provides notice of that decision during the demobilization and 
discharge process.
    Subsection (g) of section 306 of the Committee bill would 
clarify that no covered members are required to participate in 
any VA program, including the health care and dental care 
programs.
    Subsection (h) of section 306 of the Committee bill would 
require VA/DOD reports on the implementation of this section to 
be submitted to the Committees on Veterans' Affairs of the 
Senate and the House of Representatives and the Committees on 
Appropriations of the Senate and the House of Representatives. 
The first report would be required to be submitted not later 
than one year after the enactment of this section of the 
Committee bill and annually thereafter for five years.
    The elements of the report would include a description of 
activities undertaken by VA and an assessment of how such 
activities affected enrollment and participation of covered 
members in VA health care and dental programs. It would also 
include an assessment of the potential impact on the budget and 
demand for services in VA and additional resources needed to 
meet the demand. The report would also require recommendations 
for legislative or administrative action to enhance or further 
facilitate the requirements of this new section.
    It is the Committee's expectation that this section will 
address the concerns of many servicemembers who, upon 
redeployment to the United States, desire to return to their 
families as soon as possible, and who view the VA health care 
registration process as an impediment to their return to 
civilian life. The automatic enrollment of covered members is 
not intended to affect covered members' out-processing time, 
would not force any member to enroll in the VA health care 
system, and would not change existing eligibility criteria. It 
is intended to only ensure that all eligible Guard and Reserve 
members are registered and enrolled in the VA health care 
system to provide a more seamless transition from active duty 
to civilian life. Automatic enrollment is especially important 
as many OEF/OIF veterans return home with psychological wounds 
that may not manifest until months or years after their 
redeployment.

Sec. 307. Provision of chiropractic services to veterans enrolled in 
        health care system of Department of Veterans Affairs.

    Section 307 of the Committee bill, which is derived from 
S. 1204, would require VA to develop, implement, and fund a 
comprehensive policy on the provision of chiropractic services.
    Background. Under the Department of Veterans Affairs Health 
Care Programs Enhancement Act of 2001 (Public Law 107-135), VA 
carries out a program to provide chiropractic services to 
veterans through VA medical centers and clinics. The Secretary 
is required to designate at least one site in each Veterans 
Integrated Service Network (hereinafter ``VISN'') to offer 
chiropractic services. Currently, 36 VA facilities provide such 
services.
    Dr. Rick McMichael, President of the American Chiropractic 
Association, testified before the Committee on October 21, 
2009, in support of expanding VA chiropractic services. He 
stated that a significant majority of the nation's eligible 
veterans continue to be denied access to chiropractic care 
because these services are still not provided at approximately 
120 major VA facilities. Further, according to a VA report 
released in October 2009, nearly 52 percent of OEF/OIF veterans 
who have sought VA health care were treated for musculoskeletal 
ailments. Doctors of chiropractic offer vital expertise in the 
treatment of some of such ailments.
    Committee Bill. Section 307 of the Committee bill would 
require VA to develop and implement a comprehensive policy on 
the provision of chiropractic services by October 1, 2010.
    Subsection (a) of section 307 of the Committee bill would 
require the scope of this policy to include: VA-wide protocols 
for governing referrals and direct access to chiropractic 
services, and governing the scope of practice of chiropractic 
practitioners; the definition of chiropractic services to be 
provided; the assurance of prompt and appropriate chiropractic 
services by VA, when medically appropriate; VA programs of 
education and training of health care personnel on the benefits 
of chiropractic services; and VA programs of patient education 
for veterans suffering from back pain and related disorders. 
The Secretary would also be required, in consultation with 
veterans' service organizations and other relevant 
organizations, to revise such policy on a periodic basis, in 
accordance with evolving best practice guidelines.
    Subsection (b) would require the Secretary to carry out the 
policy on chiropractic services at no less than two locations 
in each VISN and in locations deemed appropriate with respect 
to demand for chiropractic services.
    Subsection (c) would require a report on the implementation 
of the chiropractic services policy no later than 180 days 
after the completion and initial implementation of such policy, 
and on October 1 of every fiscal year thereafter until fiscal 
year 2020, to the Committees on Veterans' Affairs of the Senate 
and the House of Representatives. The report would be required 
to include a description of the policy, the performance 
measures used to determine the effectiveness of such policy, an 
assessment of the adequacy of VA chiropractic services based on 
patient surveys, an assessment of the training provided to VA 
health care personnel in terms of chiropractic services and 
appropriate referrals of patients for such services, an 
assessment of the patient pair care education programs, and the 
number of episodes of chiropractic services (including 
referrals to non-VA providers) granted in the preceding fiscal 
year, by facility.

Sec. 308. Name of Department of Veterans Affairs outpatient clinic, 
        Alexandria, Minnesota.

    Section 308 of the Committee bill, which is derived from 
S. 1483, would rename the Department of Veterans Affairs 
outpatient clinic in Alexandria, Minnesota, as the ``Max J. 
Beilke Department of Veterans Affairs Outpatient Clinic.''
    Background. Max J. Beilke was a native of Alexandria, 
Minnesota. He was drafted into the U.S. Army in 1952 following 
high school. In the Army, Beilke served in Korea and Vietnam. 
He retired from active duty as a master sergeant in 1974. After 
his retirement, Beilke worked on veterans' issues as a DOD 
civilian employee. On September 11, 2001, he was killed in the 
attack on the Pentagon. Beilke was awarded the Defense of 
Freedom Medal and the Meritorious Civilian Service Award.
    Committee Bill. The Committee bill would rename the 
Department of Veterans Affairs outpatient clinic in Alexandria, 
Minnesota as the ``Max J. Beilke Department of Veterans Affairs 
Outpatient Clinic.''

                           TITLE IV--FUNDING

Sec. 401. Funding

    Section 401 of the Committee bill, adopted as an amendment 
at the Committee's January 28, 2010, meeting would require 
funding for the provisions of the Committee bill to be derived 
from certain unobligated funds.
    Background. In any fiscal year, VA's operating budget for 
medical care comes from four principal sources: Congressional 
appropriations; medical collections from VA beneficiaries and 
insurance companies; reimbursements made to VA from certain 
entities; and carryover of any combination of these sources of 
funding from one year to the next. Historically, it is common 
for there to be some amount of money assumed for obligation in 
a year other than which the money was received, however, the 
President's fiscal year 2010 budget submission assumed there 
would be no carryover of unobligated funds for medical services 
appropriated in fiscal year 2009. Despite that assumption, $619 
million was in fact carried over; the President's fiscal year 
2011 budget once again assumes no carryover of unobligated 
funding from fiscal year 2010.
    Although the Committee recognizes that variables such as 
unanticipated demand for health services or deferred spending 
on approved programs may compel VA to use carryover funds at a 
later date, to the extent that such carryover is unanticipated 
or represents a surplus of appropriation, it is important that 
it be properly accounted for and directed to a purpose Congress 
intends.
    Committee Bill. The Committee bill would direct VA to pay 
for the provisions of the bill with any unobligated carryover 
funds appropriated for VA medical services in fiscal year 2009 
or 2010 so long as it does not adversely affect health care 
delivery to veterans.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee based on 
information supplied by the CBO, estimates that implementing 
the bill would cost $3.4 billion over the 2010-2015 period, 
assuming appropriation of the specified and estimated amounts. 
CBO further estimates that enacting the bill would increase 
direct spending by $7 million over the 2010-2020 period but 
would not affect revenues. Enactment of the Committee bill 
would not affect receipts and would not affect the budget of 
state, local or tribal governments.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                               Congressional Budget Office,
                                    Washington, DC, April 28, 2010.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 1237, the Homeless 
Veterans and Other Veterans Health Care Authorities Act of 
2010.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                      Douglas W. Elmendorf,
                                                          Director.

  Enclosure.

S. 1237--Homeless Veterans and Other Veterans Health Care Authorities 
        Act of 2010

    Summary: S. 1237 would expand programs for homeless 
veterans, and make other changes to health care programs 
offered by the Department of Veterans Affairs (VA). In total, 
CBO estimates that implementing the bill would cost $3.4 
billion over the 2010-2015 period, assuming appropriation of 
the specified and estimated amounts. CBO further estimates that 
enacting the bill would increase direct spending by $7 million 
over the 2010-2020 period but would not affect revenues.\1\
---------------------------------------------------------------------------
    \1\Different time periods are relevant for enforcing the current 
pay-as-you-go rules in the Senate and the House of Representatives. CBO 
estimates that enacting S. 1237 would increase direct spending by $7 
million over both the 2010-2014 and 2010-2019 periods.
---------------------------------------------------------------------------
    Pay-as-you-go procedures apply because enacting the 
legislation would affect direct spending.
    S. 1237 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 1237 is shown in the following table. 
The costs of this legislation fall within budget functions 600 
(income security) and 700 (veterans benefits and services).

                                                    Table 1.
----------------------------------------------------------------------------------------------------------------
                                                             By fiscal year, in millions of dollars--
                                                ----------------------------------------------------------------
                                                   2010     2011     2012     2013     2014     2015   2010-2015
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Department of Housing and Urban Development-VA
 Supportive Housing Program
    Estimated Authorization Level..............        0      392      524      643      656      673     2,888
    Estimated Outlays..........................        0      338      505      626      654      670     2,793
Homeless Providers Grant and Per Diem Program
    Estimated Authorization Level..............       50       53       57       61       66        0       287
    Estimated Outlays..........................       11       73       70       61       65        6       286
Homelessness Prevention
    Authorization Level........................       50       50       50       50       50        0       250
    Estimated Outlays..........................       10       72       63       50       50        5       250
Information Management System
    Estimated Authorization Level..............       10       10       10       11       11        0        52
    Estimated Outlays..........................        2       15       12       11       11        1        52
Workforce Reintegration Program
    Authorization Level........................       10       10       10       10       10        0        50
    Estimated Outlays..........................        *        1       13       13        9        3        39
VA Personnel
    Estimated Authorization Level..............        *        2        2        2        2        2        10
    Estimated Outlays..........................        *        2        2        2        2        2        10
Chiropractic Care
    Estimated Authorization Level..............        *        1        1        2        2        2         8
    Estimated Outlays..........................        *        1        1        2        2        2         8
Special Assistant at the Department of Housing
 and Urban Development
    Estimated Authorization Level..............        *        *        *        *        *        *         1
    Estimated Outlays..........................        *        *        *        *        *        *         1
                                                ----------------------------------------------------------------
      Total Changes
        Estimated Authorization Level..........      120      518      654      779      797      677     3,547
        Estimated Outlays......................       23      502      666      765      793      689     3,439

                                           CHANGES IN DIRECT SPENDINGa

    Estimated Budget Authority.................        0        4        3        0        0        0         7
    Estimated Outlays..........................        0        4        3        0        0        0         7
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500.000.
aCBO estimates that enacting the bill would increase direct spending by $7 million over the 2010-2015 and 2010-
  2020 periods.

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

Spending subject to appropriation

    S. 1237 would expand programs for homeless veterans and 
amend other VA health care programs. In total, CBO estimates 
that implementing the bill would cost $3.4 billion over the 
2010-2015 period, assuming appropriation of the specified and 
estimated amounts.
    Department of Housing and Urban Development-VA Supportive 
Housing (HUD-VASH) Program. The HUD-VASH program is a 
collaboration between HUD and VA to provide permanent housing 
to homeless veterans and their families. Section 106 would 
authorize 40,000 rental vouchers in 2011, 50,000 in 2012, and 
60,000 in 2013 and each year thereafter. That authorization 
would exceed the current authorization for such vouchers in 
2011, the final year for which the program is now authorized. 
Based on information from HUD, CBO estimates that the average 
annual cost of those vouchers would be about $8,000 in 2011. 
Assuming appropriation of the necessary amounts, and adjusting 
for projected changes in rents and tenant incomes, CBO 
estimates that implementing this provision would cost $2.1 
billion over the 2011-2015 period.
    Veterans enrolled in the HUD-VASH program receive case 
management and supportive services through VA. Based on amounts 
appropriated for those activities in recent years and assuming 
appropriation of the necessary amounts, CBO estimates that VA 
would spend $700 million over the 2011-2015 period.
    All together, CBO estimates that implementing section 106 
would cost $2.8 billion over the 2011-2015 period.
    Homeless Providers Grants and Per Diem (GPD) Program. 
Section 101 would increase the annual amounts authorized for 
the GPD program from $150 million a year to $200 million for 
2010 and such sums as may be necessary for the 2011-2014 
period. That program provides capital grants for constructing, 
renovating, or acquiring buildings and per diem payments to 
fund operating costs. After adjusting for inflation, CBO 
estimates that implementing that provision would cost $286 
million over the 2010-2015 period, assuming appropriation of 
the necessary amounts.
    Homelessness Prevention. Section 104 would authorize the 
appropriation of $50 million a year over the 2010-2014 period 
for a new homelessness prevention program at VA. CBO estimates 
that implementing that provision would cost $250 million over 
the 2010-2015 period, assuming appropriation of the specified 
amounts.
    Information Management System. Section 105 would authorize 
the appropriation of $10 million for 2010 and such sums as may 
be necessary for the 2011-2014 period to establish a system for 
collecting and aggregating data on homeless veterans. After 
adjusting for inflation, CBO estimates that implementing that 
provision would cost $52 million over the 2010-2015 period, 
assuming appropriation of the necessary amounts.
    Workforce Reintegration Program. Section 102 would 
authorize the appropriation of $10 million a year over the 
2010-2014 period to the Department of Labor for the Workforce 
Reintegration Program. The funds would provide grants to 
agencies and organizations that provide job placement, 
training, vocational counseling, and childcare to homeless 
veterans who are female or have children. CBO estimates that 
implementing that provision would cost $39 million over the 
2010-2015 period, assuming appropriation of the specified 
amounts.
    VA Personnel. Two sections of the bill would establish new 
positions at VA. Section 301 would establish a new Assistant 
Secretary and eight Deputy Assistant Secretaries. Section 302 
would establish a Director of Physician Assistant Services in 
the Veterans Health Administration. CBO estimates that 
implementing those provisions would cost $10 million over the 
2010-2015 period, assuming appropriation of the necessary 
amounts.
    Chiropractic Care. Section 307 would require VA to provide 
comprehensive chiropractic services at two or more locations in 
each of the 21 Veterans Integrated Services Networks (VISNs), 
which are VA's regional networks of medical facilities, and in 
other locations as the Secretary determines appropriate. Nine 
VISNs currently meet those requirements and the remaining 12 
VISNs each provide care at one location. Based on information 
from VA and after adjusting for inflation, CBO estimates that 
providing chiropractic care at one additional location in each 
of those 12 VISNs would cost $8 million over the 2010-2015 
period, assuming appropriation of the necessary amounts.
    Special Assistant at HUD. Section 107 would establish a new 
position of Special Assistant for Veterans Affairs at HUD and 
require that employee to oversee HUD's programs of housing and 
homeless assistance for veterans. CBO estimates that 
implementing that provision would cost $1 million over the 
2010-2015 period, assuming the availability of appropriated 
funds.

Direct spending

    Section 401 would require VA to use certain unobligated 
balances from the Medical Services budget account to fund some 
of the activities authorized under the bill. That provision 
would extend the availability of expiring balances, resulting 
in a reappropriation of those funds.
    Based on historical data on such balances, CBO estimates 
that VA would have $8 million available to spend in 2011 (from 
funds appropriated in 2009 that would expire in 2010) and $5 
million available in 2012 (from funds appropriated in 2010 that 
would expire in 2011). CBO assumes that VA would retain about 
half of those balances to record, adjust, or liquidate existing 
obligations to the account and use the remainder on programs 
authorized by S. 2971. Enacting this bill would increase direct 
spending by about $7 million over the 2010-2020 period, CBO 
estimates.

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 and 
revenues that are subject to those pay-as-you-go procedures are 
shown in the following table.

    Table 2.--CBO Estimate of Pay-As-You-Go Effects for S.1237 as ordered reported by the  Senate Committee on Veterans' Affairs on January 28, 2010
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                    By fiscal year, in millions of dollars--
                                                      --------------------------------------------------------------------------------------------------
                                                        2010   2011   2012   2013   2014   2015   2016   2017   2018   2019   2020  2010-2015  2010-2020
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                       NET INCREASE OR DECREASE (-) IN THE DEFICIT
Statutory Pay-As-You-Go Impact                             0      4      3      0      0      0      0      0      0      0      0        7          7
--------------------------------------------------------------------------------------------------------------------------------------------------------

Intergovernmental and private-sector impact

    S. 1237 contains no intergovernmental or private-sector 
mandates as defined in UMRA. State, local, and tribal 
governments that provide assistance to veterans would benefit 
from grant and program activities authorized in the bill.
    Previous CBO Estimate: On March 15, 2010, CBO transmitted a 
cost estimate for H.R. 4810, the End Veterans Homelessness Act 
of 2010, as ordered reported by the House Committee on 
Veterans' Affairs on March 10, 2010. Section 2 of that bill is 
similar to section 101 of S. 1237; however, CBO estimates that 
S. 1237 would authorize the appropriation of slightly higher 
amounts for the GPD program than were specified in H.R. 4810.
    On March 26, 2009, CBO transmitted a cost estimate for H.R. 
1171, the Homeless Veterans Reintegration Program 
Reauthorization Act of 2009, as ordered reported by the House 
Committee on Veterans' Affairs on March 25, 2009. Section 3 of 
that bill is similar to section 102 of S. 1237; differences in 
the estimated costs reflect a later assumed enactment date for 
S. 1237.
    Estimate prepared by: Federal Costs: Sunita D'Monte; Impact 
on State, Local, and Tribal Governments: Lisa Ramirez-Branum; 
Impact on the Private Sector: Elizabeth Bass.
    Estimate approved by: Theresa Gullo, Deputy Assistant 
Director for Budget Analysis.

                      Regulatory Impact Statement

    In compliance with paragraph 11(b) of rule XXVI of the 
Standing Rules of the Senate, the Committee on Veterans Affairs 
has made an evaluation of the regulatory impact that would be 
incurred in carrying out the Committee bill. The Committee 
finds that the Committee bill would not entail any regulation 
of individuals or businesses or result in any impact on the 
personal privacy of any individuals and that the paperwork 
resulting from enactment would be minimal.

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7 of rule XXVI of the Standing 
Rules of the Senate, the following is a tabulation of votes 
cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its January 28, 2010, meeting. On that 
date, the Committee ordered S. 1237, as amended, reported 
favorably to the Senate, with amendments, by voice vote with no 
dissent. The following senators were present: Mrs. Murray, Mr. 
Brown, Mr. Tester, Mr. Begich, Mr. Burris, Mr. Burr, Mr. 
Isakson, and Chairman Akaka.
    On that date, the Committee considered an amendment offered 
by Senator Burr to prohibit certain increases to costs in 
TRICARE. The Chairman made a motion to table because he 
believed the bill is out of the Committee's jurisdiction. The 
motion to table prevailed by a 9 to 5 vote.

----------------------------------------------------------------------------------------------------------------
                Yeas                                 Senator                                 Nays
----------------------------------------------------------------------------------------------------------------
                      X (by proxy)   Mr. Rockefeller
                                 X   Mrs. Murray
                      X (by proxy)   Mr. Sanders
                                 X   Mr. Brown
                                     Mr. Webb
                                 X   Mr. Tester
                                 X   Mr. Begich
                                 X   Mr. Burris
                      X (by proxy)   Mr. Specter
                                     Mr. Burr                                                                 X
                                     Mr. Isakson                                                              X
                                     Mr. Wicker                                                    X (by proxy)
                                     Mr. Johanns                                                   X (by proxy)
                                     Mr. Graham                                                    X (by proxy)
                                 X   Mr. Chairman
----------------------------------------------------------------------------------------------------------------
                                 9   TALLY                                                                    5
----------------------------------------------------------------------------------------------------------------

    The Committee then considered an amendment offered by 
Senator Tester regarding funding for rural veterans who are 
homeless. The amendment was accepted by the Chairman.

    The Committee then considered another amendment offered by 
Senator Burr on Camp Lejeune Exposures. The amendment failed on 
a roll call vote of 5 to 9.

----------------------------------------------------------------------------------------------------------------
                Yeas                                 Senator                                 Nays
----------------------------------------------------------------------------------------------------------------
                                     Mr. Rockefeller                                               X (by proxy)
                                     Mrs. Murray                                                   X (by proxy)
                                     Mr. Sanders                                                   X (by proxy)
                                     Mr. Brown                                                     X (by proxy)
                                     Mr. Webb
                                     Mr. Tester                                                               X
                                     Mr. Begich                                                    X (by proxy)
                                     Mr. Burris                                                               X
                                     Mr. Specter                                                   X (by proxy)
                                 X   Mr. Burr
                                 X   Mr. Isakson
                      X (by proxy)   Mr. Wicker
                      X (by proxy)   Mr. Johanns
                      X (by proxy)   Mr. Graham
                                     Mr. Chairman                                                             X
----------------------------------------------------------------------------------------------------------------
                                 5   TALLY                                                                    9
----------------------------------------------------------------------------------------------------------------

    The Committee next considered an amendment offered by 
Senator Sanders on automatic enrollment of National Guard and 
Reserve in VA health care. This amendment was accepted by the 
Chairman.

    The Committee then considered an amendment offered by 
Senator Burr on carryover funds for unobligated spending. The 
amendment was accepted by the Chairman with a caveat that it 
may need technical changes to give the Secretary of VA more 
discretion.

                             Agency Report

    On October 21, 2009, Gerald M. Cross, the Acting Under 
Secretary for Health, Department of Veterans Affairs, appeared 
before the Committee and submitted testimony on a number of 
bills. In addition, on March 23, 2010, VA provided views on 
S. 1547. Excerpts of both the testimony and Department views 
are reprinted below:

  STATEMENT OF GERALD M. CROSS, MD, FAAFP, ACTING UNDER SECRETARY FOR 
  HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                                AFFAIRS

    Good Morning Mr. Chairman and Members of the Committee:
    Thank you for inviting me here today to present views on 
several bills that would affect Department of Veterans Affairs 
(VA) benefits and services. Joining me today are Mr. Brad 
Mayes, Director of the Compensation and Pension Service, Mr. 
Richard Hipolit, Assistant General Counsel, and Mr. Walter 
Hall, Assistant General Counsel. We appreciate the opportunity 
to address these bills that would affect the Department's 
health care and benefits programs.

           *       *       *       *       *       *       *

  S. 1155--``ESTABLISHING POSITION OF DIRECTOR OF PHYSICIAN ASSISTANT 
                               SERVICES''

    S. 1155 would eliminate the Physician Assistant (PA) 
Advisor position established by Public Law 106-419, the 
Veterans Benefits and Health Care Improvement Act of 2000, and 
establish a Director of Physician Assistant (PA) Services 
within the Office of the Under Secretary for Health. VA does 
not support this bill.
    The functions of the proposed Director of PA Services are 
already being performed by the PA Advisor. Moreover, the PA 
Advisor position was converted to full-time on April 14, 2008, 
and it will be based in VA Central Office at the expiration of 
the current incumbent's term in April 2010.
    In addition, VA does not support the proposed 
organizational realignment of the Director of PA Services to 
the Office of the Under Secretary for Health. The position's 
current alignment within the Office of Patient Care Services is 
consistent with most other clinical program leadership 
positions and provides the PA Advisor access to the Under 
Secretary for Health for any issues that cannot be resolved 
within the current structure. The cost of implementing this 
bill is insignificant.

           *       *       *       *       *       *       *

        S. 1204--``CHIROPRACTIC CARE AVAILABLE TO ALL VETERANS 
                             ACT OF 2009''

    S. 1204 would require VA to increase to not fewer than 75 
the number of VA facilities directly providing chiropractic 
care through VA medical centers and clinics by December 31, 
2009. In addition, S. 1204 would require that chiropractic care 
be provided at all VA medical centers by December 31, 2011.
    VA opposes S. 1204. While musculoskeletal conditions are 
common in VA patients, and are increasingly prevalent among 
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/
OIF) Veterans, there is currently a facility with an in-house 
chiropractic care program in each of our geographic service 
areas. Specifically, VA has 28.5 chiropractors providing on-
station care and services at 36 facilities. VA does not oppose 
eventually increasing the number of VA sites providing 
chiropractic care; however, the projected demand for 
chiropractic care is insufficient to justify mandating it at 
all VA medical centers by the end of 2011. Moreover, the 
requirement to increase the number of facilities in which VA 
provides chiropractic care from 36 facilities to 75 facilities 
by the end of the calendar year is unrealistic and unnecessary. 
Currently, 98 percent of VA patients are able to receive 
chiropractic care within thirty days of their desired date.
    VA estimates that S. 1204 would cost $5.3 million in fiscal 
year (FY) 2010, $5.5 million in FY 2011, $29.8 million over 5 
years, and $63.6 million over 10 years.

           *       *       *       *       *       *       *

S. 1237--``HOMELESS WOMEN VETERANS AND HOMELESS VETERANS WITH CHILDREN 
                             ACT OF 2009''

    S. 1237 would expand those eligible to receive grants under 
38 U.S.C. 2061 beyond grant and per diem providers to include 
those entities eligible to receive grant and per diem payments. 
It would also provide that both male and female homeless 
Veterans who are responsible for the care of minor dependents 
may qualify as Veterans with special needs. In addition, 
S. 1237 would authorize the use of funds for the provision of 
direct services to the dependents of homeless Veterans. Section 
3 of S. 1237 would require the Secretary of Labor to award 
grants to eligible programs and facilities to provide services 
to reintegrate homeless women Veterans and homeless Veterans 
with children into the workforce. Grant recipients would 
provide job training, counseling, job placement services and 
child care. The law would be implemented by the Assistant 
Secretary for Veterans' Employment and Training, who would 
report through the Secretary of Labor on this program 
biennially. An additional $10 million, in excess of other 
appropriated funds, would be made available for fiscal years 
2010 and 2014.

           *       *       *       *       *       *       *

       S. 1302--``VETERANS HEALTH CARE IMPROVEMENT ACT OF 2009''

    S. 1302 would require VA to submit to Congress within one 
year a plan to introduce pay-for-performance measures into 
community-based outpatient clinic (CBOC) contracts. This plan 
would require VA to include measures to ensure contracts 
utilize pay-for-performance mechanisms including incentives for 
providing high-quality health care, patient satisfaction, and 
data collection on the outcomes of services provided by CBOCs. 
The plan would also require VA to impose penalties for 
substandard care, and to eliminate abuses by CBOCs that use 
capitated-basis compensation. Moreover, VA's plan would need to 
include mechanisms to ensure Veterans are not denied care and 
do not face undue delays. VA would be required to implement 
this plan within 60 days of submitting it to Congress, though 
in implementing the plan the Secretary may initially carry out 
of one or more pilot programs to assess its feasibility and 
advisability. VA would be required to report to Congress every 
6 months providing recommendations on the feasibility and 
advisability of utilizing pay-for-performance compensation in 
providing health care services through means other than CBOCs.
    VA does not support S. 1302. VA is devoting significant 
effort into quality control and effective incentives in its 
CBOC contracting now, and that is a complex multi-faceted 
endeavor. There is a great deal of emerging research in the 
medical field on pay-for-performance, and it is clear that 
programs must be carefully thought out to avoid unintended 
consequences. Prescribing a fixed set of tools would impair VA 
flexibility. Additionally the legislation would not provide any 
additional statutory authority to establish a CBOC performance-
based patient quality care incentive contract than what is 
currently provided in the Federal Acquisition Regulations.
    VA estimates there would be no additional costs associated 
with this legislation as it only requires VA to develop a 
different type of contract during the normal acquisition 
process.

           *       *       *       *       *       *       *

S. 1427--``DEPARTMENT OF VETERANS AFFAIRS HOSPITAL QUALITY REPORT CARD 
                             ACT OF 2009''

    S. 1427 would add section 1706A to title 38 and require VA, 
within 18 months of enactment, to establish and implement a 
Hospital Quality Report Card Initiative. This initiative would 
require the Secretary to publish a report at least twice a year 
on Department medical centers containing information on 
effectiveness, safety, timeliness, efficiency, patient-
centeredness, patient satisfaction, health professional 
satisfaction, and equity of care for various populations 
(female, geriatric, disabled, rural, homeless, mentally ill, 
racial and ethnic minorities). VA would be required to grade 
facilities in these areas on a scale from A+ to F. VA would 
also be required to provide information, to the maximum extent 
practicable, on: staffing levels of nurses and other health 
professionals; rates of nosocomial infections; volumes of 
different procedures performed; hospital sanctions and 
violations; quality of care to various populations; 
availability of emergency rooms, intensive care units (ICUs), 
maternity and specialty services; quality of care in inpatient, 
outpatient, emergency, maternity and ICU; ongoing patient 
safety initiatives; use of health information technology; and 
other matters. S. 1427 would allow the Secretary to provide 
information in addition to or in lieu of the specific 
requirements identified in the bill by informing the Senate and 
House Committees on Veterans' Affairs at least 15 days before 
the report is to be published. S. 1427 would also allow 
Secretary to adjust quality measures based upon risk, but it 
would require VA to establish procedures for making unadjusted 
data available to the public in a manner deemed appropriate by 
VA and to disclose its analysis methodology. These reports 
would need to be written for non-medical professionals and 
available electronically and in hard copy upon request at each 
medical center. The legislation is intended to ensure 
information VA provides is of a type and in a form that is 
conducive to comparisons with other local or regional 
hospitals. At least once a year, VA would be required to 
annually compare quality measures across years to identify and 
report any false or artificial improvements in quality 
measurements. In addition, VA would be required to develop and 
implement effective safeguards to protect against unauthorized 
use or disclosure of medical center data and to ensure that no 
identifiable patient data is released to the public.
    VA does not oppose increasing transparency of quality 
measures for its facilities and agrees with the general premise 
of this legislation; however, the agency does not support 
S. 1427 as written because some of the requirements may not be 
possible or would require VA to develop its own data categories 
that could not be compared or benchmarked to other leading 
health care organizations.
    VA has identified health care transparency as one of its 
major Strategic Transformation Initiatives this fiscal year and 
is working with the Centers for Medicare & Medicaid Services 
(CMS) to post VA comparable data on their ``Hospital Compare'' 
Web site (www.hospitalcompare.hhs.gov). CMS requires three data 
streams, each of which has different reporting periods based on 
assuring data validity. They post process data quarterly but 
outcome and patient satisfaction data annually. VA consequently 
believes that it is impractical to report data twice a year as 
the data may be invalid. VA is similarly exploring other public 
reporting programs, such as the Medicare Prescription Drug Plan 
Finder, Medicare Options Compare, CMS' Nursing Home Compare, 
Commonwealth Fund's WhyNotTheBest, and others.
    Additionally, VA is developing composite metrics meaningful 
to both consumers and stakeholders. While seemingly simple, an 
incremental letter grade scale may not be the best way to 
communicate the quality of a particular hospital to consumers. 
For example, CMS uses a five star rating system for Nursing 
Home Compare. VA will be conducting focus groups with Veterans 
to determine how they would like to be provided quality 
information about medical facilities. VA has proposed an 
initiative to develop an internal VA Hospital Report Card 
prototype for internal measurements and comparison at all 
organizational levels. The data elements are similar but not 
exactly the same as the elements identified in this 
legislation. VA proposes to include: structure and volume; 
workforce productivity; population and disease burden; care 
delivery utilization; quality, efficiency and outcomes; and 
trends and benchmarks. This approach offers VA the flexibility 
to provide meaningful measures that may be benchmarked with 
other hospitals and develop new measures through consensus-
based processes involving all stakeholders. Measures should 
focus on areas with the greatest potential for making care 
safe, effective, timely, efficient or equitable, and patient-
centered. Primarily, these data will be used to identify areas 
where VA can improve the most.
    VA estimates S. 1427 would cost $2 million in FY 2010, $2.1 
million in FY 2011, $10.8 million over 5 years, and $24.0 
million over 10 years.

           *       *       *       *       *       *       *

           S. 1483--``DESIGNATING THE ALEXANDRIA, MINNESOTA, 
                          OUTPATIENT CLINIC''

    S. 1483 would designate the Department of Veterans Affairs 
Outpatient Clinic in Alexandria, Minnesota, as the ``Max J. 
Beilke Department of Veterans Affairs Outpatient Clinic.'' Mr. 
Beilke died in service to his country at the Pentagon on 
September 11, 2001. The Department has no objection to this 
proposal and defers to Congress in the naming of Federal 
property.

           *       *       *       *       *       *       *

       S. 1531--``DEPARTMENT OF VETERANS AFFAIRS REORGANIZATION 
                             ACT OF 2009''

    S. 1531 would amend 38 U.S.C. 308 to increase the number of 
Assistant Secretaries in the Department from seven to eight. It 
would also increase the number of Deputy Assistant Secretaries 
from 19 to 27. The bill would also require that one Assistant 
Secretary be appointed Assistant Secretary for Acquisition, 
Logistics, and Construction and would cap the number of Deputy 
Assistant Secretaries the Secretary may appoint to manage 
programs relating to construction, facilities, asset 
management, and IT. In addition, S. 1531 would modernize some 
of nomenclature relating to construction and acquisition 
functions in 38 U.S.C. 308.
    VA generally supports this legislation. Elevating the 
construction and acquisition function to the Assistant 
Secretary (AS) level will help ensure consistent and sound 
business decisions are made in VA's acquisitions, logistics, 
and construction programs. This position will also further 
transform and modernize VA's business practices and processes. 
Similarly, expanding the number of Deputy Assistant Secretaries 
(DAS) is necessary given the size, scope, and complexity of 
VA's missions and geographic distribution. However, VA opposes 
language in S. 1531 which specifies the title and 
responsibilities of the AS and which caps the number of DAS 
assigned to certain functions as this limits the agency's 
flexibility to address changing needs and demands.

           *       *       *       *       *       *       *

          S. 1547--``ZERO TOLERANCE FOR VETERANS HOMELESSNESS 
                             ACT OF 2009''

    S. 1547 proposes to alter and expand a number of 
authorities available to VA with regard to preventing and 
reducing Veteran homelessness. VA has initiated an ambitious 
plan to end homelessness among Veterans and supports the 
Committee's interest in providing additional services and 
assistance to homeless Veterans. However, VA needs additional 
time to evaluate S. 1547. We will provide views and costs on 
these provisions as soon as they are available.
                                ------                                

                         The Secretary of Veterans Affairs,
                                    Washington, DC, March 23, 2010.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: This letter is in response to your 
invitation to submit for the record the Department's views on 
several bills, S. 1467, S. 1547, and S. 1753. These bills were 
on the schedule of the October 21, 2009 legislative hearing, 
but we were unable to provide views at that time. We thank you 
for the opportunity to provide our comments and cost estimates 
for the record.

           *       *       *       *       *       *       *

          S. 1547--``Zero Tolerance for Veterans Homelessness 
                             Act of 2009''

    S. 1547 proposes to alter and expand a number of VA 
authorities designed to prevent and reduce Veteran 
homelessness. One of VA's top priorities is eliminating Veteran 
homelessness. As such, the FY 2010 President's Budget 
significantly increased funding targeted to enhancing homeless 
programs, and VA has also increased its collaboration with 
federal and local partners to expand services.
    Although VA supports the intent of this bill, we have three 
significant concerns-- 1) assigning this program to VBA instead 
of the Department in general, 2) creating an entitlement for 
homeless services, and 3) the duplication of current programs. 
As a result, VA can support certain provisions in S. 1547 as 
discussed below.
    Section 3 would require the Secretary of Veterans Affairs 
to establish a program in the Veterans Benefit Administration 
(VBA) to prevent homelessness by identifying Veterans who are 
homeless or at imminent risk of becoming homeless and by 
providing various types of assistance to those identified. Such 
assistance may include the provision of short-term or medium-
term rental assistance, housing relocation and stabilization 
services, services to resolve personal credit issues, 
assistance with security or utility deposits, moving costs, 
referral to other Government programs, and other assistance the 
Secretary determines is appropriate. VA supports the intent of 
this bill; however we note that many of these services are 
currently provided by VA or our federal partners. In some 
cases, we believe some services are more appropriately provided 
through our partners that have specific expertise and operate 
programs specific to these services. Also, the administration 
of such a comprehensive program should be assigned to the 
Department in general rather than solely to VBA. We look 
forward to working with Committee staff to identify gaps in 
services provided to homeless Veterans. VA estimates the cost 
of enacting section 3 at $50 million in the first year, and 
$250 million over 5 years.
    Section 4 would allow the use of grants for new 
construction of facilities under 38 U.S.C. 2011 and would 
permit grant applicants to be considered if the entity proposes 
to use funding from other private or non-profit sources, 
contingent upon the applicant's demonstration of oversight by a 
private non-profit organization. It would also require VA to 
conduct a study within 1 year of enactment concerning grant and 
per diem (GPD) payments under 38 U.S.C. 2012 and to develop 
improved methods for disbursing funds and reimbursing grant 
recipients. VA would, within 1 year of enactment, report on the 
findings of the study and provide any recommendations based on 
the study's findings. This section would also increase VA's 
authorization for programs carried out under 38 U.S.C. 2013 to 
$200 million for FY 2010 and ``such sums as may be necessary'' 
for each of fiscal years 2011 through 2014. In addition, 
section 4 would remove the phrase ``[s]ubject to the 
availability of appropriations'' from 38 U.S.C. 2011(a)(1). The 
amendment would establish section 2011 as an entitlement 
authority. Entitlement spending is mandatory under the Budget 
Enforcement Act.
    VA supports the increase in GPD authorization to include 
$200 million in FY 2010 and such sums as may be necessary for 
each of fiscal years 2011 through 2014. The Administration and 
the Department have a goal of ultimately ending homelessness 
among our nation's Veterans. To achieve this goal, VA will 
strive to assist every eligible homeless Veteran willing to 
accept its services. We will help them acquire safe housing and 
obtain needed treatment, services, and benefits assistance, 
while working with our partners at the Department of Labor to 
also provide opportunities to return to employment. This 
includes education, job training, substance abuse and mental 
health care, as well as an assortment of other benefits. It 
will require close partnership with Federal and State agencies, 
local, non-profit and private groups; outreach and education to 
Veterans, people and organizations providing services to 
Veterans, and the general public; universal and targeted 
prevention; treatment focused on recovery and tailored to 
individual Veterans' needs; housing and supportive services; 
and income, employment and benefits assistance. We will leave 
no opportunity unexplored, and we will continue this pursuit 
until every Veteran has safe housing available and access to 
needed treatment services.
    Though we are in favor of increasing the GPD authorization, 
the Department opposes establishing 38 U.S.C. 2011 as an 
entitlement authority. Accordingly, we recommend that the 
Committee retain the phrase ``[s]ubject to the availability of 
appropriations'' in 38 U.S.C. 2011(a)(1).
    VA currently estimates the cost of the Homeless Grants and 
Per Diem program, which is an integral part of VA's plan to end 
homelessness, to be $171.6 million in FY 2010, $217.6 million 
in FY 2011, $1.2 billion over 5 years, and $2.8 billion over 10 
years.
    Section 5 would expand the Housing and Urban Development-
Veterans Affairs Supported Housing (HUD-VASH) voucher program 
by 10,000 vouchers each year through FY 2013 (beginning with 
30,000 vouchers in 2010 and ending with 60,000 vouchers in 
2013). It would also require the Secretary of Veterans Affairs 
to ensure homeless-Veteran case managers provide appropriate 
supportive services, including medical care to Veterans to help 
achieve an end to chronic homelessness.
    VA supports the intent of this section; however, our role 
is to execute the vouchers funded through the Department of 
Housing and Urban Development. Over the last year, VA, in 
conjunction with HUD, have placed great focus on aggressively 
expanding outreach, and the agencies capacity to assign and 
execute increased numbers of housing vouchers to homeless 
Veterans. Within requested resources, we will reach our goal of 
reducing the number of homeless Veterans from 131,000 to 59,000 
by 2012. VA estimates this section would cost $43.4 million in 
FY 2010, $132.1 million in FY 2011, $1.54 billion over 5 years 
and $7.74 billion over 10 years.
    Section 6 would create a Special Assistant for Veterans 
Affairs within the Office of the Secretary for Housing and 
Urban Development. VA defers to HUD regarding section 6.
    Section 7 would require development of a homeless Veteran 
management information system available to HUD and VA with data 
on Veterans within 1 year from the date of enactment. Ten 
million dollars is authorized for this project.
    The Department notes that HUD has already created and 
implemented a Homeless Management Information System (HMIS) in 
Continuums of Care throughout the country. VA has committed to 
support the use of local Homeless Management Information 
Systems to track its own performance; however, as part of VA's 
plan to eliminate Veteran homelessness, we need a system with 
national identified data, which HMIS does not contain, in order 
to have a real time data management system to monitor its 
progress in meeting the goals for a zero tolerance for 
homelessness among Veterans. VA also has a need for a long term 
data warehouse to further evaluate the effectiveness and 
outcomes of its programs and services. The data warehouse/
registry will also assist VA in monitoring the progress and 
service utilization of Veterans who have been homeless or are 
at risk for homelessness. This data will also be used to 
generate reports to Congress regarding the effectiveness of 
VA's homeless Veteran programs.
    VA estimates the cost of supplementing HMIS with 
identifiable information to be $10 million for FY 2010. The 
proposed budget would be used to develop the many different 
intellectual documents such as requirements, project plan and 
the software requirements specification. These are needed to 
define and procure the different IT systems and services needed 
to initiate and build the needed components for the VA/VHA 
Homeless program. Funding for the out years for this effort are 
estimated to be $5 million per year for ongoing design, 
upgrades and operations costs from an overall perspective.
    Section 8 would require VA to develop a plan within 1 year 
of enactment on how to end Veteran homelessness, with special 
consideration for homeless Veterans in rural areas.
    As described above, VA has already initiated an ambitious 
goal to expand outreach, collaboration, and programs in order 
to ultimately end homelessness among our Nation's Veterans. In 
addition, legislation enacted by Congress in May of this year, 
the Homeless Emergency Assistance and Rapid Transition to 
Housing Act of 2009 (``HEARTH ACT'') (Division B of PI 111-22), 
requires that not later than 12 months after enactment, the 
United States Interagency Council on Homelessness shall 
``develop, make available for public comment, and submit to the 
President and to Congress a National Strategic Plan to End 
Homelessness, and shall update such plan annually'' (42 U.S.C. 
11313). Work on developing this plan has begun and VA, as one 
of the 19 member agencies of the Council, is at the table. As 
such, we do not believe this section is necessary.

           *       *       *       *       *       *       *

    Thank you again, Mr. Chairman, for the opportunity to 
provide VA's views on these bills.
    The Office of Management and Budget advises that there is 
no objection from the standpoint of the Department's program to 
the submission of this letter on S. 1467, S. 1547, and S. 1753 
to the Congress.
            Sincerely,
Eric K. Shinseki.

           *       *       *       *       *       *       *

                        Changes in Existing Law

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

                      Title 38. Veterans' Benefits

Part I. General Provisions

           *       *       *       *       *       *       *

               Chapter 3. Department of Veterans Affairs

SEC.

301. DEPARTMENT.

           *       *       *       *       *       *       *

[312A. DIRECTOR OF CONSTRUCTION AND FACILITIES MANAGEMENT.]

313. AVAILABILITY OF APPROPRIATIONS.

           *       *       *       *       *       *       *

SEC. 301. DEPARTMENT

           *       *       *       *       *       *       *

SEC. 308. ASSISTANT SECRETARIES; DEPUTY ASSISTANT SECRETARIES

    (a) There shall be in the Department not more than [seven] 
eight Assistant Secretaries. Each Assistant Secretary shall be 
appointed by the President, by and with the advice and consent 
of the Senate.
    (b) * * *
          (1) * * *

           *       *       *       *       *       *       *

          (6) [Capital] Construction capital facilities and 
        real property program functions.

           *       *       *       *       *       *       *

          (10) [Procurement] Acquisition functions.

           *       *       *       *       *       *       *

    (d)(1) There shall be in the Department such number of 
Deputy Assistant Secretaries, not exceeding [19] 27, as the 
Secretary may determine. Each Deputy Assistant Secretary shall 
be appointed by the Secretary and shall perform such functions 
as the Secretary prescribes.

           *       *       *       *       *       *       *

[SEC. 312A. DIRECTOR OF CONSTRUCTION AND FACILITIES MANAGEMENT

    [(a) In General.--(1) There is in the Department a Director 
of Construction and Facilities Management, who shall be 
appointed by the Secretary.
          [(2) The position of Director of Construction and 
        Facilities Management is a career reserved position, as 
        such term is defined in section 3132(a)(8) of title 5.
          [(3) The Director shall provide direct support to the 
        Secretary in matters covered by the responsibilities of 
        the Director under subsection (c).
          [(4) The Director shall report to the Deputy 
        Secretary in the discharge of the responsibilities of 
        the Director under subsection (c).
    [(b) Qualifications.--Each individual appointed as Director 
of Construction and Facilities Management shall be an 
individual who--
          [(1) holds an undergraduate or master's degree in 
        architectural design or engineering; and
          [(2) has substantive professional experience in the 
        area of construction project management.
    [(c) Responsibilities.--(1) The Director of Construction 
and Facilities Management shall--
          [(A) be responsible for overseeing and managing the 
        planning, design, construction, and operation of 
        facilities and infrastructure of the Department, 
        including major and minor construction projects; and
          [(B) perform such other functions as the Secretary 
        shall prescribe.
    [(2) In carrying out the oversight and management of 
construction and operation of facilities and infrastructure 
under this section, the Director shall be responsible for the 
following:
          [(A) Development and updating of short-range and 
        long-range strategic capital investment strategies and 
        plans of the Department.
          [(B) Planning, design, and construction of facilities 
        for the Department, including determining architectural 
        and engineering requirements and ensuring compliance of 
        the Department with applicable laws relating to the 
        construction program of the Department.
          [(C) Management of the short-term and long-term 
        leasing of real property by the Department.
          [(D) Repair and maintenance of facilities of the 
        Department, including custodial services, building 
        management and administration, and maintenance of 
        roads, grounds, and infrastructure.
          [(E) Management of procurement and acquisition 
        processes relating to the construction and operation of 
        facilities of the Department, including the award of 
        contracts related to design, construction, furnishing, 
        and supplies and equipment.]

           *       *       *       *       *       *       *

Part II. General Benefits

           *       *       *       *       *       *       *

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

                         SUBCHAPTER I. GENERAL

SEC.

1701. DEFINITIONS.

           *       *       *       *       *       *       *

1706. MANAGEMENT OF HEALTH CARE: OTHER REQUIREMENTS.

1706A. MANAGEMENT OF HEALTH CARE: MEDICAL CENTER QUALITY REPORT CARD 
                    INITIATIVE.

1707. LIMITATIONS.

1708. TEMPORARY LODGING.

           *       *       *       *       *       *       *

Subchapter I. General

           *       *       *       *       *       *       *

SEC. 1706A. MANAGEMENT OF HEALTH CARE: MEDICAL CENTER QUALITY REPORT 
                    CARD INITIATIVE

    (a) In General.--Not later than 18 months after the date of 
the enactment of the Homeless Veterans and Other Veterans 
Health Care Authorities Act of 2010, the Secretary shall 
establish and implement an initiative, to be known as the 
``Medical Center Quality Report Card Initiative'' (in this 
section referred to as the ``Initiative''), to publish 
information on health care quality in Department medical 
centers.
    (b) Publication of Information on Quality and Performance 
of Department Medical Centers.--(1)(A) Under the Initiative, 
not less frequently than twice each year, the Secretary shall 
make available to the public, on the Hospital Compare website 
of the Centers for Medicaid and Medicare Services, data 
consisting of the most current information on the quality and 
performance of each Department medical center. Such information 
shall include quality measures that allow for an assessment 
with respect to health care provided by Department medical 
centers, of the following:
          (i) Effectiveness.
          (ii) Safety.
          (iii) Timeliness.
          (iv) Efficiency.
          (v) Patient-centeredness.
          (vi) Patient satisfaction.
          (vii) Satisfaction of health professionals employed 
        at Department medical centers.
          (viii) The equity of care provided to various patient 
        populations, including female, geriatric, disabled, 
        rural, homeless, mentally ill, and racial and ethnic 
        minority populations.
    (B) For each quality measure made available under 
subparagraph (A), the Secretary shall include--
          (i) quality measures that are common to the health 
        care industry and are based on information reported in 
        paragraph (2); and
          (ii) such other information as the Secretary 
        considers appropriate.
    (C) The Secretary shall conduct focus groups with veterans 
to identify additional types of quality information and display 
formats regarding such quality measures that would be 
meaningful to the needs of veterans.
    (2)(A) In making data available pursuant to paragraph (1), 
the Secretary shall, except as provided in subparagraph (B), 
include to the maximum extent practicable information about 
Department medical centers using best available measures that 
reflect emerging quality and safety trends and the priorities 
of veteran-centered care.
    (B) In making data available to the public under paragraph 
(1), the Secretary may provide information in addition to the 
information required by subparagraph (A) or provide information 
in lieu of the information required by subparagraph (A) if the 
Secretary--
          (i) not later than 15 days before the date on which 
        such data is made available to the public, submits to 
        the Committee on Veterans' Affairs of the Senate and 
        the Committee on Veterans' Affairs of the House of 
        Representatives a certification in writing that such 
        additional or substituted information is more 
        appropriate for purposes of carrying out the 
        requirement of paragraph (2)(B); and
          (ii) includes with such data and in such 
        certification an indication of which information has 
        been added or substituted under this subparagraph.
    (3)(A) In making data available as provided for under 
paragraph (1), the Secretary may make risk adjustments to 
quality measures to account for differences relating to--
          (i) the characteristics of a Department medical 
        center, such as licensed bed size, geography, and 
        teaching hospital status; and
          (ii) patient characteristics, such as health status, 
        severity of illness, and socioeconomic status.
    (B) If the Secretary makes data available under paragraph 
(1) using risk-adjusted quality measures, the Secretary shall 
establish procedures for making the unadjusted data available 
to the public in a manner determined appropriate by the 
Secretary.
    (4) Under the Initiative, the Secretary may verify data 
made available under this subsection to ensure accuracy and 
validity.
    (5) Before disclosing to the public any data under this 
subsection, the Secretary shall disclose the methodology for 
the publication of such data and the nature and scope of such 
data to--
          (A) each organization the Secretary considers 
        relevant to such data; and
          (B) each Department medical center that is the 
        subject of such data.
    (6)(A) 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 copy of each set of 
data made available to the public under paragraph (1).
    (B) The Secretary shall ensure that each set of data made 
available to the public under paragraph (1) is made available--
          (i) in an electronic format;
          (ii) in a manner that can be understood by 
        individuals who are not medical professionals and 
        individuals with low functional health literacy; and
          (iii) at each Department medical center covered by 
        the set of data.
    (C) The Secretary shall ensure that information on health 
care quality made available under paragraph (1) is made 
available in a manner that is conducive for comparisons with 
other local medical centers or regional medical centers, as 
appropriate.
    (D) The Secretary shall establish procedures for making the 
information included in the data made available to the public 
under paragraph (1) available to the public upon request in 
non-electronic format, such as through a toll-free telephone 
number.
    (7) The analytic methodologies and limitations on 
information sources utilized by the Secretary to develop and 
disseminate comparative information under this subsection shall 
be identified and acknowledged in a notice or disclaimer as 
part of the dissemination of such information, and include the 
appropriate and inappropriate uses of such information.
    (c) Identifying and Reporting Actions That Could Lead to 
False or Artificial Improvements in Quality Measurements.--Not 
less frequently than annually, the Secretary shall compare 
quality measures data submitted by each Department medical 
center to the Secretary with quality measures data submitted to 
the Secretary in the prior year or years by each such 
Department medical center in order to identify and report 
actions that could lead to false or artificial improvements in 
the quality measurements of such Department medical centers for 
purposes of this section.
    (d) Privacy and Security.--(1) The Secretary shall develop 
and implement effective safeguards to protect against the 
unauthorized use or disclosure of Department medical center 
data that is made available under this section.
    (2) The Secretary shall develop and implement effective 
safeguards to protect against the dissemination under this 
section of inconsistent, incomplete, invalid, inaccurate, or 
subjective Department medical center data.
    (3) The Secretary shall ensure that identifiable patient 
data is not released to the public under this section.
    (e) Reports.--(1) The Secretary shall periodically submit 
to Congress a report on the effectiveness of the Initiative.
    (2) Each report required by paragraph (1) shall include the 
following:
          (A) An assessment of the effectiveness of the 
        Initiative in meeting the purpose described in section 
        302(a) of the Homeless Veterans and Other Veterans 
        Health Care Authorities Act of 2010.
          (B) If necessary, a description of the measures the 
        Secretary can undertake to ensure that the Initiative 
        meets such purpose.
    (3) The Secretary shall carry out each measure the 
Secretary includes in a report under paragraph (2)(B).
    (4) The Secretary shall make each report submitted under 
paragraph (1) available to the public.
    (f) Department Medical Center Defined.--In this section, 
the term ``Department medical center'' means a Department of 
Veterans Affairs Medical Center administered by the Secretary.
    (g) Authorization of Appropriations.--There are authorized 
to be appropriated to carry out this section such sums as may 
be necessary for each of fiscal years 2010 through 2018.

           *       *       *       *       *       *       *

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

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

    (a)(1) * * *

           *       *       *       *       *       *       *

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

           *       *       *       *       *       *       *

          (F) who was exposed to a toxic substance, radiation, 
        or other [conditions] occupational or environmental 
        hazards, as provided in subsection (e); or

           *       *       *       *       *       *       *

    (e)(1)(A) * * *

           *       *       *       *       *       *       *

    (3) * * *
          (A) * * *
          (B) in the case of care for a veteran described in 
        paragraph (1)(C), after December 31, 2002, except that 
        such care and services may also be provided to such a 
        veteran during the period beginning on the date of the 
        enactment of the Homeless Veterans and Other Veterans 
        Health Care Authorities Act of 2010 and ending on 
        December 31, 2012; and

           *       *       *       *       *       *       *

               Chapter 20. Benefits for Homeless Veterans

SUBCHAPTER I. PURPOSE; DEFINITIONS; ADMINISTRATIVE MATTERS

           *       *       *       *       *       *       *

                 SUBCHAPTER III. TRAINING AND OUTREACH

SEC.

2021. HOMELESS VETERANS REINTEGRATION PROGRAMS.

2021A. GRANT PROGRAM FOR REINTEGRATION OF HOMELESS WOMEN VETERANS AND 
                    HOMELESS VETERANS WITH CHILDREN.

2022. COORDINATION OF OUTREACH SERVICES FOR VETERANS AT RISK OF 
                    HOMELESSNESS.

           *       *       *       *       *       *       *

                    SUBCHAPTER VII. OTHER PROVISIONS

SEC.

2061. GRANT PROGRAM FOR HOMELESS VETERANS WITH SPECIAL NEEDS.

2062. DENTAL CARE.

2063. EMPLOYMENT ASSISTANCE.

2064. TECHNICAL ASSISTANCE GRANTS FOR NONPROFIT COMMUNITY-BASED GROUPS.

2065. ANNUAL REPORT ON ASSISTANCE TO HOMELESS VETERANS.

2066. ADVISORY COMMITTEE ON HOMELESS VETERANS.

2067. PREVENTION OF VETERAN HOMELESSNESS.

2068. HOMELESS VETERANS MANAGEMENT INFORMATION SYSTEM.

Subchapter I. Purpose; Definitions; Administrative Matters

           *       *       *       *       *       *       *

SEC. 2003. STAFFING REQUIREMENTS

    (a) * * *
          (1) * * *
          (2) * * *
          (3) [The housing] Any housing program for veterans 
        supported by the department of housing and urban 
        development.

           *       *       *       *       *       *       *

          (7) The program under section 2067 of this title.
          (8) [(7)] Such other programs relating to homeless 
        veterans as may be specified by the Secretary.

             Subchapter II. Comprehensive Service Programs

SEC. 2011. GRANTS

           *       *       *       *       *       *       *

    (b) * * *
          (1) * * *
                  (A) [expansion, remodeling, or alteration of 
                existing buildings, or acquisition of 
                facilities,] new construction of facilities, 
                expansion, remodeling, or alteration of 
                existing facilities, or acquisition of 
                facilities for use as service centers, 
                transitional housing, or other facilities to 
                serve homeless veterans; and

           *       *       *       *       *       *       *

    (c) Funding Limitations.--[A grant] (1) A grant under this 
section may not be used to support operational costs. [The 
amount]
    (2) The amount of a grant under this section may not exceed 
65 percent of the estimated cost of the project concerned.
    (3)(A) The Secretary may not deny an application from an 
entity that seeks a grant under this section to carry out a 
project described in subsection (b)(1)(A) solely on the basis 
that the entity proposes to use funding from other private or 
public sources, if the entity demonstrates that a private 
nonprofit organization will provide oversight and site control 
for the project.
    (B) In this paragraph, the term ``private nonprofit 
organization'' means the following:
          (i) An incorporated private institution, 
        organization, or foundation--
                  (I) that has received, or has temporary 
                clearance to receive, tax-exempt status under 
                paragraph (2), (3), or (19) of section 501(c) 
                of the Internal Revenue Code of 1986;
                  (II) for which no part of the net earnings of 
                the institution, organization, or foundation 
                inures to the benefit of any member, founder, 
                or contributor of the institution, 
                organization, or foundation; and
                  (III) that the Secretary determines is 
                financially responsible.
          (ii) A for-profit limited partnership or limited 
        liability company, the sole general partner or manager 
        of which is an organization that is described by 
        subclauses (I) through (III) of clause (i).
          (iii) A corporation wholly owned and controlled by an 
        organization that is described by subclauses (I) 
        through (III) of clause (i).

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    (i) Minimum Funding in Rural Areas.--The Secretary shall 
ensure that not less than five percent of the aggregate of the 
grant amounts awarded under this section in each fiscal year is 
awarded to eligible entities located in rural areas.

           *       *       *       *       *       *       *

SEC. 2013. AUTHORIZATION OF APPROPRIATIONS

    There is authorized to be appropriated to carry out this 
[subchapter $150,000,000 for fiscal year 2007 and each fiscal 
year thereafter.] subchapter--
          (1) $150,000,000 for each of fiscal years 2007 
        through 2009;
          (2) $200,000,000 for fiscal year 2010; and
          (3) such sums as may be necessary for each of fiscal 
        years 2011 through 2014.

                 Subchapter III. Training and Outreach

SEC. 2021. HOMELESS VETERANS REINTEGRATION PROGRAMS

           *       *       *       *       *       *       *

SEC. 2021A. GRANT PROGRAM FOR REINTEGRATION OF HOMELESS WOMEN VETERANS 
                    AND HOMELESS VETERANS WITH CHILDREN

    (a) Grants.--Subject to the availability of appropriations 
for such purpose, the Secretary of Labor shall award grants to 
eligible programs and facilities to provide the services 
described in subsection (c) to expedite the reintegration into 
the labor force of the following:
          (1) Homeless women veterans.
          (2) Homeless veterans with children.
    (b) Eligible Programs and Facilities.--A program or 
facility is an eligible program or facility for purposes of 
this section if the program or facility provides dedicated 
services for homeless women veterans or homeless veterans with 
children.
    (c) Services.--The services described in this subsection 
are the following:
          (1) Job training.
          (2) Counseling.
          (3) Job placement services, including job readiness, 
        literacy, and skills training.
          (4) Child care.
    (d) Minimum.--The Secretary shall ensure that not less than 
five percent of the aggregate of the grant amounts awarded 
under this section in each fiscal year is awarded to eligible 
programs and facilities located in rural areas.
    (e) Monitoring of Use of Funds.--The Secretary of Labor 
shall monitor and evaluate the use of amounts granted under 
this section. In monitoring and evaluating the use of such 
amounts, the Secretary shall collect from grantees such 
information as the Secretary considers appropriate, including 
data on the results or outcomes of the services provided to 
each homeless veteran under this section.
    (f) Administration.--The Secretary of Labor shall carry out 
this section through the Assistant Secretary of Labor for 
Veterans' Employment and Training.
    (g) Biennial Report to Congress.--The Secretary of Labor 
shall include as part of the report required by section 2021(d) 
of this title an evaluation of the grant program under this 
section. The information included in such report under this 
subsection shall include--
          (1) an evaluation of services furnished to veterans 
        under this section; and
          (2) an analysis of the information collected under 
        subsection (d).
    (h) Authorization of Appropriations.--(1) There is 
authorized to be appropriated to carry out this section 
$10,000,000 for each of fiscal years 2010 through 2014.
    (2) The amount authorized to be appropriated by paragraph 
(1) is in addition to any amounts authorized to be appropriated 
by section 2021(e) of this title.
    (3) Funds appropriated to carry out this section shall 
remain available until expended. Funds obligated in any fiscal 
year to carry out this section may be expended in that fiscal 
year and the succeeding fiscal year.

           *       *       *       *       *       *       *

                    Subchapter VII. Other Provisions

SEC. 2061. GRANT PROGRAM FOR HOMELESS VETERANS WITH SPECIAL NEEDS

    (a) Establishment.--The Secretary shall carry out a program 
to make grants to health care facilities of the Department and 
[to grant and per diem providers] to entities eligible for 
grants and per diem payments under sections 2011 and 2012 of 
this title in order to encourage development [by those 
facilities and providers] by those facilities and entities of 
programs for homeless veterans with special needs.
    (b) Homeless Veterans With Special Needs.--For purposes of 
this section, homeless veterans with special needs include 
homeless veterans who are--
          (1) women[, including women who have care of minor 
        dependents];
          (2) frail elderly;
          (3) terminally ill; [or]
          (4) chronically mentally ill[.] ; or
          (5) individuals who have care of minor dependents.
    (c) Provision of Services to Dependents.--A recipient of a 
grant under subsection (a) may use amounts under the grant to 
provide services directly to a dependent of a homeless veteran 
with special needs who is under the care of such homeless 
veteran while such homeless veteran receives services from the 
grant recipient under this section.
    (d) [(c)] Funding.--(1) * * *

           *       *       *       *       *       *       *

SEC. 2067. PREVENTION OF VETERAN HOMELESSNESS

    (a) Prevention of Veteran Homelessness.--Not later than 180 
days after the date of the enactment of this section, the 
Secretary shall establish a program to prevent veteran 
homelessness by--
          (1) identifying in a timely fashion any veteran who 
        is homeless or at imminent risk of becoming homeless; 
        and
          (2) providing, directly or in conjunction with an 
        existing program, assistance to veterans identified 
        under paragraph (1).
    (b) Types of Assistance.--The assistance provided under 
subsection (a)(2) may include the following:
          (1) The provision of short-term or medium-term rental 
        assistance.
          (2) Housing relocation and stabilization services, 
        including housing search, mediation, and outreach to 
        property owners.
          (3) Services to resolve personal credit issues that 
        have led to negative credit reports.
          (4) Assistance with paying security or utility 
        deposits and utility payments.
          (5) Assistance with covering costs associated with 
        moving.
          (6) A referral to a program of another department or 
        agency of the Federal Government.
          (7) Such other activities as the Secretary considers 
        appropriate to prevent veterans homelessness.
    (c) No Duplication of Services.--The Secretary may provide 
assistance under subsection (a)(2) to a veteran receiving 
supportive services from an eligible entity receiving financial 
assistance under section 2044 of this title only to the extent 
that the assistance provided under subsection (a)(2) does not 
duplicate the supportive services provided to such veteran by 
such entity or by any other Federal, State, or local entity.
    (d) Protection From Abuse.--To protect the program 
established under subsection (a) from abuse, the Secretary may 
establish a limit on the number of times that a particular 
veteran may receive assistance under the program in a fiscal 
year.
    (e) Staffing.--The Secretary shall assign such employees at 
such locations as the Secretary considers necessary to carry 
out this section.
    (f) Authorization of Appropriations.--There are authorized 
to be appropriated to carry out this section $50,000,000 for 
each of fiscal years 2010 through 2014.

SEC. 2068. HOMELESS VETERANS MANAGEMENT INFORMATION SYSTEM

    (a) Method for Data Collection and Aggregation.--(1) Not 
later than one year after the date of the enactment of this 
section, the Secretary shall, in consultation with the Special 
Assistant for Veterans Affairs of the Department of Housing and 
Urban Development and the United States Interagency Council on 
Homelessness established under section 201 of the McKinney-
Vento Homeless Assistance Act (42 U.S.C. 11311), establish a 
method for the collection and aggregation of data on homeless 
veterans participating in programs of the Department of 
Veterans Affairs and the Department of Housing and Urban 
Development, including the following with respect to such 
veterans:
          (A) Age, race, sex, disability status, marital 
        status, income, employment history, and whether the 
        veteran is a parent.
          (B) If the veteran received assistance for housing, 
        the number of days that the veteran resided in such 
        housing and the type of such housing.
          (C) If the veteran is no longer participating in a 
        program of assistance for the homeless, the reason the 
        veteran left the program.
    (2) The method required by paragraph (1) shall ensure that 
each veteran is counted only once.
    (b) Annual Data Collection and Aggregation.--Not later than 
one year after the method is established under subsection (a), 
and annually thereafter, the Secretary shall collect and 
aggregate data using the method established under subsection 
(a).
    (c) Annual Reports.--Not later than two years after the 
date of enactment of this section and annually thereafter, the 
Secretary shall submit to Congress a report on the data 
collected and aggregated under subsection (b).
    (d) Authorization of Appropriations.--There are authorized 
to be appropriated to carry out this section--
          (1) $10,000,000 for fiscal year 2010; and
          (2) such sums as may be necessary for fiscal years 
        2011 through 2014.

           *       *       *       *       *       *       *

Part V. Boards, Administrations, and Services

           *       *       *       *       *       *       *

 Chapter 73. Veterans Health Administration. Organization and Functions

Subchapter I. Organization

           *       *       *       *       *       *       *

SEC. 7306. OFFICE OF THE UNDER SECRETARY FOR HEALTH

    (a) * * *
          (1) * * *

           *       *       *       *       *       *       *

          [(9) The Advisor on Physician Assistants, who shall 
        be a physician assistant with appropriate experience 
        and who shall advise the Under Secretary for Health on 
        all matters relating to the utilization and employment 
        of physician assistants in the Administration.]
          (9) The Director of Physician Assistant Services, who 
        shall--
                  (A) serve in a full-time capacity at the 
                Central Office of the Department;
                  (B) be a qualified physician assistant; and
                  (C) be responsible and report directly to the 
                Chief Patient Care Services Officer of the 
                Veterans Health Administration on all matters 
                relating to the education and training, 
                employment, appropriate utilization, and 
                optimal participation of physician assistants 
                within the programs and initiatives of the 
                Administration.

           *       *       *       *       *       *       *

Title 5. Government Organization and Employees

           *       *       *       *       *       *       *

Part III. Employees

           *       *       *       *       *       *       *

Subpart D. Pay and Allowances

           *       *       *       *       *       *       *

Chapter 53. Pay Rates and Systems

           *       *       *       *       *       *       *

Subchapter II. Executive Schedule Pay Rates

           *       *       *       *       *       *       *

SEC. 5315. POSITIONS AT LEVEL IV

    Level IV of the Executive Schedule applies to the following 
positions, for which the annual rate of basic pay shall be the 
rate determined with respect to such level under chapter 11 of 
title 2,as adjusted by section 5318 of this title:

           *       *       *       *       *       *       *

          [Assistant Secretaries, Department of Veterans 
        Affairs (7).]
          Assistant Secretaries, Department of Veterans Affairs 
        (8)

           *       *       *       *       *       *       *

                   UNITED STATES HOUSING ACT OF 1937

Title 42. The Public Health and Welfare

           *       *       *       *       *       *       *

CHAPTER 8. LOW-INCOME HOUSING

           *       *       *       *       *       *       *

SUBCHAPTER I. GENERAL PROGRAM OF ASSISTED HOUSING

           *       *       *       *       *       *       *

SEC. 1437F. LOW-INCOME HOUSING ASSISTANCE

    (a) * * *

           *       *       *       *       *       *       *

    (o) Voucher program.
          (1) * * *

           *       *       *       *       *       *       *

          (19) Rental vouchers for veterans affairs supported 
        housing program.--
                  (A) Rental vouchers.--The Secretary shall 
                make available to public housing agencies 
                described in subparagraph (C) the amounts 
                described in subparagraph (B), to provide 
                rental assistance through a supported housing 
                program administered in conjunction with the 
                Department of Veterans Affairs.
                  (B) Amount.--The amounts specified in this 
                subparagraph are the amounts necessary to 
                ensure that--
                          (i) not more than 30,000 vouchers for 
                        rental assistance under this paragraph 
                        are outstanding at any one time during 
                        fiscal year 2010;
                          (ii) not more than 40,000 vouchers 
                        for rental assistance under this 
                        paragraph are outstanding at any one 
                        time during fiscal year 2011;
                          (iii) not more than 50,000 vouchers 
                        for rental assistance under this 
                        paragraph are outstanding at any one 
                        time during fiscal year 2012; and
                          (iv) not more than 60,000 vouchers 
                        for rental assistance under this 
                        paragraph are outstanding at any one 
                        time during fiscal year 2013 and each 
                        fiscal year thereafter.
                  (C) Public housing agencies.--A public 
                housing agency described in this subparagraph 
                is a public housing agency that--
                          (i) has a partnership with a 
                        Department of Veterans Affairs medical 
                        center or an entity determined to be 
                        appropriate by the Secretary of 
                        Veterans Affairs;
                          (ii) is located in an area that the 
                        Secretary of Veterans Affairs 
                        determines has a high concentration of 
                        veterans in need of assistance;
                          (iii) has demonstrated expertise in 
                        providing housing for homeless 
                        individuals; and
                          (iv) meets any other criteria that 
                        the Secretary, in consultation with the 
                        Secretary of Veterans Affairs may 
                        prescribe.
                  (D) Case management.--The Secretary of 
                Veterans Affairs shall ensure that the case 
                managers described in section 2003(b) of title 
                38, United States Code, provide appropriate 
                case management for each veteran who receives 
                rental assistance under this paragraph that--
                          (i) assists the veteran in--
                                  (I) locating available 
                                housing;
                                  (II) working with the 
                                appropriate public housing 
                                agency;
                                  (III) accessing benefits and 
                                health services provided by the 
                                Department of Veterans Affairs 
                                and other departments and 
                                agencies of the Federal 
                                Government;
                                  (IV) negotiating with 
                                landlords; and
                                  (V) other areas, as the 
                                Secretary determines is 
                                necessary to help the veteran 
                                maintain housing or avoid 
                                homelessness; and
                          (ii) ensures that a veteran with a 
                        severe disability, including a veteran 
                        that has been homeless for a 
                        substantial period of time, is referred 
                        to sufficient supportive services to 
                        provide the veteran with stable 
                        housing, including--
                                  (I) mental health services, 
                                including treatment and 
                                recovery support services;
                                  (II) substance abuse 
                                treatment and recovery support 
                                services, including counseling, 
                                treatment planning, recovery 
                                coaching, and relapse 
                                prevention;
                                  (III) integrated, coordinated 
                                treatment and recovery support 
                                services for co-occurring 
                                disorders;
                                  (IV) health education, 
                                including referrals for medical 
                                and dental care;
                                  (V) services designed to help 
                                individuals make progress 
                                toward self-sufficiency and 
                                recovery, including job 
                                training, assistance in seeking 
                                employment, benefits advocacy, 
                                money management, life-skills 
                                training, self-help programs, 
                                and engagement and motivational 
                                interventions;
                                  (VI) parental skills and 
                                family support; and
                                  (VII) other supportive 
                                services that promote an end to 
                                chronic homelessness.
          [(19) Rental vouchers for Veterans Affairs supported 
        housing program.--
                  [(A) Set aside.--Subject to subparagraph (C), 
                the Secretary shall set aside, from amounts 
                made available for rental assistance under this 
                subsection, the amounts specified in 
                subparagraph (B) for use only for providing 
                such assistance through a supported housing 
                program administered in conjunction with the 
                Department of Veterans Affairs. Such program 
                shall provide rental assistance on behalf of 
                homeless veterans who have chronic mental 
                illnesses or chronic substance use disorders, 
                shall require agreement of the veteran to 
                continued treatment for such mental illness or 
                substance use disorder as a condition of 
                receipt of such rental assistance, and shall 
                ensure such treatment and appropriate case 
                management for each veteran receiving such 
                rental assistance.
                  [(B) Amount.--The amount specified in this 
                subparagraph is--
                          [(i) for fiscal year 2007, the amount 
                        necessary to provide 500 vouchers for 
                        rental assistance under this 
                        subsection;
                          [(ii) for fiscal year 2008, the 
                        amount necessary to provide 1,000 
                        vouchers for rental assistance under 
                        this subsection;
                          [(iii) for fiscal year 2009, the 
                        amount necessary to provide 1,500 
                        vouchers for rental assistance under 
                        this subsection;
                          [(iv) for fiscal year 2010, the 
                        amount necessary to provide 2,000 
                        vouchers for rental assistance under 
                        this subsection; and
                          [(v) for fiscal year 2011, the amount 
                        necessary to provide 2,500 vouchers for 
                        rental assistance under this 
                        subsection.
                  [(C) Funding through incremental 
                assistance.--In any fiscal year, to the extent 
                that this paragraph requires the Secretary to 
                set aside rental assistance amounts for use 
                under this paragraph in an amount that exceeds 
                the amount set aside in the preceding fiscal 
                year, such requirement shall be effective only 
                to such extent or in such amounts as are or 
                have been provided in appropriation Acts for 
                such fiscal year for incremental rental 
                assistance under this subsection.]

           *       *       *       *       *       *       *

Chapter 44. Department of Housing and Urban Development

           *       *       *       *       *       *       *

SEC. 3533. OFFICERS OF DEPARTMENT

    (a) * * *

           *       *       *       *       *       *       *

    (g) Special Assistant for Veterans Affairs.--
          (1) Establishment.--There shall be in the Department 
        a Special Assistant for Veterans Affairs, who shall be 
        in the Office of the Secretary.
          (2) Appointment.--The Special Assistant for Veterans 
        Affairs shall be appointed by the Secretary, based 
        solely on merit and shall be covered under the 
        provisions of title 5, United States Code, governing 
        appointments in the competitive service.
          (3) Responsibilities.--The Special Assistant for 
        Veterans Affairs shall be responsible for--
                  (A) ensuring that veterans have access to 
                housing and homeless assistance under each 
                program of the Department providing such 
                assistance;
                  (B) coordinating all programs and activities 
                of the Department relating to veterans; and
                  (C) carrying out such other duties as may be 
                assigned to the Special Assistant by the 
                Secretary or by law.
      

                                  
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