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[Senate Report 110-473]
[From the U.S. Government Publishing Office]

                                                      Calender No. 1034
110th Congress                                                   Report
                                 SENATE
 2d Session                                                     110-473

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

 
            VETERANS' HEALTH CARE AUTHORIZATION ACT OF 2008

                                _______
                                

   September 18 (legislative day, September 17, 2008.--Ordered to be 
                                printed

                                _______
                                

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

                              R E P O R T

                             together with

                           SUPPLEMENTAL VIEWS

                         [To accompany S. 2969]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (S. 2969), to 
enhance the capacity of the Department of Veterans Affairs to 
recruit and retain nurses and other critical health care 
professionals, and for other purposes, having considered an 
amendment to the bill in the nature of a substitute, 
unanimously reports favorably thereon with an amendment, and an 
amendment to the title, and recommends that the bill, as 
amended, do pass.

                              Introduction

    On May 1, 2008, Chairman Akaka introduced S. 2969, the 
proposed ``Veterans' Health Care Authorization Act of 2008.'' 
S. 2969, as introduced, would enhance the capacity of the 
Department of Veterans Affairs (hereinafter, ``VA'') to recruit 
and retain nurses and other critical health care professionals.
    Earlier, on October 31, 2007, Chairman Akaka introduced, by 
request, S. 2273, the proposed ``Enhanced Opportunities for 
Formerly Homeless Veterans Residing in Permanent Housing Act of 
2007.'' S. 2273 would enhance services for previously homeless 
veterans and for veterans at risk of becoming homeless.
    On November 16, 2007, Senator Durbin introduced S. 2377, 
the proposed ``Veterans Health Care Quality Improvement Act.'' 
S. 2377 would establish quality assurance mechanisms in VA 
medical facilities, and would create additional certification 
and licensure requirements for VA physicians. S. 2377 is 
cosponsored by Senator Obama.
    On April 2, 2008, Chairman Akaka introduced S. 2796. S. 
2796 would require VA to conduct a pilot program on the use of 
community-based organizations to ensure that transitioning 
veterans and their families receive the care and benefits to 
which they are entitled.
    On April 2, 2008, Chairman Akaka introduced, by request, S. 
2797. S. 2797 would authorize major medical facility projects 
and major medical facility leases for VA for fiscal year 2009, 
among other purposes related to facilities.
    On April 2, 2008, Senator Murray introduced S. 2799, the 
proposed ``Women Veterans Health Care Improvement Act of 
2008.'' S. 2799 would require studies of the health care needs 
of women veterans and of the services available to them from 
VA, and would require expansion of the services available to 
women veterans. S. 2799 is cosponsored by Senators Boxer, 
Brown, Casey, Clinton, Hutchison, Johnson, Lincoln, Mikulski, 
Murkowski, Rockefeller, Schumer, and Wyden.
    On April 17, 2008, Chairman Akaka introduced, by request, 
S. 2889, the proposed ``Veterans Health Care Act of 2008.'' S. 
2889 would allow VA to contract with community residential care 
programs for veterans with serious traumatic brain injuries 
(hereinafter, ``TBI''), eliminate copayments for all hospice 
care, expand continuing education benefits for physicians and 
dentists, and allow the Secretary of Veterans Affairs 
(hereinafter, ``Secretary'') to disclose certain personal 
information to collect payment from third-party health plans 
under certain circumstances.
    On April 22, 2008, Senator Harkin introduced S. 2899, the 
proposed ``Veterans Suicide Study Act.'' S. 2899 would direct 
VA to conduct a study on suicides among veterans. S. 2899 is 
cosponsored by Senators Feingold, Grassley, Kerry, Klobuchar, 
Mikulski, Murray, Obama, Stabenow, and Tester.
    On April 28, 2008, Senator Clinton introduced S. 2921, the 
proposed ``Caring for Wounded Warriors Act of 2008.'' S. 2921 
would create pilot programs on training, certification, and 
compensation for family caregivers of veterans and members of 
the Armed Forces withTBI, and on the provision of respite care 
to such veterans and servicemembers by graduate students at 
affiliated universities. S. 2921 is cosponsored by Senator 
Dole.
    On April 28, 2008, Chairman Akaka introduced S. 2926, the 
proposed ``Veterans Nonprofit Research and Education 
Corporations Enhancement Act of 2008.'' S. 2926 would authorize 
multi-medical center nonprofit research corporations 
(hereinafter, ``NPCs''), clarify existing authorities, and 
strengthen VA oversight of NPCs.
    On April 29, 2008, Senator Tester introduced S. 2937. S. 
2937 would provide VA with permanent authority to provide 
health care for participants in certain Department of Defense 
(DOD) chemical and biological tests, and would expand the study 
of the impact of Project Shipboard Hazard and Defense 
(hereinafter, ``Project SHAD'') on veterans' health.
    On May 1, 2008, Senator Bond introduced S. 2963. S. 2963 
would, among other things, enhance the mental health care 
services available to members of the Armed Forces and veterans, 
and enhance counseling and other benefits available to 
survivors of members of the Armed Forces and veterans. S. 2963 
is cosponsored by Senators Boxer, Clinton, Collins, Dole, 
Domenici, Grassley, McCaskill, Murkowski, Obama, and Stevens.
    On May 6, 2008, Chairman Akaka introduced, by request, S. 
2984, the proposed ``Veterans' Benefits Enhancement Act of 
2008.'' S. 2984 would extend VA authorities for certain kinds 
of long-term care and care for veterans who participated in 
certain chemical and biological tests conducted by DOD, extend 
VA authority to continue an audit recovery program, eliminate 
or modify a number of reporting requirements, modify 
authorities relating to collections from third parties for 
certain medical care, authorize disclosure of certain personal 
information in limited circumstances, increase the threshold 
for major medical facility leases requiring Congressional 
approval from $600,000 to $1,000,000, and provide authorities 
for the operation and upkeep of the VA police force. S. 2984 
would also address a number of matters related to veterans' 
benefits.
    On May 8, 2008, Chairman Akaka introduced S. 3000, the 
proposed ``Native American Veterans Access Act of 2008.'' S. 
3000 would include Federally recognized tribal organizations in 
certain programs for State veterans homes.
    On June 19, 2008, Ranking Member Burr introduced S. 3167. 
S. 3167 would clarify the conditions under which veterans, 
their surviving spouses, and their children may be treated as 
adjudicated mentally incompetent for certain purposes.
    On June 23, 2008, Ranking Member Burr introduced S. 3178. 
S. 3178 would authorize a dental insurance program for 
veterans, survivors, and dependents of veterans.
    On March 11, 2008, the Committee held a hearing on care for 
families of wounded veterans. Testimony was offered by: Col. 
Peter Bunce (USAF, Ret.), father of Justin Bunce, a veteran of 
Operation Iraqi Freedom; Robert Verbeke, father of Daniel 
Verbeke, a veteran of Operation Iraqi Freedom; Jackie 
McMichael, wife of Michael McMichael, a veteran of Operation 
Iraqi Freedom; Lynda Davis, PhD, Deputy Assistant Secretary of 
the Navy for Military Personnel Policy, Department of the Navy; 
Kristen Day, LCSW, Chief Consultant, Care Management and Social 
Work, Office of Patient Care Services, Veterans Health 
Administration, Department of Veterans Affairs; Jane Dulin, 
LCSW, Supervisor, Soldier Family Management Branch, U.S. Army 
Wounded Warrior Program; and Steven Sayers, PhD, Clinical 
Psychologist, Philadelphia VA Medical Center and Assistant 
Professor of Psychology in Psychiatry and Medicine, University 
of Pennsylvania School of Medicine.
    On April 9, 2008, the Committee held an oversight hearing 
on personnel issues within VA. Testimony was offered by: Marisa 
W. Palkuti, MEd, Director, Healthcare Retention and Recruitment 
Office, Veterans Health Administration, Department of Veterans 
Affairs; Sheila M. Cullen, Director, San Francisco VA Medical 
Center; Steven P. Kleinglass, Director, Minneapolis VA Medical 
Center; Marjorie Kanof, MD, Managing Director, Health Care, 
Government Accountability Office; John A. McDonald, MD, PhD, 
Vice President for Health Sciences and Dean, University of 
Nevada School of Medicine, on behalf of the Association of 
American Medical Colleges; Valerie O'Meara, NP, VA Puget Sound 
Health Care System, Professional Vice President, American 
Federation of Government Employees Local 3197; Randy Phelps, 
PhD, Deputy Executive Director, American Psychological 
Association Practice Directorate; and Jennifer L. Strauss, PhD, 
Health Scientist, Center for Health Services Research in 
Primary Care, Durham VA Medical Center, and Assistant 
Professor, Department of Psychiatry and Behavioral Sciences, 
Duke University Medical Center, on behalf of the Friends of VA 
Medical Care and Health Research.
    On May 21, 2008, the Committee held a hearing on pending 
health care legislation. Testimony was offered by: Gerald M. 
Cross, MD, Principal Deputy Under Secretary for Health, 
Department of Veterans Affairs; accompanied by Walter Hall, 
Assistant General Counsel; and Kathryn Enchelmayer, Director, 
Quality Standards, Office of Quality and Performance, Veterans 
Health Administration; Carl Blake, National Legislative 
Director, Paralyzed Veterans of America; Joseph L. Wilson, 
Assistant Director for Health Policy, Veterans Affairs and 
Rehabilitation Commission, The American Legion; Joy J. Ilem, 
Assistant National Legislative Director, Disabled American 
Veterans; Chris Needham, Senior Legislative Associate, National 
Legislative Service, Veterans of Foreign Wars; Stan Luke, PhD, 
Vice President for Programs, Helping Hands Hawaii; J. David 
Cox, RN, National Secretary-Treasurer, American Federation of 
Government Employees; Cecilia McVey, MHA, RN, Former President, 
Nurses Organization of Veterans Affairs; Donna Lee McCartney, 
Chair, National Association of Veterans' Research and Education 
Foundations; Thomas Berger, PhD, Chair, National PTSD and 
Substance Abuse Committee, Vietnam Veterans of America; and 
Sally Satel, MD, Resident Scholar, American Enterprise 
Institute.

                           Committee Meeting

    After carefully reviewing the testimony from the foregoing 
hearings, the Committee met in open session on June 26, 2008, 
to consider, among other legislation, an amended version of S. 
2969, consisting of provisions from S. 2969 as introduced, from 
other legislation noted above, and several freestanding 
provisions. The Committee voted unanimously to report favorably 
S. 2969, as amended.

                     Summary of S. 2969 as Reported

    S. 2969, as reported, (hereinafter, ``the Committee bill'') 
would amend the title of the original bill, and would make 
numerous enhancements and expansions to VA health care and 
services.

                 TITLE I--DEPARTMENT PERSONNEL MATTERS

    Section 101 would authorize VA to extend title 38, United 
States Code (U.S.C.), employment status to certain employees; 
amend salary authorities for certain VA positions; amend the 
statute governing certain work schedules; amend the statute 
governing transparency and conduct of locality pay surveys; and 
enhance other authorities to improve recruitment and retention 
of medical professionals.
    Section 102 would impose limitations on overtime duty and 
would amend the statutes governing weekend duty and alternative 
work schedules for nurses.
    Section 103 would reauthorize and expand certain 
educational assistance programs to improve recruitment and 
retention.
    Section 104 would establish standards for appointment and 
practice of physicians in VA medical facilities.

                     TITLE II--HEALTH CARE MATTERS

    Section 201 would repeal the sunset provision on the 
inclusion of non-institutional extended care services in the 
definition of medical services.
    Section 202 would extend the authorities of nursing home 
care, research corporations, and recovery audits.
    Section 203 would provide permanent authority for the 
provision of hospital care, medical services, and nursing home 
care to veterans who participated in certain chemical and 
biological testing conducted by DOD.
    Section 204 would repeal the annual reporting requirements 
on nurse pay and long-term planning.
    Section 205 would amend the annual Gulf War research report 
by changing the report due date.
    Section 206 would mandate that payment by VA on behalf of a 
covered beneficiary for the Civilian Health and Medical Program 
of VA (hereinafter, ``CHAMPVA'') medical care shall constitute 
payment and eliminate any liability on the part of the 
beneficiary for that care.
    Section 207 would modify authorities relating to 
collections from third parties for medical care, including care 
provided to children of Vietnam veterans born with spina bifida 
or birth defects.
    Section 208 would authorize VA to make disclosures from 
certain medical records under limited circumstances.
    Section 209 would require the disclosure to the Secretary 
of health plan contract information and social security numbers 
of certain veterans receiving care from VA.
    Section 210 would require the designation of a National 
Quality Assurance Officer, and a Quality Assurance Officer for 
each VA facility.
    Section 211 would require a report on Department health 
care quality assurance.
    Section 212 would require VA to establish a pilot program 
on training and certification for family caregivers and 
personal care attendants for veterans of the Armed Forces with 
TBI.
    Section 213 would require VA to establish a pilot program 
on the provision of respite care to members of the Armed Forces 
and veterans with TBI by students in graduate programs of 
education related to mental health or rehabilitation.
    Section 214 would require VA to establish a pilot program 
on the use of community-based organizations to ensure that 
transitioning veterans and their families receive the care and 
benefits they need.
    Section 215 would authorize VA to contract with appropriate 
entities for specialized residential care and rehabilitation 
for certain Operation Iraqi Freedom or Operation Enduring 
Freedom (hereinafter, ``OIF/OEF'') veterans with TBI.
    Section 216 would exempt veterans receiving hospice care 
from copayment requirements.
    Section 217 would repeal the limitation on the authority of 
the Secretary to conduct a widespread human immunodeficiency 
virus (hereinafter, ``HIV'') testing program.
    Section 218 would authorize VA to disclose medical records 
to a third party for collection of charges for care or services 
provided for a non-service-connected disability.
    Section 219 would require VA to establish an expanded study 
on the health impact of Project SHAD.
    Section 220 would require VA to provide care and services 
to certain individuals in non-Department facilities under 
limited circumstances.
    Section 221 would authorize tribal organizations to access 
the construction grants and per diem payments provided under 
the State Veterans Home Program in the same manner as other 
eligible entities.
    Section 222 would authorize the extension of the pilot 
program on improvement of caregiver assistance services through 
fiscal year 2009.
    Section 223 would require VA to establish a pilot program 
on the provision of dental insurance plans to veterans, 
survivors, and dependents of veterans.

                 TITLE III--WOMEN VETERANS HEALTH CARE

    Section 301 would require VA to report on the barriers to 
women veterans' access to VA health care.
    Section 302 would require VA to develop a plan to improve 
the provision of health care services to women veterans.
    Section 303 would require an independent study on the 
health consequences of service in OIF/OEF for women veterans.
    Section 304 would require VA to implement a program of 
training and certification for VA mental health care providers 
on care for veterans suffering from military sexual trauma.
    Section 305 would require VA to establish a pilot program 
on counseling in retreat settings for women veterans newly 
separated from service in the Armed Forces.
    Section 306 would require a report on full-time women 
veterans' program managers at VA medical centers.
    Section 307 would require the Advisory Committees on Women 
Veterans and Minority Veterans to include women veterans 
recently separated from service in the Armed Forces.
    Section 308 would require VA to establish a pilot program 
on child care for certain veterans receiving health care from 
VA.

                      TITLE IV--MENTAL HEALTH CARE

    Section 401 would establish eligibility for members of the 
Armed Forces who served in OIF/OEF for readjustment counseling 
and related mental health services through the Readjustment 
Counseling Service of the Veterans Health Administration.
    Section 402 would restore the authority of the Readjustment 
Counseling Service to provide referral and other assistance to 
former members of the Armed Forces not otherwise authorized for 
counseling.
    Section 403 would require VA to conduct a study on suicides 
among veterans since January 1, 1997, and report to Congress on 
the findings.
    Section 404 would require VA to transfer $5,000,000 to the 
Secretary of Health and Human Services for the Graduate 
Psychology Education program.

                       TITLE V--HOMELESS VETERANS

    Section 501 would authorize VA to establish a pilot program 
to make grants to public and nonprofit organizations that 
coordinate the provision of supportive services to formerly 
homeless veterans residing on certain military property.
    Section 502 would authorize VA to establish a pilot program 
to make grants to public and nonprofit organizations that 
coordinate the provision of supportive services to formerly 
homeless veterans residing in permanent housing.
    Section 503 would authorize VA to establish a pilot program 
to make grants to public and nonprofit organizations that 
provide outreach to inform low-income and elderly veterans who 
reside in rural areas about pension benefits.
    Section 504 would authorize VA to establish a pilot program 
on financial support of entities that provide transportation 
assistance, childcare assistance, and clothing assistance to 
veterans entitled to certain rehabilitation services.
    Section 505 would require assessments of the pilot programs 
authorized by sections 501 through 504.
    Section 506 would increase the authorization for the 
Homeless Grant and Per Diem (GPD) Program from $130,000,000 to 
$200,000,000.

        TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS

    Section 601 would authorize multi-medical center NPCs, 
expand existing corporations to multi-medical center research 
corporations, amend authorities on the applicability of state 
law, clarify the status of corporations, and reinstate the 
requirement of 501(c)(3) status of corporations.
    Section 602 would clarify the purpose of NPCs.
    Section 603 would amend the requirements for VA and non-VA 
Board Members.
    Section 604 would amend and clarify the provision on 
general powers of corporations.
    Section 605 would redesignate section 7364A of title 38, 
U.S.C., as section 7365.
    Section 606 would amend the provision on reporting by 
adding additional information to be reported on; amend the 
provision related to the confirmation of application of 
conflict of interest regulations to include appropriate 
corporation positions; and authorize establishment of an 
appropriate payee reporting threshold.
    Section 607 would repeal the provision that sunsets the 
authority for corporations after December 31, 2008.

                        TITLE VII--CONSTRUCTION

    Section 701 would authorize funds for fiscal year 2009 
major medical facility projects.
    Section 702 would extend the authorization for major 
medical facility construction projects previously authorized.
    Section 703 would authorize funds for fiscal year 2009 
major medical facility leases.
    Section 704 would authorize the appropriation of 
$1,902,014,000 for the projects authorized by sections 701 
through 703.
    Section 705 would increase the threshold for major medical 
facility leases requiring congressional approval from $600,000 
to $1,000,000.
    Section 706 would approve the conveyance of certain non-
federal land by the city of Aurora, CO, to the Secretary for 
construction of a VA medical facility.

                  TITLE VIII--MISCELLANEOUS PROVISIONS

    Section 801 would expand the authority for VA police 
officers.
    Section 802 would provide a uniform allowance for VA police 
officers.
    Section 803 would clarify the conditions under which 
veterans, their surviving spouses, and their children may be 
treated as adjudicated mentally incompetent for certain 
purposes.

                       Background and Discussion

                 TITLE I--DEPARTMENT PERSONNEL MATTERS

    Title I of the Committee bill contains a variety of 
provisions that are designed to help ensure that VA has the 
workforce necessary to serve America's veterans most 
effectively.
    Health care providers are the backbone of the VA system. 
Yet today, it is clear, based on information received by the 
Committee during its April 9, 2008, oversight hearing on the 
Veterans Health Administration (hereinafter, ``VHA'') personnel 
issues, entitled ``Making VA the Work Place of Choice for 
Health Care Professionals,'' and from myriad other sources, 
that VA faces a looming shortage of health care personnel and 
that this situation will only worsen in the coming years 
without focused effort to improve VA's ability to attract and 
retain needed employees. A recent report by the Partnership for 
Public Service, titled Where the Jobs Are: Mission Critical 
Opportunities for America (2nd edition, 2007), gave the VHA 
poor marks for pay and benefits, and for family support. VHA 
also rated poorly among younger employees. To be the health 
care employer of choice, VA must be able to offer competitive 
salaries, work schedules, and benefits.
    In recent years, VA has faced changing demands for health 
care and for increasing competition for health care 
professionals. The Bureau of Labor Statistics showed an 18.4 
percent increase in employment in the health care industry in 
2006, and noted that employment rose significantly in 
hospitals, ambulatory health care settings, and nursing and 
residential care. With an aging veteran population, and a shift 
towards non-institutional care, VA has increased hiring of home 
health aides and nurses significantly. The return of 
servicemembers from the conflicts in Iraq and Afghanistan has 
brought new demands for specialized mental health, trauma, 
rehabilitation, and other care.
    Health care professionals employed by VA are hired under a 
variety of authorities--the regular, government-wide, personnel 
hiring authorities in title 5, United States Code (U.S.C.); the 
VA-specific personnel authority in title 38, U.S.C., and a 
hybrid employment system that relies on features of both title 
5 and title 38 authorities. The employment of persons in 
occupations--physicians, dentists, podiatrists, chiropractors, 
optometrists, registered nurses, physician assistants, and 
expanded-function dental auxiliaries--listed in section 7401(1) 
of title 38, U.S.C., is governed entirely by the title 38 
system. Other occupations, listed in section 7401(3), are 
referred to as hybrid employees.
    The title 38 appointment system, established shortly after 
World War II, was designed to be more flexible than the title 5 
system. It provides an employment process and compensation 
policies and practices that are helpful to VA in effectively 
recruiting and retaining health care providers. For example, 
under title 38, prospective hires are not required to go 
through the competition and ranking process to establish 
eligibility for employment, as is required under title 5.
    Beginning in 1983, with the passage of the ``Veterans 
Health Care Amendments of 1983,'' Public Law 98-160, Congress 
authorized VA to hire, advance, and pay certain health care 
providers under title 38, while leaving those personnel under 
the title 5 personnel system for other purposes. The 
appointment of individuals to these so-called ``hybrid'' 
occupations is governed by title 38, while pay and grievances 
are governed by title 5. Hybrid employees are also eligible for 
additional premium pay, if the Secretary determines it 
necessary for the purposes of recruitment and retention.
    Public Law 98-160 authorized VA to appoint and advance 
licensed practical/vocational nurses (LPNs/LVNs), physical 
therapists, and respiratory therapists under the hybrid system. 
Additional occupations were included in 2003, under Public Law 
108-170, in 2004, under Public Law 108-422, and in 2006, under 
Public Law 109-461.
    VA has indicated that this title 38 hybrid employment 
system permits the Department to proactively respond to 
recruitment and retention issues and reduces the costs 
associated with these issues.

Sec. 101. Enhancement of authorities for retention of medical 
        professionals.

    Section 101 of the Committee bill, which is derived from S. 
2969, as introduced, contains a number of provisions that would 
amend a variety of specific personnel authorities in title 38, 
United States Code, so as to give the Secretary additional 
tools to retain health care personnel.

Subsec. 101(a)--Secretarial authority to extend title 38 status to 
        additional positions.

    Background. The unique features of the title 5, title 38, 
and title 38 hybrid personnel systems have resulted in uneven 
conditions of employment for some employees working in the same 
occupational series and occupational groups. For example, 
corrective therapy Assistants, hired under title 5, provide 
services under the same occupational series as occupational 
therapy assistants and physical therapy assistants, hired as 
title 38 hybrids. All three work in the same organizational 
units providing rehabilitation therapy, but are hired and 
employed under different conditions.
    In addition, testimony submitted by VA for the record of 
the May 21, 2008, Committee hearing, stated that nurse 
assistants, in particular, are a high priority position that 
has proven difficult to fill. Furthermore, turnover of nurse 
assistants is fairly high.
    Committee Bill. Subsection (a)(1) of section 101 of the 
Committee bill would amend section 7401(3) of title 38, so as 
to give the Secretary of VA the authority to apply the title 38 
hybrid employment system to additional health care occupations 
when such action is deemed necessary to meet recruitment or 
retention needs. The Secretary would be required to notify the 
House and Senate Committees on Veterans' Affairs and the Office 
of Management and Budget (OMB) 45 days prior to implementing a 
decision to convert an occupation to the hybrid system. Prior 
to Congressional and OMB notification, VA would be required to 
notify labor organizations representing VHA employees in 
occupations being considered for inclusion, in order to seek 
their comments.
    In testimony submitted for the record of the Committee's 
May 21, 2008, hearing, VA indicated that it supports the 
provisions of this subsection as this change would give the 
Secretary the ability to react quickly, through the title 38 
hiring process, to bring on additional employees.
    Subsection (a)(2) of section 101 of the Committee bill 
would further amend section 7401(3) by adding nurse assistants 
to the list of occupations eligible for appointment under title 
38. By bringing this position under the title 38 hiring 
process, VA will have the ability to expedite hiring to fill 
nurse assistant positions.
    In accordance with the original purpose for a separate 
title 38 hiring system, it is the Committee's intent that VA 
continue to have the ability to expedite the hiring of certain 
health care personnel. The Committee is aware that, as 
presently implemented, the hiring process under title 38 has 
not proven as expeditious as intended and that concerns have 
been raised that adding additional professions to the list of 
hybrid positions could overburden the title 38 hybrid 
employment system. It is the Committee's belief, however, that 
VA has the capacity, resources, and responsibility to resolve 
the obstacles to expedited hiring under title 38.
    In testimony submitted for the Committee's May 21, 2008, 
hearing, VA indicated that it supports the provisions of 
subsection (a)(2) of this section of the Committee bill. VA 
cited data showing turnover rates of 10.5 percent for 2006 and 
11.1 percent for 2007, which illustrate the great difficulty VA 
experiences in retaining nurse assistants.

Subsec. 101(b) and (c)--Probationary periods for registered nurses, and 
        prohibition on temporary part-time registered nurse 
        appointments in excess of 4,180 hours.

    Subsections (b) and (c) of section 101 of the Committee 
bill are addressed below together, as they are dependent upon 
each other, and address similar issues.
    Subsection (b) would modify the terms of the probationary 
period that registered nurses must serve upon employment by VA, 
and subsection (c) would limit the extent of a temporary 
appointment of part-time registered nurses.
    Background. Subsection 7403(b) of title 38, U.S.C., 
provides that appointments of health care providers under that 
section shall be for a probationary period of two years. The 
probationary period serves to ensure an appropriate time of 
observation and vetting before an employee becomes permanent.
    Currently, part-time RNs are employed by VA on a temporary 
basis under section 7405 of title 38. As temporary employees, 
they are not eligible for the same job protection and grievance 
rights as employees appointed under section 7403 who have 
completed the probationary periods. Further, when an employee 
transitions from full to part-time, they are considered 
employees under section 7405, with commensurate loss of rights 
and protections. Valerie O'Meara, NP, representing the American 
Federation of Government Employees, testified before the 
Committee on April 9, 2008, about her experience switching from 
full- to part-time status to raise a family. She explained that 
she lost her grievance and arbitration rights, and was not 
permitted to contest Reductions-In-Force decisions. Further, 
she described the cases of older nurses who have worked a 
decade or more for the VA who switch to part-time because of 
the stress of their job or to care for their aging parents. The 
Committee believes VA would benefit from retaining the 
expertise of these registered nurses, even on a part-time 
basis.
    VA has been challenged to fill RN positions due to rising 
demand for these professionals. In testimony submitted for the 
record of the Committee's April 9, 2007, hearing, Ann Converso, 
RN, President of United American Nurses, AFL-CIO, stated that 
``[t]here exists a health care crisis in our country regarding 
the shortage of registered nurses * * *. As nurses leave the VA 
system, new nurses are not joining the VA at comparable rates, 
and patient load is increasing.'' According to the testimony of 
Sheila M. Cullen, Director, San Francisco VA Medical Center, at 
that same hearing, more than 29 percent of the employees at the 
San Francisco VA Medical Center are eligible to retire.
    Committee Bill. Subsections (b) and (c) of section 101 of 
the Committee bill would clarify the terms of a probationary 
period under section 7403 of title 38, U.S.C., and address the 
inequity faced by part-time nurses under section 7405 of title 
38.
    Subsection (b) would amend section 7403(b) by adding two 
new paragraphs. New paragraph (2) would mandate that an 
appointment of a registered nurse under the section, whether on 
a full- or part-time basis, shall be for a probationary period 
of a length considered appropriate by VA but in any event no 
more than 4,180 hours. The intent of this provision is to 
establish a maximum duration of the probationary period that 
can be applied equitably to both full- and part-time 
appointments. Further, it provides the Secretary with 
additional authority to reduce the duration of the probationary 
period.
    New paragraph (3) would mandate that an appointment on a 
part-time basis under section 7403 of a health care 
professional who has previously served on a full-time basis 
shall be without a probationary period. This provision would 
clarify that no registered nurse (RN), who has already served a 
probationary period, would be required to serve a probationary 
period upon switching from a full-time to a part-time 
appointment. The Committee sees no utility in requiring an RN 
who has served a probationary period on a full-time basis to 
serve an additional probationary period.
    Subsection (c) of section 101 would amend section 7405 of 
title 38, to add a new subsection (g). The proposed new 
subsection would specify that the appointment of an RN on a 
temporary part-time basis under section 7405 would be for a 
probationary period, as defined under section 7403(b), as would 
be amended by subsection (b) of section 101 of the Committee 
bill. Upon completion of the probationary period, the 
appointment would no longer be considered temporary, and would 
instead be considered an appointment under 7403(a). Pursuant to 
this change, and the completion of the probationary period, all 
temporary part-time appointments of RNs would be considered 
permanent.
    It is the Committee's intent that the amendments to 
sections 7403 and 7405 will eliminate disincentives to part-
time employment of RNs in VA. Many RNs, after serving a full 
career in VA, or in response to family concerns, are faced with 
the decision to either retire from VA or transition to part-
time service. Informed by the testimony presented at the 
Committee hearings on April 9, 2008, and May 21, 2008, the 
Committee believes VA would benefit from the service that these 
registered nurses would provide on a part-time basis. Further, 
increased use of part-time registered nurses will help VA fully 
staff facilities and better meet the rising demand for health 
care services.
    It is not the intent of the Committee bill to prevent or 
limit the hiring of part-time nurses beyond the probationary 
period. Rather, the Committee intends that upon completion of 
such period, the appointment be considered permanent, with all 
accompanying benefits and privileges.
    Carl Blake, National Legislative Director, Paralyzed 
Veterans of America, in testimony before the Committee on May 
21, 2008, voiced support for the provision to eliminate the 
probationary period for RNs who transition from full-time to 
part-time.

Subsec. 101(d)--Waiver of offset from pay for certain reemployed 
        annuitants.

    Subsection (d) of section 101 of the Committee bill would 
authorize VA to waive salary offsets for retirees who are 
reemployed in VHA.
    Background. Under current law, the salary of a VHA employee 
rehired after retirement from the Federal government is reduced 
according to the amount of their annuity under a government 
retirement system. The reduction is required by sections 8344 
and 8468 of title 5, U.S.C., which deal with annuity payments 
upon reemployment.
    VHA faces a growing wave of retirements at all levels of 
administration and health care providers. According to VA, at 
the end of 2006, 56 percent of medical center directors were 
eligible for retirement, and by 2013 over 90 percent of these 
key personnel will be eligible for retirement. Many of the 
likely successors for the director positions, current Associate 
Directors, are also retirement eligible. VA projects that by 
2013, 95,019 VHA employees will be eligible to retire, 
including 97 percent of current senior executives, 81 percent 
of facility Chiefs of Staff, and 91 percent of nurse 
executives. This rate of retirement eligibility is 
unprecedented, and the sudden loss of the experience and 
expertise of these employees would seriously limit VA's ability 
to deliver care.
    Because reemployed annuitants receive only that portion of 
their salary that is above their annuity payment, there is 
little incentive under the current employment system to return 
to VA employment. Annuitants who wish to continue working are 
able to receive full pay from a non-government employer, in 
addition to their annuity, something they can not do at VA.
    In testimony before the Committee on May 21, 2008, Cecilia 
McVey, MHA, RN, former President of the Nurses Organization of 
Veterans Affairs, said that ``During this time of a critical 
nursing shortage, it is more important than ever to keep these 
valuable resources to provide the best care to veterans.''
    Rehiring annuitants addresses issues arising from the high 
number of retirements facing VA. Increased employment of 
annuitants would potentially limit costs by reducing the use of 
expensive contract agreements. Retaining experienced 
professionals while younger employees develop their 
capabilities would also ensure the transfer of valuable 
institutional knowledge from one generation of leaders to 
another within VA.
    A program which allows the Government Accountability Office 
to temporarily hire retirees, without a salary offset, for the 
purposes of training, education, and mentoring, has proven 
successful.
    Committee Bill. Subsection (d) of section 101 of the 
Committee bill would amend section 7405 of title 38 so as to 
add a new subsection (g) which would authorize the Secretary to 
waive sections 8344 and 8468 of title 5, U.S.C., on a case-by-
case basis when reemploying an annuitant on a temporary basis. 
This section would further require that an annuitant to whom a 
waiver under the proposed new section (g) is granted be subject 
to the provisions of chapter 71 of title 5, relating to the 
protection of government employees from discrimination and 
retaliation.
    By authorizing the Secretary to waive these two sections of 
title 5, the Committee intends to encourage retirees to return 
to work at VHA. At present, many VA employees go on to work 
outside of VA after retiring from VA, with some even returning 
to work at VA on a contract basis. By eliminating the salary 
offset, it is the Committee's hope that there will be a 
significant pay incentive that will encourage annuitants to 
return to VA, rather than seeking employment elsewhere.

Subsec. 101(e)--Rate of basic pay for appointees to the Office of the 
        Under Secretary for Health set to rate of basic pay for senior 
        executive service positions.

    Subsection (e) of section 101 of the Committee bill would 
amend section 7404(a) of title 38, U.S.C., to set the rate of 
basic pay for appointees to the Office of the Under Secretary 
for Health.
    Background. Under current law, non-physician and non-
dentist appointees under section 7306 of title 38, which 
relates to the composition of VA's Office of Under Secretary 
for Health, including the Director of Pharmacy Benefits 
Management Strategic Health Group, the Director of Dietetics, 
the Director of Podiatry, and the Director of Optometry, among 
others, serve in executive level positions that are equivalent 
in scope and responsibility to positions in the Senior 
Executive Service (SES), which includes senior managers and 
administrators in the VA Central Office, among others. The pay 
level for section 7306 appointees is adjusted each year by 
Executive Order, as authorized by chapter 53 of title 5, and is 
capped, by subsection 7404(d) of title 38, U.S.C., at the pay 
rate for Level V of the Executive Schedule, currently just over 
$139,600 including locality pay. VA employees in the SES, on 
the other hand, can receive pay up to Level II of the Executive 
Schedule, currently $172,200.
    According to VA, the disparity between pay levels for SES 
and non-SES employees serving in similar capacities has led to 
difficulties in recruiting and retaining non-SES executive 
level managers. Executives in these positions provide valuable 
input to the Under Secretary for Health (USH), and manage 
significant elements of VHA.
    Committee Bill. Subsection (e) of section 101 of the 
Committee bill would amend section 7404(a) of title 38 so as to 
add a paragraph that would mandate that pay for certain 
appointees to the Office of the Under Secretary for Health be 
set according to the SES. This change would be effective on the 
first day of the first pay period beginning the day after 180 
days after the date of enactment of this legislation.
    This change would effectively establish that, for the 
purposes of basic pay, all senior executives in the Office of 
the Under Secretary for Health would receive pay based on Level 
II of the Executive Schedule. By implementing a uniform pay 
scale for all senior executives in that office, the Committee 
believes VA will be better able to recruit and retain highly 
qualified individuals.
    This provision was developed in close cooperation with VA, 
and VA indicated its support for this subsection in testimony 
submitted for the record of the Committee's May 21, 2008, 
hearing.
    In testimony before the Committee on May 21, 2008, Thomas 
Berger, PhD, Chair of the National PTSD and Substance Abuse 
Committee, Vietnam Veterans of America (VVA), expressed VVA's 
support for additional pay ``to enhance recruitment and 
retention of top professionals to run the VA health care 
system.''

Subsec. 101(f)--Comparability pay program for appointees to the Office 
        of the Under Secretary for Health.

    Background. VA is challenged match the compensation offered 
by non-Federal employers to senior executives. The past decade 
has seen significant changes in VA health care. In order to 
maintain its position as a premier health care provider, VHA 
will require a corps of dedicated, skilled, and experienced 
senior executives to carry out the responsibilities involved in 
delivering care to veterans. The Committee believes that VA 
must deal with pay inequities proactively.
    Committee Bill. Subsection (f) of section 101 of the 
Committee bill would amend section 7410 of title 38, relating 
to additional pay authorities for VHA employees, so as to 
authorize VHA to pay ``comparability pay'' of not more than 
$100,000 per employee to non-physician/dentist section 7306 
employees and VHA SES employees. This pay would be authorized 
so that VHA could achieve annual pay levels competitive with 
the private sector, and to relieve pay compression over the 
complex range of senior executive positions. This special pay 
would be in addition to all pay, awards, and performance 
bonuses provided under SES or 7306 authorities. Under the 
Committee bill, the higher special pay amounts would be 
reserved only for the most senior VHA executive positions and, 
when added to basic pay and bonus compensation, would be capped 
at the annual pay of the President.

Subsec. 101(g)--Special incentive pay for Department pharmacist 
        executives.

    Background. VA is challenged match the compensation offered 
by non-Federal employers to senior executives, including 
National Pharmacist Executives (NPEs). NPEs include managers of 
the VA National Formulary, Directors of the Consolidated Mail 
Outpatient Pharmacies, Consultants to the Secretary for 
pharmacy issues, Network Pharmacy Benefits Managers, and the 
Director of Emergency Pharmacy Services. Under current law, 
basic salaries for NPEs are set according to the General 
Schedule, which caps salaries for these positions between 
$140,000 and $145,000, with up to $5,000 in bonuses. According 
to surveys conducted by VA, salary ranges for national and 
regional pharmacy executives are between $180,000 and $225,000. 
Further inducements commonly available in the private sector 
include profit sharing or stock options, yearly bonuses well 
above the $5,000 currently available from VA, recruitment and 
retention bonuses, and corporate vehicles for individuals in 
regional positions.
    VA has been challenged to fill NPE positions in recent 
years, due largely to the pay disparity between VA and the 
private sector, and the lack of financial incentive to take on 
responsibilities at the national and regional level. In 
addition, applications for Chief of Pharmacy positions at VA 
facilities, the primary source of future NPEs, have fallen off 
dramatically. The Workforce Succession Strategic Plan for VHA 
FY 2006-2010 (October, 2005), listed pharmacists second only to 
RNs as national priorities for recruitment and retention.
    Committee Bill. Subsection 101(g) of the Committee bill 
would further amend section 7410, relating to additional pay 
authorities, to authorize recruitment and retention special 
incentive pay for pharmacist executives of up to $40,000. The 
determination of whether to provide such pay, and its amount, 
would be based on: grade, step, scope and complexity of the 
position, personal qualifications, characteristics of the labor 
market concerned, and such other factors as the Secretary 
considers appropriate. As with the comparability pay that would 
be authorized by subsection (f) of the Committee bill, this 
provision would provide that such pay would be in addition to 
other pay, awards, and bonuses.

Subsec. 101(h)--Pay for physicians and dentists.

    Subsection 101(h) of section 101 of the Committee bill 
would make three separate amendments to section 7431 of title 
38, relating to pay for physicians and dentists.
    Committee Bill. Paragraph (1) of subsection (h) would 
clarify the determination of the non-foreign cost of living 
adjustment (COLA), authorized by section 7431(b) of title 38, 
U.S.C. The COLA is provided to employees in locations with 
substantially higher costs of living than those of Washington, 
DC, and or environmental conditions that differ substantially 
from those in the continental United States. Similar 
provisions, applied to other government employees, exist in 
section 5941 of title 5, U.S.C.
    Paragraph (1) of subsection 101(h) of the Committee bill 
would amend section 7431(b) so as to add a new paragraph that 
would provide that the non-foreign cost of living adjustment 
allowance authorized under section 5941 of title 5, U.S.C., 
shall, in the case of VA physicians and dentists, be determined 
as a percentage of base pay only. Section 7431(b) currently 
does not specify the basis for the determination of the 
allowance, which has led to inconsistent determinations.
    Paragraph (2) of subsection (h) would amend section 
7431(c)(4)(B)(i) to exempt physicians and dentists in executive 
leadership provisions from the panel process in determining the 
amount of market pay and tiers for such physicians and 
dentists. Market pay is ``pay intended to reflect the 
recruitment and retention needs for the specialty or assignment 
* * * of a particular physician or dentist'' in a VA facility. 
Under current law, the Secretary is to take into account the 
views of ``an appropriate panel or board'' in determining the 
amount of market pay for an individual physician or dentist. In 
cases where such physicians or dentists in question occupy 
executive leadership positions such as chief officers, network 
directors, and medical center directors, the consultation of a 
panel has some limitations. The small number of providers who 
would qualify as peers for the executive leaders results in 
their serving on each other's compensation panels. This 
amendment will provide the Secretary with discretion to 
identify executive physician/dentist positions that do not 
require a panel process.
    Paragraph (3) of subsection (h) would amend section 
7431(c)(7) of title 38, so as to allow an exception to the 
prohibition in current law on a reduction in market pay when a 
physician or dentist remains in the same position or 
assignment. The exception would allow for a reduction in market 
pay when there has been a change in board certification or a 
reduction of privileges, even when the individual remains in a 
position or assignment. By allowing such reduction in market 
pay, the Committee bill would prevent a physician or dentist 
from receiving additional market compensation for credentials 
and or privileges he or she may no longer possess.
    In testimony submitted for the record of the Committee 
hearing on May 21, 2008, VA indicated support for the 
provisions in subsection 101(h) of the Committee bill.

Subsec. 101(i)--Adjustment of pay cap for nurses.

    Subsection (i) of section 101 of the Committee bill relates 
to pay for RNs.
    Background. Under current law, section 7451 of title 38 
governs basic pay levels for VA RNs, and certain other VA 
employees. Section 7451(c)(2) mandates that the maximum rate of 
basic pay for any grade for a covered position, including RNs, 
may not exceed the maximum rate of basic pay established for 
positions in level V of the Executive Schedule under section 
5316 of title 5, U.S.C. Level V is currently set at $139,600.
    In testimony submitted for the Committee's April 9, 2008, 
hearing, Ms. Converso cited a ``crisis in our country regarding 
the shortage of registered nurses.'' At the same hearing, 
Marisa W. Palkuti, M.Ed., Director, Healthcare Retention and 
Recruitment Office, VHA, cited a growing inadequacy in the 
number of health care workers, including RNs, nationwide, and 
suggested that ``[t]his shortfall will grow exponentially over 
the next 20 years.''
    During that hearing, Sheila M. Cullen, the then-Director of 
the San Francisco VA Medical Center, testified about her 
efforts to retain nurses. To compete with other health care 
employers in the region, and to address the high cost of 
living, Ms. Cullen has instituted salary increases for RNs 
between 5 and 8 percent annually in recent years.
    The current level V cap often prevents VA registered nurses 
from receiving locality pay. Locality pay, which is in addition 
to basic pay, is based on compensation levels in a local labor 
market. When a nurse's basic pay is equal to the level V cap, 
no additional locality pay can be awarded, regardless of 
conditions in local labor market, a result that has a 
detrimental effect on recruitment and retention.
    Committee Bill. Subsection (i) of section 101 of the 
Committee bill would amend section 7451(c)(2) of title 38, so 
as to adjust the pay cap for registered nurses and others in 
covered positions from Level V to Level IV. Level IV is 
currently set at $149,000, according to OMB. By raising the cap 
on nurse basic pay by $9,400, the Committee intends to provide 
VA with additional flexibility to compete in local labor 
markets. Based on testimony presented at Committee hearings, 
and on oversight activities, the Committee believes that 
additional pay would improve VA's ability to recruit and retain 
qualified nurses.
    This provision was supported by the American Federation of 
Government Employees in testimony before the Committee on April 
9 and May 21, 2008. Also, in testimony before the Committee on 
May 21, 2008, Cecilia McVey, MHA, RN, Former President of the 
Nurses Organization of Veterans Affairs, called for the 
increase in the cap on RN pay proposed by the Committee bill.

Subsec. 101(j)--Exemption for certified registered nurse anesthetists 
        from limitation on authorized competitive pay.

    Subsection (j) of section 101 of the Committee bill would 
allow pay for certified registered nurse anesthetists (CRNAs) 
to exceed the pay caps established for RNs employed by VA.
    Background. As discussed above, under subsection 101(i), 
current law limits pay for CRNAs at level V of the Executive 
Schedule, currently $139,600. Additional compensation may be 
provided to CRNAs in the form of recruitment and/or retention 
bonuses. As is currently the case with RNs, the level V cap 
often prevents CRNAs from receiving locality pay.
    In December 2007, the Government Accountability Office 
released a report on CRNA retention, titled ``Department of 
Veterans Affairs (VA) medical facilities have challenges in 
recruiting and retaining VA CRNAs for their workforce'' (GAO-
08-56). GAO found that about three-fourths of all VA medical 
facility chief anesthesiologists responding to the survey 
reported that they had difficulty recruiting CRNAs. Overall, 54 
percent of VA medical facility chief anesthesiologists reported 
temporarily closing some operating rooms and 72 percent 
reported delaying some elective surgeries due to difficulty 
fully staffing CRNAs. GAO projected that 26 percent of VA's 
CRNAs will either retire from or leave VA in the next 5 years. 
VA medical facility officials reported that the recruitment and 
retention challenges are caused primarily by the low level of 
VA CRNA salaries when compared with CRNA salaries in local 
market areas.
    In testimony before the Committee on April 9, 2008, Ms. 
Cullen, and Steven P. Kleinglass, Director of the Minneapolis 
VA Medical Center, both discussed the challenges created by the 
current limit on CRNA pay. Mr. Kleinglass noted that at the 
Minneapolis VAMC, the VA pay scale falls behind the local 
medical community as a whole, and that ``therefore, in theory, 
we should have most of our employees on a retention bonus.'' 
Ms. Cullen, in San Francisco, is prevented from offering 
locality pay due to the statutory limit, even though the local 
median salary for CRNAs is $171,334. As a result, she has had 
to implement the 25 percent retention incentive extensively. At 
the same hearing, Ms. O'Meara echoed these concerns. 
``Facilities around the country are finding it increasingly 
difficult to recruit CRNAs.''
    Committee Bill. Subsection (j) of section 101 of the 
Committee bill would further amend section 7451(c)(2) of title 
38, as amended by subsection 101(i) of the Committee bill, to 
allow pay for CRNAs to exceed the pay caps established for RNs 
employed by VA.
    This proposed exemption would provide VA with greater 
flexibility to offer additional pay to CRNAs, a necessary tool 
when CRNA positions prove difficult to fill due to insufficient 
compensation.
    This proposed amendment was endorsed in testimony before 
the Committee on May 21, 2008, by Carl Blake, National 
Legislative Director, Paralyzed Veterans of America and J. 
David Cox, RN, National Secretary-Treasurer, American 
Federation of Government Employees.

Subsec. 101(k)--Locality pay scale computation.

    Subsection 101(k) of the Committee bill would amend section 
7451(d)(3) of title 38, U.S.C., to improve implementation and 
transparency of VA's locality pay system for nurses and others 
in covered positions.
    Background. Section 7451(d) of title 38 currently 
authorizes a locality pay system (LPS) to address 
geographically-related pay issues, and to strengthen 
recruitment and retention of nurses and others in covered 
positions. That section mandates that pay for personnel in 
covered positions at each facility be adjusted periodically to 
reflect changing pay rates in local labor markets. The director 
of each facility is charged with using data from the Bureau of 
Labor Statistics (BLS) to determine prevalent pay rates, and to 
make necessary adjustments to the pay of nurses and others in 
covered positions employed by the facility in question. When 
BLS data are not available, the director is required to use 
data provided by a third party. If no third party data are 
available, the director is required to conduct a locality pay 
survey to determine prevalent pay rates. Each locality pay 
schedule, of which there are nearly 800, is required to be 
reviewed and approved by the USH.
    In the report titled ``Many Medical Facilities Have 
Challenges Recruiting and Retaining Nurse Anesthetists'' (GAO-
08-56, December, 2007), GAO found that, in 2005 and in 2006, 
over half of VA medical facilities used the LPS to determine 
whether to adjust VA CRNA salaries. However, in the eight VA 
medical facilities visited, GAO found that the majority of the 
facilities did not correctly follow VA's LPS policy. Officials 
at these facilities did not always know or were not aware of 
certain aspects of the LPS policy, and VA has not provided 
training on the LPS to VA medical facility officials since the 
policy was changed in 2001. As a result, GAO found that VA 
medical facility officials cannot ensure that VA CRNA salaries 
have been adjusted as needed to be competitive. While the 
report dealt only with CRNAs, the conclusions regarding faulty 
implementation of the LPS are likely applicable to others in 
covered positions, based on Committee oversight activities.
    The failure to properly implement the LPS runs the risk of 
negatively effecting recruitment and retention, and 
inappropriately limits the pay of nurses and others who 
continue their employment at VA. Further, due to a lack of 
transparency of the LPS process, employees do not have 
reasonable access to the surveys that determine locality pay.
    Committee Bill. Subsection (k)(1) of section 101 of the 
Committee bill would add a new subparagraph (F) to section 
7451(d)(3) of title 38. Proposed new subsection (F) would 
require the USH to provide appropriate education, training, and 
support to directors of Department health care facilities in 
the conduct and use of LPS surveys. The Committee intends for 
this change to address the inadequate training found by GAO.
    In testimony before the Committee on April 9, 2008, Ms. 
O'Meara emphasized the need for adequate training in the use 
and implementation of the LPS. At the Committee hearing on May 
21, 2008, Mr. Cox stated that ``management training on the 
nurse locality pay process will increase compliance with the 
2000 nurse locality pay law [The Veterans Benefits and Health 
Care Improvement Act of 2000, Public Law 106-419] that Congress 
enacted to address recruitment and retention.''
    In testimony submitted for the record of the Committee 
hearing on April 9, 2008, VA stated that development of web-
based training to assist in the conduct of surveys was expected 
to be available by late summer 2008, and that additional 
training events are planned. The Committee believes these are 
important improvements in education on the LPS, but believes 
that additional measures may be required.
    Subsection (k)(2) of section 101 of the Committee bill 
would add a new subparagraph (D) to section 7451(e)(4) of title 
38. Under this proposed new subparagraph (D), which is intended 
to improve transparency in the LPS, a facility director would 
be required to publicize information on the methodology used in 
making an adjustment to rates of pay based on the LPS.
    Subsection (k)(3) of section 101 of the Committee bill 
would further amend section 7451(e) by adding a new paragraph 
(6). Under current law, each facility director is required to 
report to the Secretary on wage-related staffing issues. 
Proposed new paragraph (6) would require such reports to be 
made available to any individual in a position included in such 
report, or, upon the authorization of such individual, to the 
representative of the labor organization representing that 
individual. Taken together, the Committee believes that the 
changes proposed by subsections (k)(2) and (3) of section 101 
of the Committee bill will improve transparency of the LPS.
    These amendments address concerns raised in testimony 
before the Committee on May 21, 2008, by Mr. Cox, and on April 
9, 2008, by Ms. O'Meara. According to Mr. Cox, ``greater 
employee access to pay survey data will add accountability to 
the locality pay process to ensure that surveys are done 
properly and that needed pay adjustments are made.''
    The Committee is aware that in some facilities, access to 
LPS survey data is unnecessarily challenging for many 
employees. As Ms. O'Meara said in her testimony on April 9, 
2008, ``[l]ocality pay should be provided based on local labor 
market conditions, and be paid according to consistent rules, 
not on how hard employees fight for it or whether a particular 
manager decides to pay it.''
    Concerns have been raised that the Committee bill places 
inordinate emphasis on the conduct of LPS surveys, rather than 
the use of BLS or third party data, which VA prefers. The 
Committee recognizes the value of BLS and third party data and 
does not intend that facility directors conduct their own 
surveys when such information is available. The Committee 
believes that, implemented effectively and according to 
statute, the LPS can effectively address geographically-related 
pay issues, and can strengthen recruitment and retention.

Subsec. 101(l)--Increased limitation on special pay for nurse 
        executives.

    Subsection 101(l) of the Committee bill would increase the 
authorized limit on special pay for nurse executives.
    Background. Under current law, the Secretary may provide 
between $10,000 and $25,000 in special pay to nurse executives 
at each VA health care facility and at VA Central Office. The 
amount is determined based on the grade of the nurse executive 
position, the scope and complexity of the nurse executive 
position, the personal qualifications of the nurse executive, 
the characteristics of the health care facility concerned, the 
nature and number of specialty care units at the health care 
facility concerned, demonstrated difficulties in recruitment 
and retention of nurse executives at the health care facility 
concerned, and such other factors as the Secretary considers 
appropriate.
    Given the limits on nurse pay, most nurse executives are 
already paid at or near the top of their grade. As such, VA 
lacks the ability to provide additional financial incentive to 
individuals who take on the increased responsibility of 
executive positions. Given the systemic shortage of nurses, as 
discussed with respect to sections 101(i) and 101(j) of the 
Committee bill, the Committee believes that additional 
financial incentives are warranted to attract highly qualified 
nurses to executive positions.
    Committee Bill. Subsection (l) of section 101 of the 
Committee bill would amend section 7452(g)(2) of title 38 so as 
to increase the authorized limit on special pay for nurse 
executives from $25,000 to $100,000.
    In testimony before the Committee on May 21, 2008, Mr. 
Blake expressed PVA's support for this provision of the 
Committee bill.

Subsec. 101(m)--Eligibility of part-time nurses for additional nurse 
        pay.

    Subsection (m) of section 101 of the Committee bill, which 
is derived from S. 2969, would expand eligibility for 
additional premium pay to part-time nurses.
    Background. Additional pay for nurses is authorized by 
section 7453 of title 38. In general, nurses are eligible for 
overtime pay when they work over forty hours in a week or eight 
hours in a day. Further additional pay is mandated for nurses 
who work on weekends, at night, and on holidays. Other than 
overtime pay, eligibility for additional pay is limited to 
nurses working on specified tours of duty that meet the 
requirements of each type of additional pay. Those nurses not 
assigned to a specific tour are not eligible for the additional 
pay associated with such tour, even if their period of service 
includes hours which fall within the eligible time periods. 
This limit affects the pay of both full- and part-time nurses, 
as well as nurses who are on call and not assigned to tours of 
duty.
    Based on testimony presented at Committee hearings, and 
information gathered during Committee oversight activity, as 
discussed with respect to subsections (i) and (j) of section 
101 of the Committee bill, the Committee concludes that in many 
facilities VA is challenged to fill nurse staff positions and 
some nursing tours are difficult to cover. The Committee 
believes that the current eligibility criteria for additional 
pay are too restrictive to create effective financial 
incentives to encourage nurses to work those tours.
    Further, the current additional pay statute creates 
unacceptable inequities between part-time and full-time nurses. 
In testimony before the Committee on April 9, 2008, Ms. O'Meara 
cited chronic problems with implementation of additional pay 
requirements. She urged ``the Committee to take steps to ensure 
that premium pay is available to all RNs who perform services 
on weekends or off shifts, work overtime on a voluntary or 
mandatory basis, or work during on call duty.'' By not 
providing part-time nurses additional pay on the same basis as 
full-time nurses, there is a disincentive for part-time and on-
call nurses to serve during times of the day and week that are 
harder to staff. This is contrary to the intent of the 
additional pay authorities.
    In addition, excluding part-time and on-call nurses from 
eligibility for additional pay, and denying additional pay for 
nurses not assigned to a specific eligible tour, creates 
further disparity between VA and non-VA compensation, and 
contributes to recruitment and retention challenges.
    Committee Bill. Subsection (m) of section101 of the 
Committee bill would amend section 7453 of title 38 so as to 
expand eligibility for additional premium pay to part-time 
nurses.
    An amendment to subsection (a) of section 7453 would 
provide that part-time nurses would be generally eligible for 
additional pay when they meet the criteria in other subsections 
of section 7453. Amendments to subsections (b)(concerning 
evening pay), (c) (concerning weekend pay), and (d) (concerning 
overtime pay), would, in multiple locations, replace ``tour of 
duty'' with ``period of service.'' These changes would make any 
service performed during evenings or weekends, or as overtime, 
eligible for additional pay.
    It is the Committee's intent to change the basis for 
additional pay from the tour to the nurse's period of service 
and the timing of such service. This reflects the original 
Congressional intent that additional pay is intended to create 
incentives for nurses to work at times that would otherwise be 
difficult to staff. The changes proposed by the Committee bill 
would not eliminate the utility of established tours nor would 
they reduce additional pay for such tours. Rather, the changes 
would encourage a greater number of nurses to work during such 
times, and would equitably reward all nurses who do so.
    In testimony before the Committee on May 21, 2008, Mr. 
Blake expressed the support of Paralyzed Veterans of America 
for the eligibility of part-time nurses to receive additional 
pay.
    Subsection (m)(1)(D)(i) of section 101 of the Committee 
bill would address an inequity in eligibility for additional 
pay for overtime under section 7453(e) of title 38. Under 
current law, nurses who perform continuous service in excess of 
eight hours but on two different calendar days are not eligible 
for additional pay for overtime service. This section of the 
Committee bill would amend section 7453(e) to add service 
performed in excess of eight consecutive hours to the list of 
services eligible for additional overtime pay. In testimony 
before the Committee on April 9, 2008, Ms. O'Meara emphasized 
the urgency of this legislative change.

Subsec. 101(n)--Exemption of additional nurse positions from limitation 
        on increase in rates of basic pay.

    Subsection (n) of section 101 of the Committee bill, which 
is derived from S. 2969, would make additional health care 
occupations exempt from limitations on increases in rates of 
basic pay.
    Background. Under current law, rates of basic pay for 
nurses and other health care providers may be increased under 
section 7455 of title 38. Under that section, the Secretary may 
determine that salary increases are necessary for the purposes 
of recruitment and retention, and to compete with pay for 
similar positions in non-Federal facilities in the same labor 
market.
    Under subsection (c)(1) of section 7455, the amount of 
increase in the maximum pay rate generally is limited to two 
times the amount by which the original maximum exceeds the 
minimum, and the maximum rate as so increased may not exceed 
the pay rate of the Assistant Under Secretary for Health. Nurse 
anesthetists, pharmacists, and licensed physical therapists are 
exempted from this limit, based on the challenges VA faces in 
recruiting and retaining employees in these occupations, as 
discussed earlier in connection with subsections (g), (i), and 
(j) of section 101 of the Committee bill.
    Committee Bill. Subsection (n) of section 101 of the 
Committee bill would amend section 7455(c)(1) of title 38 so as 
to make additional occupations exempt from limitations on 
increases in rates of basic pay. Specifically, this provision 
would add licensed practical nurses, licensed vocational 
nurses, and nursing positions otherwise covered by title 5, 
U.S.C., to the list of positions exempted from the limits 
imposed by section 7455(c)(1) of title 38. This provision, 
combined with subsection (i) of section 101 of the Committee 
bill, should ensure that VA has the pay flexibility to compete 
with other employers for qualified health care providers. In 
testimony before the Committee on April 9 and May 21, 2008, 
respectively, Ms. O'Meara and Mr. Cox emphasized the need for 
additional pay flexibility to strengthen VA's ability to 
compete with other employers.

Sec. 102. Limitations on overtime duty, weekend duty, and alternative 
        work schedules for nurses.

    Subsection 102 of the Committee bill, which is derived from 
S. 2969, would amend various provisions of title 38 so as to 
establish special rules for nurse staff overtime service, 
modify rules relating to leave during weekend duty, and change 
the underlying authority for alternative work schedules for 
nurses.

Subsec. 102(a)--Overtime duty.

    Background. Under current law, the Secretary may require 
nurses to perform mandatory overtime in emergency situations. 
The Committee recognizes that this authority is essential to 
ensuring adequate staffing to provide patient care. However, 
based on oversight activities, and as discussed at the 
Committee hearing on April 9, 2008, it appears that, at some 
facilities, the use of emergency mandatory overtime is 
excessive and even abusive.
    At the Committee hearing on April 9, 2008, Ms. O'Meara 
testified that ``facility directors continue to invoke the 
emergency exception when staffing shortages are the result of 
easily anticipated scheduling and hiring problems.'' At that 
same hearing, testimony on this issue was received from two VA 
medical center directors, Steven P. Kleinglass, of the 
Minneapolis VA Medical Center, and Sheila M. Cullen, of the San 
Francisco VA Medical Center. These two facilities illustrate 
two different approaches to the use of the emergency mandatory 
overtime authority. According to Mr. Kleinglass, in 
Minneapolis, mandatory overtime is used to respond to a number 
of situations, including unplanned leave, sick leave, emergency 
annual leave, absenteeism, and tardiness for duty by nursing 
staff. At the San Francisco VA Medical Center, on the other 
hand, mandatory overtime has been used only once in the past 
three years, an event implemented in cooperation with the local 
bargaining unit.
    The Committee is concerned that VA lacks a clear definition 
of ``emergency'' for the purposes of implementing mandatory 
overtime and that VA facility directors appear to have 
unbridled discretion on the interpretation and implementation 
of this authority. Without a clear definition of what 
constitutes allowable situations, the use of emergency 
authority can lead to inconsistent implementation and abuse.
    Research has highlighted the danger of excessive overtime 
service by nurses, as well as other health care providers. In 
the report ``Keeping Patients Safe: Transforming the Work 
Environment of Nurses'' (2004), the Institute of Medicine 
recommended that ``to reduce error-producing fatigue, state 
regulatory bodies should prohibit nursing staff from providing 
patient care in any combination of scheduled shifts, mandatory 
overtime, or voluntary overtime in excess of 12 hours in any 
given 24-hour period and in excess of 60 hours per 7-day 
period.''
    At least nine states have enacted legislation restricting 
the use of emergency mandatory overtime. In the interest of 
patient and employee safety and appropriate labor standards, 
these states limit the number of hours a nurse can be required 
to work, except in certain defined emergency situations.
    Committee Bill. Subsection (a) of section 102 of the 
Committee bill would add a new section 7459 to subchapter IV of 
chapter 74 of title 38. This new section would limit nursing 
staff, including RNs, licensed practical or vocational nurses, 
nurse assistants appointed under title 38 or title 5, U.S.C., 
or any other nurse position designated by the Secretary, to no 
more than 40 hours of work per administrative work week (or 24 
hours if such staff is covered by section 7456 of title 38), 
and not more than eight consecutive hours (or 12 hours if such 
staff is covered by sections 7456 or 7456A of title 38). 
Nursing staff may exceed these limits voluntarily or in 
emergency situations, as defined by the Committee bill.
    The definition of ``emergency circumstances'' would be set 
out in subsection (c) of the proposed new section 7459. Under 
this subsection, the Secretary would be authorized to require 
mandatory overtime otherwise prohibited if the following 
conditions were met: (1) the work is a consequence of an 
emergency that could not have been reasonably anticipated; (2) 
the emergency is non-recurring and is not caused by or 
aggravated by the inattention of the Secretary or lack of 
reasonable contingency planning by the Secretary; (3) the 
Secretary has exhausted all good faith, reasonable attempts to 
obtain voluntary workers; (4) the nurse staff have critical 
skills and expertise that are required for the work; and (5) 
the work involves work for which the standard of care for a 
patient assignment requires continuity of care through 
completion of a case, treatment, or procedure. Nursing staff 
would not be required to work hours after the requirement for a 
direct role by the staff in responding to medical needs 
resulting from the emergency ends.
    The concern has been raised by VA that the requirements of 
the Committee bill would unduly limit the Secretary's ability 
to ensure patient care and safety. The Committee agrees 
unequivocally that patient safety is of paramount concern. 
However, the Committee is concerned that undue reliance on 
mandatory overtime is not desirable and believes that, with 
reasonable contingency planning, including consultation with 
nurse staff, all VA facilities have the capacity to eliminate 
unnecessary use of emergency mandatory overtime. It is clear 
that many VA facilities already avoid unnecessary use of 
emergency mandatory overtime through effective planning for 
adequate nurse staffing.
    Subsection (b)(2) of the proposed new section 7459 would 
prohibit discrimination or adverse personnel action against 
nursing staff if such staff were to refuse to work hours 
prohibited by such section. This protection has proven 
necessary in the many of the states which have legislatively 
limited mandatory overtime, including Connecticut, Maryland, 
Minnesota, New Jersey, and Washington.
    In testimony before the Committee on May 21, 2008, Mr. Cox 
expressed AFGE's support for this provision of the Committee 
bill. He stated that these provisions ``will establish a 
sensible and safe overtime policy that ensures that all nursing 
positions are equally protected.''

Subsec. 102(b)--Weekend duty.

    Section 102(b) of the Committee bill, which is derived from 
S. 2969, would modify the calculation of leave for nurses 
working two 12-hour tours of duty during a weekend.
    Background. Section 7456 of title 38 authorizes the 
Secretary to provide an alternate work schedule, commonly 
referred to as the Baylor Plan, to nurse employees. Under this 
plan, an employee who performs two regularly scheduled 12-hour 
tours of duty on a weekend is paid for a full forty hours. 
Under current law, an employee who is absent on approved sick 
leave or annual leave during such a regularly scheduled 12-hour 
tour of duty is charged for such leave at a rate of five hours 
of leave for three hours of absence.
    The Baylor Plan is intended to be used when facilities are 
challenged to meet staffing needs on weekends. VA currently has 
no nurses employed under this plan.
    Committee Bill. Section 102(b) of the Committee bill would 
strike section 7456(c) of title 38, to modify the calculation 
of leave for nurses working under the Baylor Plan. The change 
would specify that leave for such an employee would be charged 
at a rate of one to one.
    The Committee expects that eliminating the current leave 
calculation will facilitate easier implementation of the Baylor 
Plan. The provision in the Committee bill was modified from an 
earlier version so as to address concerns raised by VA and to 
better achieve this goal.

Subsec. 102(c)--Alternative work schedules.

    Subsection (c) of section 102 of the Committee bill, which 
is derived from S. 2969, would modify an existing alternative 
work schedule available to VA nurses.
    Background. Section 7456A of title 38, U.S.C., authorizes 
the Secretary to provide alternative work schedules to RNs 
working for VA. These schedules, known as ``36/40'' schedules, 
allow VA nurses to work three regularly scheduled 12-hour tours 
of duty within a work week and to have that service considered 
for all purposes as a full 40-hour basic work week. These 
alternative work schedules are authorized ``in order to obtain 
or retain the services of registered nurses.''
    Alternative work schedules were authorized in December 2004 
by the Department of Veterans Affairs Health Care Personnel 
Enhancement Act of 2004, Public Law 108-445. According to the 
Senate report accompanying the legislation that resulted in the 
new law, S. Rpt. 108-375, this new authority was a response to 
an August 2003 request by VA so as to ``enhance its ability to 
recruit and retain high quality nurses.'' In that report, the 
Committee noted that, based on a survey conducted in 2000 by 
the American Organization of Nurse Executives, inflexible 
scheduling was a major cause of nurse dissatisfaction. The 
original intent of Congress in authorizing alternative work 
schedules was that such schedules be widely available so as to 
enhance VA's ability to improve employee satisfaction and 
therefore be better able to recruit and retain nurses in 
competition with other employers.
    Since the passage of Public Law 108-445, the implementation 
of 36/40 alternative work schedules has varied throughout the 
VA health care system. In testimony for the Committee hearing 
on April 9, 2008, VA indicated that it ``encourages facility 
managers to use alternate work schedules for all eligible 
employees whenever feasible,'' and noted that the use of these 
schedules ``increases VA's visibility as the employer of 
choice.''
    Some facilities, such as the San Francisco VA Medical 
Center, have made effective use of alternative schedules to 
reduce vacancy rates in nursing positions, and to improve nurse 
satisfaction. In testimony before the Committee on April 9, 
2008, the San Francisco VA Medical Center Director, Ms. Cullen, 
stated that ``most new hires are highly interested in an 
alternative work schedule. We believe that offering an 
alternative work schedule improves recruitment, retention and 
employee satisfaction.''
    Mr. Kleinglass, the Director of the Minneapolis VAMC, in 
testimony before the Committee on April 9, 2008, noted that the 
use of alternative schedules at the Minneapolis VA Medical 
Center allows staff to ``find balance between their work and 
home lives as they feel best suits their individual needs.''
    Unfortunately, based on Committee oversight work, many VA 
facilities have failed to make 36/40 alternative work schedules 
widely available. While facility directors have discretion on 
the implementation of these schedules, Congress intended that 
their use be throughout the VA health care system. In testimony 
before the Committee on April 9, 2008, Ms. O'Meara stated:

        As a result of delay and resistance by the VA at the 
        national and local levels, [alternative work schedules] 
        have failed to meet their potential for addressing VA 
        nurse recruitment and retention problems. It seems as 
        if the law was never passed.

    Committee Bill. Subsection (c) of section 102 of the 
Committee bill would amend section 7456A of title 38, U.S.C., 
so as to modify the 36/40 alternative work schedule authorized 
by that section. Specifically, this section of the Committee 
bill would amend section 7456A(b)(1)(A) to modify the 
scheduling requirement for the 36/40 alternative work schedule. 
Currently, the 36/40 alternative work schedule is defined as 
``three regularly scheduled 12-hour tours of duty within a work 
week.'' The Committee bill would redefine the schedule as six 
regularly scheduled 12-hour periods of service within an 80-
hour pay period.
    The intent of this provision is to facilitate easier 
implementation of the alternative work schedule. In testimony 
for the Committee hearing on May 21, 2008, VA noted that 
because a work week is defined as Sunday through Saturday, it 
is often difficult schedule three 12-hour tours in their 
entirety within one work week. VA expressed support for these 
provisions of the Committee bill, as they would provide greater 
flexibility to scheduling.
    By providing greater flexibility in the scheduling of the 
alternative work schedule, the Committee intends to facilitate 
and encourage wider use of such schedules. Based on hearing 
testimony and oversight activities, the Committee believes that 
by unnecessarily limiting the use of the current 36/40 
alternative work schedules, VA facilities forego a valuable 
recruitment and retention tool, and fail to keep pace with the 
health care industry.

Sec. 103. Improvements to certain educational assistance programs.

    Section 103 of the Committee bill, which is derived from S. 
XXXX, would make amendments to two existing VA Education 
Assistance Programs and would provide the Secretary with new 
authority to make repayment of educational loans for certain 
health professionals.
    Background. Chapter 76 of title 38, U.S.C., contains 
numerous authorities that are designed to enhance VA's ability 
to attract and retain health professions. Among these 
authorities are the Health Professional Scholarship Program, in 
Subchapter II and the Education Debt Reduction Program, in 
Subchapter VII.
    The authorization for the programs needs to be extended in 
order to continue to give VA this ability, as the private 
sector has made recruiting health care professionals 
increasingly competitive. Title VII of Public Law 105-368 and 
Public Law 107-135 made amendments to these programs. VA 
currently awards Employee Incentive Scholarship Program 
(hereinafter ``EISP'') scholarships to qualifying and current 
employees to help VHA meet the health care staffing 
requirements set forth in Section 7401 of title 38, U.S.C., in 
which the difficulties surrounding recruitment and retention of 
VA health care employees is specifically addressed.
    Committee Bill. Subsection (a) of section 103 of the 
Committee bill would amend section 7618 of title 38, U.S.C., so 
as to reinstate the Health Professionals Educational Assistance 
Program (HPEAP) through the end of 2013. The Committee believes 
that renewing HPEAP, which expired in 1988, will help reduce 
the nursing shortage in VA by enabling VA to provide 
scholarships to nursing personnel who, on completion of their 
education, will be obligated to work a year for every year of 
education, with a minimum obligation of two years, at a VA 
health care facility. This subsection would also expand 
eligibility for the scholarship program to all VA health 
personnel appointed to positions described under paragraphs (1) 
and (3) of section 7401 of title 38, which includes all title 
38 health care employees as well as all hybrid occupations. The 
Committee expects that this expansion of those eligible for the 
scholarship program will be helpful in VA's efforts to recruit 
and retain employees in a number of difficult-to-fill health 
care occupations.
    Subsection (b) of section 103 would amend three provisions 
in subchapter VII of chapter 76, relating to VA's Education 
Debt Reduction Program.
    Paragraph (1) of subsection (b) would amend section 
7681(a)(2) so as to add retention, along with recruitment, as a 
purpose of the debt reduction program.
    Paragraph (2) would amend subsection (a)(1) of section 7682 
and would strike subsection (c) of that section so as to make 
the debt reduction program available to ``an'' employee, not 
just to a ``recently appointed'' employee as in current law. 
The ``recently appointed'' requirement limits eligibility to 
employees who have been appointed within six months. VA's 
experience has been that this is not a sufficient period and 
that, in some cases, it takes more than six months for 
employees to become settled in their new jobs and to even 
become aware of this program.
    Paragraph (3) would amend subsection (d) of section 7683 to 
increase the maximum amounts of education debt that can be 
forgiven, both overall and in the fourth and fifth years of 
participation in the debt reduction program, so as to raise the 
overall amount from $44,000 to $70,000, and the maximum amount 
in the fourth and fifth years from $10,000 to $12,000.
    Subsection (c) of section 103 would authorize the 
Secretary, in consultation with the Secretary of Health and 
Human Services, to use the authorities in section 487E of the 
Public Health Service Loan Repayment Program for the repayment 
of educational loans of health professionals from disadvantaged 
backgrounds in order to secure clinical research expertise in 
VA from such individuals. This loan repayment program is 
currently not available to federal employees other than those 
working for the National Institutes of Health. By extending 
this authority to VA, clinicians with medical specialization 
and research interests may be more likely to join VHA.

Sec. 104. Standards for appointment and practice of physicians in 
        Department of Veterans Affairs medical facilities.

    Section 104, which is derived from S. 2377, would establish 
a new section in title 38, U.S.C., which would set out 
procedures for appointing new physicians in VA, and the 
requisite qualifications of such physicians.
    Background. Current section 7402 of title 38, U.S.C., sets 
forth the requirements that must be met in order for a person 
to be appointed as a physician with VA. Included in these 
requirements are that the applicant hold the degree of doctor 
of medicine, or doctor of osteopathy, from a university 
approved by the Secretary; that the applicant has completed an 
internship approved by the Secretary; and that the applicant be 
licensed to practice medicine, surgery, or osteopathy in a 
State.
    Under subsection (f) of section 7402, any applicant who has 
or has had multiple licenses or certifications and has had one 
or more of them suspended, revoked, or surrendered for cause, 
is subject to employment restrictions. All applicants, with 
certain exceptions, must possess basic English proficiency.
    VA also requires extensive disclosures from applicants, 
including the status of their credentials, and is permitted to 
deny appointment or terminate employment if that information is 
not disclosed. This information must be resubmitted every two 
years. A VA policy that took effect on January 1, 2008, 
requires applicants to submit an authorization to their State 
licensing boards to permit those boards to release records to 
VA. According to guidance from the Deputy Under Secretary for 
Health for Operations and Management dated October 10, 2007, VA 
Service Chiefs are required to review and document any health 
care practitioner's record that has been flagged. Additionally, 
the guidance requires Veterans Integrated Service Network 
(VISN) Chief Medical Officers (CMO) to review any record in the 
National Practitioners Data Bank relating to a practitioner 
that shows three or more medical malpractice payments, a single 
malpractice payment of $550,000 or more, or two malpractice 
payments totaling $1,000,000 or more. The VISN CMO is then 
required to review the relevant material and determine if the 
appointment is appropriate. A similar review occurs for any 
search returning negative action regarding an individual's 
credentials or licensing.
    Current law does not require physicians to be board 
certified in the area in which they will practice in order to 
be eligible for employment with VA. VA permits facility 
directors and chiefs of staff to determine that an applicant is 
qualified based on other factors. VA believes its current 
requirements are in keeping with medical standards.
    Physicians elsewhere in Federal service are not required to 
be licensed in the State in which they practice, but simply to 
be licensed in any State. VA makes use of telemedicine, and 
exchanges physicians or allows physicians to collaborate with 
others in the Federal system in different States. This also 
occurs during certain emergency situations. Additionally, some 
States have licensing procedures that take more than one year 
to complete.
    Committee Bill. Section 104 of the Committee bill would 
establish a new section in title 38, U.S.C.,--Section 7402A. 
Appointment and practice of physicians in VA medical 
facilities--which would set forth the procedures for appointing 
new physicians in VA, and the requisite or desired 
qualifications to practice as a VA physician. This provision 
would take effect immediately upon enactment, except for 
subsection (f) as that section pertains to physicians already 
employed by VA, which would go into effect 60 days after 
enactment, and subsection (g), relating to performance 
contracts with VISN directors, which would go into effect upon 
the start of the first cycle, beginning after the date of 
enactment, of performance contracts for VISN directors.
    Subsection (a) of the proposed new section would require 
the Secretary, through the USH, to develop and promulgate 
minimum standards a physician must meet in order to be 
appointed to that position in the VHA, or to be permitted to 
practice in the VA medical facilities. The standards developed 
would be required to include the requirements outlined in the 
new section 7402A.
    Subsection (b) of the proposed new section would require 
any individual seeking to be appointed as a physician within 
the VHA to provide the following information: a full and 
complete explanation of any lawsuit for medical malpractice or 
negligence that is pending or was brought against the 
applicant; any settlements agreed to as a result of a lawsuit 
for malpractice or negligence; and any investigation or 
disciplinary action against the applicant that relates to the 
applicant's work as a physician. The applicant must also 
provide authorization to the licensing board of any state where 
the applicant holds or has ever held a license to practice 
medicine, to disclose to the Secretary any records pertaining 
to: any lawsuit for malpractice or negligence brought against 
the applicant, and the details any settlements agreed to as a 
result; any court or administrative agency's judgment against 
the applicant; any disciplinary action brought against the 
applicant by any State body or administrative agency; any 
change in the status of the applicant's license to practice 
medicine, whether voluntary or involuntary; any open 
investigation of, or outstanding allegation against, the 
applicant; and any written notification from the State to the 
applicant pertaining to the potential termination of the 
applicant's license.
    Subsection (c) of the proposed new section would require 
any physician appointed to practice in the VHA, after the 
enactment of the Committee bill, to disclose to the Secretary, 
within 30 days of an occurrence: a judgment against the 
physician for medical malpractice or negligence; a payment made 
as part of a settlement for a lawsuit or action previously 
disclosed prior to appointment; or any disposition or change in 
status of any issue disclosed prior to appointment. 
Additionally, this subsection would require any physician 
practicing in VHA at the time of the enactment of the Committee 
bill to provide authorization, within 60 days after the date of 
enactment, identical to the authorization required for 
applicants, to the State licensing board of any State where the 
physician has held, or currently holds, a license to practice 
medicine. A physician currently practicing in the VHA would be 
required, as a condition of employment, to agree to disclose, 
within 30 days of occurrence, any future judgment against the 
physician or payment as part of a settlement arising from a 
lawsuit alleging malpractice or negligence, or the disposition 
or change in status of any matter disclosed pursuant to the 
authorization for disclosure the physician would be required to 
give to a State licensing board.
    Subsection (d) of the proposed new section would require 
the director of the VISN in which an applicant seeks employment 
as a VA physician to conduct an investigation into the 
information disclosed by the applicant as required by new 
subsection (b). The appropriate VISN director also would be 
required to perform a similar investigation of any material 
disclosed by a VA physician employed as of the date of 
enactment of the Committee bill, or a physician appointed after 
that date who discloses information while employed by VA, as 
required by new subsection (c). The results of all such 
investigations would be required to be fully documented.
    Subsection (e) of the proposed new section would require 
any applicant seeking to be employed as a VA physician to 
receive the approval of the appropriate VISN director. If the 
applicant has disclosed information as required by new 
subsection (b), the VISN director, if the director chooses to 
approve the applicant, would be required to certify in writing 
that the investigation of each issue required by new subsection 
(d) was completed, and the director would be required to 
provide a written explanation as to why any identified issue 
did not disqualify the applicant.
    Subsection (f) of the proposed new section would require 
each VA medical facility that employs physicians who practice 
at that facility to enroll each physician in the Proactive 
Disclosure Service of the National Practitioners Database.
    Subsection (g) of the proposed new section would require 
the Secretary to include in each performance contract with a 
VISN director, a provision that encourages the director to hire 
physicians who are board certified or eligible for such 
certification in the field in which they will be practicing 
when employed by VA. The Secretary would be authorized to 
determine the nature of this provision in the performance 
contracts.
    The Committee believes that the requirements that would be 
put in place by the proposed new section 7402A are necessary to 
strengthen qualification standards for hiring physicians at VA 
and for monitoring their performance once they are working for 
VA. Despite the measures VA has in place regarding review of 
qualifications, history, and credentials, there have been 
incidents of physicians practicing in VA with suspended 
licenses and other problems with their qualifications. One of 
the most recent incidents of such a situation occurred at the 
Marion, Illinois, VA Medical Center, and that lack of 
appropriate review resulted in several patient deaths. The fact 
that VA's existing policy failed to prevent this result 
illustrates that additional measures to prevent under-qualified 
physicians from practicing medicine are needed and that it is 
justified to give VA's hiring practices the force of law.

                     TITLE II--HEALTH CARE MATTERS

    Many provisions in this title are taken from S. 2984 which, 
as noted earlier, is a bill that was introduced at the request 
of the Administration. Chairman Akaka introduced this 
legislation, by request. This measure was included on the 
agenda for the Committee's May 21, 2008, hearing on pending 
health care legislation, and based on testimony at that 
hearing, many of the provisions from that bill are included in 
the Committee bill, as discussed below.

Sec. 201. Repeal of sunset on inclusion of non-institutional extended 
        care services in definition of medical services.

    Section 201, which is derived from S. 2984, would repeal 
the existing, temporary authority for VA to provide non-
institutional extended care services and, instead, include such 
services as part of ``medical services'' furnished by VA to 
veterans enrolled for VA care.
    Background. The initial authority for VA to provide 
comprehensive access to alternatives to nursing home care was 
included in Public Law 106-117, enacted in 1999. The Congress 
anticipated that this authority would be helpful in giving 
veterans greater options instead of relying solely on 
traditional nursing home care. Since 1999, funding for non-
institutional care for veterans has steadily increased, 
evidence that it is meeting the needs of an increasing number 
of veterans.
    Committee Bill. The Committee bill would permanently 
include non-institutional extended care services as part of the 
definition of medical services under chapter 17 of title 38, 
U.S.C., by repealing section 1701(10), and amending section 
1701(6).
    The Committee believes making non-institutional care 
services a permanent feature of VA's medical benefits package 
is necessary. The health care services provided in settings 
that are not exclusively nursing homes are now considered to be 
appropriate and standard in providing for the long-term care 
needs of veterans.

Sec. 202. Extensions of certain authorities.

    Section 202, derived from S. 2984, would extend two 
expiring authorities: (1) VA's obligation to furnish nursing 
home care to certain veterans, and (2) VA's responsibility to 
conduct audits of VA payments to outside providers in 
connection with care for veterans.
    Background. In Public Law 106-117, Congress initially 
required that veterans requiring nursing home care for a 
service-connected condition, or a veteran rated 70 percent or 
greater, have mandatory eligibility for such care. The initial 
obligation expired on December 31, 2003. Later, the authority 
was extended for an additional five years.
    Committee Bill. Subsection (a) of section 202 of the 
Committee bill would extend, through December 31, 2013, VA's 
obligation to provide nursing home care to veterans who have a 
service-connected disability rated at 70 percent or greater, 
and to veterans who need nursing home care for their service-
connected disabilities.
    This five-year extension would enable VA to continue to 
provide nursing home care and will prevent any break in needed 
nursing home care services.
    Background. The authority for an audit recovery program was 
established in Public Law 108-422, enacted in 2004. This 
program identifies overpayments resulting from processing or 
billing errors as well as fraudulent charges. Recoveries made 
under the program are available without fiscal year limitation 
and are used to provide medical care to veterans and 
beneficiaries in the year in which they are recovered. 
Currently, this authority is set to terminate on September 30, 
2008.
    Committee Bill. Section 202(b) of the Committee bill would 
extend VA's mandate in section 1703(d), of title 38, U.S.C., to 
conduct, through a contractual arrangement, audits of payments 
made by VA for care and services furnished to veterans under 
fee basis arrangements and other medical services contracts.
    The Committee believes that the operation of a recovery 
audit program is consistent with good business practice and, 
indeed, it has proven advantageous to VA. Since 2001, VA has 
recouped $63,000,000 in all covered program areas, and VA 
projects it will recover an additional $24,000,000 if the 
authority is extended through 2013. An ancillary benefit of 
this program has been the related collection of extensive 
quality information on VA's claims processing capabilities. VA 
has used this vital information in developing and/or improving 
staff training, policies, and requests for and use of new 
technology.

Sec. 203. Permanent authority for provision of hospital care, medical 
        services, and nursing home care to veterans who participated in 
        certain chemical and biological testing conducted by the 
        Department of Defense.

    Section 203, which is derived from S. 2984, would make 
permanent VA's authority to furnish care to veterans who 
participated in certain chemical and biological tests conducted 
by the Department of Defense (DOD).
    Background. According to DOD, Project SHAD was an element 
of a project called Project 112, which was a chemical and 
biological warfare test program conducted at the Deseret Test 
Center. DOD conducted Project 112 tests between 1962 and 1973. 
Project SHAD itself was a series of tests apparently designed 
to determine potential vulnerabilities of U.S. warships to 
attacks with chemical or biological warfare agents. Other 
Project 112 tests involved similar experiments conducted on 
land rather than aboard ships.
    VA first learned of Project SHAD when a veteran filed a 
claim for service-connection for disabilities that he felt were 
related to his participation in those tests.
    Public Law 108-170, enacted in 2003, authorized that 
veterans who participated in the tests receive VA care at no 
cost for any condition or illness that is not associated with 
some cause other than their participation in the testing. While 
that care is exempt from any otherwise applicable copayment 
requirements, veterans may be subject to copayments for care 
provided for conditions that the Secretary determines resulted 
from causes other than their participation in these tests. The 
initial authority to provide health care services to Project 
SHAD participants expired after December 31, 2005. The current 
authority expires on December 31, 2008.
    Committee Bill. Section 203 of the Committee bill would 
remove the sunset date on the existing authority, thereby 
making access to VA care for these veterans permanent.
    The Committee believes that the veterans who participated 
in this testing deserve to receive VA care and treatment at no 
cost to the veteran for any condition that can not be 
attributed to some cause other than the testing.

Sec. 204. Repeal of certain annual reporting requirements.

    Section 204, which is derived from S. 2984, would repeal 
the requirement for VA to submit to Congress two annual 
reports, one relating to pay adjustments for registered nurses, 
and one relating to VA's long-range health planning.
    Background. Public Law 101-366, The Department of Veterans 
Affairs Nurse Pay Act of 1990, established a reporting 
requirement relating to pay adjustments for registered nurses 
because, at that time, annual General Schedule (GS) 
comparability increases were extended to VA nurses at the 
discretion of the facility Director. However, with the 
subsequent enactment of Public Law 106-419, the Veterans 
Benefits and Health Care Improvement Act of 2000, GS 
comparability increases must be given to VA nurses and other 
health care personnel described in section 7451.
    With respect to VA's long-range health care planning, VA's 
annual budget documents contain information on VHA's tactical 
and strategic goals, performance measures, and supporting 
activities; current and anticipated methods for serving VA's 
special populations; and other priorities, resource 
requirements and distribution methodologies. With the advent of 
VA's 5-Year Strategic Plan in 2004, VA's budget submission also 
includes the top 20 priorities for medical construction 
projects.
    Committee Bill. Subsection (a) of section 204 of the 
Committee bill would repeal the requirement to report annually 
on any pay adjustments made to the basic pay of VA nurses and 
other health care personnel described in section 7451 of title 
38, U.S.C. In light of the fact that covered staff receive, at 
a minimum, the annual increases in pay provided under the GS 
schedule, the Committee views this annual report as 
unnecessary.
    Subsection (b) of this section of the Committee bill would 
repeal the requirement for the Secretary to annually report on 
VA's long-range health planning, including operation and 
construction plans for medical facilities. The Committee is 
satisfied that this report contains information that is already 
submitted in other reports and plans, particularly those 
prepared annually in connection with VA's budget request.

Sec. 205. Modifications to annual Gulf War research report.

    Section 205, which is derived from S. 2984, would make 
changes to VA's annual report on Gulf War research.
    Background. Under current law, section 707 of the Persian 
Gulf War Veterans' Health Status Act, Public Law 102-585, the 
Executive Branch, through a designated head of an appropriate 
department or agency, is required to report to the Committees 
on Veterans' Affairs of the Senate and the House of 
Representatives on the status and results of all research 
undertaken in the area of Gulf War Illnesses and the research 
priorities identified during the previous year. Since the 
requirement was enacted in 1992, the Secretary has been the 
official responsible for compiling and submitting this report. 
This report is due by March 1 of each year. Under current law, 
this report is a continuing obligation.
    Committee Bill. Section 205 of the Committee bill would 
change the due date of this annual report to Congress on the 
research on the health effects of service during the Persian 
Gulf War from March 1 to July 1 of each year, and also 
establish a sunset date for this reporting requirement of July 
2013.
    VA has testified that it is difficult if not impossible to 
submit the report by the current March 1 statutory deadline and 
it is the Committee's view that a July 1 deadline is more 
attainable. Imposition of a sunset date is intended to afford 
Congress sufficient opportunity to assess, in five year's time, 
whether there exists a continued need for this formal reporting 
requirement.

Sec. 206. Payment for care furnished to CHAMPVA beneficiaries.

    Section 206, which is derived from S. 2984, would clarify 
the status of payments made by VA to health care providers on 
behalf of beneficiaries under the CHAMPVA program.
    Background. CHAMPVA is a health care program in which VA 
shares the cost of covered health care services and supplies 
with eligible beneficiaries. The program is administered by 
Health Administration Center. To be eligible for CHAMPVA, a 
person must be in one of these categories: (1) the spouse or 
child of a veteran who has been rated permanently and totally 
disabled for a service-connected disability by VA; or (2) the 
surviving spouse or child of a veteran who died from a VA-rated 
service connected disability; or (3) the surviving spouse or 
child of a veteran who was at the time death rated permanently 
and totally disabled from a service connected disability; or 
(4) the surviving spouse or child of a service member who died 
in the line of duty of a cause other than willful misconduct 
(in most of these cases, these family members are eligible for 
DOD's health care program known as TRICARE).
    While VA's regulations for the CHAMPVA program, located 
within 38 CFR (Code of Federal Regulations) section 17.55, 
provide for VA payments to providers under the CHAMPVA program 
to constitute payment in full, VA's enforcement of this 
regulation has been hampered by the lack of statutory 
authority. VA has indicated that some providers still attempt 
to bill beneficiaries for the difference between the billed 
amount and the amount payable under the CHAMPVA program.
    Committee Bill. Section 206 of the Committee bill would 
provide that payments made by the Secretary to providers who 
furnish medical care to a beneficiary covered under CHAMPVA 
shall constitute payment in full and thereby extinguish the 
beneficiary's liability to the provider for that care.

Sec. 207. Payor provisions for care furnished to certain children of 
        Vietnam veterans.

    Section 207, which is derived from S. 2984, would amend two 
sections of title 38, U.S.C., relating to care furnished to 
certain children of Vietnam veterans, so as to clarify payment 
procedures for such care.
    Background. Public Law 104-204, enacted in 1996, authorized 
VA to furnish health care--either directly or through 
contracts--to certain children of Vietnam veterans. The purpose 
was to provide for the special needs of certain children of 
Vietnam veterans who were born with the birth defect spina 
bifida and, in the case of children of women Vietnam veterans, 
other covered birth defects, possibly as the result of the 
exposure of one or both parents to herbicides during active 
service in the Republic of Vietnam during the Vietnam era. In 
order to carry out this health care program, VA developed a fee 
for service (indemnity plan) program that provides 
reimbursement for medical services and supplies related to 
spina bifida and conditions associated with spina bifida. 
Currently, providers must accept VA's payment as payment in 
full for the services provided, but because VA's payments are 
based on the CHAMPVA fee payment schedule, and not actual 
charges, many providers no longer agree to participate in these 
treatment programs.
    Committee Bill. Subsection (a) of section 207 of the 
Committee bill would amend section 1803 of title 38, U.S.C., to 
add a new subsection which would designate VA as the primary 
payer for care or services furnished to children of Vietnam 
veterans suffering from spina bifida or other disability 
associated with spina bifida. This new subsection would 
expressly permit the provider (or his agent) who furnished such 
care to seek payment from a third party payer, if the 
beneficiary has a health care plan that would otherwise be 
responsible for payment for the care and services, for the 
difference between the amount billed and the amount paid by the 
Secretary. The new subsection would prohibit the health care 
provider (or the provider's agent) from imposing any additional 
charges on the beneficiary who received the care, or the 
beneficiary's family, for any service or item for which the 
Secretary has made payment under this section. It would limit 
the total amount a provider could receive for furnishing care 
or services under this section from all payer sources to the 
amount billed to VA. Finally, the new subsection would require 
VA, upon request, to provide a third party with information 
concerning claims under this section.
    Subsection (b) of section 207 of the Committee bill would 
amend section 1813 of title 38, to enact the same provisions as 
detailed in subsection (a) above, but, in the case of this 
subsection, for children of women Vietnam veterans with other 
specified birth defects.
    It is the Committee's intention that because providers 
would be permitted to bill beneficiaries' health insurance for 
amounts not paid by VA, this would lead to potentially higher 
reimbursements for providers. The Committee is hopeful that 
this would encourage more providers to participate with VA 
under these programs.

Sec. 208. Disclosures from certain medical records.

    Section 208, which is derived from S. 2984, would permit VA 
health care practitioners to disclose the relevant portions of 
certain VA records to surrogate decision makers who are 
authorized to make decisions on behalf of patients who lack 
decision-making capacity.
    Background. Section 7332 of title 38, U.S.C., authorizes VA 
to disclose treatment information for drug abuse, alcoholism 
and alcohol abuse, HIV infection, and sickle cell anemia only 
for certain purposes which are set out in the section. 
Disclosure to surrogate decision makers for the purpose of 
making informed decisions regarding the treatment of patients 
who lack decision-making capacity, but to whom the patients had 
not specifically authorized release of section 7332-protected 
information prior to losing decision-making capacity, is not 
one of the specified purposes.
    Committee Bill. Section 208 of the Committee bill would 
amend section 7332 of title 38, U.S.C., to permit VA health 
care practitioners to disclose the relevant portions of VA 
records of the treatment of drug abuse, alcoholism and alcohol 
abuse, HIV infection, and sickle cell anemia to surrogate 
decision makers who are authorized to make decisions on behalf 
of patients who lack decision-making capacity, but to whom the 
patient has not specifically authorized release of section 
7332-protected information prior to losing decision-making 
capacity. This change would allow for such disclosure only 
under the circumstances where the information is clinically 
relevant to decision that the surrogate is being asked to make. 
The term ``representative'' means the individual, organization, 
or other body authorized under section 7331 of title 38 and the 
regulations implementing that provision, to give informed 
consent on behalf of a patient who lacks decision-making 
capacity.

Sec. 209. Disclosure to Secretary of health plan contract information 
        and social security number of certain veterans receiving care.

    Section 209, which is derived from S. 2984, would add a 
section to chapter 17 of title 38, U.S.C., to authorize VA to 
require that those seeking or receiving VA health care provide 
certain information in connection with such care.
    Background. Although VA has authority under section 1729 of 
title 38, U.S.C., to recover from health insurance carriers the 
reasonable charges for treatment of a veteran's nonservice-
connected disabilities, there is no express statutory authority 
that requires an applicant for, or recipient of, VA medical 
care to provide information concerning health insurance 
coverage.
    Under Section 7 of the Privacy Act, VA cannot deny to an 
individual any right, benefit, or privilege provided by law 
because of such individual's refusal to disclose his or her 
social security number. However, this prohibition does not 
apply with respect to any disclosure that is required by 
Federal statute.
    Committee Bill. Section 209 would amend title 38 by adding 
section 1709 which would authorize the Secretary to require 
that applicant for, and recipients of, VA medical care and 
services provide their health plan contract information and 
social security numbers to the Secretary upon request.
    Subsection (a) would require specific information on any 
health plan contract which provides coverage. Information that 
may be required regarding health plan coverage would include 
the name of the health plan contract, the name of the veteran's 
spouse, if coverage is under the spouse's health plan contract, 
the plan number, and the plan's group code. This authority will 
ensure that VA is able to obtain contract information for a 
particular health plan.
    Subsection (b) provides that the Secretary may require 
applicants for, or recipients of, VA medical care or services 
to provide their social security numbers and those of 
dependents or VA beneficiaries upon whom the applicant or the 
recipient's eligibility is based. This subsection, in 
conjunction with subsection (c), discussed below, affords the 
Secretary the statutory authority to require applicants for, 
and recipients of, VA health care benefits to disclose social 
security numbers.
    Subsection (c) provides that the Secretary would be 
authorized to deny the application of, or terminate the 
provision of medical care or services to individuals who fail 
to provide information requested pursuant to subsection (b). 
The subsection further provides that the Secretary may 
reconsider the application for or reinstate the provision of 
care or services once the information requested pursuant to 
subsection (b) has been provided.
    Subsection (d) provides that this section may not be 
construed as authority to deny medical care and treatment to an 
individual in a medical emergency. If a medical emergency 
exists, VA will not be permitted to deny eligibility for 
medical care or services should the applicant or recipient fail 
to provide health plan contract information or social security 
numbers.
    Because eligibility for medical care and services is 
conditioned on the applicant or recipient's provision of health 
plan contract information or social security numbers, VA 
believes that the applicant or recipient will have an incentive 
to provide the requested information. VHA must match veterans' 
income data with the Internal Revenue Services and the Social 
Security Administration to carry out its income verification 
responsibility under section 5317 of title 38, U.S.C. Such 
matching requires the use of verified social security numbers. 
According to VHA, officials have obtained verified social 
security numbers for approximately 97 percent of its enrolled 
veterans and 86 percent of the spouses for whom income is 
reported. While this suggests that the voluntary reporting 
process is working, VHA estimates that they still have more 
than 1,000,000 veterans enrolled for whom no social security 
number has been provided. Further, VHA argues that they have 
been unable to match income for more than 675,000 spouses 
because the social security numbers have not been provided.
    The Committee expects VA to provide a high degree of 
confidentiality for beneficiaries' health plan information and 
social security numbers.

Sec. 210. Enhancement of quality assurance.

    Section 210 of the Committee bill, which is derived from S. 
2377, would require actions to enhance VA's quality assurance 
efforts. Specifically, this section of the Committee bill would 
require that: (1) the USH (a) designate a physician to serve as 
VHA's principal quality assurance officer and (b) other 
physicians to serve as quality assurance officers for each 
VISN; (2) the director of each VHA facility appoint a quality 
assurance officer for each facility; (3) the USH establish 
mechanisms to allow VHA employees to submit confidential 
reports on matters related to health care quality; and (4) the 
Secretary undertake a comprehensive review of all VA quality 
and patient safety policies.
    Background. Under current law, section 7311 of title 38, 
U.S.C., VA operates a quality assurance system to monitor and 
evaluate the quality of VA health care. That system is headed 
by the Chief Quality and Performance Management Officer of the 
National Quality and Performance Office. While a number of 
other entities have a role in VA quality assurance efforts, 
including the Office of the Inspector General, the Office of 
the Medical Inspector, the National Patient Safety Office, and 
the Office of Compliance and Business Integrity, none has a 
permanent oversight capacity at every VA medical center. The VA 
quality assurance and monitoring program, including the 
National Surgical Quality Improvement Program (NSQIP), have 
proven effective in certain situations. However, in a report 
titled ``Quality of Care Issues, VA Medical Center, Marion, 
Illinois'' (January 2008), the VA Office of the Inspector 
General (hereinafter, ``OIG'') found that the quality assurance 
process was ineffective in many respects. The peer review 
process, the tracking of performance data on providers, and 
mortality assessments as carried out at the Marion, Illinois, 
VA Medical Center were all found to be deficient. The OIG 
concluded that:

        [T]he oversight reporting structure for quality 
        management reviews at the Marion VAMC was fragmented 
        and inconsistent, making it extremely difficult to 
        determine the extent of oversight of patient quality or 
        corrective actions taken to improve patient care. This 
        occurred partially because quality management 
        responsibilities were split between multiple groups at 
        the facility with little or no management oversight.

The OIG further concluded that the Marion VAMC Surgery Service 
leadership was ineffective, and that communication among the 
nurse responsible for NSQIP at the facility, surgical 
providers, and the Chief of Surgery was highly ineffective, 
allowing multiple quality management processes to fail.
    Based on information related to the Marion, IL, experience 
and other oversight activity, the Committee believes that VA's 
internal processes can ensure quality in some circumstances, 
but that significant improvements are necessary. Continuous and 
attentive monitoring is not fully in place, and facility 
leadership across the VA system must prioritize quality 
assurance.
    Committee Bill. Section 210 of the Committee bill would add 
a new section 7311A to chapter 73 of title 38, U.S.C. This new 
section would require the USH to appoint a National Quality 
Assurance Officer, reporting directly to the Under Secretary, 
who would develop requirements and standards for a national 
quality assurance program, and prescribe regulations for its 
implementation.
    The Committee believes that such a position would be 
helpful in order to ensure the thorough and uniform discharge 
of quality assurance requirements under such programs and 
activities throughout VA facilities. The USH would also be 
required to designate quality assurance officers for each VISN. 
Such officers would direct the quality assurance effort of each 
network and coordinate, monitor, and oversee the quality 
assurance programs and activities of the medical facilities in 
the Network.
    Additionally, section 210 of the Committee bill would 
require each VA medical center Director to appoint a physician, 
from that facility, to be the quality assurance officer for 
that facility. The Director would be required to ensure that 
other clinical or administrative duties of the person appointed 
as the quality assurance officer are reduced so as to not 
interfere with the person's quality assurance duties. The 
quality assurance officer would report to the director of the 
facility and to the quality assurance officer of the VISN of 
which that facility is a part.
    Section 210 would also require the USH to put in place a 
system through which VHA employees might submit reports, on a 
confidential basis, on quality of care matters to the quality 
assurance officer at the employee's facility. Such a system 
would provide a safe channel through which employees might 
report their concerns about care being furnished at the 
facility. Such a system should make it possible for any such 
reports to receive appropriate attention and review.
    This section of the Committee bill also would require the 
Secretary to submit a report to Congress on all policies and 
protocols of VA that pertain to maintenance of health care 
quality and protection of patient safety at VA medical 
facilities. This report would be required to include an 
assessment of NSQIP, with special emphasis on the effectiveness 
of the design and structure of the program's data collection, 
evaluation, and assessment structure, and the sufficiency of 
resources allocated to that program. In testimony before the 
Committee on May 21, 2008, Dr. Gerald Cross, Principal Deputy 
Under Secretary for Health, expressed VA's support for the 
provisions of this section of the Committee bill that would 
require a comprehensive review and report on health care 
quality and patient safety policies across the VA health care 
system.

Sec. 211. Reports on improvements to Department health care quality 
        assurance.

    Section 211, which is derived from S. 2377, would require 
the Secretary to report on VA efforts to implement the 
provisions of the Committee bill concerning quality assurance.
    Background. There are currently no regular requirements for 
VA to report to Congress on VHA quality assurance efforts. This 
lack of effective reporting mechanisms can contribute to 
ineffective quality oversight. While the Inspector General 
performs valuable oversight of individual facilities and 
specific events, the Committee believes a comprehensive annual 
reporting requirement would more effectively ensure oversight 
and accountability by the Committee and the Congress.
    Committee Bill. Section 211 would require the Secretary to 
submit a report to the Committees on Veterans' Affairs and 
Appropriations of the Senate and the Committees on Veterans' 
Affairs and Appropriations of the House of Representatives by 
December 15, 2009, and annually thereafter, through 2012. This 
report would detail VA efforts, over the preceding fiscal year, 
to implement the provisions of sections 104 (relating to 
standards for appointment and practice of VHA physicians) and 
210 (relating to quality assurance officers) of the Committee 
bill, along with any recommendations the Secretary may have to 
improve the implementation of these sections or to otherwise 
improve the quality of VA health care. The Committee expects 
that this reporting requirement will lead to increased 
oversight of VA's efforts to improve quality assurance efforts 
and activities.

Sec. 212. Pilot program on training and certification for family 
        caregiver personal care attendants for veterans and members of 
        the Armed Forces with TBI.

    Section 212 of the Committee bill, which is derived from S. 
2921, would require the Secretary, in collaboration with the 
Secretary of Defense, to carry out a pilot program to evaluate, 
over a three-year period, the provision of health care 
training, certification and compensation to family members of 
veterans and members of the Armed Forces with TBI, so as to 
allow family members to function as personal care attendants.
    Background. Currently, VA operates a Personal Care 
Attendant certification program at the San Diego, California, 
VA Medical Center for patients with spinal cord injury. 
According to the VHA directives, family members can be personal 
care providers as long as they are certified by a Spinal Cord 
Injury Center. Once certified, VA can compensate these family 
members for the services they provide at a rate not to exceed 
the hourly rate paid to VA nursing assistants.
    There have been two prior attempts to address the issue of 
training family caregivers for veterans with TBI. Section 744 
of Public Law 109-364, the John Warner National Defense 
Authorization Act of 2007 (hereinafter, ``NDAA 2007''), 
required the establishment of a panel to develop training 
curricula for family members on caregiving techniques for TBI 
patients. Section 214 of Public Law 109-461, The Veterans 
Benefits, Health Care, and Information Technology Act of 2006, 
mandated a VA pilot program to improve caregiver assistance 
services, including training and certification.
    Committee Bill. Section 212 of the Committee bill would 
require the Secretary, in collaboration with the Secretary of 
Defense, to carry out a 3-year pilot program in three VA 
medical facilities and, if the Secretaries determine it is 
appropriate, one DOD medical facility. In selecting locations, 
the Secretary would be required to attempt to locate the pilot 
program at VA Tier I polytrauma centers. VA currently operates 
four such centers at the Minneapolis, Tampa, Richmond, and Palo 
Alto VA medical centers. A fifth center is slated to open at 
the San Antonio VA Medical Center in the near future.
    The Secretary would be required to develop a training 
program for those who would serve as personal care attendants 
under the pilot program. This training would be required to 
incorporate standards of certification programs of national 
brain injury care specialist organizations as well as best 
practices of caregiving organizations, such as the National 
Family Caregivers Association. This training program would be 
required to draw on the training curricula that were developed 
under NDAA 2007.
    The Secretary would be responsible for determining whether 
a family member would be eligible for participation in the 
pilot program, based upon the needs of the patient, as 
determined by the patient's physician. A family caregiver 
certified as a personal care attendant under this pilot program 
would be eligible to be paid by VA for the care the personal 
care attendant provides.
    The Secretary or the Secretary of Defense would be required 
to pay any costs of training family members of veterans or 
members of the armed services, respectively, to be personal 
care attendants. Under the pilot program, the Secretary would 
be allowed to provide information to a properly certified 
personal care attendant, including an assessment of the 
attendant's needs and a referral to any services provided in 
the attendant's community that are relevant to the attendant's 
needs. These services could be provided by community-based 
organizations, publicly funded programs, or VA. In making this 
assessment, the Secretary would be required, to the greatest 
extent practicable, to utilize existing caregiver assessment 
tools currently in use by VA.
    The Secretary would be required to report to Congress on 
the pilot program within two years of the date of enactment of 
this Act. The report would include the Secretary's 
recommendations regarding the expansion or modification of the 
pilot program.
    This section of the Committee bill specifies that nothing 
within the provision would grant a right to family members to 
receive the training and certification under the pilot program, 
nor would anything prevent the Secretary from allowing a non-
family member to act as personal care attendant if the patient 
prefers such a person to a family member.
    The Committee believes that this pilot program has the 
potential of allowing for a more efficient and appropriate 
program of recovery and long-term care for those with TBIs, for 
whom institutional long-term care would be too intensive or 
otherwise inappropriate. This program would allow veterans to 
stay in their own homes but still receive necessary living 
assistance.
    This proposed pilot program is supported by The American 
Legion, Veterans of Foreign Wars, Disabled American Veterans, 
Paralyzed Veterans of America, Vietnam Veterans of America, 
Wounded Warrior Project, and the Brain Injury Association of 
America.

Sec. 213. Pilot program on provision of respite care to members of the 
        Armed Forces and veterans with TBI by students n graduate 
        programs of education related to mental health or 
        rehabilitation.

    Section 213, which is derived from S. 2921, would require 
the Secretary of Veterans Affairs, in collaboration with the 
Secretary of Defense, to carry out a three-year pilot program 
to assess the feasibility and advisability of providing respite 
care to veterans and service members through the services of 
students in certain graduate education programs.
    Background. There has been a marked increase in the number 
of family members taking on the role of primary caregiver for 
injured and disabled veterans since the start of the wars in 
Iraq and Afghanistan. This is consistent with the overall trend 
of long-term care moving from institutional to non-
institutional settings. In response to the impact on family 
members furnishing care, there has also been an increasing use 
of non-institutional care options to relieve and assist family 
caregivers.
    VA has a long record of entering into affiliations with 
academic institutions for the purposes of training clinicians, 
as well as for enhancing research opportunities. Academic 
affiliations enhance the education and experience of both VA 
professionals and the students attending the academic 
affiliates.
    In testimony submitted for the Committee's May 21, 2008, 
hearing, the Brain Injury Association of America (BIAA), 
described the need for providing supportive services for family 
caregivers:

        Particularly in light of the fact that caregivers often 
        report severe financial strain and frequently must give 
        up their jobs in order to take care of their loved one 
        with TBI, increased financial support and access to 
        respite care for family caregivers of returning 
        servicemembers with TBI is vital and long overdue.

    BIAA cites one study that found that 47 percent of family 
caregivers had given up their jobs at one year after the injury 
occurred. At two years, that number was still 33 percent. These 
demands have been linked to the occurrence of stress reaction 
and other physical and emotional problems.
    Committee Bill. Section 213 of the Committee bill would 
establish a three-year pilot program to test the feasibility 
and advisability of using graduate students in certain mental 
health and rehabilitation programs to provide respite care to 
members of the Armed Forces and veterans with TBI. The students 
would provide relief to family caregivers and assist in 
developing cognitive and social skills in the patient.
    This pilot program would be carried out at no more than ten 
separate locations selected by the Secretary, all of which must 
be VA medical facilities that are in proximity to or affiliated 
in some manner with an educational institution that has a 
graduate program in mental health or rehabilitation related 
field. The Secretary would be required to give special 
consideration to VA facilities that are Tier I polytrauma 
centers, and VA facilities that are in proximity to regions 
with large concentrations of veterans with TBI.
    The Secretary would be required to recruit, train, and 
assign graduate students in the designated fields of education 
in order to provide respite care to veterans and servicemembers 
in the pilot program. The Secretary, in collaboration with the 
head of the selected graduate program, would be required to 
determine the amount of training required, the number of hours 
of care to be provided, and the requirements for successful 
participation for the graduate students participating in the 
program. The Secretary would be required to incorporate into 
the training program any applicable standards and protocols of 
national brain injury care specialist organizations, as well as 
recognized caregiving best practices.
    For purposes of the pilot program, the Committee bill would 
define ``respite care'' as the temporary provision of care to 
an individual to provide relief to the regular caregiver, and 
the term ``family member'' to include friends or partners of 
the patient.
    The Committee believes that the provision of respite care 
as outlined in this pilot program could be vital in further 
strengthening the family caregiver model a feasible system of 
care.

Sec. 214. Pilot program on the use of community-based organizations and 
        local and State government entities to ensure that veterans 
        receive care and benefits for which they are eligible.

    Section 214 of the Committee bill, which is derived from S. 
2796, would require VA to carry out a pilot program to study 
the use of community-based organizations, and local and State 
government entities, to help ensure that veterans receive 
needed care and benefits.
    Background. Dr. Stanley Luke, PhD, Vice President for 
Programs of Helping Hands Hawaii, one of Hawaii's largest 
social service nonprofits and a provider of direct services to 
Hawaii veterans, testified before the Committee on May 21, 
2008, expressing support for the pilot program contemplated by 
this section of the Committee bill. According to Dr. Luke, as a 
consequence of cultural or other factors in certain locations, 
VA personnel may sometimes not be most appropriate to reach out 
to veterans and that, in such instances, local organizations, 
with specific local cultural skills, may be better able to 
relate to, and interact with, veterans and their families in 
specific locations.
    Helping Hands Hawaii has attempted to assist veterans 
through outreach, assistance in interacting with VA, explaining 
eligibility and available benefits and services, and providing 
mental health care. The pilot program provided for under this 
section of the Committee bill would have VA focus more intently 
on this approach and study whether these efforts can be 
effectively replicated.
    Committee Bill. Section 214 of the Committee bill would 
require the Secretary to establish and implement a pilot 
program to study the use of community-based organizations, and 
local and State government entities, in the provision of care 
and benefits to veterans. This program would specifically seek 
to improve coordination between community, State, and Federal 
providers of health care and benefits to veterans who are 
transitioning from military to civilian life; to make medical 
care and mental health care more available to veterans who are 
transitioning; to provide assistance to families of 
transitioning veterans; and to provide greater outreach to 
veterans and their families, and to inform them about their 
eligibility for, and availability of, benefits and care.
    The pilot program would continue for a period of two years 
after enactment of the Committee bill, and be carried out at 
five locations that the Secretary would select. In selecting 
the program locations, the Secretary would be required to place 
special emphasis on rural areas, areas with high proportions of 
minority groups, areas with high proportions of individuals who 
have limited access to health care, and areas that are not in 
close proximity to an active duty military station.
    The Secretary would award grants to organizations and 
entities for them to use in providing services under the pilot 
program. Any organization or entity wishing to participate in 
the program would be required to submit an application to the 
Secretary containing a description of how the program was 
developed in consultation with VA and a plan for the 
organization to coordinate activities with local, State, and 
Federal government agencies that provide services so as to 
avoid duplication of services.
    The Secretary would be required to promulgate regulations 
governing the appropriate use of grant funds by organizations. 
The Secretary would also be required to submit a report on the 
pilot program within 180 days after the program's end. The 
report would include findings and conclusions, an assessment of 
the benefits that were provided, and any recommendations from 
the Secretary regarding whether to continue the pilot program.

Sec. 215. Specialized residential care and rehabilitation for certain 
        veterans.

    Section 215, which is derived from S. 2889, would authorize 
VA to contract for specialized residential care and 
rehabilitation services for certain veterans of OIF/OEF.
    Background. Veterans with TBI or other serious disabilities 
and conditions have significant long-term care needs. These 
veterans may not need nursing home care, but they do not always 
have the resources needed to remain at home and live 
independently. This presents a challenge both for the veteran 
and the health care system.
    Committee Bill. Section 215 of the Committee bill would 
amend title 38, U.S.C., by adding a new subsection (g) to 
section 1720 so as to authorize the Secretary in carrying out 
its community residential care program, to contract for 
specialized residential care and rehabilitation services for 
eligible veterans. Veterans covered by this provision would be 
veterans of OEF/OIF who: (1) suffer from TBI; (2) have an 
accumulation of deficits in activities of daily living and 
instrumental activities of daily living that affects their 
ability to care for themselves; and (3) would otherwise receive 
their care and rehabilitation in a nursing home care, which 
exceeds their needs.
    It is the intent of the Committee that VA should have 
authority to provide veterans with significant long-term needs 
with a much more appropriate treatment setting for long-term 
rehabilitation services.

Sec. 216. Exemption from copayment requirement for veterans receiving 
        hospice care.

    Section 216, which is derived from S. 2889, would eliminate 
copayment requirements for veterans receiving VA hospice care 
in any setting.
    Background. In 2004, with the enactment of Public Law 108-
422, Congress eliminated copayment requirements for veterans 
receiving hospice care in VA nursing homes, but that change did 
not eliminate copayments for hospice care furnished in other 
settings. The Medicare program does not impose copayments for 
hospice care, regardless of the setting. The Committee does not 
believe that VA should require such copayments either.
    Committee Bill. Section 216 would amend section 1710 of 
title 38, U.S.C., to eliminate copayment requirements for 
veterans receiving VA hospice care either in a VA hospital, or 
at home on an outpatient basis. The Committee bill would exempt 
all hospice care from copayments, thereby providing equitable 
treatment for all veterans receiving such care.

Sec. 217. Repeal of limitation on authority to conduct a widespread HIV 
        testing program.

    Section 217, which is derived from S. 2889, would remove a 
restriction in current law on VA's ability to conduct 
widespread testing for HIV among VA patients.
    Background. Currently, section 124 of Public Law 100-322 
permits VA to test a patient for HIV infection only if the 
veteran receives pre-test counseling and provides written 
informed consent for such testing. This differs from other 
blood testing that VA conducts routinely, which requires only a 
patient's verbal informed consent. VA advises that the 
requirements for pre-test counseling and signed consent often 
delay testing for HIV infection.
    Committee Bill. Section 217 would repeal section 124 of 
Public Law 100-322. Eliminating this section from the law would 
bring VA's statutory HIV testing requirements in line with 
current guidelines issued by the Centers of Disease Control and 
Prevention and will not diminish patient rights, as VA would 
still be required to obtain the patient's verbal informed 
consent. Generally, informed consent requires the responsible 
practitioner to discuss and inform the patient about the 
procedure/treatment and its risks and benefits, as well as 
answer any questions that patient may have about the procedure/
treatment. In addition, a patient may always reject VA 
treatment or procedures.
    The Committee believes that by eliminating section 124 of 
Public Law 100-322, veterans would benefit from earlier medical 
intervention, thereby improving the potential health outcomes 
of infected patients, while at the same time advancing the 
country's broader public health goals.

Sec. 218. Authority to disclose medical records to third party for 
        collection of charges for provision of certain care.

    Section 218, which is derived from S. 2889, would amend two 
provisions of title 38, U.S.C., so that VA could disclose 
individually-identifiable patient medical information in 
connection with the collection of charges for VA care or 
services.
    Background. Under section 1729 of title 38, U.S.C., VA has 
authority to recover from health plans or health insurance 
carriers the reasonable charges for treatment of a veteran's 
nonservice-connected disabilities. In order to recover charges 
and obtain reimbursement for care, VA must submit bills or 
claims containing information to the health plan for the 
episode of care. If during the episode, the veteran was 
diagnosed or treated for certain conditions, this information 
is communicated via the bill to the health plan.
    Section 5701 of title 38 permits VA to release the names 
and home addresses of veterans and their dependents without 
consent only for very limited purposes. There is some question 
whether disclosures for billing purposes are currently 
permitted under subsection (b)(6) of that section in cases in 
which the United States has not yet instituted litigation to 
collection an amount owed VA under section 1729.
    Section 7332 of title 38 similarly permits VA to release 
indentifying information and treatment information, without 
prior written consent for the medical conditions covered by the 
section--drug abuse, alcoholism or alcohol abuse, HIV 
infection, or sickle cell anemia--only for certain, limited 
purposes specified in subsection (b) of 7332. The authorized 
exceptions do not include releasing identifiable patient 
information to a third-party health plan for collection 
purposes, without the patient's prior written authorization.
    Committee Bill. Section 218 would add new subsections to 
section 5701 and 7332 of title 38, U.S.C., to authorize the 
Secretary to disclose individually-identifiable patient medical 
information without the prior written consent of a patient to a 
third-party health plan to collect reasonable charges under 
section 1729 of this title for care or services provided for a 
non-service-connected disability.
    The amendment to section 5701 would specifically authorize 
disclosure of a patient's name and address information for 
collection purposes. Disclosure of the information other than 
the patient's name and address is authorized under existing 
authority in subsection 5701(e). Similarly, the section 7322 
change would authorize disclosure of both individual identifier 
information and the medical information for purposes of 
carrying out VA's responsibilities under section 1729.
    The Committee notes that such disclosures without a 
patient's prior written authorization are generally permitted 
under regulations promulgated pursuant to section 264 of the 
Health Insurance Portability and Accountability Act of 1996 
(HIPAA). Since health plans that VA would bill for the 
reasonable cost of medical care under this authority are 
covered by the HIPAA privacy regulations, they will be able to 
use and disclose the patient-identifiable information provider 
in accordance with HIPAA.
    The Committee anticipates that these changes to current law 
will result in higher revenue collections.

Sec. 219. Expanded study on the health impact of Project SHAD.

    Section 219 of the Committee bill, which is derived from S. 
2937, would require VA to contract with the Institute of 
Medicine of the National Academies (IOM) for an expanded study 
on the health impact of Project SHAD.
    Background. During the period 1962-1974, the Defense 
Department conducted a series of tests of chemical and 
biological materials in water-borne settings. The tests, known 
as Project SHAD exposed hundreds of veterans to VX nerve gas, 
E. Coli, and other substances.
    The Project SHAD tests were intended to show the 
vulnerability of Navy ships to chemical and biological warfare 
agents. By learning how those agents would disperse, military 
planners hoped to be able to improve procedures to protect 
crewmembers and decontaminate ships.
    Beginning in 2002, VA contracted with IOM to conduct a 
study of the health effects on veterans who participated in 
Project SHAD (contract number No. V101(93)P-1637, T/0). While 
there are many known medical problems associated with repeated 
chemical and biological weapons exposure, the Committee is 
concerned that the study, which was released last year, is 
incomplete because it omits a number of Project SHAD veterans 
who were known to DOD and to VA.
    Committee Bill. Section 219 of the Committee bill would 
require the Secretary to enter into a contract with IOM, within 
90 days after the enactment of this Act, for the purposes of 
IOM conducting a study of the health impacts of Project SHAD on 
servicemembers participating in the tests. The Committee bill 
would require that this study include all servicemembers 
involved in the tests, insofar as is practicable and consistent 
with the requirements of conducting sound research. The 
Committee Bill would authorize the utilization of the results 
from the study ``Long-Term Health Effects of Participation in 
Project SHAD'' conducted by IOM.
    Congress has previously approved unfettered, VA-provided 
care for veterans who participated in Project SHAD. While the 
Committee believes that these veterans deserve and should 
receive care from VA at no cost for any condition that cannot 
be attributed to other causes, the Committee believes there is 
value in examining the impact of such testing on participants 
in order to better understand the potential effects of other 
such testing.
    The Committee also notes that there is value in continued 
research into the areas of chemical and biological weapons 
exposure and that VA and DOD should make every effort to 
identify and contact all former servicemembers who participated 
in Project SHAD as well as testing that occurred during a 
similar time period at Edgewood Arsenal, Dugway Proving 
Grounds, Ft. McClellan, and Ft. Detrick.

Sec. 220. Use of non-Department facilities for rehabilitation of 
        individuals with TBI.

    Section 220 of the Committee bill would amend a recently 
enacted section of title 38, U.S.C., so as to specify the 
circumstances in which non-VA facilities would be utilized as 
part of the rehabilitation and community reintegration plans 
for veterans and members of the Armed Forces who are receiving 
care from VA for TBI.
    Background. VA has done much in recent years to develop its 
capability to treat TBI. However, VA has limited experience in 
treating younger veterans with debilitating injuries such as 
TBI. As a result, Congress passed a series of VA-related 
provisions in NDAA 2007, the bulk of which sought to expand and 
enhance TBI care at VA facilities. As part of those provisions, 
Congress also gave VA the ability to enter into cooperative 
agreements with public or private entities to send certain 
veterans suffering with TBI to non-Department facilities for 
rehabilitative care. In some circumstances, VA may find the 
service of a non-VA facility to be better suited to providing 
the care required by some veterans with TBI. In the Senate-
passed version of NDAA 2007, specific criteria for eligibility 
and standards of care were laid out, but these provisions were 
dropped in reconciliation negotiations with the House.
    Committee Bill. Section 220 of the Committee bill would 
amend section 1710E of title 38, U.S.C., so as to add two new 
subsections that were included in the Senate-passed legislation 
from the NDAA 2007. Proposed new subsection (b) would specify 
that non-VA facilities would be used when the Secretary cannot 
provide treatment or services at the frequency or for the 
duration required by the individual plan of veteran or 
servicemember suffering from TBI or when the Secretary 
determines that it is optimal for the veteran or 
servicemember's recovery and rehabilitation. Proposed new 
subsection (d) would establish standards for the selection of a 
non-Department facility, requiring that the facility itself 
maintains care standards that have been established by an 
independent, peer-reviewed organization that accredits 
specialized rehabilitation programs for adults with TBI.
    The Brain Injury Association of America supports section 
220, ``as it sets forth a pivotal mechanism for enhancing 
cooperation between the private sector and the VA health care 
system. Such cooperation is vitally necessary in order to 
provide access to, and choice within, the full continuum of 
care that returning service members with TBI need and 
deserve.''

Sec. 221. Inclusion of tribal organizations in certain programs for 
        State veterans homes.

    Section 221 of the Committee bill, which is derived from S. 
3000, would include tribal organizations in certain authorities 
relating to State veterans' homes. The health facilities of 
tribal organizations would be eligible to be treated as 
veterans homes for funding purposes, and tribal organizations 
would be eligible to apply for veteran State home construction 
grants.
    Background. State veterans homes are homes established by 
the States for disabled veterans in need of long-term care. 
They provide nursing home care, domiciliary care, and adult day 
care. VA partners with States in two ways to assist in funding 
the homes. Under Sections 1741-1743 of title 38, U.S.C., VA has 
the authority to carry out a per diem payment program in which 
it provides a portion of the daily cost of care for each 
veteran residing in a home. Under Sections 8131-8137 of title 
38, VA has the authority to conduct a construction grant 
program, in which it can provide up to 65 percent of the total 
cost of building a home, with the States required to put up 35 
percent. Under current law, tribal organizations are not 
considered states for the purposes of being eligible for either 
of these programs.
    Based on the 2000 U.S. Census, VA projected in a September 
2006 report that during the time period from 2005 and 2020, the 
number of older veterans overall will decline by 10 percent. 
During that same time, VA projected a nearly 60 percent 
increase in the number of older American Indian and Alaska 
Native veterans. The expected decline in the overall number of 
older veterans is attributed largely to the World War II and 
Korean War-era veteran populations, which are declining largely 
for age-related reasons. In contrast, American Indian veterans 
are much less likely to be World War II or Korean War-era, and 
more likely to be Vietnam-era than the overall veteran 
population.
    As early as the 1990s, Native Americans have identified a 
pressing need for improved long-term care in Native 
communities. In 1995, the National Indian Council on Aging 
described long-term care as the most pressing issue facing 
American Indian elders. According to a survey reported in the 
2002 American Indian and Alaska Native Roundtable on Long-Term 
Care, only 17 percent of tribes report having nursing homes 
available on the reservation or in the tribal community. 
Nineteen percent reported that their tribe was planning to 
create or expand long-term care services. Despite recognition 
of the need for long-term care, as well as interest among 
tribes in developing such care, Native American communities are 
constrained by limited federal funding and the abject poverty 
that characterizes much of Indian Country.
    Committee Bill. Subsection (a) of section 221 of the 
Committee bill would amend section 8138 of title 38, U.S.C., so 
as to allow for the treatment of health facilities of tribal 
organizations, or beds within such facilities, as State 
veterans homes. As a result of this amendment, tribal 
organization health facilities would be treated in the same 
manner as other health facilities (or beds), with the exception 
of newly designated subsection (f) of section 8138, which sets 
September 30, 2009, as the expiration date for the treatment of 
new health facilities as State homes, which would not apply to 
the health facilities of tribal organizations.
    Subsection (b) of section 221 of the Committee bill would 
amend title 38 in a number of ways so as to give the Secretary 
the authority to award construction grants to tribal 
organizations for the construction of State veterans homes as 
set forth in subchapter III of chapter 81 of title 38.
    Subsection (b)(1)(A) would provide that, for the purposes 
of the subchapter, ``tribal organization'' would have the 
meaning given to the term in section 3765 of title 38.
    Subsection (b)(1)(B) would amend section 8132 of title 38, 
the declaration of purpose for the subchapter, to include 
tribal organizations along with the ``several states'' as the 
entities to be assisted in creating State veterans homes.
    Subsection (b)(1)(C) would amend title 38 by adding a new 
section--Section 8133A. Tribal organizations--so as to give the 
Secretary the express authority to award construction grants to 
tribal organizations. This new section would provide that 
grants to tribal organizations shall be awarded in the same 
manner as States, with certain exceptions. One such exception 
shall be that, for the purpose of assigning priority under 
subsection (c)(2) of section 8135 of title 38, if a tribal 
organization is located within a State that has previously 
applied for a construction grant, the tribal organization shall 
be treated as if it previously applied as well. Other 
exceptions may be prescribed by the Secretary to take into 
account the unique circumstances of tribal organizations.
    Recognizing the limited long-term care options in Native 
American communities, as well as the sovereign status of 
Federally-recognized tribes, section 221 would enable the 
Secretary to award State veterans home grants directly to 
tribal organizations.
    As reported by the Harvard Project on American Indian 
Economic Development: ``Where tribes make their own decisions 
about what approaches to take and what resources to develop, 
they consistently out-perform outside decision makers.'' The 
Committee expects that, by including tribal organizations among 
those eligible to apply for State veteran homes grants, these 
organizations will be able to provide more effective long-term 
care for the veterans in their communities.

Sec. 222. Extension of pilot program on caregiver assistance services.

    Section 222 of the Committee bill would amend section 
214(d) of the Veterans Benefits, Health Care, and Information 
Technology Act of 2006 (Public Law 110-461) to extend the pilot 
program on caregiver assistance services for an additional 
year, to 2009.
    Background. In December 2006, Congress passed S. 3421, The 
Veterans Benefits, Health Care, and Information Technology Act 
of 2006, which became Public Law 109-461. A provision of this 
legislation created a two-year pilot program to assist home-
based caregivers of disabled veterans. At the time, spouses and 
family members acting as the primary caregivers for wounded 
veterans was a growing trend, and the need to provide 
supportive services to these caregivers was becomingly 
increasingly apparent. The intent behind the pilot was to 
incentivize field clinicians to create innovative, localized 
programs to assist caregivers in their respective communities. 
Along with the authorization for the pilot itself, Congress 
authorized $5,000,000 for the administration of the program.
    VA is currently providing approximately $4,700,000 for 
these pilot programs to expand and improve health care 
education and provide needed training and resources for 
caregivers who assist disabled and aging veterans in their 
homes. This funding enhances the support and training for 
family members and other caregivers who work to care for these 
veterans.
    There are currently eight caregiver projects across the 
country. Among the key services provided to caregivers are 
transportation, respite care, case management and service 
coordination, assistance with personal care (bathing and 
grooming), social and emotional support, and home safety 
evaluations. Education programs teach caregivers how to obtain 
community resources such as legal assistance, financial 
support, housing assistance, home delivered meals and spiritual 
support.In addition, caregivers are taught skills such as time 
management techniques, medication management, communication 
skills with the medical staff and the veteran, and ways to take 
better care of themselves.
    Many of the projects use technology, including computers, 
web-based training, video conferencing and teleconferencing to 
support the needs of caregivers who often cannot leave their 
homes to participate in support activities.
    Committee Bill. Section 222 of the Committee bill would 
amend section 214(d) of the Veterans Benefits, Health Care, and 
Information Technology Act of 2006, Public Law 110-461, so as 
to extend the pilot program on caregiver assistance services 
for an additional year, through the end of fiscal year 2009.
    Families and other caregivers are on the front lines of 
efforts to care for veterans who have served this nation. 
Because the pilot program was enacted late in 2006, sites were 
announced fully one year later and the money has already been 
allocated to the various programs, VA needs an additional 
year's authorization to fully carry out the pilot program.

Sec. 223. Pilot program on provision of dental insurance plans to 
        veterans and survivors and dependents of veterans.

    Section 223 of the Committee bill, which is derived from S. 
3178, would direct the Secretary to carry out a pilot program 
to assess the feasibility of providing a dental insurance plan 
to eligible veterans, survivors, and dependents of veterans.
    Background. VA provides a full range of dental services at 
its facilities. However, under current law, section 1712 of 
title 38, U.S.C., dental services are only offered to certain 
veterans or to veterans under special circumstances. For 
example, veterans who have a service-connected compensable 
dental condition, are former prisoners of war, or who have 100 
percent service-connected disabilities are eligible for any 
needed dental care. Other veterans are eligible only for dental 
care necessary to resolve problems arising in certain narrowly 
defined situations, such as a veteran whose dental condition is 
aggravating a service-related condition or who requires dental 
care to continue participation in a vocational rehabilitation 
program. In addition, CHAMPVA does not provide dental coverage 
for survivors and dependents of veterans receiving care under 
that program except under very limited circumstances. CHAMPVA, 
established by Public Law 93-82, is primarily a fee-for-service 
program that provides reimbursement for most medical care for 
certain eligible dependents and survivors of veterans rated 
permanently and totally disabled from a service-connected 
condition. The program reimburses providers and facilities a 
fixed amount for treatment given, less any co-pay from 
beneficiaries.
    DOD administers a health care system for active duty 
servicemembers, military retirees, certain Reserve and National 
Guard members, and eligible family members under the TRICARE 
program. Through TRICARE, dental benefits may be provided to 
select beneficiaries at military treatment facilities; for 
others, voluntary dental insurance coverage is available 
through a DOD contract with private insurers is available. 
Section 703 of Public Law 104-201, NDAA 2007, established the 
TRICARE Retiree Dental Program (TRDP) through which military 
retirees and their eligible family members are given the option 
to purchase dental coverage under a contract managed by DOD. 
Over 1,000,000 eligible participants have some level of dental 
coverage under TRDP. TRDP enrollees have access to a network of 
about 112,000 dental plan providers across the nation. Premiums 
currently range from $14 to $48 per month for an individual 
policy, depending on the region and type of dental plan 
selected.
    Committee Bill. Section 223 of the Committee bill, in a 
freestanding provision, would require the Secretary to carry 
out a pilot program on the provision of dental insurance plans 
to veterans and survivors, and dependents of veterans.
    Subsection (a) of section 223 would require the Secretary 
to carry out the pilot program so as to assess the feasibility 
and advisability of providing dental insurance.
    Subsection (b) of section 223 would define the participants 
in the pilot program as veterans enrolled in VA's medical care 
system and survivors and dependents of veterans eligible for 
medical care under CHAMPVA.
    Subsection (c) of section 223 would specify that the pilot 
program is to be carried out in not less than two and no more 
than four VISNs.
    Subsection (d) of section 223 would specify that the 
Secretary is to contract with a dental insurer to administer 
the dental plan.
    Subsection (e) of section 223 would require the dental plan 
under the pilot program to provide benefits considered 
appropriate by the Secretary, including diagnostic, 
preventative, endodontic, surgical, and emergency services.
    Subsection (f) of section 223 would provide that enrollment 
in the dental insurance plan would be voluntary and would be 
for such minimum period of enrollment as the Secretary 
prescribes.
    Subsection (g) would require the Secretary to set premiums 
for dental plan coverage on an annual basis and would specify 
that the premiums would be paid entirely by plan enrollees.
    Subsection (h) of section 223 would permit the voluntary 
disenrollment from a dental plan if the disenrollment occurs 
within 30 days of the beginning of the enrollment period or, 
under certain allowable circumstances, such as a relocation to 
a jurisdiction outside a plan area or a serious medical 
condition preventing use of plan benefits, if the disenrollment 
does not jeopardize the fiscal integrity of the dental plan.
    Subsection (i) of section 223 would specify that nothing 
regarding the pilot program will affect VA's responsibility to 
provide dental care under section 1712 of title 38 nor would an 
individual's participation in an insurance plan under the pilot 
program affect the individual's entitlement to dental services 
under that section.
    Subsection (j) would specify that the dental insurance plan 
under the pilot program is to be administered pursuant to 
regulations prescribed by VA.
    The Committee is interested in testing within the VA health 
care system the TRDP concept of supplementing dental benefits 
provided at government facilities with more comprehensive, 
voluntary dental insurance coverage financed through enrollee 
premiums. This concept is not meant to minimize VA's obligation 
to provide high quality dental services under existing 
requirements of law.

                 TITLE III--WOMEN VETERANS HEALTH CARE

Sec. 301. Report on barriers to receipt of health care for women 
        veterans.

    Section 301 of the Committee bill, which is derived from S. 
2799, would require the Secretary to submit a report to 
Congress, no later than June 1, 2009, on the barriers to women 
veterans' access to VA health care.
    Background. Under current law, VA is authorized to provide 
care to all veterans, including women veterans. While there has 
been some specific legislative action on certain areas of care 
for women veterans, such as for homeless reintegration 
services, the Committee believes that much more can be done. 
Although this approach has yielded some clear successes, there 
are concerns that there may be insufficient attention to 
ensuring uniform access to gender-specific services across the 
VA health care system. According to DOD, women represent 
approximately 17 percent of all deployed service members, and 
therefore are a growing portion of the veteran population.
    Committee Bill. Section 301 of the Committee Bill would 
require VA to submit a report to Congress, not later than June 
1, 2009, that would include, among other elements, information 
on an identification and assessment of any stigma associated 
with women veterans seeking mental health care, access to care 
for women veterans described in terms of distance to VA 
facilities, availability of child care, the comfort and 
personal safety perception of women veteran patients, the 
sensitivity of VA health care providers to issues affecting 
women veterans, and the effectiveness of outreach to women 
veterans.
    The Committee seeks to ensure that appropriate attention 
and resources are directed to the needs of women veterans. For 
that to happen, those needs must be properly identified and 
described. That is the goal of this mandated study.
    VA testified at the Committee's May 21, 2008, hearing on 
pending legislation that it was already in the process of 
conducting an assessment of barriers to care for women 
veterans. The results of that effort can either be provided to 
the Committee as soon as the results are available or can be 
made a part of the report mandated by this section of the 
Committee bill.

Sec. 302. Plan to improve provision of health care services to women 
        veterans.

    Section 302 of the Committee bill, which is derived from S. 
2799, would require VA to develop a plan to improve the 
provision of health care services to women veterans, and to 
submit this plan to Congress no later than 18 months after 
enactment of the Committee bill.
    Background. Public Law 102-585, enacted in 1992, authorized 
new and expanded services for women veterans, including 
counseling for sexual trauma on a priority basis, specific 
health services for women, such as Pap smears, mammography, and 
general reproductive health care (including birth control and 
treatment of menopause) at many VA medical facilities.
    Public Law 104-262, enacted in 1996, expanded services 
further to include maternity and infertility benefits. In 
fiscal year 1997, the USH appointed the first full-time 
Director for the Women Veterans Health Program. The program 
oversees a system of medical and psychosocial services for 
women.
    As discussed above, in connection with section 301 of the 
Committee bill, the Committee is concerned that these benefits 
are not being furnished evenly across the VA system.
    The 2008 Report of the Advisory Committee on Women Veterans 
found that:

        The new and complex needs of today's women veterans, 
        particularly those who served in Operations Enduring 
        and Iraqi Freedom, require that VA assess the 
        effectiveness of its existing gender specific programs 
        and initiate new ones that strategically address the 
        many needs of this cohort in a way that is inviting, 
        compassionate, and demonstrate a driven yield toward 
        the best outcomes.

    The burgeoning demand for care from women veterans requires 
that VA be fully prepared to deal with their health care needs. 
The estimated population of women veterans as of 2001 was 
1,600,000, or about 7.2 percent of the total veteran 
population. Currently, women make up 14.8 percent of the active 
duty military force and approximately 22.8 percent of the 
reserve force. By 2010, they are expected to represent over 14 
percent of the total veteran population. Fifty-six percent of 
women veterans who use VA are less than 45 years of age.
    Committee Bill. Section 302 of the Committee bill would 
require VA to develop a plan on the provision of health care 
services to women veterans. The plan would include how VA 
intends to improve current services to women veterans, as well 
as how to appropriately provide for the future needs of women 
currently serving in OIF/OEF. As part of this plan, the 
Secretary would be required to identify the types of health 
care services that will be available to women veterans at each 
VA medical center, as well as what personnel would be required 
to provide such services. This plan would have to submitted to 
the two Veterans' Affairs Committees not later than 18 months 
after the date of enactment of the Committee bill.
    It is the Committee's view that requiring VA to develop a 
plan is a first step to ensuring that the needs of women 
veterans are met, now and into the future.

Sec. 303. Independent study on health consequences of women veterans of 
        military service in OIF/OEF.

    Section 303, which is derived from S. 2799, would require 
the Secretary to enter into an agreement with a non-Department 
entity to conduct an independent study on the health 
consequences of service by women veterans in OIF/OEF.
    Background. Public Law 98-160, enacted in 1983, established 
the Advisory Committee on Women Veterans (hereinafter, 
``Advisory Committee''). In addition, Public Law 103-446, 
enacted in 1994, created the Center for Women Veterans 
(hereinafter, ``Center''). Both entities play invaluable roles 
in helping to shape VA's responses to the needs and concerns of 
women veterans.
    The Advisory Committee evaluates existing VA programs and 
makes recommendations for the enhancement of programs and 
services for women veterans while the Center oversees all VA 
programs for women veterans. However, neither entity is 
specifically charged to focus on the possible health 
consequences for women veterans who have served on activity 
duty in the Armed Forces in deployment in OIF/OEF.
    There are more women serving in the U.S. Armed Forces than 
in any other period in American history. More than 160,000 
female U.S. servicemembers have served in Iraq, Afghanistan, 
and the Middle East since 2003. At least 450 women 
servicemembers have been wounded in Iraq, more female 
casualties than in the Korean, Vietnam, and first Gulf Wars 
combined.
    Another consequence of the increased number of women 
serving in the U.S. military is an increase in the occurrence 
of rape and sexual assault by their male comrades. Connie Lee 
Best, PhD, a Clinical Psychologist and Professor in the 
Department of Psychiatry and Behavioral Sciences at the Medical 
University of South Carolina testified before the Committee on 
April 25, 2007, noting that:

        Numerous research studies have documented rates of rape 
        ranging from lows of six percent for active duty to 
        rates that are significantly higher. One study found 
        that 23% of female users of VA health care reported 
        experiencing at least one sexual assault while in the 
        military.

    Given the extensive service of women in OIF/OEF, the 
Committee is of the view that VA must fully assess the health 
consequences of their service. Only then will VA know how best 
to meet their specific needs.
    Committee Bill. Section 303 of the Committee bill would 
require the Secretary to enter into an agreement with a non-
Department entity, such as the IOM, to conduct an independent 
study on the health consequences of service in OIF/OEF for 
women veterans. The study would include an examination of any 
and all possible environmental and occupational exposures and 
their effects on the general, mental, and reproductive health 
of women veterans who served in OIF/OEF. It would also include 
an analysis of all published literature on such exposures, as 
well as on combat trauma, including military sexual trauma. The 
study would be required to be completed and submitted to 
Congress no later than 18 months after the enactment of the 
Committee bill, and the Secretary would be required to submit a 
response to the report of the study no later than 90 days 
following the submission of the findings of the study.

Sec. 304. Training and certification for mental health care providers 
        on care for veterans suffering from sexual trauma.

    Section 304 of the Committee bill, which is derived from S. 
2799, would require VA to implement a program for education, 
training, and certification for VA mental health care providers 
on care and counseling services for veterans suffering from 
military sexual trauma.
    Background. Public Law 102-585, enacted in 1999, authorized 
VA to include outreach and counseling services for women 
veterans who experienced incidents of sexual trauma while 
serving on active duty in the military. The law was later 
amended by Public Law 103-452 so as to authorize VA to provide 
counseling related to sexual trauma to men, as well as to 
women. Public Law 108-422, enacted in 2004, extended VA's 
authority permanently to provide Military Sexual Trauma (MST) 
counseling and treatment to active duty service members or 
those serving on active duty for training.
    VA has a number of strong programs geared toward mental 
health needs generally. However, MST is a discrete phenomenon 
and must be addressed as such. In addition, given the high 
numbers of women subjected to MST, as discussed above in 
connection with Section 303 of the Committee bill, the 
Committee believes that a more targeted approach is necessary.
    Dr. Connie Best testified before the Committee in 2007 
that:

        * * * the VA is staffed by some of the best mental 
        health providers and by some with exceptional expertise 
        in MST. However, I believe the one of the problems 
        facing the VA in their responsibility to meet the needs 
        of today's veterans who have experienced MST is one of 
        sheer numbers * * *. That means more qualified and 
        appropriately trained providers must be available. 
        Those providers must be able to provide specialized 
        sexual assault services and understand the interaction 
        of sexual trauma with combat-related trauma.

    Dr. Best suggested that VA should add specialized training 
programs for providers in the treatment of MST.
    Committee Bill. Section 304 of the Committee bill would 
amend section 1720D of title 38, U.S.C., so as to add two new 
subsections.
    Proposed new subsection (d) would require VA to implement a 
program for education, training, and certification for VA 
mental health care providers on care and counseling services 
for veterans suffering from MST. The new subsection would 
require that the training be carried out in a consistent manner 
and that it include principles of evidence-based treatment and 
care for sexual trauma. VA would also be required to determine 
the minimum qualifications necessary for mental health 
professionals certified under the program to provide evidence-
based care and therapy to veterans for MST.
    Proposed new subsection (e) would require VA to report to 
Congress annually on the care and counseling provided under 
section 1720D. Specifically, VA would provide information on 
the number of mental health professionals and primary care 
providers who have been certified under the program; the amount 
and nature of continuing medical education provided under such 
program to professionals and providers who have been so 
certified; the number of women veterans who received counseling 
and care and services from professionals and providers who have 
been trained or certified under the program; the number of 
training, certification, and continuing medical education 
programs operating under subsection (d); and the number of 
trained full-time equivalent employees required in each 
facility of VA to meet the needs of veterans requiring 
treatment and care for sexual trauma.
    Finally, subsection (b) of section 304 of the Committee 
bill, in a freestanding provision, would require the Secretary 
to establish education, training, certification, and staffing 
standards for VA health care facilities for full-time employees 
who are trained to provide sexual trauma counseling and care.

Sec. 305. Pilot program on counseling in retreat settings for women 
        veterans newly separated from service in the Armed Forces.

    Section 305 of the Committee bill, which is derived from S. 
2799, would require VA to carry out a pilot program to evaluate 
the feasibility and advisability of providing reintegration and 
readjustment services in group retreat settings to certain 
women veterans.
    Background. VA operates a program of readjustment 
counseling which is provided through community-based facilities 
known as Vet Centers. Currently, there are 232 Vet Centers, 
located in all fifty states, the District of Columbia, Guam, 
Puerto Rico and the U.S. Virgin Islands. Each provides 
assistance to veterans in need of readjustment counseling. The 
Vet Centers are managed by the Readjustment Counseling Service 
located in the VHA.
    VA appears to appreciate the value of retreats for its 
employees, especially those involved in mental health issues. 
Recent retreats include one on the implementation of the VA's 
Mental Health Strategic Plan and another for those advocating 
recovery models of care in VISN 3.
    The Committee believes that there is merit to evaluating 
the impact of providing reintegration assistance in retreat 
settings to woman veterans returning from a prolonged 
deployment.
    Committee Bill. Section 305 of the Committee bill, in a 
freestanding provision, would require VA to establish, not 
later than six months after the date of enactment of the 
Committee bill, a pilot program designed to evaluate the 
feasibility of providing reintegration and readjustment 
services in a group retreat setting. Under the pilot program, 
which would be carried out through the Readjustment Counseling 
Service, these services would be provided to women veterans who 
are newly separated from service in the Armed Forces after a 
prolonged deployment. This pilot program would be required to 
be carried out for two years, beginning on the date the program 
begins, in no fewer than five locations selected by the 
Secretary.
    Participation in the pilot program would be strictly 
voluntary. Services provided under the program would include 
information and assistance on reintegration into family, 
employment, and community; financial and occupational 
counseling; information and counseling on stress reduction and 
conflict resolution; and any other counseling the Secretary 
considers appropriate to assist the participants in 
reintegrating into their families and communities.
    The Committee bill would authorize the appropriation of 
$2,000,000 annually in fiscal years 2009 and 2010 to carry out 
the pilot program. VA would be required to report to Congress 
on the pilot program no later than 180 days after completion of 
the program.

Sec. 306. Report on full-time Women Veterans Program Managers at 
        medical centers.

    Section 306 of the Committee bill, which is derived from S. 
2799, would require the Secretary to submit to Congress a 
report on the employment of program managers solely for the 
management and oversight of women veterans' health care needs. 
This report would include whether or not each facility employs 
at least one such full-time employee.
    Background. Women Veterans Program Managers are generally 
available at each VA facility, although not all are full-time 
positions.
    These coordinators ensure that women veterans are afforded 
equal access to all services. They work to ensure that women 
veterans receive high quality comprehensive medical care in an 
environment that is sensitive to the privacy needs of women. 
Women Veterans Program Managers also advocate for gender-
specific issues and needs.
    The Committee recognizes the valuable contributions of the 
Women Veterans Program Managers and believes that it is 
essential that every VA medical center have sufficient 
resources to ensure that these positions are full-time.
    Committee Bill. Section 306 of the Committee Bill would 
require the Secretary, acting through the USH, to submit a one-
time report on Women Veterans Program Managers, so as to 
determine how many of these positions are filled on a full-time 
basis.

Sec. 307. Service on certain advisory committees of women recently 
        separated from service in the Armed Forces.

    Section 307 of the Committee bill, which is derived from S. 
2799, would require the Secretary to appoint women veterans who 
are recently separated from the Armed Forces to VA's Advisory 
Committee on Women Veterans and to the Advisory Committee on 
Minority Veterans.
    Background. Public Law 98-160, enacted in 1983, established 
the Advisory Committee on Women Veterans and set forth specific 
criteria for membership on the Committee, including those with 
service-connected disabilities, those who represent women 
veterans, and others. There is no specific requirement that any 
member of this Advisory Committee be a woman veteran who has 
recently separated from service in the Armed Forces.
    Public Law 103-446, enacted in 1994, established the 
Advisory Committee on Minority Veterans and set forth specific 
criteria for membership on the Committee including 
representatives of veterans who are minority group members, 
individuals who are recognized authorities in fields pertinent 
to the needs of veterans who are minority group members, 
veterans who are minority group members and who have experience 
in a military theater of operations, and others. There is no 
specific requirement that any member of this Advisory Committee 
be a woman veteran who is also a member of a minority group and 
who is recently separated from service in the Armed Forces.
    Committee Bill. Subsection (a) of section 307 of the 
Committee bill would amend section 542(a)(2)(A) so as to 
require the Secretary to appoint women veterans who are 
recently separated from the Armed Forces, to the VA Advisory 
Committee on Women Veterans.
    Subsection (b) of section 307 of the Committee bill would 
require the Secretary to appoint women veterans who are also 
members of a minority group and recently separated from the 
Armed Forces to serve on the Advisory Committee on Minority 
Veterans.
    Subsection (c) of section 307 of the Committee bill would 
provide that the amendments made by this section shall apply 
with appointments made to the two advisory committees on or 
after the date of enactment of the Committee bill.

Sec. 308. Pilot program on subsidies for child care for certain 
        veterans receiving health care.

    Section 308 of the Committee bill, which is derived from S. 
2799, would require the Secretary to implement a pilot program 
to assess the feasibility and advisability of providing 
subsidies to certain veterans in order to allow them to 
purchase child care services to facilitate better access to 
health care from VA.
    Background. There is no current authority for VA to 
reimburse veterans for child care expenses incurred while 
receiving VA medical care. The Committee recognizes that some 
veterans face significant barriers to receiving health care 
from VA and that the absence of adequate child care for those 
veterans who are primary caretakers of children is one such 
impediment. This problem can be even more daunting for veterans 
in that situation who are in need of intensive health care 
services, such as care for Post Traumatic Stress Disorder 
(PTSD), mental health, and other therapeutic programs.
    In order to address the issue of the need for child care 
for its own employees, VA created the VA Child Care Subsidy 
Program, as authorized by Public Law 107-67, the Treasury and 
General Government Appropriations Act for Fiscal Year 2002. 
That law authorized the use of appropriated funds by executive 
agencies in order to provide child care services for Federal 
civilian employees. The VA program is needs based, with the 
amount of reimbursement available to an employee depending on 
total family income and the amount paid for child care. In 
order to qualify for reimbursement, children must be placed in 
a licensed day care, home care or before/after school program, 
and beneficiaries must complete and submit an application form.
    The Committee believes that this existing VA program 
provides an excellent model for VA to emulate as it moves 
forward with the child care subsidies for veterans which would 
be authorized by this section of the Committee bill.
    Committee Bill. Section 308 of the Committee bill, in a 
freestanding provision, would require VA to carry out a pilot 
program to examine what effect subsidies for child care for 
certain veterans receiving VA health care would have on 
improving access to health care services. The pilot program 
would be authorized for two years, beginning on the date the 
program begins, and would be required to be carried out in no 
fewer than three VISNs.
    Subsidies for child care would only be available during the 
time period that a veteran is actually receiving specified 
health care services at a VA medical facility, and during the 
time required by the veteran to travel to and from the site of 
treatment. Veterans eligible for subsidies would be those who 
are the primary caretaker of a child or children and who are 
receiving regular or intensive mental health care, or other 
intensive health care services determined by the Secretary as 
ones for which access would be improved by payment of a subsidy 
for child care.
    The pilot program would be required to be modeled, insofar 
as practicable, on the VA Child Care Subsidy Program and would 
use the same income eligibility and payment structure as used 
in that program. The Secretary would be required to report on 
the program to Congress within six months of the conclusion of 
the program on the Secretary's findings and conclusions about 
the program, along with any recommendations the Secretary 
considers appropriate. The Committee bill would authorize the 
appropriation of $1,500,000 annually for fiscal year 2009 and 
2010 for the purposes of the pilot program.

Sec. 309. Care for newborn children of women veterans receiving 
        maternity care.

    Section 309 of the Committee bill, which is derived from S. 
2799, would authorize the Secretary to provide health care 
services, for not more than seven days after birth, to a 
newborn child of a woman veteran who is receiving maternity 
care from VA.
    Background. Under current law, VA is authorized to provide 
maternity and infertility benefits to women veterans who enroll 
for VA care. Obstetrical care, excluding care for the newborn, 
is provided under contract.
    While a veteran's care extends to maternity, prenatal, and 
postnatal care for female veterans, there is no authority for 
the provision of, or payment for, any care for the newborn 
child of a female veteran patient. This results in a 
significant gap in care for the increasing number of women 
veterans enrolled with VA.
    The current women veteran population is predominantly pre-
retirement and of child bearing age. Therefore, it is a 
disservice to our growing female veteran population and an 
inequity to not provide some newborn care.
    According to various studies, the average hospital stay for 
low-birth weight infants (a common reason for prolonged 
neonatal hospital stays) ranges from 6.2 to 68.1 days, whereas 
the average hospital stay for average-sized infants was 2.3 
days. Seven days of coverage would assist the mothers of 
newborns in need of simple, routine care, as well as many in 
need of more complex hospitalization.
    Committee Bill. Section 309 of the Committee bill would add 
a new section--Section 1786. Care for newborn children of women 
veterans receiving maternity care--to Subchapter VIII of 
chapter 17 of title 38, U.S.C. This new section would authorize 
the Secretary to provide health care services, for not more 
than seven days after birth, to a newborn child of a woman 
veteran who is receiving maternity care from VA, if the mother 
gave birth in a VA medical facility, or in an outside facility 
pursuant to a contract between that facility and VA. These 
services would include all post-delivery care, including 
routine care, required by a newborn.
    It is the Committee's belief that this limited but 
important step will help to ensure that the needs of women 
veterans enrolling for VA care are met in a more complete 
manner.

                      TITLE IV--MENTAL HEALTH CARE

Sec. 401. Eligibility of members of the Armed Forces who serve in 
        Operation Iraqi Freedom or Operation Enduring Freedom for 
        counseling and services through Readjustment Counseling 
        Service.

    Section 401, which is derived from S. 2963, would allow 
members of the Armed Forces, including members of National 
Guard or Reserves, who serve in OIF/OEF to receive services 
through VA's Readjustment Counseling Service.
    Background. Currently, certain veterans are eligible for 
readjustment counseling services under section 1712A of title 
38, U.S.C. Those eligible for these services include recently 
separated servicemembers from OIF/OEF as well as members of the 
National Guard or Reserves who were mobilized for service in 
OIF/OEF and served for the period of their mobilization. Under 
current law, members of the Armed Forces still on active duty 
are not eligible for readjustment counseling services from VA.
    Committee Bill. Section 401 of the Committee bill, in a 
freestanding provision, would establish eligibility for 
readjustment counseling services for any member of the Armed 
Forces who serves on active duty in OIF/OEF, including a member 
of the National Guard or Reserves.
    Subsection (a) of section 401 would set forth the basic 
eligibility for this population of servicemembers for 
readjustment counseling and related mental health services 
under section 1712A of title 38, U.S.C. These services would be 
provided through VA's Vet Centers.
    Subsection (b) of section 401 would not require that a 
servicemember be currently on active duty to be eligible for 
these services.
    Subsection (c) of section 401 would condition the 
eligibility for these services on regulations prescribed 
jointly by the Secretaries of Defense and VA.
    Subsection (d) of section 401 would limit the availability 
of services under this section to the availability of 
appropriations for the provision of these services, so as to 
ensure that allowing a new population segment into the Vet 
Center system will not be a detriment to those the Vet Centers 
are currently serving.
    The Committee recognizes that, in many parts of the active 
duty and reserve Armed Forces, there is stigma associated with 
seeking assistance in connection with mental health concerns. 
In light of the clear indications that many who serve in combat 
may experience psychological impact from such service--as shown 
by a 2008 Rand Corporation Study on mental health in OIF/OEF 
veterans, (Tanielian and Jaycox [Eds.], ``Invisible Wounds of 
War: Psychological and Cognitive Injuries, Their Consequences, 
and Services to Assist Recovery,'' Santa Monica, CA: RAND 
Corporation, 2008.)--there appears to be significant value in 
allowing servicemembers still on active duty to come to VA's 
Vet Centers for help in dealing with such concerns.
    At the same time, the Committee is concerned about placing 
an undue burden upon the Vet Centers, given their current 
responsibility to not only provide readjustment counseling to 
currently eligible veterans, but also to provide outreach to 
returning servicemembers and newly discharged veterans.

Sec. 402. Restoration of authority of Readjustment Counseling Service 
        to provide referral and other assistance upon request to former 
        members of the Armed Forces not authorized counseling.

    Section 402 of the Committee bill, which is derived from S. 
2963, would restore the authority of VA's Readjustment 
Counseling Service to provide referral and other assistance, 
upon request, to former members of the Armed Forces who have 
been discharged or released from active duty but who are not 
otherwise eligible for such counseling and services.
    Background. VA was first authorized to furnish readjustment 
counseling services to Vietnam-era veterans in 1979 in Public 
Law 96-22. Included in that original authority was a provision 
that required VA to provide referral services and other 
assistance to veterans who sought readjustment counseling but 
who were not eligible to receive those services because of the 
nature of their discharge from the military or for other 
reasons.
    This authority was repealed in 1996 in Public Law 104-262, 
the Veterans Health Care Eligibility Reform Act of 1996.
    Committee Bill. Section 402 of the Committee bill would 
amend section 1712A of title 38, U.S.C., by adding a subsection 
(c) which would restore the provisions which require VA to 
provide referral services and other assistance to veterans who 
request readjustment counseling but who are not eligible for 
such services.
    It is the Committee's intent that those who have been 
discharged under conditions other than honorable still be 
afforded assistance in acquiring mental health services and 
also in gaining review of their discharges. The Committee 
believes that VA should be available to provide some assistance 
to those who have served and are in need of readjustment 
assistance, even if they are not eligible for the full array of 
VA benefits.

Sec. 403. Study on suicides among veterans.

    Section 403 of the Committee bill, derived from S. 2899, 
would require VA to conduct a study on suicides among veterans 
since January 1, 1997, and report to Congress on the findings.
    Background. Numerous reports have been released in the past 
six months, illustrating that the rate of suicide among 
veterans has been steadily increasing. One such report was the 
RAND study (Tanielian and Jaycox [Eds.], ``Invisible Wounds of 
War: Psychological and Cognitive Injuries, Their Consequences, 
and Services to Assist Recovery,'' Santa Monica, CA: RAND 
Corporation, 2008.), which reported that 1 in 5 veterans of the 
wars in Iraq and Afghanistan are returning and suffering with 
stress or mental health disorders, but that only half of those 
veterans are actually receiving treatment for these conditions.
    VA's own Office of Mental Health reported that the number 
of suicides attempted at VA facilities increased from 492 in 
2000 to 790 in 2007. Additionally, according to VA data, 
suicide among male veterans between 18 and 29 years of age has 
increased from 26.94 suicides per 100,000 to 45.82 suicides per 
100,000--nearly a 100 percent increase. This is the highest 
rate since at least 2001.
    Yet, there remains no centralized database of veteran 
suicides and attempts.
    Committee Bill. Section 403 of the Committee bill, in a 
freestanding provision, would require VA to conduct a study to 
determine the number of veterans who died by suicide between 
January 1, 1997, and the date of enactment of the Committee 
bill.
    Subsection (a) of section 403 would set forth the basic 
requirements for the study.
    Subsection (b) of section 403 would require VA, in carrying 
out this study, to coordinate with DOD, Veterans Service 
Organizations (VSOs), the Centers for Disease Control and 
Prevention (CDC), and state public health offices and veterans 
agencies.
    Subsection (c) of section 403 would require VA to submit a 
report to the Committees on Veterans' Affairs of the Senate and 
the House of Representatives on the findings of the study.
    Subsection (d) of section 403 would authorize the 
appropriation of such sums as may be necessary to carry out the 
study.
    Because the data show that the incidence of suicide among 
veterans is on the rise, the Committee believes a need exists 
to have more comprehensive and accurate information so this 
issue can be more successfully addressed.

Sec. 404. Transfer of funds to Secretary of Health and Human Services 
        for Graduate Psychology Education program.

    Section 404 would mandate the transfer of $5,000,000 from 
VHA accounts to the Secretary of Health and Human Services for 
the Graduate Psychology Education program.
    Background. The Graduate Psychology Education program was 
established under section 755(b)(1)(J) of the Public Health 
Services Act. This program is the only federal program solely 
dedicated to training post-doctoral psychologists.
    Recent studies have projected continuing high demand for 
psychological treatment of PTSD, TBI, and other combat-related 
stress disorders. Reports issued by GAO, the Department of 
Defense Mental Health Task Force, the Presidential Task Force 
on Returning Global War on Terror Heroes, IOM, and the 
President's Commission on Care For America's Returning Wounded 
Warriors, have identified shortages of trained mental health 
providers, detailed problems in the training pipeline, and 
provided recommendations concerning the workforce needed to 
deal with what is projected to be an increased demand for 
mental health care among servicemembers and veterans.
    VA faces immediate challenges in recruiting mental health 
professionals with focused specialty training in combat-related 
stress disorders and post deployment readjustment. Establishing 
a collaborative VA-HHS training pipeline should help ensure a 
steady flow of specially-trained psychologists to serve the 
veteran population. Graduates of these training programs will 
continue to practice their specialty and will also be 
candidates for hire by VA or civilian practices that serve 
veteran patient populations. Many of the positions may be in 
rural communities where veterans, especially those from 
National Guard and Reserve units, often return to find VA 
facilities distant or community-based outpatient clinics 
lacking mental health professionals.
    Committee Bill. Section 404 of the Committee bill would, in 
a freestanding provision, mandate the transfer of funds from VA 
to the Department of Health and Human Services (HHS) for the 
Graduate Psychology Education program and delineate the use of 
the funds and the preferences for VA health care facilities.
    Subsection (a) of section 404 would require VA, no later 
than the September 30, 2009, to transfer $5,000,000 from 
accounts of VHA to HHS for the Graduate Psychology Education 
program.
    Subsection (b) of section 404 would specify that the funds 
transferred by VA to HHS be used to make grants that would 
support the training of psychologists in the treatment of PTSD, 
TBI, and other combat-related psychological disorders.
    Subsection (c) of section 404 would establish a preference 
in the awarding of grants under this provision to VA health 
care facilities and to graduate educational programs affiliated 
with VA facilities.
    The Committee intends for the grantee training programs 
receiving support through this effort to be involved with VA 
clinicians and facilities as training sites, thus ensuring that 
the substantial services provided in the course of training 
will go to veterans. Ensuring an adequate supply of well-
trained psychologists--specializing in combat stress 
disorders--is in the strong interest of the Nation, VA, and 
individual veterans.

                       TITLE V--HOMELESS VETERANS

    Veterans remain one of the more disproportionately 
represented groups among the overall homeless population. It 
has been estimated that one in every three homeless persons is 
a veteran. Carl Blake, National Legislative Director, Paralyzed 
Veterans of America, testified before the Committee on May 21, 
2008, that ``[w]hile estimates vary, it is believed that as 
many as 250,000 veterans are on the street in any given night. 
This fact seems incomprehensible in light of the sacrifices 
that these men and women have made.''
    VA administers a number of programs aimed at combating and 
preventing homelessness among veterans. These programs include 
the provision of residential domiciliary-based care (including 
mental health care and substance-use disorder treatment), a 
grant and per diem program to assist community-based entities 
that serve homeless veterans, employment and job training 
assistance, and supported permanent housing.
    The Committee has been at the forefront of the issue and 
has worked cooperatively with VA to expand and enhance its 
authority to serve this unique population. Title V of the 
Committee bill includes a number of provisions, some from VA, 
some suggested by advocates, some from legislation, all of 
which are designed to enhance and improve VA efforts to address 
the overall problem and to provide assistance to homeless 
veterans

Sec. 501. Pilot program on financial support for entities that 
        coordinate the provision of supportive services to formerly 
        homeless veterans residing on certain military property.

    Section 501 of the Committee bill, which is derived from S. 
2273, would authorize the Secretary to create and implement a 
pilot program to carry out, and evaluate the impact of, 
providing grants to certain organizations that will assist 
formerly homeless veterans living on certain government 
property.
    Background. The National Coalition for Homeless Veterans 
(NCHV), in testimony before the Committee on May 21, 2008, 
cited VA's 2006 Community Homelessness Assessment and Local 
Education Networking Groups report, ``The lack of affordable 
permanent housing is cited as the No. 1 unmet need of America's 
veterans.'' This need is listed as the second highest unmet 
need in the 2007 report.
    Currently, veterans can utilize services from organizations 
that are sponsored by the Homeless Grant and Per Diem (GPD) 
program, but organizations sponsored by this program can only 
provide services to a veteran for up to two years. Domiciliary 
Care for Homeless Veterans provides treatment and 
rehabilitation to homeless veterans, but the average length of 
stay is only four months. VA's Compensated Work Therapy/
Transitional Residence program provides both a residence and 
employment in conjunction with work-skills training and other 
rehabilitation. The average stay in this program is only 174 
days. VA's Supported Housing program allows VA staff to assist 
in locating permanent housing for veterans, but does not 
provide any funding or vouchers to allow VA to provide that 
housing.
    A new VA pilot program provides loan guarantees for 
transitional family housing, but not permanent long-term 
housing. All of these programs are beneficial steps, but many 
veterans are still not ready for transition to independent 
living at the end of these programs. NCHV points out that 
despite these programs, ``many formerly homeless veterans still 
cannot afford fair market rents, nor will most of them qualify 
for mortgages even with the VA home loan guarantee. They are, 
essentially, still at risk of homelessness.'' Dr. Gerald M. 
Cross, MD, Principal Deputy Under Secretary for Health at VA, 
testified at the Committee's May 21, 2008, hearing that 
military facilities that have been recently closed or had a 
major mission change could potentially be prime locations to 
house already homeless veterans or those in danger of becoming 
homeless.
    Committee Bill. Section 501 of the Committee bill would 
authorize the Secretary, subject to the availability of 
appropriations, to carry out, and evaluate the impact of, a 
pilot program which would provide grants to entities that 
coordinate the provision of supportive services for very low 
income (as defined in the Resident Characteristics Report of 
the Department of Housing and Urban Development), formerly 
homeless veterans living on property that had been a military 
installation closed as part of the 2005 round of defense base 
closure and realignment under the Defense Base Closure and 
Realignment Act of 1990, or under subchapter III of chapter 5 
of title 40, U.S.C., and which the Secretary of Defense 
determines, after reviewing any local authority's redevelopment 
plans for the property, that the property can be used to assist 
the homeless in accordance with any such redevelopment plan.
    The program would be carried out through the provision of 
grants from the Secretary to public and nonprofit 
organizations, including faith-based organizations. The 
Secretary would be authorized to issue grants at not more than 
ten properties that had been military installations that were 
closed as described above. The Secretary would be required to 
determine and publish criteria for awarding the grants. This 
pilot program would span a period of five years from the 
program's beginning. In order to carry out this program, 
$3,000,000 from General Operating Expenses would be authorized 
for the program in each fiscal year from 2009 to 2013.
    The Committee agrees with VA's position that military 
facilities that have been recently closed or have had a major 
mission change could serve as excellent locations to house 
homeless veterans, or those in danger of becoming homeless. In 
developing economic revitalization and community development 
plans, local authorities could utilize grants under the program 
that would be established by this provision so as to aid in 
financing the conversion of such properties. The Committee 
believes that veterans with certain applicable skills--
including but not limited to such occupations as carpentry, 
plumbing, and landscaping--could be employed in the property 
conversion process, or in other aspects of a community's 
redevelopment plan, a process that could further aid very low-
income veterans. It is the Committee's belief that this 
combination of available housing and employment under local 
revitalization plans or in areas of the local economy could 
enable participating veterans to become self supporting.

Sec. 502. Pilot program on financial support of entities that 
        coordinate the provision of supportive services to formerly 
        homeless veterans residing in permanent housing.

    Section 502 of the Committee bill, which is derived from S. 
2273, would authorize the Secretary to implement a pilot 
program to carry out, and evaluate the impact of, providing 
grants to certain organizations for the coordination of efforts 
to provide supportive services from the local community to very 
low income, formerly homeless veterans.
    Background. Currently, there are a number of community-
based and/or non-profit organizations that can and do provide a 
variety of services to assist formerly homeless veterans with 
their reintegration into society. These groups, coupled with 
VA's current efforts to provide supportive services, seek to 
prevent homelessness from recurring, which is consistent with 
the overall direction of efforts against homelessness. The 
focus among both VA providers and community groups is shifting 
to prevention rather than reaction to homelessness occurring. 
This is done largely through intensive case management and 
collaboration with VSOs to find permanent housing for these 
veterans.
    Committee Bill. Section 502 of the Committee bill would 
authorize the Secretary, subject to the availability of 
appropriations, to carry out, and evaluate the impact of, a 
pilot program which would provide grants to nonprofit and 
public organizations, including faith-based organizations, to 
coordinate providing supportive services from the local 
community to very low income (as defined in the Resident 
Characteristics Report from the Department of Housing and Urban 
Development), formerly homeless veterans who are residing in 
permanent housing. The Secretary would be authorized to award 
grants at up to ten locations. Locations that would qualify for 
grants would include any property in the United States that 
provides permanent housing to formerly homeless veterans. 
Criteria for receiving grants would be developed and published 
by the Secretary. This program would be conducted over a five 
year period, beginning at the start of the pilot program. In 
order to carry out this program, $3,000,000 from General 
Operating Expenses would be authorized for the program in each 
fiscal year from 2009 to 2013.
    This effort, in ten communities across the nation, would 
further assist veterans in reintegrating into the community and 
becoming self sufficient. The Committee expects that the ten 
locations selected for the pilot program under section 502 of 
the Committee bill will all be different from the locations 
selected for the pilot program under section 501, described 
above.
    Joseph L. Wilson, Deputy Director of the Veterans Affairs 
and Rehabilitation Commission of The American Legion, described 
the need for the type of pilot program authorize in this 
section of the Committee bill and in the prior section, in his 
May 21, 2008, testimony before the Committee, saying ``[w]hile 
permanent housing provides a stable base for veterans and their 
families the need for resources to improve their way of life is 
just as important * * *. These funded pilot programs will 
extend more opportunities for formerly homeless veterans, which 
in turn allow them to achieve and maintain a quality existence, 
deserving of their service to our country.''

Sec. 503. Pilot program on financial support of entities that provide 
        outreach to inform certain veterans about pension benefits.

    Section 503 of the Committee bill, which is derived from S. 
2273, would authorize the Secretary to implement a pilot 
program to carry out, and evaluate the impact of, providing 
grants to certain organizations to inform certain veterans and 
their spouses about VA pension benefits.
    Background. A recent study, (Greg Greenberg, Joyce H. Chen, 
Robert A. Rosenheck, Wesley J. Kasprow. ``Receipt of Disability 
through an Outreach Program for Homeless Veterans.'' Military 
Medicine 172, no. 5 (May 1, 2007): 461-5.), has concluded that 
there is an acute need for outreach to low-income and elderly 
veterans, and their spouses, to inform them of their potential 
eligibility for need-based pension benefits from VA. Some of 
these veterans and their spouses live in areas that are far 
from VA facilities, and hence are underserved in outreach from 
VA.
    Pension benefits are given by VA to wartime veterans who 
have limited income, and are either 65 years of age, or older, 
or who are permanently and totally disabled.
    Committee Bill. Section 503 of the Committee bill would 
authorize the Secretary to carry out, and evaluate the impact 
of, a pilot program which would provide grants to nonprofit or 
public organizations, including faith-based organizations, to 
provide outreach and information to low-income and elderly 
veterans and their spouses, who live in rural areas, of 
benefits and services they may qualify for under chapter 15 of 
title 38, U.S.C., the chapter relating to VA's needs-based 
pension program. The Secretary would develop criteria for 
awarding the grants, and publish them in the Federal Register. 
This program would span a period of five years from the date of 
its inception. In order to carry out this program, $1,275,000 
from General Operating Expenses would be authorized for the 
program in each fiscal year from 2009 to 2013.
    The Committee believes that utilizing local organizations 
and their existing networks would be an effective way of 
disseminating key information to veterans and their spouses 
about the VA pension program.

Sec. 504. Pilot program on financial support of entities that provide 
        transportation assistance, child care assistance, and clothing 
        assistance to veterans entitled to a rehabilitation program.

    Section 504 of the Committee bill, which is derived from S. 
2273, would authorize the Secretary to carry out a pilot 
program that would involve providing financial assistance to 
certain veterans who are eligible for rehabilitation programs 
under chapter 31 of title 38, U.S.C.
    Background. VA found that subsistence allowances provided 
under chapter 31 of title 38, U.S.C., the chapter which sets 
forth VA's Vocational Rehabilitation Program, were insufficient 
for veterans to support themselves or their families while 
utilizing the vocational rehabilitation services provided 
therein. Clothing, transportation, and child care needs were 
specifically cited by VA as being major areas of concern for 
those participating in the program.
    Committee Bill. Section 504 of the Committee bill would 
authorize the Secretary, subject to appropriations, to carry 
out a pilot program to examine the feasibility and advisable of 
providing financial assistance to eligible entities in order 
that those entities could establish new, or expand upon 
existing, programs to provide assistance to transitioning 
individuals who are eligible for rehabilitation programs under 
chapter 31 of title 38, U.S.C.
    The assistance that would be provided by eligible entities 
under the pilot program would include: (1) transportation 
assistance, including providing or paying for transportation or 
other transportation related expenses (such as orientation to 
using the transportation); (2) child care assistance to enable 
participation in rehabilitation programs, including providing 
or paying for child care; and (3) clothing assistance, 
including help in finding suitable work clothing and providing 
a clothing purchase allowance.
    An eligible individual under this section of the Committee 
bill would include a person described in section 3102 of title 
38, or someone who was separated or released from active duty 
in the Armed Forces on or after October 1, 2006, because of a 
service-connected disability. A qualified individual under 
section 3102 would be a person who is a veteran: with a 20 
percent or greater service-connected disability, incurred or 
aggravated after September 16, 1940; receiving medical care, 
from a Government facility or at Government direction, for a 
service-connected disability, that will likely be rated at or 
above 20 percent, while awaiting discharge from active duty; 
the Secretary believes is in need of rehabilitation because of 
an employment handicap; or a veteran, with a service-connected 
disability of 10 percent or greater, incurred or aggravated on 
or after September 16, 1940, and who also, in the determination 
of the Secretary, suffers from a serious employment handicap. 
Grant criteria would be established and published by the 
Secretary, but would have to include the kinds of projects for 
which grants are available, the number of projects for which 
grants are available, and provisions to ensure projects do not 
duplicate existing services. Grants would not be permitted for 
paying the operating costs of the receiving entities.
    Eligible entities under this section of the Committee bill 
would include public and nonprofit organizations, including 
faith-based organizations which (1) have the capacity to 
effectively administer a grant from the Secretary; (2) 
demonstrate the availability of sufficient financial resources 
for the establishment or expansion of programs; and (3) agree 
to and have the capacity to meet the pilot program's criteria 
as promulgated by the Secretary. Grant recipients would be 
selected by the Secretary based upon an organization's 
submission of an application which would be required to 
contain: (1) the amount sought; (2) plans, specifications, and 
the schedule for implementing the organization's program; and 
(3) an agreement to provide the services at accessible 
locations, maintain confidentiality of the records of 
individuals participating in the program, and establish fiscal 
control and accounting procedures to ensure proper disbursement 
and accounting.
    If a grant or part of a grant under this program were 
unused, or if the organization does not establish a program to 
provide services, or ceases the program for which they were 
awarded a grant, the U.S. would be authorized to recover any 
unused amounts of awarded grants and the Secretary would be 
authorized to obligate any amount so recovered, without fiscal 
year limitation, in order to continue the pilot program. No 
amount could be recovered until three years from the date on 
which the grant was awarded. Authority for the pilot program 
would end three years after the date of the program's 
inception. Five million dollars would be allotted in each 
fiscal year from 2008-2010 to implement the pilot program.
    It is the Committee's hope that, by increasing the benefits 
available to veterans under going rehabilitation, and providing 
this aid early, it is more likely that the veteran will 
successfully complete vocational rehabilitation, which could 
have a substantial effect on the unemployment rate among 
veterans, specifically disabled veterans.

Sec. 505. Assessment of pilot programs.

    Section 505 of the Committee bill, which is derived from S. 
2273, would require the Secretary to submit a report to 
Congress on each of the pilot programs detailed in sections 
501-504 of the Committee bill at least one year before the end 
of each program's authorization. Each report would be required 
to contain the lessons learned by the Secretary which can be 
applied to other similar programs, any recommendations from the 
Secretary as to whether to continue the pilot program, the 
number of veterans and dependents served by the pilot program, 
an assessment of the quality of service provided by the 
program, the amount of funds provided to grant recipients under 
the program, and the names of all organizations that have 
received grants.

Sec. 506. Increased authorization of appropriations for comprehensive 
        service programs.

    Section 506 of the Committee bill, would increase the 
amount authorized for comprehensive service programs for 
homeless veterans, under subchapter II of chapter 20, title 38, 
U.S.C., from $130,000,000 annually to $200,000,000 annually. 
The programs referred to in this section are the GPD programs. 
Under this program, VA can provide grant funds to assist in the 
construction or renovation of a community-based, non-profit 
facility for the purposes of housing and providing services to 
homeless veterans. These facilities' programs may also be 
eligible for per diem funds from VA to offset the cost of care, 
for each veteran they serve.
    These programs have been largely successful and as such, 
the Committee believes that the threshold for total 
authorization should be increased to allow more resources to be 
directed to this program. The Senate Appropriations Committee 
included $200,000,000 for the GPD Program in the Military 
Construction-Department of Veterans Affairs Appropriations Bill 
for Fiscal Year 2009 that was reported out of Committee on July 
XX, 2008, subject to the passage of a corresponding increase in 
the authorization level.

        TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS

    Title VI of the Committee bill includes a number of 
provisions that would amend subchapter IV of chapter 73 
relating to nonprofit research and education corporations 
(NPCs).
    NPCs were first authorized in 1988 in Public Law 100-322. 
Prior to 1988, it was difficult for VA to accept private or 
non-VA public funding for its research program. The methods in 
place, such as the General Post Fund, were not well-suited to 
this task. The General Post Fund was primarily designed to 
accept and administer veterans' bequests, the regulations of 
which made it difficult to flexibly disburse funds. 
Additionally, university partners who could administer funds 
for VA frequently had high overhead costs, reducing the amount 
of funding available for actual research. NPCs were designed to 
be a mechanism that could flexibly administer such funds, be 
regulated and overseen by the Federal Government, and remain 
affiliated with, but not part of, VA.
    While NPCs were originally designed to support only VA 
research, Congress has since expanded their role to include 
support of education and training. Since that initial authority 
was provided, the number of NPCs that have been established has 
ranged from 96 to 84, with prior year revenues totaling more 
than $240,000,000 reported in June 2008. NPCs play a central 
role in VA research, making up 18 percent of VA's total 
research funding. Through NPCs, VA researchers access funding 
from, and collaborate with, DOD and the National Institutes of 
Health of HHS. NPCs also give VA researchers access to research 
support from foundations, corporations, and private 
organizations.
    NPCs were originally intended to support the research 
programs of individual medical centers. This facility-specific 
approach effectively supports individual programs, and NPCs are 
essential components of many facilities' research efforts. 
However, in the twenty years since the inception of NPCs, the 
character of VA research has changed and the standards applied 
to nonprofit corporation governance and management have become 
more rigorous. Some facility research programs may simply be 
too small to generate a revenue stream sufficient to support 
the infrastructure and governance necessary to meet these 
standards, but the facilities would nonetheless benefit from 
having ready access to the benefits NPCs provide.
    In general, the provisions of Title VI of the Committee 
bill would alter the existing law to allow for multi-medical 
center non-profit research corporations. Traditional NPCs are 
chartered in the state in which they are physically located and 
affiliated with one VA facility. In order to combine resources, 
NPCs affiliated with nearby medical centers, possibly in 
different states, need the ability to form higher-revenue 
corporations, known as multi-medical center research 
corporations, without unduly imposing on the VA a requirement 
for multiple personnel from multiple facilities to serve on an 
NPC board of directors.
    The Committee bill would grant authority to the Secretary 
to establish multi-medical center research corporations, to 
approve the conversion of single-facility NPCs to multi-medical 
center research corporations. It also details the composition 
of the board of directors for such corporations. The bill also 
would make permanent the authority of the Secretary to 
establish NPCs, clarify the powers of such corporations to 
allow them to more flexibly disburse their funds, and clarify 
the purposes of NPCs to remove ambiguity about their role in 
supporting education and training. Finally, this title would 
improve the oversight of NPCs, and make a clerical amendment.

Sec. 601. General authorities on establishment of corporations.

    Section 601 of the Committee bill, which is derived from S. 
2926, would expand authorizations for the establishment of 
NPCs, and clarify the definition and purpose of such 
corporations.
    Background. Current law relating to the authority to 
establish NPCs, section 7361 of title 38, U.S.C., allows NPCs 
to be established at one VA medical center, and in one state. 
As discussed above, NPCs were originally intended to support 
the research programs of individual medical centers but that 
model is no longer optimal. Current law requires that NPCs be 
tax exempt organizations but does not specify the specific 
terms of that status, which has led to some confusion about the 
tax and regulatory status of NPCs in some states and among some 
stakeholders.
    Committee Bill. Section 601 of the Committee bill would 
amend section 7361 of title 38 in a number of ways, with the 
principal focus on authorizing the creation of multi-medical 
center research corporations.
    Subsection (a)(1) of section 601 would amend section 7361 
so as to insert a new subsection (b) that would expressly 
authorize the establishment of ``multi-medical center research 
corporations.'' The board of directors of a multi-medical 
center research corporation would have to include the director 
of each VA medical center involved in the corporation. A multi-
medical center research corporation would be authorized to 
manage finances relating to research or education, or both, 
performed at the VA medical centers involved.
    Additionally, single-facility NPCs and multi-medical center 
research corporations would retain unchanged their current 
ability to administer funds for research programs conducted at 
multiple facilities, regardless of whether those facilities are 
served by a multi-medical center research corporation. NPCs 
could also serve as pass-through entities for programs 
performed at multiple facilities.
    Subsection (a)(2) of section 601 would add a new subsection 
(f) to section 7361 that would authorize an existing NPC to 
become a multi-medical center research corporation if its board 
of directors approves such an expansion and it is also approved 
by the Secretary. Ms. Donna McCartney, Chair of the National 
Association of Veterans' Research and Education Foundations 
(NAVREF) and Executive Director of the Palo Alto Institute for 
Research and Education, testified before the Committee on May 
21, 2008, that this provision is necessary because:

        ``* * * it will allow interested VA facilities with 
        small research programs to join with larger ones. Or 
        several smaller facilities may pool their resources to 
        support management of one NPC with funds and staffing 
        adequate to ensure an appropriate level of internal 
        controls, including segregation of financial duties.''

    Subsection (b) of section 601 would further amend section 
7361 by adding a new subsection (c) which would consist of the 
provisions of current section 7365, relating to the 
applicability of State law to NPCs, modified so as to specify 
that multi-medical center corporations operating in different 
states would be created under and subject to the laws of one of 
the States in which the corporation operates.
    Subsection (c) of section 601 would further amend section 
7361 by recasting as a new subsection (d)(1) a provision in 
subsection (a) of current section 7361 relating to the 
obligation of NPCs to comply only with those Federal laws, 
regulations, and executive orders and directives that apply to 
private non-profit corporations generally and by adding a new 
paragraph (2) to subsection (d) which would expressly provide 
that NPCs are not owned or controlled by, or are not an agency 
or instrumentality of, the United States.
    Subsection (d) of section 601 would further amend section 
7361 by restoring the requirement that all NPCs must operate as 
501(c)(3) tax exempt organizations. This amendment is designed 
to eliminate confusion in some states and among some 
stakeholders over the tax status of NPCs. In testimony, for the 
record of the Committee's May 21, 2008, hearing, VA expressed 
support for section 601 and specifically for permitting the 
formation of multi-medical center research corporations.

Sec. 602. Clarification of purposes of corporations.

    Section 602 of the Committee bill, which is derived from S. 
2926, would clarify the purpose of NPCs to include specific 
reference to their role as funding mechanisms for approved 
research and education, in addition to their role in 
facilitating research and education.
    Background. Current law is not specific with respect to the 
role of NPCs in supporting research and education, and does not 
include multi-medical center corporations. Further, the statute 
currently contains provisions that appear to allow NPCs to 
offer residencies and similar programs, possibly in conflict 
with the prohibition against nonprofit corporations conferring 
personal benefits on individuals.
    Committee Bill. Section 602 of the Committee bill would 
amend section 7362 of title 38, U.S.C., in a number of ways, 
with the principal focus on providing that, in addition to 
supporting the conduct and administration of VA research 
projects and education activities, NPCs may support functions 
more generally related to VA research and education.
    Subsection (a) of section 602 would amend subsection (a) of 
section 7362 so as to clarify that NPCs are intended to provide 
``a flexible funding mechanism'' for both the conduct of 
approved research and education at one or more VA medical 
centers and to fund ``functions'' relating to research and 
education. These functions would include, but not be limited 
to: travel to scientific conferences; recruitment of clinician 
investigators; improvements in laboratories; procurement of 
general use research equipment, and support for the 
institutional review board; the animal laboratory and the 
facility human protections program. Under current law, support 
for such functions often cannot be tied to specific research 
projects and, as such, may not be permitted.
    Ms. McCartney's testimony noted that there have been 
differences in interpretation regarding the permissibility of 
NPC expenditures supporting VA research and education 
generally, instead of being tied directly to an approved 
project. This section of the Committee bill would clarify that 
issue.
    Subsection (b) of section 602 would amend subsection (b) of 
section 7362 so as to make a technical modification to a 
defined term relating to education and training.
    Subsection (c) of section 602 would further amend 
subsection (b) of section 7362 so as to strike a provision that 
allows NPCs to include, under the education function of a 
corporation, the employment of individuals as part of a 
residency or similar program. By removing this language 
relating to residencies and similar programs, it is not the 
Committee's intent that this change diminish the authority of 
NPCs to support elements of education and training activities 
for VA trainees, such as VA residents, but simply to clarify 
that NPCs cannot be chief sponsors of residencies, as they are 
neither hospitals nor academic institutions and that function 
may conflict with regulations governing 501(c)(3) 
organizations. NPCs would still be able to support education 
and training activities for VA trainees, and, for purposes of 
this section, employees of the VHA include VA trainees.
    Subsection (d) of section 602 would further amend 
subsection (b) of section 7362 so as to clarify that NPCs are 
authorized to provide education and training to patients as 
well as families of patients. The Committee recognizes that 
patients' families often play a central role in the care and 
recovery of veteran patients. As such, education for family 
members directly supports the care and recovery of these 
veterans. The return of wounded service members from Iraq and 
Afghanistan, many with severe TBI or debilitating multiple 
traumas, is placing growing demands on family caregivers. 
Clarifying that NPCs can provide such education would be an 
important form of support for family caregivers.

Sec. 603. Modification of requirements for boards of directors of 
        corporations.

    Section 603 of the Committee bill, which is derived from S. 
2926, would address the requirements for the composition of NPC 
boards of directors.
    Background. Under current section 7363, certain non-VA 
personnel who serve on the board of an NPC must be familiar 
with issues involving medical and scientific research or 
education. This limits the composition of boards of directors, 
and prevents potential board members from serving who may have 
valuable business, legal, or financial expertise.
    In addition, subsection (c) of section 7363 requires that 
members of NPC boards have no ``financial relationship'' with 
any entity that is a source of funding for VA, with the 
exception of governmental and non-profit entities. This phrase 
has been interpreted by VA as an absolute prohibition on any 
financial relationship on the part of a board member with a 
precluded entity, either in the past or present. That 
prohibition was included in the original NPC authorizing 
legislation, Public Law 100-322, in 1988. Subsequently, the 
Office of Government Ethics (OGE) promulgated government-wide 
conflict of interest regulations in 5 CFR (Code of Federal 
Regulations) Part 2635, and the waiver regulations required by 
section 208 of title 18, U.S.C., in 5 CFR Part 2640 in August 
1992, and December 1996, respectively. In light of those 
actions by OGE, the requirements placed on NPC board members 
have become more onerous than those applied to many government 
and non-profit employees.
    Further, the financial conflict of interest requirements of 
current subsection (c) of section 7363(c) go beyond the 
requirements in paragraph (1) of subsection (c) of section 
7366, which state that NPC board members ``shall be subject to 
Federal laws and regulations applicable to Federal employees 
with respect to conflicts of interest in the performance of 
official functions.'' Under that paragraph, NPC board members 
are governed by the statutory criminal code, section 208 of 
title 18, U.S.C., and conflict of interest regulations, 5 CFR 
Sec. Sec. 2635.401-2635.403. Those regulations, in addition to 
guidance from the Internal Revenue Service and the Office of 
Government Ethics, provide for the permissibility of de minimus 
affiliations, and for the ability to recuse oneself when 
necessary to avoid conflicts of interest.
    Committee Bill. The Committee bill would amend section 7363 
of title 38, U.S.C., in a number of ways so as to describe 
membership in boards of multi-medical center research 
corporations, allow non-VA individuals with diverse backgrounds 
to serve on NPC boards, and to modify the provisions relating 
to conflicts of interest.
    Subsection (a) of section 603 would amend paragraph (1) of 
subsection (a) of section 7363 so as to restructure the current 
law without changing the intent or effect except to provide 
that the directors of each medical center affiliated with a 
multi-medical center research corporation are to be members of 
that corporation's board of directors.
    Subsection (b) of section 603 would amend paragraph (2) of 
subsection (a) of section 7363 so as to require that not less 
than two non-VA personnel be members of the board, and, in 
addition to those with medical or scientific expertise, would 
permit individuals to be on an NPC board who have backgrounds 
or business, legal, or financial expertise that would benefit a 
board.
    Ms. McCartney testified that this provision of the 
Committee bill would substantially aid NPCs in acquiring the 
expertise needed to efficiently run research corporations, 
including legal and financial management expertise.
    Subsection (c) of section 603 would amend subsection (c) of 
section 7363 so as to eliminate the requirement in current law 
that members of NPC boards have no financial relationship with 
any entity that is a source of funding for research or 
education by VA, with the exception of governmental and non-
profit entities. By eliminating the restrictions in current 
law, this section of the Committee bill would bring NPCs into 
conformity with other 501(c)(3) entities and Federal conflict 
of interest regulations.
    Ms. McCartney emphasized the importance of this change and 
the Committee concurs with her view that there is no reason to 
hold board members of NPCs to a higher standard than what 
applies to similar organizations or to government employees.

Sec. 604. Clarification of powers of corporations.

    Section 604 of the Committee bill, which is derived from S. 
2926, would restate NPCs' authorities so as to clarify that 
they may accept, administer, and transfer funds for various 
purposes.
    Background. Section 7364 of title 38, U.S.C., entitled 
``General powers,'' sets forth the core authorities of NPCs. 
Over the years, the incompleteness and imprecision of some of 
these provisions have created obstacles to the conduct of NPC 
business. In addition, current law is unclear and potentially 
contradictory on some financial and personnel issues.
    Current section 7364 does not fully address the financial 
authorities necessary to NPCs. While the provision specifies 
that NPCs may accept gifts and grants, it does not mention 
other sources of funding common to NPCs, such as fees, 
reimbursements, and bequests. In some situations, VA has 
interpreted existing law to mean that NPCs may only accept the 
types of income explicitly specified in current section 7364. 
In addition, the authority of NPCs to utilize funds is poorly 
defined, as it leaves out the administration, retention, and 
spending of such funds.
    Under current law, NPCs do not have the authority to charge 
non-VA attendees fees for educational or training programs nor 
do they have authority to retain such fees. While NPCs are 
tasked with facilitating education and training, and to accept 
funds in support of such activities, section 8154 of title 38 
provides that only the Secretary has authority to conduct VA 
educational programs, and to charge non-VA attendees fees for 
such programs. That provision also specifies that the fees 
collected be credited to the applicable VA medical 
appropriation. As a result, even when non-VA attendees are 
willing to pay fees to contribute to the costs of educational 
or training events, NPCs do not have explicit authority to 
charge or retain such funds, a result which presents a 
significant obstacle to the conduct of such events.
    Cooperative Research and Development Agreements (CRADAs) 
are agreements mandated by VA to establish the terms and 
conditions for certain industry-sponsored studies performed at 
VA medical centers and administered by NPCs. Each CRADA must be 
reviewed and approved by a VA attorney. Although NPCs generally 
handle the preliminary negotiations relating to the development 
of CRADAs, VA attorney review is often extensive, and can take 
a number of hours, incurring significant costs. While NPCs 
frequently have funds available to reimburse the Office of 
General Counsel (OGC) for these costs, OGC does not have 
authority to accept or retain reimbursement for its services.
    Current section 7364 does not specifically address the 
transfer of funds between VA and NPCs for costs associated with 
personnel assignments under the Intergovernmental Personnel Act 
(IPA), under subchapter VI of chapter 33 of title 5, U.S.C. IPA 
assignments between VA medical centers and NPCs have been 
common since the inception of NPCs. The assignment of NPC 
employees to VA has proven to be of significant benefit to VA 
research. In a May 2008 report titled, ``Audit of Veterans 
Health Administration's Oversight of Nonprofit Research and 
Education Corporations,'' the VA OIG found that under current 
law, reimbursements from VA to NPCs, pursuant to the IPA, 
constitute transfers of funds appropriated to VA prohibited by 
subsection 7362(a) of title 38. This finding jeopardizes an 
important element of the partnership between VA and NPCs.
    Current section 7364 authorizes NPCs to spend funds only on 
research projects that have been approved by the VA facility 
Research and Development Committee. Requiring approval prior to 
any expenditure of funds unduly hinders operations and planning 
necessary to the application or preparation for research 
projects, such as the costs of hiring a grant writer or study 
coordinator to prepare a grant proposal.
    Committee Bill. Section 604 of the Committee bill would 
amend section 7364 of title 38, U.S.C., by striking the current 
sections (a) through (c) and inserting new subsections (a) 
through (e) which, collectively, would set forth the general 
powers of NPCs and clarify the relationship between VA and 
NPCs.
    Proposed paragraph (1)(A) of new subsection (a) of section 
7364 would allow NPCs to accept, administer, retain, and spend 
funds derived from gifts, contributions, grants, fees, 
reimbursements, and bequests from individuals and public and 
private entities. New paragraph (1)(B) would authorize NPCs to 
enter into contracts and agreements with individuals and public 
and private entities. These changes make explicit the financial 
authorities of NPCs, which the Committee views as consistent 
with the intent of the original authorizing legislation.
    Proposed new paragraph (1)(C) of new subsection (a) would 
authorize NPCs to charge registration fees for education and 
training programs they administer, and to retain such funds.
    Proposed paragraph (2) subsection (a) would prohibit the 
use of funds appropriated to VA to pay fees charged by NPCs. 
Taken together, these provisions would enable NPCs, and the 
research programs served by NPCs, to gain financial support for 
their educational and training programs.
    Proposed paragraph (1)(D) of new subsection (a) would 
authorize NPCs to reimburse OGC for certain expenses of 
providing legal services attributable to NPC research and 
education agreements. With financial assistance from NPCs, OGC 
would be better able to staff Regional Counsel offices and the 
VA Central Office so as to meet the demand to review the 
growing number of CRADAs. Proposed new paragraph (3) of 
subsection (a) would further mandate that funds reimbursed to 
OGC by NPCs are to be used only for staff and training, and 
related travel, for the provision of legal services related to 
review of research agreements such as CRADAs.
    Proposed paragraph (1)(E) of new subsection (a) is a 
renumbering of the text of subsection (a)(2) of current section 
7364.
    Proposed paragraph (1) of new subsection (b) is a 
renumbering of the text of the second sentence of subsection 
(a) of current section 7362. The language would be moved to new 
section 7364 in order to group it with other provisions 
addressing NPC funding issues.
    Proposed new paragraph (2) of subsection (b) would 
authorize VA to reimburse an NPC for all or a portion of the 
pay or benefits, or both, of an NPC employee assigned to VA 
under the IPA. The Committee believes that this authorization 
will remove any uncertainty about the appropriateness of using 
VA-appropriated funds to reimburse NPCs for personnel appointed 
to VA pursuant to the IPA in the past and going forward.
    Proposed new subsection (c) of section 7364 would grant 
powers to NPCs allowing them to disburse limited funds for 
essential activities that must be accomplished prior to 
research project approval. Such activities would include grant 
proposal writing, development, and review. Currently, NPCs are 
not permitted to disburse any funds in support of a research 
program until that program has been approved by VA. The 
Committee believes that this restriction is impractically 
rigid, and hinders NPC ability to appropriately prepare for 
project proposals.
    Proposed new subsection (d) of section 7364 would grant 
powers to NPCs allowing them to disburse limited funds for 
essential activities that must be accomplished prior to 
education and training activity approval. Such essential 
activities would include grant request writing, strategy 
development, creating presentations and briefings and perhaps 
even making deposits to reserve meeting space. Currently, NPCs 
are not permitted to disburse any funds in support of an 
education activity until that program has been approved. The 
Committee believes that this restriction is impractically 
rigid, and hinders NPCs' ability to appropriately prepare for 
education activities.
    Proposed new subsection (e) of section 7364 would permit 
the USH to establish policies and procedures for the spending 
of funds by NPCs. These policies and procedures would be 
required to not only comply with applicable regulations, but 
also to be designed to facilitate the mission of NPCs as 
flexible funding mechanisms. Ms. McCartney voiced strong 
support for these provisions in her testimony before the 
Committee on May 21, 2008.

Sec. 605. Redesignation of section 7364A of title 38, U.S.C.

    Section 605 of the Committee bill, which is derived from S. 
2926, would redesignate section 7364A as section 7365, as a 
conforming amendment to the provision in section (b)(2) of 
section 601 of the Committee bill, which struck current section 
7365 after moving the contents of that section to new 
subsection (c) of section 7361.

Sec. 606. Improved accountability and oversight of corporations.

    Section 606 of the Committee bill, which is derived from S. 
2926, would strengthen VA oversight of NPCs.
    Background. VA is responsible for oversight of the NPCs, 
and a number of bodies carry out that duty. The Secretary 
established the VA Nonprofit Corporation Oversight Board in 
2004 to review the activities of VA NPCs for consistency with 
VA policy and interests. Earlier, in 2003, VHA established the 
Nonprofit Research and Education Corporation Program Office 
(NPPO) to provide oversight of NPC activities. The NPPO is 
responsible for providing oversight and guidance affecting 
operations and financial management, performing substantive 
reviews of the annual reports submitted by each NPC, compiling 
the information for VA's annual submission to Congress, 
improving accountability, and ensuring deficiencies are 
corrected. In accordance with the Chief Financial Officers 
(CFO) Act of 1990 (Public Law 101-576) and a 1994 General 
Counsel opinion, VHA's CFO also has financial oversight 
responsibility for NPCs.
    The May 2008 OIG report discussed earlier found a number of 
problems with VA oversight of NPCs. The OIG found that ``NPCs 
did not implement adequate controls to properly manage funds'' 
and that VA failed to adequately implement ``effective 
oversight procedures'' or require ``minimum control 
requirements for NPC activities.'' While the OIG did not find 
significant problems resulting from ineffective oversight, the 
report concluded that ``VHA cannot be reasonably assured that 
the NPCs are fully complying with applicable laws or 
regulations or effectively managing research and education 
funds.''
    Committee Bill. Subsection (a) of section 606 of the 
Committee bill would amend subsection (b) of section 7366 of 
title 38, U.S.C., so as to require NPCs to include the 
corporation's most recent IRS Form 990 ``Return of Organization 
Exempt from Income Tax'' or equivalent documents, and the 
applicable schedules, in an NPC's annual report to the 
Secretary. The information in Form 990 is extensive, and would 
be valuable to the Secretary in the conduct of thorough 
oversight.
    Subsection (b) of section 606 would amend subsection (c) of 
section 7366 so as to make the laws and regulations governing 
conflicts of interest within NPCs conform to laws governing 
similar entities, and to those governing conflicts of interest 
among Federal employees, as discussed above under section 603 
of the Committee bill.
    Subsection (c) of section 606 would amend subsection 
(d)(3)(c) of section 7366 so as to raise the threshold for 
reporting identifying information for payees from $35,000 to 
$50,000. Current law requires the Secretary, in annual reports 
to Congress, to provide identifying information on every payee 
paid more than $35,000. The proposed increase would make the 
statute governing NPC practices consistent with IRS standards 
for scrutinizing compensation for higher paid employees. The 
Committee believes that the original intent of this reporting 
requirement was to scrutinize large payments and compensation 
of higher paid employees, and that rising salaries over time 
have simply overtaken the current statute.

Sec. 607. Repeal of sunset.

    Section 607 of the Committee bill, which is derived from S. 
2926, would repeal the existing sunset on the Secretary's 
authority to establish NPCs.
    Background. Section 7368 of title 38, U.S.C., precludes the 
establishment of new NPCs after December 31, 2008. VA requested 
that the authority to establish and administer these 
corporations be extended.
    Committee Bill. Section 607 of the Committee bill would 
repeal section 7368 of title 38, U.S.C., thereby removing any 
limitation on the Secretary's authority to establish NPCs. The 
Committee believes that NPCs make a significant contribution to 
VA research and medical capabilities and promote important 
educational activity. It is the Committee's intent that the 
Secretary develop approval criteria on the establishment of 
NPCs. Such criteria should permit the establishment of an NPC 
only when it would make a substantive contribution to research 
or education activity or both, and when it is believed that the 
NPC could generate sufficient revenue to support the necessary 
management and compliance infrastructure.

                        TITLE VII--CONSTRUCTION

Sec. 701. Authorization of fiscal year 2009 major medical facility 
        projects.

    Section 701 of the Committee bill, which is derived from S. 
2797, would authorize the Secretary to conduct four major 
medical facility projects during fiscal year 2009.
    The first of these projects would be the construction of an 
80-bed facility in Palo Alto, California, to replace the 
existing acute psychiatric inpatient facility that is 
seismically unsafe. This construction project would not exceed 
$54,000,000.
    The second project would be construction of an outpatient 
clinic in Lee County, FL, which would not exceed $131,800,000 
in construction costs. This facility would serve the increasing 
demand for diagnostic procedures, ambulatory surgery, and 
specialty care.
    The third project would be the construction costs 
associated with seismic corrections to Building 1 of the VA 
Medical Center in San Juan, PR, which would not exceed 
$225,900,000 in renovation costs.
    The fourth project would be the construction of a state-of-
the-art polytrauma center in San Antonio, TX, which would not 
exceed $66,000,000 in construction costs.

Sec. 702. Extension of authorization for Department of Veterans Affairs 
        Medical Center, New Orleans, LA, major medical facility 
        construction project already authorized.

    Section 702 of the Committee bill, which is derived from S. 
2797, would provide an extension in the previously enacted 
authorization for a replacement VA medical center in New 
Orleans, LA.
    Background. The New Orleans VAMC was severely damaged by 
flooding from Hurricane Katrina and it was determined that it 
would be more cost-effective to construct a new hospital rather 
than try to remediate the mold in, and repair the damage to, 
the former hospital. A construction project to replace the 
facility was previously authorized by section 801 of the 
Veterans Benefits, Health Care, and Information Technology Act 
of 2006, Public Law 109-461. Under that authorization, the 
costs of this project were not to exceed $300,000,000.
    This project has already been funded by Public Law 109-461. 
At the time of the initial authorization, the Congress 
understood that the replacement facility was intended to be co-
located with the Louisiana State University (LSU) Health 
Sciences Center in New Orleans, and it is the Committee's 
understanding that this is still VA's intent. However, this 
current extension of the authorization has been requested by VA 
without regard to whether the project is in fact co-located 
with the LSU facility.
    Committee Bill. Section 702 of the Committee bill would 
extend, through fiscal year 2009, the authorization for the 
previously authorized project to allow the renovation of the VA 
medical center, or the construction of a new facility, in New 
Orleans, Louisiana. This section would also increase the amount 
authorized from $300,000,000 to $625,000,000.

Sec. 703. Authorization of fiscal year 2009 major medical facility 
        leases.

    Section 703 of the Committee bill, which is derived from S. 
2797, would authorize the Secretary to enter into major leases 
for twelve VA medical facilities, as follows:

     an outpatient clinic in Brandon, FL, for 
$4,326,000;
     a community-based outpatient clinic (CBOC) in 
Colorado Springs, CO, for $10,300,000;
     an outpatient clinic in Eugene, OR, for 
$5,826,000;
     the expansion of an outpatient clinic in Green 
Bay, WI, for $5,891,000;
     an outpatient clinic in Greenville, SC, for 
$3,731,000;
     a CBOC in Mansfield, OH, for $2,212,000;
     a satellite outpatient clinic in Mayaguez, PR, for 
$6,276,000;
     a CBOC in Southeast Phoenix, Mesa, AZ, for 
$5,106,000;
     interim research space in Palo Alto, CA, for 
$8,636,000;
     expansion of a CBOC in Savannah, GA, for 
$3,168,000;
     a CBOC in Northwest Phoenix, Sun City, AZ, for 
$2,295,000; and
     a primary care annex in Tampa, FL, for $8,652,000.

Sec. 704. Authorization of appropriations.

    Section 704 of the Committee bill, which is derived from S. 
2797, would authorize appropriations for the total amounts of 
the projects provided for in sections 701, 702, and 703 of the 
Committee bill. Those amounts are $477,700,000 for section 701, 
$625,000,000 for section 702, and $66,419,000 for section 703. 
Section 704 also enumerates the constraints for spending the 
funds allotted for sections 701 and 702, specifically that the 
funding for sections 701 and 702 may only come from funds 
appropriated for fiscal year 2009 for projects listed under 
those sections; funds that remain available for Construction, 
Major Projects for a fiscal year either before or after fiscal 
year 2009, which are still available for obligation; and funds 
appropriated for Construction, Major Projects, for fiscal year 
2009 or a fiscal year either before or after fiscal year 2009 
for a category of activity that is not specific to a project.

Sec. 705. Increase in threshold for major medical facility leases 
        requiring Congressional approval.

    Section 705 of the Committee bill, which is derived from S. 
2984, would increase the threshold at which a lease for a 
medical facility is considered ``major'' and thus requiring 
Congressional approval.
    Background. Section 8104(a)(2) of title 38, U.S.C., 
requires Congressional authorization for all major medical 
facility leases prior to appropriation of funds. Public Law 
105-368, Section 704, amended subsection 8104(a)(3)(B) to 
define a major medical facility lease as one whose annual rent 
is greater than $600,000.
    Section 8104(b) of title 38, U.S.C., requires VA to notify 
and submit a prospectus for all major medical facility leases 
exceeding the $600,000 threshold.
    Committee Bill. Section 705 of the Committee bill would 
amend section 8104(a)(3)(B) so as to increase to $1,000,000 the 
threshold at which the lease of a medical facility by VA would 
be considered a ``major medical facility lease'' under section 
8104 of title 38, U.S.C., and, thus requiring Congressional 
approval.
    It is the Committee's view that this modification simply 
reflects changes in the market costs and would give VA greater 
flexibility to commence such projects.

Sec. 706. Conveyance of certain non-Federal land by City of Aurora, CO, 
        to Secretary for construction of veterans medical facility.

    Section 706 of the Committee bill, which is derived from S. 
3030, directs the Secretary of the Interior to take steps to 
facilitate the transfer of a parcel of land in Aurora, CO, to 
VA for use in connection with the construction of a VA medical 
facility there.
    Background. The parcel of land that is proposed for 
transfer to VA under section 706 of the Committee bill was 
originally Federal land, belonging to the U.S. Army Garrison 
Fitzsimons, Adams County, CO, and was ceded to the city of 
Aurora on May 24, 1999. In 2004, as part of the Capital Asset 
Realignment for Enhanced Services (CARES) study of VA's 
infrastructure, then-Secretary Anthony J. Principi submitted to 
Congress a series of recommendations for closures, 
consolidations, and new construction. The construction of a new 
hospital in the Denver, CO, area was part of this new plan, to 
be carried out in cooperation with DOD and the University of 
Colorado.
    However, due to the skyrocketing costs of the project and 
the shifting trends in health care delivery from inpatient to 
outpatient settings, VA conducted another review of needs in 
the area and drew up a revised plan for the Denver area and 
VISN 19 that included a large ambulatory clinic in Denver, 
leasing two floors of inpatient space in a new University of 
Colorado bed tower, and expansions of outlying clinics within 
the Network. At this time, there has been no conclusion as to 
which plan will move forward. Either way, the land transfer 
must occur in order to give VA the flexibility to commence with 
whichever project Congress authorizes.
    Committee Bill. Section 706 of the Committee bill would 
require the Secretary of the Interior, within 60 days of 
enactment of this Act, to allow the city of Aurora, CO, to 
donate an area of land to the Federal government for the 
purposes of constructing a VA medical facility.

                  TITLE VIII--MISCELLANEOUS PROVISIONS

Sec. 801. Expansion of authority for Department of Veterans Affairs 
        police officers.

    Section 801 of the Committee bill, which is derived from S. 
2984, would expand certain authorities set out in title 38, 
U.S.C., relating to VA police officers so as to better reflect 
the current scope of their duties and responsibilities.
    Background. When originally enacted, section 902 of title 
38, U.S.C., was formulated in a manner that suited a health 
care system that delivered the majority of its services in 
centralized campus environments. As a result, VA police 
officers rarely had official business off VA property. Today, 
however, VA medical facilities now include large campuses, 
urban hospitals, CBOCs, and storefront Vet Centers. VA's 
increasingly decentralized delivery points for care necessitate 
that VA police officers travel frequently among VA facilities 
and off-campus sites. This includes travel off Department 
property to conduct administrative portions of investigations, 
such as interviewing witnesses or crime victims. It also 
includes travel off-campus to bring about the safe return of 
high-risk patients who have eloped and are a danger to 
themselves or others. The responsibilities of VA police 
officers also extend to responding to emergencies and disasters 
at the local, regional, and national levels.
    Because the jurisdiction of VA police officers is limited 
by current law to Department property, VA police officers are 
not able to carry their Department-issued weapons off property 
when conducting official business or on official travel.
    Committee Bill. Subsection (a)(1) of section 801 of the 
Committee bill would amend section 902(a) of title 38, U.S.C., 
so as to permit VA police officers to: (1) carry VA-issued 
weapons, including firearms, while off VA property in an 
official capacity or while in official travel status; (2) 
conduct investigations, on and off VA property, of offenses 
that may have been committed on VA property, consistent with 
agreements with affected local, state, or Federal law 
enforcement agencies; (3) carry out, as needed and appropriate, 
any of the duties described in section 902(a)(1), as revised, 
when engaged in such duties pursuant to other Federal statutes; 
and (4) execute any arrest warrant issued by a competent 
judicial authority.
    Subsection (a)(2) of section 801 would further amend 
section 902 of title 38 to specify that the powers granted to 
VA police officers be exercised in accordance with guidelines 
approved by the Secretary and the Attorney General of the 
United States.
    Under current law, a VA officer who observes criminal 
activity beyond Department property cannot legally respond when 
a VA patient or provider is the victim. It is the Committee's 
view that this limitation unduly restricts the ability of VA 
police to fully carry out their assigned responsibilities. 
Extending these authorities would be consistent with powers 
Congress has granted to other Federal law enforcement officers, 
such as those in the Federal Protective Service, the Department 
of Homeland Security, Pentagon Force Protection Agency, and the 
United States Capitol Police.

Sec. 802. Uniform allowance for Department of Veterans Affairs police 
        officers.

    Section 802 of the Committee bill, which is derived from S. 
2984, would amend title 38, U.S.C., so as to modify the 
authority of VA to pay an allowance to VA police officers for 
the purchase of uniforms.
    Background. VA employs approximately 2,600 uniformed police 
officers. VA uniformed police officers are generally paid 
approximately $40,000 per year. Under current law, which was 
enacted in 1991, VA may pay no more than $200 per fiscal year, 
with authority to increase the amount to $400 in one fiscal 
year. Because there has been no increase since 1991, VA 
uniformed police officers have to pay out of their own funds to 
supplement their initial uniform purchases and maintain their 
uniforms. The Office of Personnel Management (OPM) has 
published new regulations to increase the authorized uniform 
allowance for other, non-VA Federal police officers to $800 for 
initial and annual purchases.
    Committee Bill. Section 802 of the Committee bill would 
amend section 903(b) of title 38, U.S.C., which governs the 
uniform allowance for VA police officers, to limit the 
allowable amount to the lesser of: (1) the amount prescribed by 
the OPM; or (2) the estimated or actual costs as determined by 
periodic surveys conducted by VA. The provision would also 
amend section 903(c) of title 38 to provide that the allowance 
established under subsection (b) of section 902 of title 38, as 
modified by the Committee bill, shall be paid at the beginning 
of an officer's appointment for those appointed on or after 
October 1, 2008, and for other officers at the request of the 
officer, subject to the fiscal year limitations established in 
subsection (b), as modified by the Committee bill.
    The Committee believes that in order to compete for good 
candidates to become VA police officers and to retain those 
already employed by VA, there is a need to increase the uniform 
allowance and for VA to ensure that the annual allowance 
remains at an appropriate level.

Sec. 803. Conditions for treatment of veterans, their surviving 
        spouses, and their children as adjudicated mentally incompetent 
        for certain purposes.

    Section 803 of the Committee bill, which is derived from S. 
3167, would clarify the conditions under which veterans, their 
surviving spouses, and their children may be treated as 
adjudicated mentally incompetent for certain purposes.
    Background. The Federal Gun Control Act of 1968 
(hereinafter, ``GCA'') and subsequent amendments established 
categories of persons who are prohibited from receiving or 
possessing firearms. Included among the categories is any 
person who has been ``adjudicated as a mental defective or who 
has been committed to a mental institution.'' Part 478.11 of 
title 27, Code of Federal Regulations (CFR), defines the 
meaning of the phrase ``adjudicated as a mental defective'' as 
follows:

        (a) a determination by a court, board, commission, or 
        other lawful authority that a person, as a result of 
        marked subnormal intelligence, or mental illness, 
        incompetency, condition, or disease: (1) is a danger to 
        themselves or others; or (2) lacks the capacity to 
        contract or manage his own affairs.

    The regulation was later codified with the enactment of 
Section 3(2) of Public Law 110-180, the ``NICS Improvement 
Amendments Act of 2007.''
    The Brady Handgun Violence Prevention Act of 1993 
(hereinafter, the ``Brady Act'') required the Attorney General 
to establish a system to assist federally licensed gun dealers 
in determining whether a gun buyer is prohibited under the GCA 
from purchasing a firearm. The system developed pursuant to the 
Brady Act, known as the National Instant Criminal Background 
Check System (hereinafter, ``NICS''), is a computerized 
database operated by the Federal Bureau of Investigation (FBI) 
NICS Section. The NICS can be queried by gun dealers to 
determine whether the name of a prospective buyer is on the 
list and, therefore, legally prohibited from purchasing a 
firearm.
    The Brady Act also requires Federal agencies to, upon the 
request of the Attorney General, submit to the NICS information 
on persons prohibited from purchasing a firearm. The Attorney 
General made such a request to VA in 1998. Under a memorandum 
of understanding entered into between the FBI and VA, VA agreed 
to make available for inclusion on the NICS database 
information about VA beneficiaries who are determined to be 
mentally incompetent on account of their inability to contract 
or manage their own affairs pursuant to part 3.353 of title 38, 
CFR. Determinations of incompetency under part 3.353 result in 
an appointment of a fiduciary.
    The evidence gathered to support a finding of incompetency 
under part 3.353 of VA's regulations is used to inform a 
judgment about whether a beneficiary is capable of managing 
their VA benefit payments. No evidence is gathered as part of 
this process to inform a judgment about whether a beneficiary 
presents a danger to themselves or others, or whether they 
should be prohibited from purchasing, possessing, or operating 
a firearm. Furthermore, although beneficiaries are entitled to 
a hearing once notified that it is proposed they will be 
determined incompetent, the initial hearing is before VA 
personnel, not an independent authority.
    Since 1998, VA has shared information with NICS on over 
116,325 beneficiaries for whom it has appointed a fiduciary, 
including veterans, surviving spouses, and dependent children 
of veterans. The total number of cases sent to NICS from all 
Federal agencies as of April 30, 2008, is 117,280, meaning that 
VA beneficiaries constitute the overwhelming majority of 
individuals referred to NICS by the Federal government. This is 
so despite the fact that other agencies, such as the Social 
Security Administration, appoint fiduciaries to manage benefit 
payments for their beneficiaries in a manner similar to VA's 
process.
    U.S. States and territories may also submit information to 
the NICS about individuals who have been adjudicated mental 
defective under the GCA. In total, 435,520 names have been 
submitted as of April 30, 2008, although only eight states are 
responsible for 99.5 percent of the submissions. California, 
Virginia, and Michigan alone have sent 87 percent of the total. 
A quick survey of the process used by some states to submit the 
names of individuals to the NICS is illustrative of the 
variation involved. For instance, in Michigan a court must 
enter an order declaring someone a mental defective or 
incompetent. In Texas, the NICS process is triggered after a 
criminal court reports incompetency. California sends 
information to the NICS on those who have been involuntarily 
committed to a mental institution, afforded a hearing, and who 
are held for a 3-day period at a mental institution.
    The Committee is concerned that VA's process for sharing 
beneficiary information with the NICS is not only uniquely 
targeted within the Federal government, but it also appears to 
be unique among states who share information with the NICS. 
Whereas VA uses government employees to, indirectly, make NICS 
decisions, many states rely on a judicial authority. Whereas 
VA's threshold for determining an individual mentally 
incompetent is whether they can manage their financial affairs, 
many states rely on a far more stringent standard. The 
Committee, therefore, proposes to raise the standard within VA 
while still remaining faithful to the overarching purpose of 
the NICS which is to keep people who are dangerous to 
themselves or others from purchasing a firearm.
    Committee Bill. Section 803 of the Committee Bill would 
amend chapter 55 of title 38, U.S.C., by adding a new section 
to clarify that in any case arising out of VA's administration 
of benefits under title 38, a veteran, surviving spouse, or 
child who is mentally incapacitated, deemed mentally 
incompetent, or experiencing an extended loss of consciousness, 
shall not be considered adjudicated as a mental defective under 
the GCA without the order or finding of a judge, magistrate, or 
other judicial authority of competent jurisdiction that such 
individual is a danger to him- or herself or others.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee based on 
information supplied by the CBO, estimates that enactment of 
the Committee bill would, relative to current law, increase 
discretionary spending by $7.2 billion over the 2009-2013 
period, assuming appropriation of the specified and estimated 
amounts. The Committee bill could affect direct spending and 
revenues, but CBO estimates that impact would not be 
significant. 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, August 11, 2008.
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. 2969, the Veterans 
Health Care Authorization Act of 2008.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                           Peter R. Orszag,
                                                          Director.
    Enclosure.

S. 2969--Veterans Health Care Authorization Act of 2008

    Summary: S. 2969 would make several changes to existing 
veterans' health care programs and create a number of new 
health care programs for veterans. The bill also would 
authorize the Department of Veterans Affairs (VA) to construct 
or lease several medical facilities. In total, CBO estimates 
that implementing the bill would cost $7.2 billion over the 
2009-2013 period, assuming appropriation of the specified and 
estimated amounts. Enacting the bill could affect direct 
spending and revenues, but CBO estimates that impact would not 
be significant.
    S. 2969 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. 2969 is shown in the Table 1. The costs 
of this legislation fall within budget function 700 (veterans 
benefits and services).

        Table 1.--Estimated Budgetary Impact of S. 2969, Veterans Health Care  Authorization Act of 2008
----------------------------------------------------------------------------------------------------------------
                                                            By fiscal year, in millions of dollars--
                                               -----------------------------------------------------------------
                                                   2009       2010       2011       2012       2013    2009-2013
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATIONa

Estimated Authorization Level.................      1,519        745      1,230      1,730      2,269      7,495
Estimated Outlays.............................        423      1,010      1,538      1,943      2,315      7,231
----------------------------------------------------------------------------------------------------------------
aIn addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
  enacting section 801 of S. 2969 would increase direct spending and revenues by less than $500,000 a year.

    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted near the start of fiscal year 2009, 
that the authorized and estimated amounts will be appropriated 
each year, and that outlays will follow historical spending 
patterns for similar programs. (S. 2969 also would authorize 
the appropriation of $5 million in 2008 for a pilot program 
providing assistance to veterans eligible for rehabilitation 
programs; however, those amounts are not included in this cost 
estimate because CBO assumes that no further appropriations 
will be provided in 2008 for such programs.)

Spending subject to appropriation

    CBO estimates that implementing S. 2969 would cost $7.2 
billion over the 2009-2013 period, assuming appropriation of 
the specified and estimated amounts (see Table 2). Most of the 
bill's estimated costs stem from provisions that would extend 
authorities related to providing nursing home care and 
authorizations of appropriations for medical construction 
projects.
    Extension of Current Authorities. Sections 201, 202, and 
203 would extend several authorities for VA to provide health 
care to certain veterans and to perform certain audits. In 
total, CBO estimates that implementing those provisions would 
cost $3.8 billion over the 2009-2013 period, assuming 
appropriation of the estimated amounts.

                          Table 2.--Components of Discretionary Spending Under S. 2969
----------------------------------------------------------------------------------------------------------------
                                                            By fiscal year, in millions of dollars--
                                               -----------------------------------------------------------------
                                                   2009       2010       2011       2012       2013    2009-2013
----------------------------------------------------------------------------------------------------------------
Extension of Current Authorities
    Estimated Authorization Level.............        136        355        739      1,157      1,609      3,996
    Estimated Outlays.........................        122        333        701      1,115      1,564      3,835
Construction of Medical Facilities
    Estimated Authorization Level.............      1,159         20         20         20         20      1,239
    Estimated Outlays.........................        100        321        378        285        120      1,204
Testing for HIV
    Estimated Authorization Level.............         43        114        188        265        343        953
    Estimated Outlays.........................         38        107        181        257        335        918
Homeless Veterans
    Authorization Level.......................         70         70         70         70         70        350
    Estimated Outlays.........................         63         70         70         70         70        343
Pilot Program for Dental Insurance
    Estimated Authorization Level.............         10         65         85         85         85        330
    Estimated Outlays.........................          9         60         83         85         85        322
Education Assistance
    Estimated Authorization Level.............         28         47         62         68         74        279
    Estimated Outlays.........................         25         45         60         67         74        271
Medical Personnel
    Estimated Authorization Level.............         27         27         28         28         28        139
    Estimated Outlays.........................         24         27         27         28         28        134
Pilot Programs
    Estimated Authorization Level.............         26         21          9          7          7         70
    Estimated Outlays.........................         24         22         10          7          7         70
Health Care for Female Veterans
    Estimated Authorization Level.............          6         12         14         15         15         62
    Estimated Outlays.........................          6         11         13         14         15         59
Expanded Eligibility for Vet Centers
    Estimated Authorization Level.............          6          6          5          4          4         25
    Estimated Outlays.........................          5          6          5          4          4         24
Specialized Residential and Rehabilitation
 Care
    Estimated Authorization Level.............          2          3          5          6          8         24
    Estimated Outlays.........................          2          3          5          6          8         24
Quality Assurance Officers
    Estimated Authorization Level.............          3          3          3          3          3         15
    Estimated Outlays.........................          2          3          3          3          3         14
Uniforms for Police Officers
    Estimated Authorization Level.............          1          1          1          1          1          5
    Estimated Outlays.........................          1          1          1          1          1          5
Hospice Care
    Estimated Authorization Level.............          *          *          *          *          *          2
    Estimated Outlays.........................          *          *          *          *          *          2
Study on Suicides
    Estimated Authorization Level.............          1          *          0          0          0          1
    Estimated Outlays.........................          1          *          0          0          0          1
Other Provisions
    Authorization Level.......................          1          1          1          1          1          5
    Estimated Outlays.........................          1          1          1          1          1          5
                                               -----------------------------------------------------------------
      Total Changes
        Estimated Authorization Level.........      1,519        745      1,230      1,730      2,269      7,495
        Estimated Outlays.....................        423      1,010      1,538      1,943      2,315      7,231
----------------------------------------------------------------------------------------------------------------
Notes: Components may not sum to totals because of rounding; * = less than $500,000.

    Nursing Home Care. Section 202(a) would extend, through 
December 31, 2013, a requirement that VA provide nursing home 
care to veterans who have a disability rating of 70 percent or 
greater or those who require such care for a service-connected 
disability. Under current law, that requirement expires on 
December 31, 2008.
    According to VA, the department spent about $1.2 billion on 
such care in 2007. VA provided nursing home care to disabled 
veterans under other permanent authorities before the 
requirement in current law was enacted, but that care was 
provided at the discretion of the Secretary of Veterans 
Affairs. CBO expects that if the requirements of 38 U.S.C. 
1710A are not extended, VA would continue to provide care in 
the near term to most disabled veterans eligible under that 
authority, but that VA would gradually revert to providing more 
limited nursing home care under previously used authorities. 
Therefore, after adjusting for inflation, CBO estimates that 
extending this requirement would have initial costs of about 
$115 million in 2009 growing to $1.5 billion by 2013, assuming 
appropriation of the estimated amounts.
    Noninstitutional Extended Care. Section 201 would make 
permanent a provision in current law that allows VA to provide 
noninstitutional extended care to veterans through December 31, 
2008. According to VA, the department spent about $45 million 
on such care in 2007. VA has indicated that it has existing 
authority under other provisions of current law to provide 
noninstitutional extended care, but those authorities are 
limited and would affect VA's ability to provide the current 
level of services. After adjusting for inflation, CBO estimates 
that extending this requirement would have initial costs of $5 
million in 2009, growing to almost $60 million by 2013, 
assuming appropriation of the estimated amounts.
    Participants in Chemical and Biological Testing. From 1962 
to 1973, the Department of Defense (DOD) conducted certain 
tests to determine the vulnerability of personnel, buildings, 
and ships to various biological and chemical threats. Veterans 
who were exposed to agents used in those tests are eligible to 
receive free health care from VA, though copayments are 
required for treatment of diseases or injuries that are 
obviously not related to military service. The authority to 
provide this benefit expired on December 31, 2007. Section 203 
would make this authority permanent.
    Based on data from VA that about 300 such veterans received 
health care in 2007 at an average cost of $5,800, CBO estimates 
that implementing this section would cost $1 million in 2009 
and $9 million over the 2009-2013 period, assuming 
appropriation of the estimated amounts.
    Audits of Medical Services Contracts. Section 202(b) would 
extend through 2013 a provision in current law that allows VA 
to perform audits of its contracts to provide medical care and 
services outside the department. Under current law, the 
authority will expire on September 30, 2008. Those audits are 
designed to allow VA to reduce errors and fraud related to 
payments under the contracts. Any additional collections 
generated by audits are retained and spent by the department. 
Based on information from VA regarding recent audits, CBO 
estimates that extending this authority to conduct audits would 
have no net budgetary impact, as it would allow VA to collect 
and spend $9 million a year.
    Construction of Medical Facilities. Title VII would 
authorize funding for constructing, renovating, improving, or 
leasing several medical facilities by VA. CBO estimates that 
implementing title VII would cost $1.2 billion over the 2009-
2013 period, assuming appropriation of the authorized and 
estimated amounts.
    Section 704 would specifically authorize the appropriation 
in 2009 of $1.1 billion for five large construction projects 
and $56 million for leasing 11 clinics or other facilities. 
Based on information from VA's 2009 budget request for leasing 
medical facilities, CBO expects that VA would enter into 20-
year lease agreements for those facilities. As a result, CBO 
estimates that in addition to the specified amounts authorized 
to be appropriated in 2009, VA would have additional costs of 
about $20 million a year starting in 2010. (Costs are higher in 
2009 than in other years because VA would pay the lessors 
additional amounts in the first year of the lease for necessary 
improvements and upgrades.) In addition, section 705 would 
increase the threshold for major construction projects that 
require Congressional approval from $600 million to $1 billion.
    Testing for Human Immunodeficiency Virus (HIV). Section 217 
would eliminate a rule prohibiting VA from conducting 
widespread testing for HIV infection in the population of 
veterans who use VA health care facilities. It also would 
eliminate current requirements for separate written consent for 
HIV tests and pre- and post-test counseling.
    Based on data from VA, CBO estimates that under section 217 
the number of HIV tests administered by VA would increase 
significantly, from the current annual level of about 125,000 
tests to 200,000 in 2009 and to 250,000 a year over the 2010-
2013 period. Based on studies of veterans enrolled in VA health 
care, CBO expects that increased testing would lead to an 
increase in the number of newly diagnosed veterans and that 
those veterans would be identified earlier in the course of the 
disease.\1\ We expect that people who are tested for HIV at, 
and receive general care in, VA health care facilities would 
prefer to maintain continuity of care with VA health care 
providers, and thus would be treated by VA for HIV disease. 
Based on data from VA and the Kaiser Family Foundation, CBO 
estimates that the average cost of treatment in 2009 would be 
$18,000 per patient in the early stages of HIV infection, and 
$35,000 per patient in the advanced stages of the disease.
---------------------------------------------------------------------------
    \1\Ronald O. Valdiserri, Fred Rodriguez, and Mark Holodniy, 
``Frequency of HIV Screening in the Veterans Health Administration: 
Implications for Early Diagnosis of HIV Infection,'' AIDS Education and 
Prevention, vol. 20, no. 3 (2008), pp. 258-264; and Douglas K. Owens 
and others, ``Prevalence of HIV Infection Among Inpatients and 
Outpatients in Department of Veterans Affairs Health Care Systems: 
Implications for Screening Programs for HIV,'' American Journal of 
Public Health, vol. 97, no. 12 (2007), pp. 2173-2178.
---------------------------------------------------------------------------
    CBO estimates that under the bill, VA would start providing 
comprehensive HIV treatment to an additional 1,600 newly 
diagnosed veterans in 2009 at an average cost of $27,000 per 
person. By 2013, CBO estimates that the number of additional 
veterans being treated for HIV would grow to about 12,000. 
Because an increasing proportion of those veterans would be 
diagnosed in the early stages of the disease when treatment is 
least expensive, the average cost of treatment, before 
considering the effects of inflation, would decrease over time. 
Adjusting for inflation, CBO estimates that implementing 
section 217 would cost about $920 million over the 2009-2013 
period, assuming appropriation of the necessary funds.
    Homeless Veterans. Section 506 would authorize additional 
appropriations of $70 million a year for existing programs to 
care for homeless veterans. Under current law, VA makes grants 
and per diem payments to entities that provide outreach, 
rehabilitation, transitional housing, counseling, training, and 
other assistance to homeless veterans. CBO estimates that 
implementing this provision would cost about $345 million over 
the 2009-2013 period, assuming appropriation of the specified 
amounts.
    Pilot Program for Dental Insurance. Section 223 would 
require VA to implement a pilot program to provide dental 
insurance to all enrolled veterans and their survivors and 
dependents. VA would be directed to carry out the program in at 
least two but no more than four Veterans Integrated Services 
Networks (VISNs; regional networks of medical facilities). CBO 
estimates that implementing this provision would cost about 
$320 million over the 2009-2013 period, assuming appropriation 
of the estimated amounts.
    The bill would require VA to contract with a dental insurer 
who would administer the program. However, the bill would grant 
VA wide discretion in designing several critical parameters of 
the pilot program, such as the covered benefits, requirements 
for enrollment and disenrollment, and premiums. Veterans would 
be required to pay premiums and copayments. For purposes of 
this estimate, CBO assumes that the pilot program would be 
carried out at three VISNs and that the pilot program would be 
similar to the TRICARE Dental Program, which is available to 
reservists, their family members, and active-duty 
servicemembers. CBO expects that VA would experience an initial 
surge in enrollment as people who may have delayed addressing 
their dental needs would avail themselves of that opportunity, 
but that those individuals would disenroll soon after their 
needs were met.
    CBO estimates that the program would begin accepting 
enrollees around the middle of fiscal year 2009, and based on 
the participation rates for the TRICARE program, that about 
12,000 veterans, survivors, and dependents would join that 
year. We estimate that enrollment would rise to 78,000 in 2010 
and 97,000 in 2011 before stabilizing at a level of about 
90,000 a year.
    The TRICARE program pays an annual maximum of $1,200 for 
nonorthodontic services, and many diagnostic and preventive 
services do not count toward the cap. Based on costs for the 
TRICARE program and for dental care provided by VA to a limited 
number of veterans, CBO estimates that in 2009 VA would pay 
about $800 per enrollee under the pilot program. After 
adjusting for inflation, CBO estimates that the pilot program 
would have initial costs of about $10 million in 2009 and that 
costs would rise to around $60 million by 2010, before 
stabilizing at $85 million a year thereafter.
    Education Assistance. Three separate provisions in section 
103 would authorize VA to provide scholarships and assistance 
with education loans to certain employees. In total, CBO 
estimates that enacting those provisions would cost about $270 
million over the 2009-2013 period, assuming appropriation of 
the estimated amounts.
    Health Professionals Scholarship Program. Section 103(a) 
would reinstate a scholarship program for health professionals 
that expired in 1998. The provision would give VA the authority 
to provide funds to cover tuition, fees, and other costs 
related to their education. In exchange for financial 
assistance, recipients would be obligated to work at VA for a 
specified period of time.
    Based on information from VA, CBO estimates that after a 
six-month period to establish the program, VA would grant about 
125 awards in 2009 with an average award of $46,000. In the 
following years, CBO estimates VA would grant 250 new awards a 
year. Based on information from VA, CBO expects that 
scholarships would last an average of two years. After 
adjusting for an estimated 6 percent annual increase in tuition 
and other costs, CBO estimates that implementing this provision 
would cost $6 million in 2009 and $105 million over the 2009-
2013 period, assuming appropriation of the estimated amounts.
    Debt Reduction. Two other provisions of section 103 would 
allow VA to assist its employees in repaying their education 
loans. Subsection (b) would expand the use of VA's Education 
Debt Reduction Program by increasing the maximum amounts 
payable over a five-year period from $44,000 to $60,000 and 
expanding eligibility from those recently appointed to all 
employees involved in direct patient care. About 6,500 
employees currently receive an average annual benefit of $5,800 
under this program. Based on information from VA, CBO estimates 
that 450 additional employees each year would receive an 
average amount of $8,725 a year for five years and that 
employees currently eligible (about 6,500) also would receive 
the higher annual benefit. After adjusting for inflation, CBO 
estimates that implementing this provision would cost $17 
million in 2009 and $132 million over the 2009-2013 period, 
assuming appropriation of the estimated amounts.
    The second provision, subsection 103(c), would allow 
certain clinical researchers at VA who have disadvantaged 
backgrounds to use a National Institutes of Health (NIH) 
program for repayment of education loans. The NIH program 
provides up to $35,000 in assistance per employee. Based on 
information from VA, CBO estimates that 100 employees each year 
would receive an average amount of $30,000 a year over three 
years. Assuming appropriation of the estimated amounts, CBO 
estimates that implementing this provision would cost $3 
million in 2009 and $35 million over the 2009-2013 period.
    Medical Personnel. Section 101 contains several provisions 
that would affect pay for medical personnel. In total, CBO 
estimates that implementing those provisions would cost about 
$135 million over the 2009-2013 period, assuming appropriation 
of the estimated amounts.
    Pay Comparable to Private Sector. Section 101(f) would 
allow VA to pay additional compensation of up to $100,000 a 
year to certain employees to match salary levels paid in the 
private sector. Based on information from VA, CBO estimates 
that the department would pay an average additional amount of 
$62,500 a year to about 170 people, at a cost of about $11 
million a year.
    Overtime Pay. Section 101(m) would loosen certain pay 
restrictions, thereby allowing nurses, physician assistants, 
and certain other employees to earn additional pay for evening 
or weekend work. Under current law, employees can earn 
additional pay for working evenings or weekends only on their 
regular tour of duty. The bill would allow such pay for any 
evening or weekend hours worked, even if those were occasional 
or ad-hoc. In 2007, such employees worked roughly 1.8 million 
hours of overtime at an average overtime rate of about $50 an 
hour. CBO estimates that under current law VA does not pay 
night or weekend differentials for 75 percent of those hours 
(1.4 million hours). After adjusting for inflation, CBO 
estimates that under the bill VA would pay additional night 
differentials of $5 per hour for about 485,000 hours and 
weekend differentials of $13 per hour for 385,000 hours, for a 
total annual costs of about $8 million over the 2009-2013 
period, assuming appropriation of the estimated amounts.
    Higher Pay for Nurses. Subsections 101(i) and 101(j) would 
increase the pay caps for registered nurses and certified 
registered nurse anesthetists. Based on information from VA, 
CBO estimates that the department would pay an average 
additional amount of $12,000 a year to about 400 nurses at a 
cost of about $5 million a year. Subsection (l) would increase 
the maximum special pay for nurse executives from $25,000 to 
$100,000. Based on information from VA, CBO estimates that the 
department would pay an average additional amount of $10,000 to 
about 135 nurse executives at a cost of about $1 million a 
year. In total, CBO estimates that implementing those three 
provisions would increase pay for nurses by $6 million a year.
    Incentive Pay for Pharmacist Executives. Section 101(g) 
would allow VA to pay additional compensation of up to $40,000 
a year to pharmacist executives as a recruitment and retention 
tool. Based on information from VA, CBO estimates that the 
department would pay an additional $40,000 a year to 40 people 
at a cost of about $2 million a year.
    Increased Pay Scale for Appointees. Section 101(e) would 
allow VA to pay certain appointees using a higher pay scale. 
Based on information from VA, CBO estimates that the department 
would pay an average additional amount of $3,500 to about 70 
people, at an annual cost of about $250,000 a year.
    Pilot Programs. Several sections of S. 2969 would require 
VA to carry out pilot programs to provide or pay for health 
care and related benefits. In total, CBO estimates that 
enacting those provisions (not including the dental pilot 
program, which is discussed above) would cost about $70 million 
over the 2009-2013 period, assuming appropriation of the 
specified and estimated amounts.
    Personal Care Attendants. Section 212 would require VA to 
implement a pilot program to train and certify family 
caregivers of veterans and servicemembers with Traumatic Brain 
Injuries (TBI) to serve as personal care attendants, and to 
compensate such family members for the care they would provide. 
The program would operate at three VA facilities for a period 
of three years. Based on information from VA, CBO expects that 
the department would use existing contracts with home health 
agencies to provide training and certification, that roughly 50 
family members a year would become family care attendants, and 
the department would pay them about $45,000 a year. CBO 
estimates that implementing the pilot would cost $6 million 
over the 2009-2013 period.
    Respite Care. Section 213 would require VA to implement a 
pilot program to use graduate students from schools affiliated 
with VA to provide respite care to veterans and servicemembers 
with TBI. VA has indicated that it would be unable to implement 
this provision, as it would violate existing agreements for 
academic affiliations. Therefore, CBO estimates this provision 
would have no cost.
    Transition Assistance. Section 214 would require VA to 
implement a pilot program to provide grants to community-based 
organizations and state and local entities that provide 
assistance to veterans transitioning to civilian life. The 
program would operate in five locations for a period of two 
years. VA currently provides such assistance through Vet 
Centers. Based on information from VA regarding spending on Vet 
Centers, CBO estimates that implementing that pilot would cost 
$6 million over the 2009-2013 period.
    Caregiver Assistance. Section 222 would extend through 
2009, and authorize the appropriation of $5 million for, an 
existing pilot program to assist caregivers of veterans. The 
program provides a variety of services such as education and 
training, transportation, respite care, home care services, 
adult-day health care (a therapeutically-oriented outpatient 
program that provides health maintenance and rehabilitative 
services), and hospice care. CBO estimates that extending that 
pilot program by one year would cost $5 million over the 2009-
2013 period.
    Counseling for Female Veterans. Section 305 would require 
VA to implement a pilot program providing counseling in group 
retreat settings to female veterans who have recently separated 
after lengthy deployments, and would authorize the 
appropriation of $2 million per year for 2009 and 2010 for that 
purpose. CBO estimates that this pilot program would cost $4 
million over the 2009-2013 period.
    Child Care. Section 308 would require VA to implement a 
pilot program providing child care for certain female veterans 
who use VA medical facilities, and would authorize the 
appropriation of $1.5 million per year for 2009 and 2010 for 
that purpose. CBO estimates that this pilot program would cost 
$3 million over the 2009-2013 period.
    Homeless Veterans. Title V would require VA to carry out 
four separate pilot programs to provide outreach and various 
services to homeless veterans and would authorize the 
appropriation of $45 million over the 2009-2013 period for 
those purposes. CBO estimates that implementing those pilot 
programs would cost $45 million over the 2009-2013 period.
    Health Care for Female Veterans. Title III of the bill 
would authorize several programs targeted to women veterans. 
CBO estimates that implementing those provisions would cost 
about $60 million over the 2009-2013 period, assuming 
appropriation of the authorized and estimated amounts.
    Training for Mental Health Providers. Section 304 would 
require VA to educate, train, and certify mental health 
professionals who specialize in treating sexual trauma. VA has 
indicated that it has ongoing training for such providers 
through 2009; under the bill, such training would be extended 
permanently. Based on information from VA's Office of Mental 
Health Services, CBO estimates that VA would need 40 employees 
a year to provide training an annual cost of about $8 million a 
year.
    Care for Newborns. Section 309 would allow VA to provide 
care for up to seven days to the newborn children of female 
veterans who receive maternity care through the department. 
Based on data from VA, CBO estimates that about 2,000 babies 
would become eligible for such care in 2009 at an average cost 
of $2,650 per baby. After adjusting for inflation and 
population growth--the number of female veterans of child-
bearing age is expected to rise in future years--CBO estimates 
that implementing this provision would cost $30 million over 
the 2009-2013 period.
    Study on Health Consequences of Service in Operation Iraqi 
Freedom and Operation Enduring Freedom (OIF/OEF). Section 303 
would require VA to contract with an outside entity to conduct 
a study on the health consequences facing female OIF/OEF 
veterans as a result of their service. Based on information 
from VA, CBO estimates that implementing this provision would 
cost $1 million over the 2009-2013 period.
    Expanded Eligibility for Vet Centers. Section 401 would 
allow members of the Armed Forces, including reservists, who 
served in OIF/OEF to receive readjustment counseling and 
related services through VA's Vet Centers. Vet Centers are 
community-based counseling centers that provide free mental 
health services to combat veterans and their families. 
According to VA data, there are about 232 centers nationwide, 
and they served roughly 165,000 veterans in 2007. In 2008, Vet 
Centers received $131 million in appropriated funds.
    DOD data on OIF/OEF deployments indicate that roughly 1 
million servicemembers are currently or have previously been 
deployed and are nonveterans. After adjusting for expected 
separations (OIF/OEF veterans are eligible under current law) 
and smaller expected deployments starting in 2009, CBO 
estimates that of those remaining, about a third would seek 
mental health services. However, DOD indicates that 
servicemembers are already offered free on- and off-base 
counseling similar to that provided through Vet Centers. 
Therefore, CBO estimates that about 14,000 servicemembers (5 
percent of those seeking mental health services) would use Vet 
Centers in 2009 and that the number of users would decline to 
about 6,000 in 2013. Using a per person cost of $415 in 2009 
(about half the expected cost for veterans) and adjusting for 
annual inflation, CBO estimates that implementing this 
provision would cost about $24 million over the 2009-2013 
period, assuming appropriation of the estimated amounts.
    Specialized Residential and Rehabilitation Care. Section 
215 would require VA to contract with appropriate entities to 
provide specialized care to OIF/OEF veterans whose TBI are so 
severe that they cannot live independently and would otherwise 
require nursing home care. According to VA, some veterans with 
TBI but without sufficient family support or financial means to 
afford private residential care often end up in nursing homes 
that do not provide appropriate care. Under the bill, VA would 
place such veterans in specialized programs that would provide 
appropriate residential and rehabilitation care.
    Based on information from VA regarding the number of such 
veterans and the cost of their care, CBO estimates that in 
2009, VA would pay roughly $84,000 for care provided to 20 
veterans with TBI. After adjusting for inflation, CBO estimates 
that over the 2009-2013 period, VA would pay for care provided 
to about 50 veterans a year at an average annual cost of $5 
million, and that implementing this provision would cost $24 
million over that period, assuming appropriation of the 
estimated amounts.
    Quality Assurance Officers. Section 210 would require VA to 
designate board-certified physicians as quality assurance 
officers in its 135 medical facilities. Under current law, VA 
has nurses serving in those positions. Based on information 
from VA, CBO expects that in most facilities the department 
would be able to re-allocate clinical and administrative duties 
to designate currently-employed physicians for those roles. 
However, CBO estimates that about 25 facilities would need to 
hire physicians at a net additional cost to the department of 
$100,000 per person (the cost to replace a nurse with a 
physician), and that implementing this provision would cost $14 
million over the 2009-2013 period, assuming appropriation of 
the estimated amounts.
    Uniforms for Police Officers. Section 802 would double the 
uniform allowances payable to about 2,600 department police 
officers from $400 for initial purchases and $200 for recurring 
purchases to $800 and $400 respectively. CBO estimates that 
implementing this provision would cost about $1 million a year 
over the 2009-2013 period, assuming availability of 
appropriated funds.
    Hospice Care. Section 216 would prohibit VA from collecting 
copayments from veterans receiving hospice care. This 
prohibition would apply to care received at both inpatient and 
outpatient facilities. Depending upon where veterans receive 
hospice care, copayments range from $15 per day to a maximum of 
$97 per day. Most veterans receiving this type of care from VA 
are not charged copayments--only veterans whose disabilities 
are unrelated to their military service and whose incomes are 
above a certain level are required to make copayments.
    Based on information from VA that fewer than 450 veterans 
made copayments averaging about $800 last year for hospice 
care, CBO estimates that implementing this provision would 
decrease collections by less than $500,000 each year and by 
about $2 million over the 2009-2013 period. Those collections 
are recorded as offsets to discretionary appropriations. As 
part of the annual appropriations process, the Congress gives 
VA authority to spend those collections. Therefore, maintaining 
the same level of health care services for veterans would 
necessitate additional funding each year to make up for the 
loss of copayments under this bill. Thus, implementing this 
provision would cost less than $500,000 in 2009 and about $2 
million over the 2009-2013 period.
    Study on Suicides. Section 403 would require VA to conduct 
a study and report to the Congress on the number of veterans 
who died by suicide between 1997 and the date of enactment of 
the bill. VA would be required to coordinate with DOD, veterans 
service organizations, the Centers for Disease Control and 
Prevention, and state public health offices and veterans 
agencies. Based on information from VA, CBO estimates that 
implementing this provision would cost $1 million in 2009 and 
less than $500,000 in 2010, assuming availability of 
appropriated funds.
    Other Provisions. Several sections of the bill, when taken 
individually, would have no significant impact on spending 
subject to appropriation (most would have costs, but a few 
would have savings). Taken together, CBO estimates that 
implementing the following provisions would cost $1 million a 
year, assuming availability of appropriated funds:

     Sections 204 would repeal a reporting requirement 
pertaining to nurses' pay.
     Section 205 would modify a reporting requirement 
pertaining to Gulf War veterans.
     Section 209 would require veterans receiving care 
through the department to provide their Social Security number 
as well as pertinent information about their coverage through 
other health plans. Based on information from VA, CBO estimates 
that under the bill the department would be able to better 
match patient records with those of Internal Revenue Service 
and the Social Security Administration, and would collect an 
additional $100 each from roughly 36,500 veterans. Those 
additional collections of $4 million a year would be retained 
by the department and spent on medical care and services.
     Section 211 would require annual reports on the 
quality of the department's physicians and health care.
     Section 218 would allow VA to disclose the names 
and addresses of veterans and servicemembers who use VA care to 
third-party insurers, so that VA can recover the costs of such 
care. Based on a VA field survey, CBO estimates that under the 
bill the department would collect an additional $9 million a 
year. Those amounts would be retained by the department and 
spent on medical care and services.
     Section 219 would require an expanded study on the 
health impact of chemical and biological testing conducted by 
DOD in the 1960s and 70s.
     Section 220 would modify authority granted to VA 
under Public Law 110-181 to pay for care provided to veterans 
with TBI to conform with how VA is implementing the program 
under current law.
     Section 306 would require a report on full-time 
managers of programs for female veterans.
     Section 404 would require VA to transfer $5 
million to the Secretary of Health and Human Services for a 
psychology education program.
     Title VI would modify several authorities 
pertaining to research and education corporations and 
permanently extend VA's authority to establish such 
corporations. According to VA, those corporations are private, 
nonprofit entities that are prohibited from using appropriated 
funds and rely solely on cash or in-kind donations.

Direct spending and revenues

    Section 801 would enhance the law enforcement authorities 
of VA police officers. Because those prosecuted and convicted 
under section 801 of the bill could be subject to criminal 
fines, the federal government might collect additional fines if 
the legislation is enacted. Criminal fines are recorded as 
revenues, then deposited in the Crime Victims Fund, and later 
spent. CBO expects that any additional revenues and direct 
spending would not be significant because of the relatively 
small number of cases likely to be affected. Therefore, 
enacting the bill would have no significant effects on direct 
spending or revenues.

Intergovernmental and private sector impact

    S. 2969 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 July 28, 2008, CBO transmitted a 
cost estimate for H.R. 6445 as ordered reported by the House 
Committee on Veterans' Affairs on July 16, 2008. Section 217 of 
S. 2969 is similar to section 6 of H.R. 5856, and their 
estimated costs are identical.
    On May 12, 2008, CBO transmitted a cost estimate for H.R. 
5856 as ordered reported by the House Committee on Veterans' 
Affairs on April 30, 2008. Title VII of S. 2969 is similar to 
H.R. 5856, but the House act would authorize funding for 
additional facilities and CBO estimated it would cost $2.2 
billion over the 2009-2013 period ($1 billion more than title 
VII of S. 2969), assuming appropriation of the specified and 
estimated amounts.
    On August 23, 2007, CBO transmitted a cost estimate for S. 
1233, as ordered reported by the Senate Committee on Veterans' 
Affairs on June 27, 2007. Sections 103(a) and 216 of S. 2969 
are similar to sections 601 and 309 of S. 1233 respectively. 
CBO estimates that the scholarship program authorized by S. 
2969 would require a six-month start-up period and would grant 
fewer scholarships in the first year. The cost estimates for 
the provisions affecting hospice care are identical; however S. 
2969 assumes a later enactment date.
    On July 27, 2007, CBO transmitted a cost estimate for H.R. 
2874 as ordered reported by the House Committee on Veterans' 
Affairs on July 17, 2007. Section 203 of S. 2969 is similar to 
section 4 of H.R. 2874. The cost estimates are identical; 
however S. 2969 assumes a later enactment date.
    Estimate prepared by: Federal Costs: Sunita D'Monte and 
Alexis Miller (2262840); Impact on State, Local, and Tribal 
Governments: Lisa Ramirez-Branum (2253220); Impact on the 
Private Sector: Daniel Frisk (2262900).
    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 Committee on Veterans' Affairs at its 
June 26, 2008, meeting ordered S. 2969, reported favorably to 
the Senate by voice vote. One amendment was accepted by voice 
vote.

                             Agency Report

    On May 21, 2008, Gerald M. Cross, MD, Principal Deputy 
Under Secretary for Health, Department of Veterans Affairs, 
appeared before the Committee and submitted testimony on 
various bills incorporated into the Committee bill. In 
addition, on July 8, 2008, VA provided views on S. 2969. 
Excerpts of both the testimony and Department views are 
reprinted below:

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

    Good morning Mr. Chairman and Members of the Committee:
    Thank you for inviting me here today to present the 
Administration's views on a number of bills that would affect 
Department of Veterans Affairs (VA) programs of benefits and 
services. With me today are Walter A. Hall, Assistant General 
Counsel, and Kathryn Enchelmayer, Director, Quality Standards, 
Office of Quality and Performance. I am pleased to provide the 
Department's views on 14 of the 17 bills under consideration by 
the Committee. Unfortunately, we received S.2963 too late to 
include in our written statement, but we will provide views and 
costs for the record. In addition, the Administration's 
position is currently under review for S.2969. Therefore, it is 
not included in our written statement and we will forward those 
views as they are available. Similarly, the Administration is 
still developing its position on S.2926 and we will provide 
those views for the record. I will now briefly describe the 14 
bills, provide VA's comments on each measure and estimates of 
costs (to the extent cost information is available), and answer 
any questions you and the Committee members may have.
    Mr. Chairman, today's agenda includes four bills that 
consist of legislative proposals the Administration submitted 
to the Congress: S.2273; S.2797; S.2889, and S.2984. Thank you 
for introducing these bills at our request. We believe each 
bill would significantly enhance the health care services we 
provide to veterans as well as our means of furnishing these 
benefits. I will begin my testimony by addressing the major 
health care related provisions in these important bills.

           *       *       *       *       *       *       *

   S. 2273--``ENHANCED OPPORTUNITIES FOR FORMERLY HOMELESS VETERANS 
              RESIDING IN PERMANENT HOUSING ACT OF 2007''

    S. 2273 would authorize VA to conduct two five-year pilot 
grant programs under which public and non-profit organizations 
(including faith-based and community organizations) would 
receive funds for coordinating the provision of local 
supportive services for very low income, formerly homeless 
veterans who reside in permanent housing. Under one of the 
pilot programs, VA would provide grants to organizations 
assisting veterans residing in permanent housing located on 
military property that the Secretary of Defense closed or 
slated for closure as part of the 2005 Base Realignment and 
Closure program and ultimately designated for use in assisting 
the homeless. The other pilot program would provide grants to 
organizations assisting veterans residing in permanent housing 
on any property across the country. Both programs would require 
the Secretary to promulgate regulations establishing criteria 
for receiving grants and the scope of supportive services 
covered by the grant program.
    In 1987, when VA began its specific assistance to veterans 
who were homeless, few recognized that long-term or permanent 
housing with supportive services was necessary to return these 
veterans to full function. It is now well understood that the 
provision of long-term housing coupled with needed supportive 
services is vital to enable them to lead independent lives in 
their communities. Although supportive services are widely 
available to these veterans through VA and local entities, most 
housing assistance that is available to them is limited to 
temporary or transitional housing. Generally sources of long-
term housing for these veterans are lacking. Military 
facilities recently slated for closure or major mission changes 
may provide an excellent site for long-term or permanent 
housing for these vulnerable veterans who remain at risk of 
becoming homeless. Local redevelopment authorities could take 
these VA grant programs into account when designing their local 
plans to convert the property for use in assisting formerly 
homeless veterans. This would not only help the veterans but 
also enhance the community's efforts at economic 
revitalization. We estimate the costs associated with each of 
these pilots to be $375,000 in Fiscal Year 2009 and $11,251,000 
over a five-year period.

           *       *       *       *       *       *       *

   S. 2797--AUTHORIZATION OF FISCAL YEAR 2009 MAJOR MEDICAL FACILITY 
                                PROJECTS

    Section 1 would authorize the following four major medical 
construction projects:

     Construction of an 80-bed replacement facility in 
Palo Alto, California, in an amount not to exceed $54,000,000;
     Construction of an Outpatient Clinic in Lee 
County, Florida to meet the increased demand for diagnostic 
procedures, ambulatory surgery, and specialty care, in an 
amount not to exceed $131,800,000;
     Seismic Corrections on Building 1 in San Juan, 
Puerto Rico, in an amount not to exceed $225,900,000; and,
     Construction of a state-of-the-art polytrauma 
health care and rehabilitation center in San Antonio, Texas, in 
an amount not to exceed $66,000,000.

    Section 2 would authorize the following major medical 
facility projects:

     Replacement of the VA Medical Center in Denver, 
Colorado, in an amount not to exceed $769,200,000.
     Restoration, new construction or replacement of 
the medical center facility in New Orleans, Louisiana, in an 
amount not to exceed $625,000,000.

    VA received authorization for lesser sums under Public Law 
109-461 for these two major projects. In February 2008 we 
requested authorization in the amount of $769.2 million for the 
Denver-replacement project. However, the Department has 
identified an alternative option to purchase land and construct 
the new Denver VA facility while also leasing beds from the 
University of Colorado Hospital. Since our fiscal year 2009 
major-facility-authorization request was submitted in February, 
we met with officials of the University of Colorado and the new 
University of Colorado Hospital (UCH) to discuss how best to 
replace the services and improve the access now being provided 
by the aging VA Medical Center in Denver. We are still 
finalizing the details of this approach, but our preliminary 
analysis shows that it would be better, for several reasons, to 
lease space in the inpatient unit that UCH plans to build and 
to have VA's new state-of-the- art health care facility focus 
on the provision of primary and specialty care, outpatient 
surgery, and nursing home care. This proposed and innovative VA 
partnership with UCH would also extend to the sharing of 
certain adjunct inpatient resources, such as laboratory and 
medical-imaging services, and include VA's leasing research 
space from the University of Colorado Denver. The leased 
inpatient space would be staffed by VA health-care 
professionals and accessed via a separate VA entrance and 
lobby. In all respects to our patients, it would be a VA 
facility. This change in construction plans would more 
effectively increase and improve veterans' access to care 
throughout the Rocky Mountain region. As part of this strategy, 
we would need to additionally seek authority to enter into a 
contract for a lease for an outpatient clinic in Colorado 
Springs, Colorado; the revised amount for this lease would 
exceed the current request. We will provide Committee the final 
authorization amounts needed for these projects shortly.
    Section 3 would authorize VA to enter into leases for the 
following twelve facilities:

     Brandon, Florida, Outpatient Clinic, $4,326,000;
     Colorado Springs, Colorado, Community-Based 
Outpatient Clinic, $3,995,000; (the final amount needed for 
this project is pending)
     Eugene, Oregon, Outpatient Clinic, $5,826,000;
     Green Bay, Wisconsin, Expansion of Outpatient 
Clinic, $5,891,000;
     Greenville, South Carolina, Outpatient Clinic, 
$3,731,000;
     Mansfield, Ohio, Community-Based Outpatient 
Clinic, $2,212,000;
     Mayaguez, Puerto Rico, Satellite Outpatient 
Clinic, $6,276,000;
     Mesa, Arizona, Southeast Phoenix Community-Based 
Outpatient Clinic, $5,106,000;
     Palo Alto, California, Interim Research Space, 
$8,636,000;
     Savannah, Georgia, Expansion of Community-Based 
Outpatient Clinic, $3,168,000;
     Sun City, Arizona, Northwest Phoenix Community-
Based Outpatient Clinic, $2,295,000; and,
     Tampa, Florida, Primary Care Annex, $8,652,000.

    Section 4 would authorize for appropriation the sum of 
$477,700,000 for fiscal year 2009 for construction of the four 
major medical projects listed in Section 1 and $1,394,200,000 
for the two projects listed in Section 2. Section 4 would also 
authorize for appropriation for fiscal year 2009 $60,114,000 
from the Medical Facilities account for the leases listed in 
Section 3. However, we will likely revise our request for both 
those Section 2 construction projects and the Section 3 leases. 
Our final recommendation on the amounts will be provided to the 
Committee shortly.

           *       *       *       *       *       *       *

             S. 2889--``VETERANS HEALTH CARE ACT OF 2008''

    Mr. Chairman, you have asked us to testify on sections 2, 
3, 4, 5, and 6, of S.2889. Section 2 would authorize VA to 
contract for specialized residential care and rehabilitation 
services for veterans of Operation Enduring Freedom and 
Operation Iraqi Freedom (OEF/OIF) who: (1) suffer from 
traumatic brain injury, (2) have an accumulation of deficits in 
activities of daily living and instrumental activities of daily 
living that affects their ability to care for themselves, and 
(3) would otherwise receive their care and rehabilitation in a 
nursing home. These veterans do not require nursing home care, 
but they generally lack the resources to remain at home and 
live independently. This legislation would enable VA to provide 
them with long-term rehabilitation services in a far more 
appropriate treatment setting than we are currently authorized 
to provide. VA estimates the discretionary cost of section 2 to 
be $1,427,000 in fiscal year 2009 and $79,156,000 over a 10-
year period.
    Section 3 would require VA to provide full-time VA 
physicians and dentists the opportunity to continue their 
professional education through VA-sponsored continuing 
education programs. It would also authorize VA to reimburse 
these employees up to $1000 per year for continuing 
professional education that is not available through VA-
sources. Currently, VA is required by statute to reimburse each 
of these individuals up to $1000 per year for expenses they 
incur in obtaining continuing education, even though VA has the 
capacity and resources to meet most of their professional 
continuing education needs in-house. Enactment of section 3 
would result in cost-savings to VA, while serving as an 
effective recruitment and retention tool for the Veterans 
Health Administration. We estimate section 3 would result in 
discretionary savings of $8,700,000 in fiscal year 2009 and a 
total discretionary savings of $87,000,000 over a 10-year 
period.
    Section 4 would eliminate co-payment requirements for 
veterans receiving VA hospice care either in a VA hospital or 
at home on an outpatient basis. In 2004, Congress amended the 
law to eliminate copayment requirements for hospice care 
furnished in a VA nursing home. Section 4 would result in all 
VA hospice care being exempt from copayment requirements, 
regardless of setting. Projected discretionary revenue loss is 
estimated to be $149,000 in fiscal year 2009 and $1,400,000 
over 10 years.
    Section 5 would repeal outdated statutory requirements that 
require VA to provide a veteran with pre-test counseling and to 
obtain the veteran's written informed consent prior to testing 
the veteran for HIV infection. Those requirements are not in 
line with current guidelines issued by the Centers for Disease 
Control and Prevention and other health care organizations, 
which, with respect to the issue of consent, consider HIV 
testing to be similar to other blood tests for which a patient 
need only give verbal informed consent. According to many VA 
providers, the requirements for pre-test counseling and prior 
written consent delay testing for HIV infection and, in turn, 
VA's ability to identify positive cases that would benefit from 
earlier medical intervention. As a result, many infected 
patients unknowingly spread the virus to their partners and are 
not even aware of the need to present for treatment until 
complications of the disease become clinically evident and, 
often, acute. Testing for HIV infection in routine clinical 
settings no longer merits extra measures that VA is now 
required by law to provide. Many providers now consider HIV to 
be a chronic disease for which continually improving therapies 
exist to manage it effectively. Repealing the 1988 statutory 
requirements would not erode the patient's rights, as VA would, 
just like with tests for all other serious conditions, still be 
legally required to obtain the patient's verbal informed 
consent prior to testing. VA estimates the discretionary costs 
associated with enactment of section 5 to be $73,680,000 for 
fiscal year 2009 and $301,401,000 over a 10-year period.
    Section 6 would amend sections 5701 and 7332 of title 38, 
United States Code, to authorize VA to disclose individually-
identifiable patient medical information without the prior 
written consent of a patient to a third-party health plan to 
collect reasonable charges under VA collections authority for 
care or services provided for a non-service-connected 
disability. The section 5701 amendment would specifically 
authorize disclosure of a patient's name and address 
information for this purpose. The section 7332 amendment would 
authorize disclosure of both individual identifier information 
and medical information for purposes of carrying out the 
Department's collection responsibilities. VA estimates that 
enactment of section 6 will result in net discretionary savings 
of $9,025,000 in fiscal year 2009 and $108,858,000 over ten 
years.

           *       *       *       *       *       *       *

         S. 2984--``VETERANS BENEFITS ENHANCEMENT ACT OF 2008''

    This bill includes several important program authority 
extensions, including VA's mandate to provide nursing home care 
to veterans with service-connected disabilities rated 70 
percent or more and to veterans whose service-connected 
disabilities require such care; VA's authority to establish 
research corporations; and VA's mandate to conduct audits of 
payments made under fee basis agreements and other medical 
services contracts. We urge the Committee to take action on all 
of the expiring authorities contained in the bill. Costs 
associated with these extensions will be paid from future 
discretionary appropriations. In the case of the audit-recovery 
program, we estimate discretionary recoveries in the amount of 
$9 million for fiscal year 2008 and a ten-year total in 
recoveries of $70 million.
    A significant provision of S.2984 would permit VA health 
care practitioners to disclose the relevant portions of VA 
records of the treatment of drug abuse, alcoholism and alcohol 
abuse, infection with the human immunodeficiency virus, and 
sickle cell anemia to surrogate decision makers who are 
authorized to make decisions on behalf of patients who lack 
decision-making capacity, but to whom the patient had not 
specifically authorized release of that legally protected 
information prior to losing decision-making capacity. It would, 
however, allow for such disclosure only under circumstances 
when the practitioner deems such content necessary for the 
representative to make an informed decision regarding the 
patient's treatment. This provision is critical to ensure that 
a patient's surrogate has all the clinically relevant 
information needed to provide full and informed consent with 
respect to the treatment decisions that the surrogate is being 
asked to make.
    Another key provision would authorize VA to require that 
applicants for, and recipients of, VA medical care and services 
provide their health-plan contract information and social 
security numbers to the Secretary upon request. It would also 
authorize VA to require applicants for, or recipients of, VA 
medical care or services to provide their social security 
numbers and those of dependents or VA beneficiaries upon whom 
the applicant or recipient's eligibility is based. Recognizing 
that some individuals do not have social security numbers, the 
provision would not require an applicant or recipient to 
furnish the social security number of an individual for whom a 
social security number has not been issued. Under this 
provision, VA would deny the application for medical care or 
services, or terminate the provision of, medical care or 
services, to individuals who fail to provide the information 
requested under this section. However, the legislation provides 
for the Secretary to reconsider the application for, or 
reinstate the provision of, care or services once the 
information requested under this section has been provided. Of 
note, this provision makes clear that its terms may not be 
construed to deny medical care and treatment to an individual 
in a medical emergency.
    Although VA has authority under 38 U.S.C. 1729 to recover 
from health insurance carriers the reasonable charges for 
treatment of a veteran's nonservice-connected disabilities, 
there is no permanent provision in title 38 to require an 
applicant for, or recipient of, VA medical care to provide 
information concerning health insurance coverage. This 
provision would ensure that VA obtains the health-plan contract 
information from the applicant for, or recipient of, medical 
care or services.
    Moreover, social security numbers enable VHA to make 
accurate and efficient medical care eligibility determinations 
and to instantaneously associate medical information with the 
correct patient by matching those social security numbers 
against records of other entities. Medical care eligibility 
determinations may be based on such factors as qualifying 
military service, service-connected disabilities, and household 
income. VHA may obtain or verify such information from internal 
VA components such as the Veterans Benefits Administration 
(VBA) which currently has authority to require social security 
numbers for compensation and pension benefits purposes, and 
outside sources, such as the Department of Defense (DOD), 
Internal Revenue Service and Social Security Administration. 
The availability of social security numbers ensures accurate 
matches of an individual's information with both internal and 
external sources. The income verification match programs are 
wholly dependent on social security numbers.
    Be assured that VA will provide the same high degree of 
confidentiality for the beneficiaries' health plan information 
and social security numbers as it provides to patients' medical 
information in its records and information systems. There are 
no direct costs associated with this provision other than 
administrative costs associated with collecting revenue. Those 
costs will be paid from future discretionary appropriations.
    Mr. Chairman, I now move to address the other bills on the 
agenda today.

           *       *       *       *       *       *       *

       S. 2377--``VETERANS HEALTH CARE QUALITY IMPROVEMENT ACT''

    S. 2377 is an excessively prescriptive bill that would 
impede the fundamental operations and structure of VHA. We have 
very recently provided the Committee with a copy of the 
Department's views on H.R. 4463, the identical House companion 
bill. Our views letter provides our detailed discussion of 
every provision. We would like to take this opportunity to 
discuss the provisions that cause us the most concern.
    The requirement that within one year of appointment each 
physician practicing at a VA facility (whether through 
appointment or privileging) be licensed to practice medicine in 
the State where the facility is located is particularly 
troubling and we believe harmful to the VA system. VA strongly 
objects to enactment of this provision. VHA is a nationwide 
health care system. By current statute, to practice in the VA 
system, VA practitioners may be licensed in any State. If this 
requirement were enacted, it would impede the provision of 
health care across State borders and reduce VA's flexibility to 
hire, assign and transfer physicians. This requirement also 
would significantly undermine VA's capacity and flexibility to 
provide telemedicine across State borders. VA makes extensive 
use of telemedicine. In addition, VA's ability to participate 
in partnership with our other Federal health care providers 
would be adversely impacted in times such as the aftermath of 
Hurricanes Katrina and Rita, where we are required to mobilize 
members of our medical staff in order to meet regional crises.
    Currently, physicians who provide medical care elsewhere in 
the Federal sector (including the Army, Navy, Air Force, U.S. 
Public Health Service Commissioned Corps, U.S. Coast Guard, 
Federal Bureau of Prisons and Indian Health Service) need not 
be licensed where they actually practice, so long as they hold 
a valid State license. Requiring VA practitioners to be 
licensed in the State of practice would make VA's licensure 
requirements inconsistent with these other Federal health care 
providers and negatively impact VA's recruitment ability 
relative to those agencies. In addition, many VA physicians 
work in both hospitals and community-based outpatient clinics. 
Many of our physicians routinely provide care in both a 
hospital located in one State and a clinic located in another 
State. A requirement for multiple State licenses would place VA 
at a competitive disadvantage in recruitment of physicians 
relative to other health care providers.
    Although the provision would allow physicians one year to 
obtain licensure in the State of practice, many States have 
licensing requirements that are cumbersome and require more 
than one year to meet. Such a requirement could disrupt the 
provision of patient care services while VA physicians try to 
obtain licensure in the State where they practice or transfer 
to VA facilities in States where they are licensed. The 
potential costs of this disruption are unknown at this time.
    Further, we are not aware of any evidence of a link between 
differences in State licensing practices and quality of patient 
care. In 1999, the General Accounting Office reviewed the 
effect on VA's health care system that a requirement for 
licensure in the State of practice would have. The GAO report 
concluded, in part, that the potential costs to VA of requiring 
physicians to be licensed in the State where they practice 
would likely exceed any benefit, and that quality of care and 
differences in State licensing practices are not directly 
linked. See GAO/HEHS-99-106, ``Veterans' Affairs Potential 
Costs of Changes in Licensing Requirement Outweigh Benefit'' 
(May 1999).
    Another provision would provide that physicians may not be 
appointed to VA unless they are board certified in the 
specialties of practice. However, this requirement could be 
waived (not to exceed one year) by the Regional Director for 
individuals who complete a residency program within the prior 
two year period and provide satisfactory evidence of an intent 
to become board certified. VA strongly opposes this provision 
of S.2377. Current law does not require board certification as 
a basic eligibility qualification for employment as a VA 
physician. VA policy currently provides that board 
certification is only one means of demonstrating recognized 
professional attainment in clinical, administrative or research 
areas, for purposes of advancement. However, we actively 
encourage our physicians to obtain board certification. 
Facility directors and Chiefs of Staff must ensure that any 
non-board certified physician, or physician not eligible for 
board certification, is otherwise well qualified and fully 
capable of providing high quality care for veteran patients. VA 
should be given considerable flexibility regarding the 
standards of professional competence that it requires of its 
medical staff, including the requirement for specialty 
certification. Were this measure enacted, it could have a 
serious chilling effect on our ability to recruit very 
qualified physicians. At this point in time, VA has physician 
standards that are in keeping with those of the local medical 
communities.
    Moreover, the bill would provide that the board 
certification and in-State licensure requirements would take 
effect one year after the date of the Act's enactment for 
physicians on VA rolls on the date of enactment. This would at 
least temporarily seriously disrupt VA's operations if 
physicians are unable to obtain board certification and in-
State licensure within one year, or are unable to transfer to a 
State where they are licensed.
    Mr. Chairman, we want to emphasize that we support the 
intent of several provisions of S.2377 and have already been 
taking actions to achieve many of the same goals. We would 
welcome the opportunity to meet with the Committee to discuss 
recent actions we have undertaken to improve the quality of 
care across the system, including program oversight related 
measures.

           *       *       *       *       *       *       *

 S. 2383--PILOT PROGRAM PROVIDING MOBILE HEALTH CARE AND OTHER SERVICES

    S. 2383 would require the Secretary, acting through the 
Director of the Office of Rural Health (DORH), to conduct a 
pilot program to furnish outreach and health care services to 
veterans residing in rural areas through the use of a mobile 
system equipped with appropriate program staff and supplies. 
The mobile system would have to be capable of furnishing the 
following services:

     counseling and education services on how to access 
VA health care, educational, pension, and other VA benefits;
     assistance to veterans in completing paperwork 
needed to enroll in VA's health care system;
     prescriptions for, and delivery of, medications;
     mental health screenings to identify potential 
mental health disorders, particularly for veterans returning 
from deployment overseas in OEF/OIF;
     job placement assistance and information on 
employment or training opportunities;
     substance abuse counseling; and
     bereavement counseling for families of active duty 
servicemembers who were killed in the line of duty while on 
active service.

    Staffing for the mobile system would be required to include 
VA physicians; nurses; mental health specialists; casework 
officers; benefits counselors, and such other personnel deemed 
appropriate by the Secretary. To the extent practicable, 
personnel and resources from area community-based outpatient 
clinics could be used to assist in this effort. The bill sets 
forth a number of requirements related to the development and 
coordination of the pilot program as well as to the conduct of 
the mobile system (including the minimum frequency of visits to 
rural areas participating in the pilot programs).
    S. 2383 would also mandate that the Secretary act jointly 
with the Secretary of Defense to identify veterans not enrolled 
in, or otherwise being cared for by, VA's health care system. 
VA would be further required to coordinate efforts with county 
and local veterans service officers to inform those veterans of 
upcoming visits by the mobile unit and the concomitant 
opportunity to complete paperwork for VA benefits. The bill 
would authorize $10 million to be appropriated for the mobile 
system each of fiscal years 2008 through 2010.
    VA does not support S.2383, because it is not necessary and 
is duplicative of ongoing efforts by the Department. VA's 
Office of Rural Health is already in the process of standing up 
a mobile system by which to provide medical care and services 
to veterans residing in rural areas, and VA's Vet Centers are 
already using mobile units to furnish readjustment counseling 
services. The Vet Centers and VBA also have in place extensive 
outreach program targeted at these veterans. VA has recently 
created a Task Force to review the adequacy of the assets and 
resources dedicated to these efforts thus far. Particularly 
with respect to the mobile system, we urge the Committee to 
refrain from taking action on the bill until we have sufficient 
experience with this model of delivery to ascertain its 
effectiveness and to identify and cure any deficiencies. We 
would be glad to brief the Committee on our activities to date.
    As a technical matter, the duration of the pilot program is 
unclear, but we assume it is three years based on the terms of 
the bill's provision authorizing appropriations for fiscal 
years 2008-2010. Additionally, medications are currently mailed 
to these veterans and so it is not necessary to provide those 
benefits through a mobile system.

           *       *       *       *       *       *       *

        S. 2573--``VETERANS MENTAL HEALTH TREATMENT FIRST ACT''

    Mr. Chairman, S.2573 is a very ambitious bill that would 
provide the Department with significant new tools to maximize 
and reward a veteran's therapeutic recovery from certain 
service-related mental health conditions, and, to the extent 
possible, reduce the veteran's level of permanent disability 
from any of the covered conditions. The goal of the legislation 
is to give the veteran the best opportunity to reintegrate 
successfully and productively into the civilian community.
    Specifically, S.2573 would require the Secretary to carry 
out a mental health and rehabilitation program for a veteran 
who has been diagnosed by a VA physician with any of the 
following conditions:

     Post Traumatic Stress Disorder (PTSD);
     depression; or
     anxiety disorder

that is service-related, as defined by the bill. The bill would 
also cover a diagnosis of a substance use disorder related to 
service-related PTSD, depression, or anxiety. For purposes of 
this program, a covered condition would be considered to be 
service-related if: (1) VA has previously adjudicated the 
disability to be service-connected; or (2) the VA physician 
making the diagnosis finds the condition plausibly related to 
the veteran's active service. S.2573 would also require the 
Secretary to promulgate regulations identifying the standards 
to be used by VA physicians when determining whether a 
condition is plausibly related to the veteran's active 
military, naval, or air service.
    The bill sets forth conditions of participation for the 
veterans taking part in the program. If a veteran has not filed 
a VA claim for disability for the covered condition, the 
veteran would have to agree not to submit a VA claim for 
disability compensation for the covered condition for one year 
(beginning on the date the veteran starts the program) or until 
the date on which the veteran completes his or her treatment 
plan, whichever date is earlier.
    If the veteran has filed a disability claim but it has not 
yet been adjudicated by the Department, the veteran could elect 
either to suspend adjudication of the claim until he or she 
completes treatment or to continue with the claims adjudication 
process. As discussed below, the stipend amounts payable to the 
veteran under the program will depend on which election the 
veteran makes.
    If the veteran has a covered condition that has been 
adjudicated to be service connected, then the individual would 
have to agree not to submit a claim for an increase in VA 
disability compensation for one year (beginning on the date the 
veteran starts the program) or until the date the veteran 
completes treatment, whichever is earlier.
    S. 2573 would establish a financial incentive in the form 
of ``wellness'' stipends to encourage participating veterans to 
obtain VA care and rehabilitation before pursuing, or seeking 
additional, disability compensation for a covered condition. 
The amount of the stipend would depend on the status of the 
veteran's disability claim. If the veteran has not filed a VA 
disability claim, VA would pay the veteran $2000 upon 
commencement of the treatment plan, plus $1500 every 90 days 
thereafter upon certification by the VA clinician that the 
veteran is in substantial compliance with the plan. This 
recurring stipend would be capped at $6000. The veteran would 
receive an additional $3000 at the conclusion of treatment or 
one year after the veteran begins treatment, whichever is 
earlier.
    If the veteran has filed a disability claim that has not 
yet been adjudicated, the participating veteran who elects to 
suspend adjudication of the claim until he or she completes 
treatment would receive ``wellness'' stipends in the same 
amounts payable to veterans who have not yet filed a disability 
claim. If the participating veteran elects instead to continue 
with the claims adjudication process, the veteran would receive 
``wellness'' stipends in the same amounts payable to veterans 
whose covered disabilities have been adjudicated and found to 
be service-connected: $667 payable upon the veteran's 
commencement of treatment and $500 payable every 90 days 
thereafter upon certification by the veteran's clinician that 
the individual is in substantial compliance with the plan. 
Recurring payments would be capped at $2000, and the veteran 
would receive $1000 when treatment is completed or one year 
after beginning treatment, whichever is earlier.
    If the Secretary determines that a veteran participating in 
the program has failed to comply substantially with the 
treatment plan or any other agreed-upon conditions of the 
program, the bill would require VA to cease payment of future 
``wellness'' stipends to the veteran.
    Finally, S.2573 would limit a veteran's participation in 
this program to one time, unless the Secretary determines that 
additional participation in the program would assist in the 
remediation of the veteran's covered condition.
    VA does not support S.2573. While philosophically we 
discern and appreciate the aims of the bill, particularly the 
holistic and integrated approach to the receipt of VA benefits, 
this is a very complex proposal that requires further in-depth 
study of all of the bill's implications, including those 
related to cost. In addition, we have numerous concerns with 
the bill as currently drafted.
    S.2573 assumes that early treatment intervention by VA 
health care professionals for a covered condition would be 
effective in either reducing or stabilizing the veteran's level 
of permanent disability from the condition, thereby reducing 
the amount of VA disability benefits ultimately awarded for the 
condition. No data exist to support or refute that assumption.
    With the exception of substance abuse disorders, we are 
likewise unaware of any data to support or refute the bill's 
underlying assumption that paying a veteran a ``wellness 
stipend'' will ensure the patient's compliance with his or her 
treatment program. Although there is a growing trend among 
health insurance carriers or employers to provide short-term 
financial incentives for their enrollees or employees to 
participate in preventive health care programs (e.g., reducing 
premiums for an enrollee who participate in a fitness program, 
loses weight, or quits smoking), we are unaware of any data 
establishing that these and similar financial incentives 
produce long-term cost-savings to the carrier or employer. It 
would be extremely difficult, if not impossible, to quantify 
savings or offsets because there is no way to know whether a 
particular patient's health status would have worsened without 
VA's intervention and whether the intervention directly 
resulted in a certain or predictable total amount in health 
care expenditure savings. We would experience the same 
difficulties trying to identify what would have been the level 
of disability and costs of care for a particular veteran had he 
or she not participated in the early clinical intervention 
program established by S.2573.
    Providing these mental health care benefits independent of 
the medical benefits package provided to enrolled veterans 
gives rise to other concerns. A veteran's mental health and 
physical health are integral, and it would be very difficult to 
discern if certain conditions or physical manifestations that 
may result from or be related to a mental health condition are 
covered by S.2573. As a provider, VA would need to assume that 
this bill would cover needed care for physical conditions that 
result from, or are associated with, the covered mental health 
condition under treatment. (Our approach would be similar to 
the approach taken under the Department's authority in 38 
U.S.C. 1720D to provide both counseling and care needed to 
treat psychological conditions resulting from sexual trauma.) 
For instance, recent scientific literature has linked heart 
disease to stress. Heart disease might at some point be linked 
to depression, PTSD and/or anxiety disorder. We believe that 
unless the scientific literature conclusively rules out an 
association between a covered mental health condition and the 
veteran's physical condition, the veteran should receive the 
benefit of the doubt. This could expand the scope of S.2573 
beyond the drafter's intent, because the types of physical 
conditions considered by the scientific community to be 
associated with mental health conditions could expand over 
time. Should this happen, S.2573 could lead to VA essentially 
operating two different health care systems based on separate 
sets of eligibility criteria, undermining the accomplishments 
achieved under VA health care reform.
    It is also troubling to us that S.2573 would require VA to 
treat specific diseases and not the veteran as a whole. This 
approach places VA practitioners in the difficult and untenable 
position of being able to identify conditions they cannot 
treat. This creates a particularly serious ethical dilemma for 
the practitioner who knows that his or her veteran-patient has 
no other access to the needed health care services. In our 
view, authority to treat specific diseases--and not the 
person--is counter to the principles of patient-centered and 
holistic medicine.
    The ``wellness'' stipends, themselves, raise several 
complex issues. None of VA's current benefits systems is 
equipped to administer such a novel benefit, and no current 
account appears to be an appropriate funding source from which 
to pay them. After much grappling with the issue, we have 
concluded that because the bill would amend only chapter 17 of 
title 38, United States Code, these stipends would have to be 
administered by VHA and paid from funds made available for 
medical care.
    There would be significant indirect costs as well. VHA 
currently lacks the IT infrastructure, expertise, and staff to 
administer monetary benefits. Administering the easiest of 
monetary benefits would be challenging for VHA, but it is 
nearly insurmountable in connection with this bill, which calls 
for a very complex, nationwide patient tracking and monitoring 
system that also has the capacity to administer payments at 
different points in time for veterans participating in the 
program. The fact that the duration of each veteran's treatment 
plan is highly individualized only complicates the requirements 
of such a system-design, as does the fact that the bill would 
permit some veterans to receive treatment (and payment) 
extensions.
    As a result, we do not believe that S.2573 would be cost-
effective as currently drafted. The maximum we could pay any 
veteran under the bill would be $11,000; however, it is 
reasonable to assume that the costs associated with designing, 
operating, and administering such a complex benefit program 
would far surpass the actual amounts we would pay out to the 
veterans (individually or collectively).
    S. 2573 also places our physicians and practitioners in the 
difficult position of determining whether their patients will 
receive wellness stipends available under the program. It is 
quite atypical for a VA physician's clinical determination to 
have direct financial implications or consequences for his or 
her patients. VA physicians and practitioners seek to help 
their veteran-patients attain maximum functioning as quickly as 
clinically possible. S.2573 would create potential conflict for 
our health care practitioners. They should focus solely on 
issues of health care and not feel pressure to grant requests 
for extensions of treatment in order to maximize the amount of 
money patients receive under the program.
    It would also be difficult to define ``substantial 
compliance,'' for purposes of S.2573, in a way that is 
measurable and objective as well as not easily amenable to 
fraud or abuse. For instance, substantial compliance could be 
defined in part by a veteran stating that he or she took 
prescribed medications as ordered by the physician and VA could 
confirm the veteran obtained refills in a timely manner. But 
that information does not actually verify that the patient in 
fact ingested the medication or did so as prescribed. There 
would unavoidably be some patients whose motivation for 
participating in this program is strictly financial, and they 
would invariably find ways to circumvent whatever criteria we 
establish in order to receive their stipends. Although these 
payments would not be sizeable, they are sufficient to entice 
some patients who would not otherwise access VA's health care 
system to participate in the program. We fear these patients 
would cease their treatment and stop accessing needed VA 
services once their treatment and payments end.
    Finally, if the use of ``wellness'' stipends were able to 
produce reliable, positive results in terms of patients' 
compliance or outcomes, there would then be a demand to extend 
this reward system to other VA treatment programs. And once a 
benefit is provided, it is difficult to ever repeal it. We say 
this only to point out that the cost implications in the out-
years could be very difficult to estimate accurately.
    Costing this bill is very complex, as there is no way for 
us to determine the total number of veterans who would 
participate in the pilot program, in which year they would 
enter the program, their ultimate disability status, and the 
amount of medical care they would each require. We estimate the 
increase in medical administrative costs for every 40,000 new 
veterans entering the VA system to be $280 million per year in 
addition to $293,340,000 per year in maximum stipend payments. 
The estimated one-time cost for eligible living veterans is 
$6,712,891,046. These costs do not factor in the costs of 
developing the IT infrastructure needed to administer the 
benefit. In light of these serious concerns and the bill's 
unknown total cost implications, we are unable to supports its 
enactment.

           *       *       *       *       *       *       *

       S. 2639--``ASSURED FUNDING FOR VETERANS HEALTH CARE ACT''

    S. 2639 would establish, by formula, the annual level of 
funding for all VHA programs, activities, and functions 
(excluding the construction, acquisition, and alteration of VA 
medical facilities and provision of grants to assist States in 
the construction or alteration of State home facilities).
    VHA funding for fiscal year 2008 (the first fiscal year 
covered by the bill) would be automatically established at 130 
percent of the amounts obligated by VHA (for all its 
activities, programs, and functions) for fiscal year 2006. 
Thereafter, VHA funding would be automatically determined by a 
fixed formula. The formula would, generally speaking, be based 
on the number of enrollees each year and the number of other 
persons receiving VA care during the preceding year multiplied 
by a fixed per capita amount. The per capita amount would be 
adjusted annually in accordance with increases in the Consumer 
Price Index.
    It has been VA's long-standing position that we do not 
support the concept of using a fixed formula to determine VHA 
funding. We believe that it is inappropriate and unworkable to 
apply an inflexible formula to a health care system that, by 
its very nature, is dynamic. The provision of care evolves 
continually to reflect advances in state of the art 
technologies (including pharmaceuticals) and medical practices. 
It is not possible to estimate the concomitant costs or savings 
resulting from those evolving changes. Moreover, patients' 
health status, demographics, and usage rates are each subject 
to distinct trends that are difficult to predict. The proposed 
formula would not take into account any changes in these and 
other important trends. As such, there is no certainty that the 
amount of funding dictated by the proposed formula would be 
appropriate to the demands that will be placed on VA's health 
care system in the upcoming years.
    Use of an automatic funding mechanism would also eliminate 
the valuable opportunity that members of the Congress and the 
Executive Branch have to carry out their responsibility to 
identify and directly address the health care needs of veterans 
through the budget process. It could also depress the 
Department's incentive to improve its operations and be more 
efficient. It is important to note that S.2639 would not ensure 
open enrollment, as the Department would still be required to 
make an annual enrollment decision. That decision would 
directly affect the number of enrolled veterans and thus the 
amount of funding calculated under the formula. Finally, 
references to ``guaranteed funding'' in the legislation may 
give the public the false impression that VA is being provided 
full funding for VA health care. It is not possible to 
determine whether the amount determined by the formula would be 
adequate. Because of S.2639's potential for all of these 
unanticipated and unintended serious consequences, we continue 
to favor the current discretionary funding process that uses 
actuarially-based budget estimates to project the future health 
care needs of enrolled veterans.

           *       *       *       *       *       *       *

S. 2796--PILOT PROGRAM USING COMMUNITY BASED ORGANIZATIONS TO INCREASE 
       THE COORDINATION OF VA SERVICES TO TRANSITIONING VETERANS

    S. 2796 would require the Secretary to carry out a two-year 
pilot grant program (at five VA medical centers) to assess the 
feasibility of using community-based organizations to increase 
the coordination of VA benefits and services to veterans 
transitioning from military service to civilian life, to 
increase the availability of medical services available to 
these veterans, and to provide their families with their own 
readjustment services. Specifically, grantees could use grant 
funds to operate local telephone hotlines; organize veterans 
for networking purposes; assist veterans in preparing 
applications for VA benefits; provide readjustment assistance 
to families of veterans transitioning from military life to 
civilian life; provide outreach to veterans and their families 
about VA benefits; and coordinate the provision of health care 
and other benefits being furnished to transitioning veterans.
    VA does not support S.2796, because it is duplicative of 
the Department's ongoing efforts. Vet Centers are already 
providing much of the outreach, readjustment counseling 
services, and family support services that would be required by 
this bill. Additionally, VA case managers and federal recovery 
coordinators already coordinate the delivery of health care and 
other VA services available to veterans transitioning from 
military service to civilian life, including supportive 
services for their families. VA is committing ever increasing 
resources to these ends. Use of grant funds to establish local 
hotlines would duplicate and dilute the effectiveness of VA's 
central hotlines. The duplicated efforts required by the bill 
would likely create significant confusion for the beneficiary. 
Further, funding family readjustment services wholly unrelated 
to the veteran's readjustment needs would divert medical care 
funds needed for veterans' health care.
    To the extent the Secretary determines external resources 
are necessary to provide the services described in the bill, VA 
already has the necessary authority to contract for them. We 
favor using contracts instead of grants, as the former allow VA 
to respond to changing local needs. That approach also gives us 
an accurate way to project the cost of the services. S.2796, on 
the other hand, would not. It would also not be cost-effective 
as it is likely that a grant awarded under the program would be 
for an amount significantly less than the cost VA incurs in 
administering the grant. We also note the bill would not 
include authority for VA to recapture unused grant funds in the 
event a grantee fails to provide the services described in the 
grant.
    We note further that when selecting pilot sites the 
Secretary would have to consider medical centers that have ``a 
high proportion of minority groups and individuals who have 
experienced significant disparities in the receipt of health 
care.'' We are uncertain what this language means and on what 
basis such a determination would be based.
    Although the proposed pilot project is limited to five VA 
medical centers, the scope of the uses for the grant funds is 
very broad, and the bill does not specify the number and amount 
of the grants to be awarded. We are unable to estimate the cost 
estimate of S.2796 due to the bill's lack of specificity.

           *       *       *       *       *       *       *

         S. 2799--``WOMEN VETERANS HEALTH CARE IMPROVEMENT ACT 
                               OF 2008''

    In general, title I of S.2799 would require VA to conduct a 
number of studies related to health care benefits for women 
veterans. Section 101 would require VA, in collaboration with 
VHA's War-Related Injury and Illness Study Centers, to contract 
for an epidemiologic cohort (longitudinal) study on the health 
consequences of combat service of women veterans who served in 
OEF/OIF. The study would need to include information on their 
general, mental, and reproductive health and mortality and 
include the provision of physical examinations and diagnostic 
testing to a representative sample of the cohort.
    The bill would require VA to use a sufficiently large 
cohort of women veterans and require a minimum follow-up period 
of ten years. The bill also would require VA to enter into 
arrangements with the Department of Defense (DOD) for purposes 
of carrying out this study. For its part, DOD would be required 
to provide VA with relevant health care data, including pre-
deployment health and health risk assessments, and to provide 
VA access to the cohort while they are serving in the Armed 
Forces.
    Mr. Chairman, we do not support section 101. It is not 
needed. A longitudinal study is already underway. In 2007, VA 
initiated its own 10-year study, the ``Longitudinal 
Epidemiologic Surveillance on the Mortality and Morbidity of 
OIF/OEF Veterans including Women Veterans.'' Several portions 
of the study mandated by section 101 are already incorporated 
into this project and planning for the actual conduct of the 
study is underway. The study has already been approved to 
include 12,000 women veterans. However, section 101 would 
require us to expand our study to include women active duty 
servicemembers. We estimate the additional cost of including 
these individuals in the study sample to be $1 million each 
year and $3 million over a 10-year period.
    Section 102 would require VA to conduct a comprehensive 
assessment of the barriers to the receipt of comprehensive VA 
health care faced by women veterans, particularly those 
experienced by veterans of OEF/OIF. The study would have to 
research the effects of 9 specified factors set forth in the 
bill that could prove to be barriers to access to care, such as 
the availability of child care and women veterans' perception 
of personal safety and comfort provided in VA facilities.
    Neither do we support section 102. It is not necessary 
because a similar comprehensive study is already underway. VA 
contracted for a ``National Survey of Women veterans in fiscal 
year 2007-2008,'' which is a structured survey based on a pilot 
survey conducted in VISN 21. This study is examining barriers 
to care (including access) and includes women veterans of all 
eras of service. Additionally, it includes women veterans who 
never used VA for their care and those who no longer continue 
to use VA for their health care needs. We estimate no 
additional costs for section 102 because VA's own comparable 
study is underway, with $975,000 in funding committed for 
fiscal years 2007 and 2008.
    Section 103 would require VA to conduct, either directly or 
by contract, a comprehensive assessment of all VA programs 
intended to address the health of women veterans, including 
those related to PTSD, homelessness, substance abuse and mental 
health, and pregnancy care. As part of the study, the Secretary 
would have to determine whether the following programs are 
readily available and easily accessed by women veterans: health 
promotion programs, disease prevention programs, reproductive 
health programs, and such other programs the Secretary 
specifies. VA would also have to identify the frequency such 
services are provided; the demographics of the women veteran 
population seeking such services; the sites where the services 
are provided; and whether waiting lists, geographic distance, 
and other factors obstructed their receipt of any of these 
services.
    In response to the comprehensive assessment, section 103 
would further require VA to develop a program to improve the 
provision of health care services to women veterans and to 
project their future health care needs. In so doing, VA would 
have to identify the services available under each program at 
each VA medical center and the projected resource and staffing 
requirements needed to meet the projected workload demands.
    Section 103 would require a very complex and costly study. 
While we maintain data on veteran populations receiving VA 
health care services that account for the types of clinical 
services offered by gender, VA's Strategic Health Care Group 
for Women Veterans already studies and uses available data and 
analyses to assess and project the needs of women veterans for 
the Under Secretary for Health. Furthermore, we lack current 
resources to carry out such a comprehensive study within the 
18-month time-frame. We would therefore have to contract for 
such a study with an entity having, among other things, 
significant expertise in evaluating large health care systems. 
This is not to say that further assessment is not needed. We 
recognize there may well be gaps in services for women 
veterans, especially given that VA designed its clinics and 
services based on data when women comprised a much smaller 
percentage of those serving in the Armed Forces. However, the 
study required by section 103 would unacceptably divert 
significant funding from direct medical care. Section 103 would 
have a cost of $4,354,000 in fiscal year 2008.
    Section 104 would require VA to contract with the Institute 
of Medicine (IOM) for a study on the health consequences of 
women veterans' service in OEF/OIF. The study would need to 
include a review and analysis of the relevant scientific 
literature to ascertain environmental and occupational exposure 
experienced by women who served on active duty in OEF/OIF. It 
would then have to address whether any associations exist 
between those environmental and occupational exposures and the 
women veterans' general health, mental health, or reproductive 
health.
    We do not object to section 104. We suggest the language be 
modified to allow VA to decide which organization is best 
situated to carry out this study (taking into account the best 
contract bid). While IOM has done similar studies in the past, 
this provision would unnecessarily foreclose the possibility of 
using other organizations. We estimate the one-time cost of 
section 104 to be $1,250,000, which can be funded from existing 
resources.
    Section 201 would authorize VA to furnish care to a newborn 
child of a woman veteran who is receiving VA maternity care for 
up to 30 days after the birth of the child in a VA facility or 
a facility under contract for the delivery services. We can 
support this provision with modifications. As drafted, the 
provision is too broadly worded. We believe this section should 
be modified so that it applies only to cases where a covered 
newborn requires neonatal care services immediately after 
delivery. The bill language should also make clear that this 
authority would not extend to routine baby well-baby services.
    We are currently unable to estimate the costs associated 
with section 201 without data on projected health care workload 
demands and future utilization requirements. We have contracted 
for that data and we will forward the estimated costs for this 
section as soon as they are available.
    Section 202 would require the Secretary to establish a 
program for education, training, certification and continuing 
medical education for VA mental health professionals furnishing 
care and counseling services for military sexual trauma (MST). 
VA would also be required to determine the minimum 
qualifications necessary for mental health professionals 
certified under the program to provide evidence-based 
treatment. The provision would establish extremely detailed 
reporting requirements. VA would also have to establish 
education, training, certification, and staffing standards for 
VA health care facilities for full-time equivalent employees 
who are trained to provide MST services.
    We do not support the training-related requirements of 
section 202 because they are duplicative of existing programs. 
In fiscal year 2007, VA funded a Military Sexual Trauma Support 
Team, whose mission is, in part, to enhance and expand 
MSTrelated training and education opportunities nationwide. VA 
also hosts an annual four-day long training session for 30 
clinicians in conjunction with the National Center for PTSD, 
which focuses on treatment of the after-effects of MST. VA also 
conducts training through monthly teleconferences that attract 
130 to 170 attendees each month. VA has recently unveiled the 
MST Resource Homepage, a Web page that serves as a 
clearinghouse for MST-related resources such as patient 
education materials, sample power point trainings, provider 
educational opportunities, reports of MST screening rates by 
facility, and descriptions of VA policies and benefits related 
to MST. It also hosts discussion forums for providers. In 
addition, VA primary care providers screen their veteran-
patients, particularly recently returning veterans, for MST, 
using a screening tool developed by the Department. We are 
currently revising our training program to further underscore 
the importance of effective screening by primary care providers 
who provide clinical care for MST within primary care settings.
    We object strongly to the requirement for staffing 
standards. Staffing-related determinations must be made at the 
local level based on the identified needs of the facility's 
patient population, workload, staffing, and other capacity 
issues. Retaining this flexibility is essential to permit VA 
and individual facilities to respond to changing needs and 
available resources. Imposition of national staffing standards 
would be an utterly inefficient and ineffective way to manage a 
health care system that is dynamic and experiences continual 
changes in workload, utilization rates, etc.
    Section 203 would require the Secretary to establish, 
through the National Center for PTSD, a similar education, 
training, and certification program for health care 
professionals providing evidence-based treatment of PTSD and 
other co-morbid conditions associated with MST to women 
veterans. It would require VA to provide these professionals 
with continuing medical education, regular competency 
evaluations, and mentoring.
    VA does not support section 203 because it is duplicative 
of, and would divert resources from, activities already 
underway by the Department. VA is strongly committed to making 
state-of-the-art, evidence-based psychological treatments 
widely available to veterans and this is a key component of 
VA's Mental Health Strategic Plan. We are currently working to 
disseminate evidence-based psychotherapies for a variety of 
mental health conditions throughout our health care system. 
There are also two programs underway to provide clinical 
training to VA mental health staff in the delivery of certain 
therapies shown to be effective for PTSD, which are also 
recommended in the VA/DOD Clinical Practice Guidelines for 
PTSD. Each training program includes a component to train the 
professional who will train others in this area, to promote 
wider dissemination and sustainability over time.
    Section 204 would require the Secretary, commencing not 
later than six months after the date of enactment, to carry out 
a two-year pilot program, at no fewer than three VISN sites, to 
pay veterans the costs of child care they incur to travel to 
and from VA facilities for regular mental health services, 
intensive mental health services, or other intensive health 
care services specified by the Secretary. The provision is 
gender-neutral. Any veteran who is a child's primary caretaker 
and who is receiving covered health care services would be 
eligible to participate in the pilot program. VA does not 
support this provision. Although the inability to secure child 
care may be a barrier to access to care for some veterans, 
funding such care would divert those funds from direct patient 
care. We estimate the cost of section 204 to be $3 million.
    Section 205 would require VA, not later than six months 
after the date of enactment, to conduct a pilot program to 
evaluate the feasibility of providing reintegration and 
readjustment services in a group retreat setting to women 
veterans recently separated from service after a prolonged 
deployment. Participation in the pilot would be at the election 
of the veteran. Services provided under the pilot would 
include, for instance, traditional VA readjustment counseling 
services, financial counseling, information on stress 
reduction, and information and counseling on conflict 
resolution.
    VA has no objection to section 205; however, we are unclear 
as to the purpose of and need for the bill. We note the term 
``group retreat setting'' is not defined. We would not 
interpret that term to include a VA medical facility, as we do 
not believe that would meet the intent of the bill. We also 
assume this term would not include Vet Centers as we could not 
limit Vet Center access to any one group of veterans. Moreover, 
many Vet Centers, such as the one in Alexandria, Virginia, are 
already well designed to meet the individual and group needs of 
women veterans. Section 205 would have no costs.
    Section 206 would require the Secretary to ensure there is 
at least one full-time employee at each VA medical center 
serving as a women veterans program manager. We strongly 
support this provision. The position of the women veterans 
program manager has evolved from an overseer of local programs 
to ensure access to care for women veterans to a position 
requiring sophisticated management and administrative skills 
necessary to execute comprehensive planning for women's health 
issues and to ensure these veterans receive quality care as 
evidenced, in part, by performance measures and outcome 
measurements. The duties of this position will only continue to 
grow as we strive to expand services to women veterans. Thus, 
we believe there is support for the dedication of a full-time 
employee equivalent at every VA medical center. We estimate 
section 206 would result in additional costs of $7,131,975 for 
fiscal year 2010 and $86,025,382 over a 10-year period.
    Next, section 207 would require the Department's Advisory 
Committee on Women Veterans, created by statute, to include 
women veterans who are recently separated veterans. It would 
also require the Department's Advisory Committee on Minority 
Veterans to include recently separated veterans who are 
minority group members. These requirements would apply to 
committee appointments made on or after the bill's enactment. 
We support section 207. Given the expanded role of women and 
minority veterans serving in the Armed Forces, the Committees 
should address the needs of these cohorts in carrying out their 
reviews and making their recommendations to the Secretary. 
Having their perspective may help project both immediate and 
future needs.

           *       *       *       *       *       *       *

          S. 2824--COLLECTIVE BARGAINING RIGHTS FOR REVIEW OF 
                            ADVERSE ACTIONS

    The major provision of S.2824 would make matters relating 
to direct patient care and the clinical competence of clinical 
health care providers subject to collective bargaining. It 
would repeal the current restriction on collective bargaining, 
arbitrations, and grievances over matters that the Secretary 
determines concern the professional conduct or competence, peer 
review, or compensation of Title 38 employees. The Secretary 
would also be required to bargain over direct patient care and 
clinical competency issues, the processes VA uses to assess 
Title 38 professionals' clinical skills, and the discretionary 
aspects of Title 38 compensation, including performance pay, 
locality pay, and market pay. Because they would be negotiable 
these matters would also be subject to nonclinical, non-VA 
third-party review.
    VA strongly opposes this provision. Prior to 1991, Title 38 
professionals did not have the right to engage in collective 
bargaining at all. The current restriction on collective 
bargaining rights is a sound compromise between VA's mission--
best serving the needs of our nation's veterans--and the 
interest of Title 38 physicians, nurses, and other 
professionals in engaging in collective bargaining. 
Importantly, Congress recognized that the Secretary, as the 
head of the VA health care system, would be in the best 
position to decide when a particular proposal or grievance 
falls within one of the statutory areas excluded from 
bargaining. Such determinations should not be legislated. 
Neither should they be made by a non-clinical third party who 
is not accountable for assuring the health and safety of the 
veterans the Department is responsible for. If the Secretary 
and the Under Secretary for Health are going to be responsible 
and accountable for the quality of care provided to and the 
safety of veterans, they must be able to determine which 
matters affect that care. They must be able to establish 
standards of professional conduct by and competency of our 
clinical providers based on what is best for our veterans 
rather than what is the best that can be negotiated or what an 
arbitrator decides is appropriate. The Under Secretary for 
Health has been delegated the authority to make these 
discretionary determinations. VA has not abused this 
discretionary authority. Since 1992, there have been no more 
than 13 decisions issued in a one-year period and, in most 
cases, even far fewer decisions than that. This is particularly 
striking given the number of VA health care facilities and 
bargaining unit employees at those facilities. We are therefore 
at a loss to understand the need for this provision.
    S. 2824 would also transfer VA's Title 38 specific 
authorities, namely the right to make direct patient care and 
clinical competency decisions, assess Title 38 professionals' 
clinical skills, and determine discretionary compensation for 
Title 38 professionals, to independent third-party arbitrators 
and other non-VA nonclinical labor third parties who lack 
clinical training and understanding of health care management 
to make such determinations. For instance, labor grievance 
arbitrators and the Federal Service Impasses Panel would have 
considerable discretion to impose a clinical or patient care 
resolution on the parties. VA would have limited, if any, 
recourse if such an external party erred in its consideration 
of the clinical or patient care issue. The exceptions to 
collective bargaining rights for Title 38 employees identify 
areas that directly impact VA's ability to manage its health 
care facilities and monitor the professional conduct and 
competence of its employees; management actions concerning 
these areas must be reserved for VA professionals.
    This bill would allow unions to bargain over, grieve, and 
arbitrate subjects that are even exempted from collective 
bargaining under Title 5, including the manner by which an 
employee is disciplined and the determination of the amount of 
an employee's compensation. That would be unprecedented in the 
Federal government. Such a significant change in VA's 
collective bargaining obligations would adversely impact VA's 
budget and management rights; it would also skew the current 
balance maintained between providing beneficial working 
conditions for Title 38 professionals and meeting patient care 
needs, jeopardizing the lives of our veterans. There would be 
no costs associated with this provision.

           *       *       *       *       *       *       *

            S. 2921--CARING FOR WOUNDED WARRIORS ACT OF 2008

    Section 2 would require the Secretary to conduct up to 
three pilot programs, in collaboration with the Secretary of 
Defense, to assess the feasibility of training and certifying 
family caregivers to be personal care attendants for veterans 
and members of the of the Armed Forces suffering from TBI. VA 
would be required to determine the eligibility of a family 
member to participate in the pilot programs, and such a 
determination would have to be based on the needs of the 
veteran or servicemember as determined by the patient's 
physician. The training curricula would be developed by VA and 
include applicable standards and protocols used by 
certification programs of national brain injury care specialist 
organizations and best practices recognized by caregiver 
organizations. Training costs would be borne by VA, with DOD 
required to reimburse VA at TRICARE rates for the costs of 
training family members of servicemembers. Family caregivers 
certified under this program shall be eligible for VA 
compensation and may receive assessments of their needs in the 
role of caregiver and referrals to community resources to 
obtain needed services.
    VA does not support section 2. Currently, we are able to 
contract for caregiver services with home health and similar 
public and private agencies. The contractor trains and pays 
them, affords them liability protection, and oversees the 
quality of their care. This remains the preferable arrangement 
as it does not divert VA from its primary mission of treating 
veterans and training clinicians.
    Section 3 would require VA, in collaboration with DOD, to 
carry out a pilot program to assess the feasibility of 
providing respite care to family caregivers of servicemembers 
and veterans diagnosed with TBI, through the use of students 
enrolled in graduate education programs in the fields of mental 
health or rehabilitation. Students participating in the program 
would, in exchange for graduate course credit, provide respite 
relief to the servicemember's or veteran's family caregiver, 
while also providing socialization and cognitive skill 
development to the servicemember or veteran. VA would be 
required to recruit these students, train them in the provision 
of respite care, and work with the heads of their graduate 
programs to determine the amount of training and experience 
needed to participate in the pilot program.
    We do not support section 3, which we recognize is an 
effort to compel VA to use existing arrangements with 
affiliated academic institutions as a novel means of providing 
respite care to family caregivers of TBI patients. Individuals 
providing respite care do not require advanced degrees, only 
appropriate training. Respite care is an unskilled type of 
service that does not qualify for academic credit or serve to 
meet any curricula objectives in the graduate degree programs 
related to mental health or rehabilitation. Further, section 3 
would require VA to use graduate students in roles that are not 
permissible under academic affiliation agreements, and we have 
serious doubts this proposal would be acceptable to graduate 
schools.
    Moreover, VA has a comprehensive respite care program. We 
also have specialized initiatives underway for TBI patients to 
reduce the strain on their caregivers, which overlap with this 
bill. Plus we provide respite care by placing the veteran in a 
local VA facility for the duration of the respite period. 
Veterans may receive up to 30 days of respite care per year. We 
estimate the costs of S.2921 to be $39,929,000 for fiscal year 
2010 and $790,374,000 over a ten-year period.

           *       *       *       *       *       *       *

                S. 2899--``VETERANS SUICIDE STUDY ACT''

    S. 2899 would require the Secretary to conduct a study to 
determine the number of veterans who have committed suicide 
between January 1, 1997, and the date of the bill's enactment. 
The study would have to be carried out in coordination with the 
Secretary of Defense, Veterans Service Organizations, the 
Centers for Disease Control and Prevention, and State public 
health offices and veterans agencies. The bill would require 
the Secretary to submit a report to Congress on his findings 
within 180 days of the bill's enactment.
    VA understands the intent of the Senate in proposing 
S.2899. However, we would like to make the Senate aware of the 
difficulties in accomplishing the legislation's intent--and 
what VA is doing, and intends to do, to improve our ability to 
obtain and report on suicide numbers.
    At present, determining suicide rates among veterans is a 
challenging puzzle. Multiple data sources must be used, and 
data must be carefully checked and rechecked. Each system helps 
obtain a piece of the complicated puzzle that constitutes the 
process of accurately estimating rates of veteran suicides. 
These are time-consuming processes--but they are the best ways 
VA knows to obtain aggregate data on suicide.
    VA relies on multiple sources of information to identify 
deaths that are potentially due to suicide. This includes VA's 
own Beneficiary Identification and Records Locator Subsystem, 
called BIRLS; records from the Social Security Administration; 
and data compiled by the National Center for Health Statistics 
in its National Death Index (NDI).
    Calculating suicide rates specifically for veterans is made 
even more difficult by the fact that the National Death Index 
does not include information about whether a deceased 
individual is a veteran or not. NDI is simply a central 
computerized index of death record information on file in the 
vital statistics offices of every state. The Index is compiled 
from computer files submitted by State vital statistics 
offices. Death records are added to the file annually, about 
twelve months after the end of a calendar year.
    Given that the NDI does not indicate veteran status, VA 
regularly submits requests for information to NDI. VA sends NDI 
a list of all patients who have not been treated at any VA 
medical centers in the past twelve months and before, to see if 
they are still among the living. NDI checks this list against 
their records, and tells VA which veterans have died, and the 
cause of their death as listed on the veterans' death 
certificates. From this information, VA is able to learn the 
approximate number of veterans under its care who have died of 
suicide, and to use that information to make comparisons on 
rates of suicide among those veterans and all other Americans.
    This information tells VA about the suicide rates among 
veterans under its care, but says nothing about the rates of 
suicide among veterans who are not currently in the system. For 
those veterans, an even more complicated process has to be 
followed in order to estimate rates. VA obtains regular updates 
from the Department of Defense's Defense Manpower Data Center 
on soldiers separating from the military. Those new veterans 
immediately become part of total population and suicide 
calculations.
    Additionally, the Department will, among other things, also 
systematically assess its efforts to inform funeral directors 
about the importance of determining whether or not a person who 
has died of suicide is or is not a veteran, and what sorts of 
information to consider in making that determination. Finally, 
VA will investigate working directly with state vital records 
offices, as the NDI does, to obtain information on veteran 
suicides directly from them.
    VA asks that the Senate give us time to complete these 
actions before requiring any study of the numbers of suicides 
among veterans. We are ``pushing the envelope'' to get the most 
accurate data available on suicides in the shortest possible 
time frame, and we commit to sharing that data with Congress as 
soon as it becomes available.
    We estimate the cost of this bill to be $1,580,006 in 
fiscal year 2008 and $2,078,667 over a 10-year period.

           *       *       *       *       *       *       *

S. 2937--PERMANENT TREATMENT AUTHORITY FOR VETERANS WHO PARTICIPATED IN 
                          CERTAIN DOD TESTING

    Section 1 would make permanent the Secretary's authority to 
provide needed inpatient, outpatient, and nursing home care to 
a veteran who participated in a test conducted by the 
Department of Defense (DOD) Deseret Test Center as part of its 
chemical and biological warfare testing program conducted from 
1962-1973, for any condition or illness possibly associated 
with such testing at no cost to the veteran. This authority 
will expire after December 31, 2008.
    VA supports section 1, which we note is identical to our 
own proposal in S.2984. We estimate the discretionary cost of 
this provision to be $4,458,000 in fiscal year 2009 and 
$144,434,000 over a 10-year period.
    Section 2 would require the Secretary, not later than 90 
days after the date of the Act's enactment, to enter into a 
contract with IOM to conduct an expanded study on the health 
impact of participation in Project Shipboard Hazard and Defense 
(Project SHAD). Such a study should include, to the extent 
practicable, all veterans who participated in Project SHAD. VA 
does not support this provision, as we doubt that an expanded 
study could be conducted by IOM or any other organization 
because IOM has already thoroughly studied the health of SHAD 
veterans and made a concerted attempt to identify all involved 
veterans for its study.
    Mr. Chairman, this concludes my prepared statement. I would 
be pleased to answer any questions you or any of the members of 
the Committee may have.
                                ------                                

                         The Secretary of Veterans Affairs,
                                      Washington, DC, July 21, 2008
Hon. Daniel A. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: On May 21, 2008, you chaired a hearing 
to receive comments on 17 healthcare-related bills that were 
before the Committee. At the hearing, the Department testified 
on 14 of the bills. We stated that we needed additional time to 
coordinate the Administration's positions on S. 2926, S. 2963, 
and S. 2969. With this letter, we are providing views for the 
record on S. 2926 and S. 2963. The Administration's views on S. 
2969 are being transmitted to you by separate letter.

 S. 2926--Veterans Research and Education Corporations Enhancement Act 
                                of 2008

    S. 2926 contains many clarifying and technical provisions; 
however, we will discuss only the substantive provisions of the 
bill. The most important change to be accomplished by S. 2926 
is contained in Section 2. It would amend 38 U.S.C. 7361 to 
allow two or more medical centers, with the concurrence of the 
Secretary, to form a Multi-Medical Center Research Corporation 
(MMCRC). The MMCRC would be authorized to support research and 
education projects at the two or more medical centers that had 
formed it. This section would also allow an existing non-profit 
research corporation (NPC), with the approval of the medical 
centers involved and the Secretary, to expand into a MMCRC. 
Under current law, a VA medical center may establish an NPC 
that is authorized to facilitate approved research and 
education projects at that medical center.
    This provision of section 2 would not change the 
requirement that four members of senior management of one 
medical center, the Director, the Chief of Staff and, as 
appropriate, the Assistant Chiefs of Staff for Research and for 
Education, will serve on the board of the NPC. Rather, it would 
provide that this core group be augmented by the medical center 
director from each of the other facilities to be served by that 
NPC. This would provide VA with one official from each facility 
served by the MMCRC who may be held accountable by VA. It would 
require the NPC boards to decide whether their NPCs should 
evolve into MMCRCs and require them to obtain VA approval. This 
would ensure that the board has accepted the responsibilities 
that an MMCRC entails and that VA has considered whether the 
arrangement is reasonable and in the best interests of the 
Department.
    Section 2(c) would make clear that NPCs are subject to VA 
oversight and regulation, but not under the direct control of 
the Department. It would also expressly provide that the NPCs 
are not ``owned or controlled by the United States'' or ``an 
agency or instrumentality of the United States.'' This is 
currently made clear only in the legislative history of the 
statute.
    Section 3 would clarify that NPCs may support VA research 
and education generally. More specifically, it would amend 38 
USC 7362 to state that NPCs may support ``functions related to 
the conduct of'' VA research and education--but still only VA 
research and education--not just administer approved research 
or education projects. Currently, the corporations may 
facilitate only VA-approved research and education projects.
    Section 4 would broaden the qualifications for the non-VA 
board members to include business, legal and financial 
backgrounds, thus allowing NPCs to use these board positions to 
acquire the legal and financial expertise needed to ensure 
sound governance and financial management. Currently, the law 
requires that there be members of the board of directors of an 
NPC who are not Federal employees and who ``are familiar with 
issues involving medical and scientific research or 
education.''
    Section 4 would also update the conflict of interest 
provision currently in section 7363(c) of title 38, United 
States Code, which prevents individuals from serving on the 
board if they are ``affiliated with, employed by, or have any 
other financial relationship with'' a for-profit entity that is 
a source of funding for VA research.
    Section 5 would enhance several powers of the NPCs. Section 
5(a) collects in one place all discussion of NPC powers and 
makes several important clarifications. First, it would provide 
NPCs with authority to retain fees charged to non-VA attendees 
for educational programs in order to cover the costs of 
attendance by such participants. Current law authorizes NPCs to 
facilitate education, but does not authorize them to retain 
fees charged to non-VA attendees for educational programs they 
administer.
    Second, it would permit the NPCs to reimburse the VA Office 
of General Counsel (OGC) for resources necessary for prompt 
review of Cooperative Research and Development Agreements 
(CRADAs). This would permit Regional Counsel offices to address 
the growing volume of CRADAs, the form of agreement mandated by 
VA to establish terms and conditions for industry-sponsored 
studies performed at VA medical centers and administered by 
NPCs. Under the bill, any such reimbursements would be used by 
OGC for only staffing and training in connection with such 
legal services.
    Third, section 5(a) of the bill would permit NPCs to expend 
funds for necessary planning purposes, prior to approval of a 
research project or education program by VA, such as the 
expenses of preparing a grant proposal. Currently, the NPCs can 
assist VA with funding only for research or education projects 
that have already been approved by VA.
    Section 5(b) would continue the proscription on VA transfer 
of appropriated funds to NPCs, but would make explicit the 
authority of a medical center to ``reimburse the corporation 
for all or a portion of the pay, benefits, or both of an 
employee of the corporation who is assigned to the Department 
medical center if the assignment is carried out pursuant to 
subchapter VI of chapter 33 of title 5.'' This would codify 
that reimbursements from VA to NPCs pursuant to 
Intergovernmental Personnel Act (IPA) assignments are 
allowable.
    Section 7 would increase NPC reporting requirements to 
include IRS Form 990, which contains a wealth of information 
about revenues and expenditures as well as major programmatic 
accomplishments. Section 8 would eliminate the sunset clause on 
establishing new NPCs.
    We support the provision in section 2 of S. 2926 that would 
authorize the establishment of new multi-center non-profit 
research corporations (NPCs) and the consolidation of existing 
single facility NPCs into multi-facility NPCs. This would offer 
the prospect of NPC-assistance in funding research projects to 
VA medical centers (VAMCs) that are unable to support their own 
dedicated corporation. This provision would also provide the 
system with the tools needed to consolidate or close NPCs that 
are too small to institute proper internal controls without the 
loss of the funding support for VA research and education 
programs that the NPCs provide. By requiring the Director of 
all VAMCs supported by an NPC to sit on its board of directors, 
the provision would provide this beneficial increased 
flexibility without sacrificing VA oversight.
    With respect to the draft bill's remaining provisions, 
however, we ask the Committee to defer further action on this 
draft bill in order to give the Department an opportunity to 
address underlying structural issues and to formulate policy 
related to the governance and finance of the VA affiliated non-
profit research corporations. A steering committee has been 
chartered by the Veterans Health Administration Office of 
Research and Development, to provide recommendations regarding 
governance, oversight, and finance issues related to the 
corporations by the end of the fiscal year. We will be happy to 
provide you with a copy of their final report and 
recommendations.

S. 2963--VA Mental Health and Other Benefits Extended to Members of the 
                              Armed Forces

    Section 1 of the bill would require the Secretary of the 
Department of Veterans Affairs (VA), acting through the Under 
Secretary for Health, to carry out a program to provide 
scholarships to individuals pursuing education or training in 
behavioral health care specialties critical to the operations 
of the Department's Vet Centers. Individuals eligible for the 
program would include those pursing education or training 
leading to licensure or certification in behavioral health care 
specialties, which the Secretary deems are critical to the 
operation of the Vet Centers and who otherwise meet other 
criteria or requirements established by the Secretary. The 
amount of any scholarship provided under the program would be 
determined by the Secretary; however, the total amount 
available for all the scholarships provided under the program 
in any fiscal year could not exceed $2 million.
    In exchange for the scholarship, an individual 
participating in the program would be required to enter into an 
agreement with the Secretary and fulfill a service obligation 
in a Vet Center, as specified in the agreement. Section 1 would 
also require these agreements to include repayment provisions 
in the event the individual does not fulfill the service 
obligation. The bill would also specify that these scholarships 
are to be paid from amounts made available to VA for the 
provision of readjustment benefits.
    VA supports the concept of using scholarships for this 
purpose; however, this provision is unnecessary. Under existing 
authority, we could establish by regulation a special 
scholarship program for individuals pursuing degrees in mental 
health specialties and require those individuals to agree to 
serve for a specified period in VA's Vet Centers. The current 
program is used very successfully to recruit individuals for 
difficult-to-recruit and difficult-to-retain health care 
positions throughout the country. We believe it is essential to 
target scholarships to difficult-to-recruit and difficult-to-
retain occupations across the Veterans Health Administration 
system, rather than limiting scholarships to specific 
facilities.
    We note that current law provides express terms governing a 
participant's service obligation and liability if a breach 
occurs at any phase in the program. These statutory provisions 
help ensure that VA is able to reap the benefits of tangible 
and intangible investments made by the Department. In addition, 
current law imposes treble damages for a scholarship 
participant who fails to complete the service obligation. In 
sharp contrast, section 1 would require VA to promulgate 
regulations relating to repayment of the amount of a 
scholarship provided under this section. Imposing significant 
penalties for those who breach their service obligations helps 
VA to deter individuals from using VA as an interest-free, tax-
free educational loan program. Section 1 provides no effective 
means of ensuring that VA will receive the benefit of the 
participants' professional services as VA employees. Finally, 
because Vet Centers are currently funded through the medical 
care appropriations we believe the cost of such scholarship 
program shall be funded from the same appropriations, rather 
than the readjustment benefits program.
    We estimate the cost of section 1 to be $2,313,938 for 
fiscal year 2009 and $24,483,918 over a 10-year period.
    Section 2 of S. 2963 would extend eligibility for VA's 
readjustment counseling and related services provided through 
the Department's Vet Centers to members of the Armed Forces, 
including members of the National Guard or Reserve, who serve 
on active duty in Operation Enduring Freedom or Operation Iraqi 
Freedom (OEF/OIF). Service members would be eligible for the 
readjustment counseling services even if they are on active 
duty at the time they receive them. They would have to also 
meet eligibility requirements prescribed jointly by the 
Secretary of Veterans Affairs and the Secretary of Defense.
    VA supports section 2. We can most effectively address the 
readjustment needs of former combat-theater service members who 
are still on active duty through early intervention--even 
before they are discharged. With our expertise, we can help 
prepare them for many of the common readjustment problems 
experienced by veterans with combat service. Extending 
readjustment counseling and related services to this population 
may also help to resolve problems that otherwise might prevent 
some of them from pursuing long-term military careers. We note 
that VA provides these services in a confidential setting and 
in a manner that helps to reduce any concern that an active-
duty military member may have about any stigma related to 
seeking counseling or other mental health services. Thus, we 
see significant benefits to this section.
    We also note that, by operation of law, these service 
members' immediate family members would remain eligible for 
certain family-support services while the service member is on 
active duty. These services would be provided only to the 
extent that they are needed for, or in furtherance of, the 
active-duty member's successful readjustment to civilian life.
    The Department estimates the cost of section 2 to be 
$14,791,000 for fiscal year 2009 and $178,418,309 over a 10-
year period. The increased fiscal year 2009 workload resulting 
from this proposal can be absorbed within the fiscal year 2009 
President's Budget request, which includes funding for the 
establishment of 39 new Vet Centers.
    Section 3 would require the Secretary to provide referral 
services at Vet Centers to individuals who have been discharged 
or released from active military, naval, or air service but who 
are not eligible to receive readjustment counseling and related 
services. It would also require VA to advise these individuals 
of their right to apply to the appropriate military, naval, or 
air service for review and upgrade of their discharge status.
    VA does not support section 3. Vet Centers provide 
readjustment counseling and related services to veterans who: 
(1) meet the title 38 definition of veteran (i.e., ``a person 
who served in the active military, naval, or air service, and 
who was discharged or released therefore under conditions other 
than dishonorable)''; and (2) served in a combat theater. It is 
unclear whether this provision is intended to address all of 
those with ``less than honorable'' discharges. If so, the 
language of this section is exceptionally broad and would 
broaden eligibility for these referral services to non-combat 
veterans. These clarifications need to be made before VA can 
develop a position and cost estimate for the provision.
    Section 4 would require that the suicide by certain former 
members of the Armed Forces that occurs during the two-year 
period beginning on the date of separation or retirement from 
the Armed Forces be treated as a death in the line of duty for 
purposes of survivors' eligibility for certain benefits. The 
former Armed Forces members who would be covered are those 
``with a medical history of a combat-related mental health 
condition or Post Traumatic Stress Disorder (PTSD) or Traumatic 
Brain Injury (TBI).'' The benefits that would be covered under 
section 4 are ``[b]urial benefits,'' Survivor Benefit Plan 
benefits under title 10, United States Code, ``[b]enefits under 
the laws administered by the Secretary of Veterans Affairs,'' 
and Social Security Act benefits. Furthermore, for purposes of 
benefits under section 4, the date of death would be considered 
to be the date of separation or retirement from the Armed 
Forces, except that, for purposes of determining ``the scope 
and nature of the entitlement,'' the date of death would be 
considered to be the date of the suicide. We believe this last 
provision would provide the date of death for purposes of 
determining the effective date of an award or amount of 
benefits, although this is not clear from the bill's language. 
Essentially, under section 4, the suicide of a covered 
individual would be treated as a service-connected death for VA 
benefit purposes.
    Although VA supports the concept of section 4 and 
recognizes its compassionate intent, we cannot support this 
provision because it may have a negative impact. In some cases, 
the veterans' combat-related mental health conditions may make 
them susceptible to considering suicide. Knowing survivor 
benefits would be awarded to their spouses and children might 
exacerbate their conditions, making them even more susceptible 
to acting on their suicide ideations. Their illnesses may cause 
them to reject any opportunity to obtain medical assistance, 
believing instead that their families will benefit more from 
their suicide. This might especially be the case for those who 
feel overwhelmed by their obligation to provide for their 
families.
    We also have several technical concerns with section 4. 
Subsection (b) identifies the covered former Armed Forces 
members as those ``with a medical history of a combat-related 
mental health condition or [PTSD] or [TBI].'' It is unclear 
from the language whether the adjective ``combat-related'' is 
meant to modify PTSD and TBI as well as mental health 
condition. The statement of the bill's sponsor upon introducing 
the bill suggests so. ``This legislation guarantees benefits * 
* * provided they have a documented medical history of a 
combat-related mental-health condition, including PTSD or 
TBI.'' 154 Cong. Rec. S3716 (daily ed. May 1, 2008). However, 
the bill language should be clarified.
    Subsection (c)(1) identifies ``[b]urial benefits'' as one 
of the covered benefits, but fails to specify from which 
Federal department or agency. We note that subsection (c)(3) 
identifies as covered benefits ``[b]enefits under the laws 
administered by [VA],'' which would cover VA burial benefits 
and therefore implies that subsection (c)(1) refers to another 
agency. Again, the introductory statement of the bill's sponsor 
suggests a solution to this interpretive question. ``The 
Service Member's survivor will be entitled to the same * * * 
active duty burial benefits that they would have received'' had 
the former service member died on active duty, id., but 
clarification of the bill language may be in order.
    VA is still in the process of developing costs for section 
4.
    Section 5 would require DOD to carry out a grant program 
for non-profit organizations furnishing support services to 
survivors of deceased service members and veterans. As to this 
section, VA defers to the views of the Secretary of Defense.
    The Office of Management and Budget advises that there is 
no objection to the submission of this report from the 
standpoint of the Administration's program.
            Sincerely yours,
James B. Peake, M.D.

           *       *       *       *       *       *       *

                         The Secretary of Veterans Affairs,
                                    Washington, DC, August 8, 2008.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: I am pleased to respond to your July 8, 
2008, request for the views of the Department of Veterans 
Affairs (VA) on the amendment proposed by Ranking Republican 
Member Richard Burr to S. 2969, 110th Congress. As you are 
aware, the Committee recently approved an amended version of S. 
2969, which is now entitled the ``Veterans Health Care 
Authorization Act of 2008.'' Senator Burr's amendment, which 
was incorporated in the amended bill, would add a new section 
5511 to title 38, United States Code, relating to the Brady 
Handgun Violence Prevention Act, Public Law 103-159 (Brady 
Act). Because the amendment in its current form does not 
directly affect VA programs, such an amendment would be more 
appropriate for inclusion in title 18 of the United States 
Code.
    The amendment relates to enforcement of 18 U.S.C. 922, 
which is administered by the Department of Justice (DOJ). 
Specifically, the amendment would affect the manner in which 
DOJ implements 18 U.S.C. 922, which prohibits certain persons 
from receiving firearms. The amendment does not affect VA's 
provision of benefits to veterans and their families. Because 
the substance of the amendment relates to matters within DOJ's 
jurisdiction, as drafted, it is more appropriate for inclusion 
in title 18.
    At the request of the Attorney General pursuant to section 
103(e)(1) of the Brady Act, VA provides DOJ with information 
concerning persons VA finds to be ``mentally incompetent''--a 
finding VA bases solely on a person's ability to contract or 
manage his or her affairs in the context of VA benefits. VA's 
role with respect to the Brady Act is limited to providing DOJ 
such requested information; VA does not determine whether such 
information should prohibit a person from possessing firearms. 
DOJ is responsible for determining whether persons reported by 
VA or other Federal agencies are prohibited by 18 U.S.C. 922 
from possessing firearms.
    The amendment would provide that a veteran, surviving 
spouse, or child found mentally incompetent by VA would not be 
deemed to fall within the prohibition of 18 U.S.C. 922 unless 
a judicial authority has determined that the individual is a 
danger to himself or herself or others. You have requested VA's 
views concerning how this Department would implement the 
requirement for a judicial finding. We note that the language 
of the amendment would not direct VA to obtain such findings. 
VA does not implement or enforce the provisions of 18 U.S.C. 
922 that would be affected by the requirement for a judicial 
finding under this amendment. Moreover, as VA's process for 
making incompetency determinations is administrative, as 
opposed to judicial, VA could not implement the requirement for 
a judicial finding.
    You have also requested information concerning the number 
of instances per year in which VA determines that an individual 
is a danger to himself or herself or others. As discussed 
above, VA does not make such determinations. VA competency 
determinations are made under 38 C.F.R. 3.353 based solely on 
evaluation of whether the individual ``lacks the mental 
capacity to contract or to manage his or her own affairs, 
including disbursement of funds without limitation.'' Although 
VA medical staff might, in isolated instances, offer opinions 
regarding an individual's mental status and potential for harm 
when requested with regard to state court proceedings, such 
medical opinions, like VA's competency determinations, are 
neither VA determinations of danger to self or others nor 
adjudications of mental defectiveness under 18 U.S.C. 922. 
Consequently, VA currently has no system for identifying or 
collecting data on such matters.
    Because the amendment itself would not impose any 
additional reporting or implementation responsibilities, there 
would be no direct costs associated with this amendment.
    In summary, VA believes the amendment, as drafted, is more 
appropriate for inclusion in title 18 of the United States Code 
because it does not directly affect VA programs. Because the 
amendment pertains directly to a title 18 program, the 
Committee may wish to accord DOJ an opportunity to provide 
views on this legislation.
    We are sending a copy of this report to Ranking Member 
Burr.
    The Office of Management and Budget has advised that there 
is no objection to the submission of this report from the 
standpoint of the Administration's program.
            Sincerely yours,
James B. Peake, M.D.

           *       *       *       *       *       *       *

          SUPPLEMENTAL VIEWS OF HON. DANIEL K. AKAKA, CHAIRMAN

    I am submitting Supplemental Views to express my concerns 
about section 803 of the Committee bill, which would change 
VA's actions in fulfilling the Department's responsibilities 
under the Brady Handgun Violence Prevention Act, Public Law 
103-159, and that law's implementing regulations as set forth 
in a Memorandum of Understanding between VA and the Department 
of Justice.
    This provision was added to the Committee bill by an 
amendment offered by the Committee's Ranking Minority Member, 
Senator Burr. Senator Burr's amendment was derived from S. 
3167, which he introduced on June 19, 2008, after the Committee 
had completed its legislative hearings related to the 
Committee's June 26, 2008, markup. As a consequence of that 
timeline, the Committee was unable to secure any testimony or 
other input on the provision prior to the markup. Subsequent to 
the markup, I sought official views on this provision, first 
from the Department of Veterans Affairs and then, once those 
views were received, from the Department of Justice. VA's 
official views are included in this report.
    I begin by noting that I am not on the Judiciary Committee 
nor do I have any other reason to have strong familiarity with 
the Brady Act. Because I do not have that background, there are 
many questions that I would have sought to have answered in a 
hearing, were it to be established that this measure belongs in 
our Committee rather than in Judiciary. On that point, I agree 
that S. 3167, as drafted, was appropriately referred to the 
Veterans' Affairs Committee, but I do not agree that the 
subject matter belongs in our Committee.
    For example, one question--how do the changes made by the 
NICS Improvement Amendments Act of 2007, Public Law 110-180, 
which was just signed earlier this year, change VA's process 
for providing names to the Department of Justice? I have seen 
the changes made by that Act described as:

        Prevent[ing] use of federal ``adjudications'' that 
        consist only of medical diagnoses without findings that 
        the people involved are dangerous or mentally 
        incompetent.

    This description, which was applauding the new law, went on 
to say that this change would ensure that purely medical 
records are never used in NICS. Gun ownership rights would only 
be lost as a result of a finding that the person is a danger to 
themselves or others, or lacks the capacity to manage his own 
affairs [emphasis added]. That last test seems to me to be 
fully consistent with what VA has been doing for a number of 
years. If that is correct--and I acknowledge, frankly, that I 
am not certain, nor do I believe that the Veterans' Affairs 
Committee knows, because there has been no hearing--the reason 
for making a change to the current practice is not clear to me.
    What effect will the standard included in the amendment--
requiring adjudication by ``a judge, magistrate, or other 
judicial authority'' that someone is a ``danger to him- or 
herself''--have on VA's ability to provide input to the NICS? 
Will this change result in a delay in providing notification to 
NICS of the names of individuals who are not in a position to 
purchase a firearm? Is this the standard applied by other 
governmental organizations? Again, I do not know the answer, 
because there was no hearing.
    VA's current actions to provide input to NICS are done in 
accordance with provisions in title 27 of the Code of Federal 
Regulations which spell out the requirements of the law. In the 
relevant regulation, 27 CFR 478.11, the term in the law--
``adjudicated as a mental defective''--is defined to include 
those determined by ``a lawful authority'' to lack ``mental 
capacity to contract or manage his own affairs.'' It is the 
names of those who VA has found meet that standard that VA has 
been reporting to the Department of Justice. To characterize 
VA's actions as arbitrary and unfair, as was done during the 
Committee markup, is wrong. Perhaps the implementing 
regulations should be changed--again, a task for a Committee 
other than the Veterans' Affairs Committee--but it is hard to 
fault VA's compliance with the regulations.
    My last concern with this provision, and the process by 
which it was brought before the Committee, goes to the question 
of urgency. As I noted above, the legislation from which the 
amendment was derived was introduced one week prior to a 
previously-scheduled markup. The amendment addresses a practice 
that dates back to 1998. What possible reason exists for 
suggesting that there is an urgent need to address this issue? 
Rather than proceeding in haste, and in the wrong Committee, I 
believe that the legislation should have been considered in the 
normal course by the Judiciary Committee.

           *       *       *       *       *       *       *

                        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 5. AUTHORITY AND DUTIES OF THE SECRETARY

           *       *       *       *       *       *       *

Subchapter III. Advisory Committees

           *       *       *       *       *       *       *

SEC. 542. ADVISORY COMMITTEE ON WOMEN VETERANS

    (a)(1) The Secretary shall establish an advisory committee 
to be known as the Advisory Committee on Women Veterans 
(hereinafter in this section referred to as ``the Committee'').
    (2)(A) The Committee shall consist of members appointed by 
the Secretary from the general public, including--
          (i) representatives of women veterans;
          (ii) individuals who are recognized authorities in 
        fields pertinent to the needs of women veterans, 
        including the gender-specific health-care needs of 
        women; [and]
          (iii) representatives of both female and male 
        veterans with service-connected disabilities, including 
        at least one female veteran with a service-connected 
        disability and at least one male veteran with a 
        service-connected disability[.] ; and
          (iv) women veterans who are recently separated from 
        service in the Armed Forces.

           *       *       *       *       *       *       *

SEC. 544. ADVISORY COMMITTEE ON MINORITY VETERANS

    (a)(1) The Secretary shall establish an advisory committee 
to be known as the Advisory Committee on Minority Veterans 
(hereinafter in this section referred to as ``the Committee'').
    (2)(A) The Committee shall consist of members appointed by 
the Secretary from the general public, including--
          (i) representatives of veterans who are minority 
        group members;
          (ii) individuals who are recognized authorities in 
        fields pertinent to the needs of veterans who are 
        minority group members;
          (iii) veterans who are minority group members and who 
        have experience in a military theater of operations; 
        [and]
          (iv) veterans who are minority group members and who 
        do not have such experience[.] ; and
          (v) women veterans who are minority group members and 
        are recently separated from service in the Armed 
        Forces.

           *       *       *       *       *       *       *

     CHAPTER 9. SECURITY AND LAW ENFORCEMENT ON PROPERTY UNDER THE 
JURISDICTION OF THE DEPARTMENT

           *       *       *       *       *       *       *

SEC. 902. ENFORCEMENT AND ARREST AUTHORITY OF DEPARTMENT POLICE 
                    OFFICERS

    (a)(1) Employees of the Department who are Department 
police officers shall, with respect to acts occurring on 
Department property[, enforce]--
          (A) enforce Federal laws;
          (B) enforce the rules prescribed under section 901 of 
        this title; [and]
          (C) [subject to paragraph (2), traffic and motor 
        vehicle laws of a State or local government within the 
        jurisdiction of which such Department property is 
        located.] enforce traffic and motor vehicle laws of a 
        State or local government (by issuance of a citation 
        for violation of such laws) within the jurisdiction of 
        which such Department property is located as authorized 
        by an express grant of authority under applicable State 
        or local law;
          (D) carry the appropriate Department-issued weapons, 
        including firearms, while off Department property in an 
        official capacity or while in an official travel 
        status;
          (E) conduct investigations, on and off Department 
        property, of offenses that may have been committed on 
        property under the original jurisdiction of Department, 
        consistent with agreements or other consultation with 
        affected local, State, or Federal law enforcement 
        agencies; and
          (F) carry out, as needed and appropriate, the duties 
        described in subparagraphs (A) through (E) of this 
        paragraph when engaged in duties authorized by other 
        Federal statutes.
    [(2) A law described in subparagraph (C) of paragraph (1) 
may be enforced under such subparagraph only as authorized by 
an express grant of authority under applicable State or local 
law. Any such enforcement shall be by the issuance of a 
citation for violation of such law.]
    (2) [(3)] Subject to regulations prescribed under 
subsection (b), a Department police officer may make arrests on 
Department property for a violation of a Federal law or any 
rule prescribed under section 901(a) of this title , and on any 
arrest warrant issued by competent judicial authority.
    (b) * * *
    (c) [The Secretary shall consult with the Attorney General 
before prescribing regulations under paragraph (1) of 
subsection (b).] The powers granted to Department police 
officers designated under this section shall be exercised in 
accordance with guidelines approved by the Secretary and the 
Attorney General.
    (d) * * *

SEC. 903. UNIFORM ALLOWANCE

    (a) * * *
    [(b) The amount of the allowance that the Secretary may pay 
under this section--
          [(1) may be based on estimated average costs or 
        actual costs;
          [(2) may vary by geographic regions; and
          [(3) except as provided in subsection (c), may not 
        exceed $ 200 in a fiscal year for any police officer.]
    (b)(1) The amount of the allowance that the Secretary may 
pay under this section is the lesser of--
          (A) the amount currently allowed as prescribed by the 
        Office of Personnel Management; or
          (B) estimated costs or actual costs as determined by 
        periodic surveys conducted by the Department.
    (2) During any fiscal year no officer shall receive more 
for the purchase of a uniform described in subsection (a) than 
the amount established under this subsection.
    (c) [The amount of an allowance under this section may be 
increased to an amount up to $ 400 for not more than one fiscal 
year in the case of any Department police officer. In the case 
of a person who is appointed as a Department police officer on 
or after January 1, 1990, an allowance in an amount established 
under this subsection shall be paid at the beginning of such 
person's employment as such an officer. In the case of any 
other Department police officer, an allowance in an amount 
established under this subsection shall be paid upon the 
request of the officer.] The allowance established under 
subsection (b) shall be paid at the beginning of a Department 
police officer's employment for those appointed on or after 
October 1, 2008. In the case of any other Department police 
officer, an allowance in the amount established under 
subsection (b) shall be paid upon the request of the officer.

PART II. GENERAL BENEFITS

           *       *       *       *       *       *       *

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

                         SUBCHAPTER I. GENERAL

SEC.

1701. DEFINITIONS.

           *       *       *       *       *       *       *

1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION AND 
                    SOCIAL SECURITY NUMBER OF CERTAIN VETERANS 
                    RECEIVING CARE.

           *       *       *       *       *       *       *

SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS

           *       *       *       *       *       *       *

1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING MATERNITY 
                    CARE.

                         Subchapter I. General

SEC. 1701. DEFINITIONS

           *       *       *       *       *       *       *

          (6) The term ``medical services'' includes, in 
        addition to medical examination, treatment, and 
        rehabilitative services, the following:
                  (A) Surgical services.
                  (B) Dental services and appliances as 
                described in sections 1710 and 1712 of this 
                title.
                  (C) Optometric and podiatric services.
                  (D) Preventive health services.
                  (E) Noninstitutional extended care services, 
                including alternatives to institutional 
                extended care which the Secretary may furnish 
                directly, by contract, or through provision of 
                case management by another provider or payor.
                  (F) [(E)] In the case of a person otherwise 
                receiving care or services under this chapter--
                          (i) wheelchairs, artificial limbs, 
                        trusses, and similar appliances;
                          (ii) special clothing made necessary 
                        by the wearing of prosthetic 
                        appliances; and
                          (iii) such other supplies or services 
                        as the Secretary determines to be 
                        reasonable and necessary.
                  (G) [(F)] Travel and incidental expenses 
                pursuant to section 111 of this title.

           *       *       *       *       *       *       *

          [(10)(A) During the period beginning on November 30, 
        1999, and ending on December 31, 2008, the term 
        ``medical services'' includes noninstitutional extended 
        care services.
          [(B) For the purposes of subparagraph (A), the term 
        ``noninstitutional extended care services'' means such 
        alternatives to institutional extended care which the 
        Secretary may furnish (i) directly, (ii) by contract, 
        or (iii) (through provision of case management) by 
        another provider or payor.]

           *       *       *       *       *       *       *

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

           *       *       *       *       *       *       *

    (d)(4) The authority of the Secretary under this subsection 
terminates on [September 30, 2008] September 30, 2013.

           *       *       *       *       *       *       *

SEC. 1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION 
                    AND SOCIAL SECURITY NUMBER OF CERTAIN VETERANS 
                    RECEIVING CARE

    (a) Required Disclosure of Health-Plan Contracts.--(1) Any 
individual who applies for or is in receipt of care described 
in paragraph (2) shall, at the time of such application, or 
otherwise when requested by the Secretary, submit to the 
Secretary such current information as the Secretary may require 
to identify any health-plan contract (as defined in section 
1729(i) of this title) under which such individual is covered, 
to include, as applicable--
          (A) the name, address, and telephone number of such 
        health-plan contract;
          (B) the name of the individual's spouse, if the 
        individual's coverage is under the spouse's health-plan 
        contract;
          (C) the plan number; and
          (D) the plan's group code.
    (2) The care described in this paragraph is--
          (A) hospital, nursing home, or domiciliary care;
          (B) medical, rehabilitative, or preventive health 
        services; or
          (C) other medical care under laws administered by the 
        Secretary.
    (b) Required Disclosure of Social Security Number.--(1) Any 
individual who applies for or is in receipt of care described 
in paragraph (2) shall, at the time of such application, or 
otherwise when requested by the Secretary, submit to the 
Secretary--
          (A) the individual's social security number; and
          (B) the social security number of any dependent or 
        Department beneficiary on whose behalf, or based upon 
        whom, such individual applies for or is in receipt of 
        such care.
    (2) The care described in this paragraph is--
          (A) hospital, nursing home, or domiciliary care;
          (B) medical, rehabilitative, or preventive health 
        services; or
          (C) other medical care under laws administered by the 
        Secretary.
    (3) This subsection does not require an individual to 
furnish the Secretary with a social security number for any 
individual to whom a social security number has not been 
assigned.
    (c) Failure to Disclose Social Security Number.--(1) The 
Secretary shall deny an individual's application for, or may 
terminate an individual's enrollment in, the system of patient 
enrollment established by the Secretary under section 1705 of 
this title, if such individual does not provide the social 
security number required or requested to be submitted pursuant 
to subsection (b).
    (2) Following a denial or termination under paragraph (1) 
with respect to an individual, the Secretary may, upon receipt 
of the information required or requested under subsection (b), 
approve such individual's application or reinstate such 
individual's enrollment (if otherwise in order), for such 
medical care and services provided on and after the date of 
such receipt of information.
    (d) Construction.--Nothing in this section shall be 
construed as authority to deny medical care and treatment to an 
individual in a medical emergency.

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

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

           *       *       *       *       *       *       *

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

           *       *       *       *       *       *       *

    (3) Hospital care, medical services, and nursing home care 
may not be provided under or by virtue of subsection 
(a)(2)(F)--
          (A) in the case of care for a veteran described in 
        paragraph (1)(A), after December 31, 2002;
          (B) in the case of care for a veteran described in 
        paragraph (1)(C), after December 31, 2002; and
          (C) in the case of care for a veteran described in 
        paragraph (1)(D) who--
                  (i) is discharged or released from the active 
                military, naval, or air service after the date 
                that is five years before the date of the 
                enactment of the National Defense Authorization 
                Act for Fiscal Year 2008 [enacted Jan. 28, 
                2008], after a period of five years beginning 
                on the date of such discharge or release; or
                  (ii) is so discharged or released more than 
                five years before the date of the enactment of 
                that Act and who did not enroll in the patient 
                enrollment system under section 1705 of this 
                title before such date, after a period of three 
                years beginning on the date of the enactment of 
                that Act[; and].
          [(D) in the case of care for a veteran described in 
        paragraph (1)(E), after December 31, 2007.]
    (f)(1) The Secretary may not furnish hospital care or 
nursing home care (except if such care constitutes hospice 
care) under this section to a veteran who is eligible for such 
care under subsection (a)(3) of this section unless the veteran 
agrees to pay to the United States the applicable amount 
determined under paragraph (2) or (4) of this subsection.

           *       *       *       *       *       *       *

    (g)(1) The Secretary may not furnish medical services 
(except if such care constitutes hospice care) under subsection 
(a) of this section (including home health services under 
section 1717 of this title) to a veteran who is eligible for 
hospital care under this chapter by reason of subsection (a)(3) 
of this section unless the veteran agrees to pay to the United 
States in the case of each outpatient visit the applicable 
amount or amounts established by the Secretary by regulation.

           *       *       *       *       *       *       *

SEC. 1710A. REQUIRED NURSING HOME CARE

           *       *       *       *       *       *       *

    (d) The provisions of subsection (a) shall terminate on 
[December 31, 2008] December 31, 2013.

           *       *       *       *       *       *       *

SEC. 1710E. TRAUMATIC BRAIN INJURY: USE OF NON-DEPARTMENT FACILITIES 
                    FOR REHABILITATION

    (a) Cooperative agreements.-- * * *
    (b) Covered Individuals.--The care and services provided 
under subsection (a) shall be made available to an individual--
          (1) who is described in section 1710C(a) of this 
        title; and
          (2)(A) to whom the Secretary is unable to provide 
        such treatment or services at the frequency or for the 
        duration prescribed in such plan; or
          (B) for whom the Secretary determines that it is 
        optimal with respect to the recovery and rehabilitation 
        for such individual.''
    (c) [(b)] Authorities of State protection and advocacy 
systems.-- * * *
    (d) Standards.--The Secretary may not provide treatment or 
services as described in subsection (a) at a non-Department 
facility under such subsection unless such facility maintains 
standards for the provision of such treatment or services 
established by an independent, peer-reviewed organization that 
accredits specialized rehabilitation programs for adults with 
traumatic brain injury.

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

           *       *       *       *       *       *       *

    (c) Upon receipt of a request for counseling under this 
section from any individual who has been discharged or released 
from active military, naval, or air service but who is not 
otherwise eligible for such counseling, the Secretary shall--
          (1) provide referral services to assist such 
        individual, to the maximum extent practicable, in 
        obtaining mental health care and services from sources 
        outside the Department; and
          (2) if pertinent, advise such individual of such 
        individual's rights to apply to the appropriate 
        military, naval, or air service, and to the Department, 
        for review of such individual's discharge or release 
        from such service.

SEC. 1720. TRANSFERS FOR NURSING HOME CARE; ADULT DAY HEALTH CARE

           *       *       *       *       *       *       *

    (g) The Secretary may contract with appropriate entities to 
provide specialized residential care and rehabilitation 
services to a veteran of Operation Enduring Freedom or 
Operation Iraqi Freedom who the Secretary determines suffers 
from a traumatic brain injury, has an accumulation of deficits 
in activities of daily living and instrumental activities of 
daily living, and because of these deficits, would otherwise 
require admission to a nursing home even though such care would 
generally exceed the veteran's nursing needs.

           *       *       *       *       *       *       *

SEC. 1720D. COUNSELING AND TREATMENT FOR SEXUAL TRAUMA

           *       *       *       *       *       *       *

    (d)(1) The Secretary shall implement a program for 
education, training, certification, and continuing medical 
education for mental health professionals to specialize in the 
provision of counseling and care to veterans eligible for 
services under subsection (a). In carrying out the program, the 
Secretary shall ensure that all such mental health 
professionals have been trained in a consistent manner and that 
such training includes principles of evidence-based treatment 
and care for sexual trauma.
    (2) The Secretary shall determine the minimum 
qualifications necessary for mental health professionals 
certified by the program under paragraph (1) to provide 
evidence-based treatment and therapy to veterans eligible for 
services under subsection (a) in facilities of the Department.
    (e) The Secretary shall submit to Congress each year a 
report on the counseling and care and services provided to 
veterans under this section. Each report shall include data for 
the preceding year with respect to the following:
          (1) The number of mental health professionals and 
        primary care providers who have been certified under 
        the program under subsection (d), and the amount and 
        nature of continuing medical education provided under 
        such program to professionals and providers who have 
        been so certified.
          (2) The number of women veterans who received 
        counseling and care and services under subsection (a) 
        from professionals and providers who have been trained 
        or certified under the program under subsection (d).
          (3) The number of training, certification, and 
        continuing medical education programs operating under 
        subsection (d).
          (4) The number of trained full-time equivalent 
        employees required in each facility of the Department 
        to meet the needs of veterans requiring treatment and 
        care for sexual trauma.
          (5) Such other information as the Secretary considers 
        appropriate.
    (f) [(d)] In this section, the term ``sexual harassment'' 
means repeated, unsolicited verbal or physical contact of a 
sexual nature which is threatening in character.

           *       *       *       *       *       *       *

                Subchapter VIII. Health Care of Persons 
                          Other Than Veterans

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

    (a) * * *

           *       *       *       *       *       *       *

    (e) Payment by the Secretary under this section on behalf 
of a covered beneficiary for medical care shall constitute 
payment in full and extinguish any liability on the part of the 
beneficiary for that care.

           *       *       *       *       *       *       *

SEC. 1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING 
                    MATERNITY CARE

    (a) In General.--The Secretary may furnish health care 
services described in subsection (b) to a newborn child of a 
woman veteran who is receiving maternity care furnished by the 
Department for not more than 7 days after the birth of the 
child if the veteran delivered the child in--
          (1) a facility of the Department; or
          (2) another facility pursuant to a Department 
        contract for services relating to such delivery.
    (b) Covered Health Care Services.--Health care services 
described in this subsection are all post-delivery care 
services, including routine care services, that a newborn 
requires.

    CHAPTER 18. BENEFITS FOR CHILDREN OF VIETNAM VETERANS AND OTHER 
                                VETERANS

Subchapter I. Children of Vietnam Veterans Born With Spina Bifida

           *       *       *       *       *       *       *

SEC. 1803. HEALTH CARE

           *       *       *       *       *       *       *

    (b) * * *
    (c) Where payment by the Secretary under this section is 
less than the amount of the charges billed, the health care 
provider or agent of the health care provider may seek payment 
for the difference between the amount billed and the amount 
paid by the Secretary from a responsible third party to the 
extent that the provider or agent thereof would be eligible to 
receive payment for such care or services from such third 
party, but--
          (1) the health care provider or agent for the health 
        care provider may not impose any additional charge on 
        the beneficiary who received the medical care, or the 
        family of such beneficiary, for any service or item for 
        which the Secretary has made payment under this 
        section;
          (2) the total amount of payment a provider or agent 
        of the provider may receive for care and services 
        furnished under this section may not exceed the amount 
        billed to the Secretary; and
          (3) the Secretary, upon request, shall disclose to 
        such third party information received for the purposes 
        of carrying out this section.
    (d) [(c)] For the purposes of this section--

           *       *       *       *       *       *       *

SEC. 1813. HEALTH CARE

           *       *       *       *       *       *       *

    (b) * * *
    (c) Seeking Payment From Third Parties.--Where payment by 
the Secretary under this section is less than the amount of the 
charges billed, the health care provider or agent of the health 
care provider may seek payment for the difference between the 
amount billed and the amount paid by the Secretary from a 
responsible third party to the extent that the health care 
provider or agent thereof would be eligible to receive payment 
for such care or services from such third party, but--
          (1) the health care provider or agent for the health 
        care provider may not impose any additional charge on 
        the beneficiary who received medical care, or the 
        family of such beneficiary, for any service or item for 
        which the Secretary has made payment under this 
        section;
          (2) the total amount of payment a provider or agent 
        of the provider may receive for care and services 
        furnished under this section may not exceed the amount 
        billed to the Secretary; and
          (3) the Secretary, upon request, shall disclose to 
        such third party information received for the purposes 
        of carrying out this section.
    (d) [(c)] Definitions.-- * * *

           *       *       *       *       *       *       *

CHAPTER 20. BENEFITS FOR HOMELESS VETERANS

           *       *       *       *       *       *       *

Subchapter II. Comprehensive Service Programs

           *       *       *       *       *       *       *

SEC. 2013. AUTHORIZATION OF APPROPRIATIONS

    There is authorized to be appropriated to carry out this 
subchapter [$130,000,000] $200,000,000 for fiscal year 2007 and 
each fiscal year thereafter.

           *       *       *       *       *       *       *

PART IV. GENERAL ADMINISTRATIVE PROVISIONS

           *       *       *       *       *       *       *

CHAPTER 51. CLAIMS, EFFECTIVE DATES, AND PAYMENTS

           *       *       *       *       *       *       *

           CHAPTER 55. MINORS, INCOMPETENTS, AND OTHER WARDS

SEC.

5501. COMMITMENT ACTIONS.

           *       *       *       *       *       *       *

5510. ANNUAL REPORT.

5511. CONDITIONS FOR TREATMENT OF VETERANS, THEIR SURVIVING SPOUSES, 
                    AND THEIR CHILDREN AS ADJUDICATED MENTALLY 
                    INCOMPETENT FOR CERTAIN PURPOSES.

           *       *       *       *       *       *       *

SEC. 5501. COMMITMENT ACTIONS

           *       *       *       *       *       *       *

SEC. 5510. ANNUAL REPORT

           *       *       *       *       *       *       *

SEC. 5511. CONDITIONS FOR TREATMENT OF VETERANS, SURVIVING SPOUSES, AND 
                    CHILDREN AS ADJUDICATED MENTALLY INCOMPETENT FOR 
                    CERTAIN PURPOSES

    In any case arising out of the administration by the 
Secretary of laws and benefits under this title, a veteran, 
surviving spouse, or child who is mentally incapacitated, 
deemed mentally incompetent, or experiencing an extended loss 
of consciousness shall not be considered adjudicated as a 
mental defective under subsection (d)(4) or (g)(4) of section 
922 of title 18 without the order or finding of a judge, 
magistrate, or other judicial authority of competent 
jurisdiction that such veteran, surviving spouse, or child is a 
danger to him- or herself or others.

           *       *       *       *       *       *       *

                 CHAPTER 57. RECORDS AND INVESTIGATIONS

                         Subchapter I. Records

SEC. 5701. CONFIDENTIAL NATURE OF CLAIMS

           *       *       *       *       *       *       *

    (l) Under regulations that the Secretary shall prescribe, 
the Secretary may disclose the name or address, or both, of any 
individual who is a present or former member of the Armed 
Forces, or who is a dependent of a present or former member of 
the Armed Forces, to a third party, as defined in section 
1729(i)(3)(D) of this title, in order to enable the Secretary 
to collect reasonable charges under section 1729(a)(2)(E) of 
this title for care or services provided for a non-service-
connected disability.

           *       *       *       *       *       *       *

             PART V. BOARDS, ADMINISTRATIONS, AND SERVICES

CHAPTER 73. VETERANS HEALTH ADMINISTRATION-ORGANIZATION AND FUNCTIONS

           *       *       *       *       *       *       *

          SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION

SEC.

7311. QUALITY ASSURANCE.

7311A. QUALITY ASSURANCE OFFICERS.

           *       *       *       *       *       *       *

SUBCHAPTER IV. RESEARCH CORPORATIONS

           *       *       *       *       *       *       *

7365. [7364A.] COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT CLAIMS 
                    LAWS.

[7365. APPLICABLE STATE LAW]

           *       *       *       *       *       *       *

[7368. EXPIRATION OF AUTHORITY.]

           *       *       *       *       *       *       *

          Subchapter II. General Authority and Administration

SEC. 7311. QUALITY ASSURANCE

           *       *       *       *       *       *       *

    (b)(1) * * *

           *       *       *       *       *       *       *

    (4) As part of the quality assurance program, the Under 
Secretary for Health shall establish mechanisms through which 
employees of Veterans Health Administration facilities may 
submit reports, on a confidential basis, on matters relating to 
quality of care in Veterans Health Administration facilities to 
the quality assurance officers of such facilities under section 
7311A(b) of this title. The mechanisms shall provide for the 
prompt and thorough review of any reports so submitted by the 
receiving officials.

           *       *       *       *       *       *       *

SEC. 7311A. QUALITY ASSURANCE OFFICERS

    (a) National Quality Assurance Officer.--(1) The Under 
Secretary for Health shall designate an official of the 
Veterans Health Administration to act as the principal quality 
assurance officer for the quality assurance program required by 
section 7311 of this title. The official so designated may be 
known as the ``National Quality Assurance Officer of the 
Veterans Health Administration'' (in this section referred to 
as the ``National Quality Assurance Officer'').
    (2) The National Quality Assurance Officer shall report 
directly to the Under Secretary for Health in the discharge of 
responsibilities and duties of the Officer under this section.
    (3) The National Quality Assurance Officer shall be the 
official within the Veterans Health Administration who is 
principally responsible for the quality assurance program 
referred to in paragraph (1). In carrying out that 
responsibility, the Officer shall be responsible for--
          (A) establishing and enforcing the requirements of 
        that program; and
          (B) carrying out such other responsibilities and 
        duties relating to quality assurance in the Veterans 
        Health Administration as the Under Secretary for Health 
        shall specify.
    (4) The requirements under paragraph (3) shall include 
requirements regarding the following:
          (A) A confidential system for the submittal of 
        reports by Veterans Health Administration personnel 
        regarding quality assurance at Department facilities.
          (B) Mechanisms for the peer review of the actions of 
        individuals appointed in the Veterans Health 
        Administration in the position of physician.
          (C) Mechanisms for the accountability of the facility 
        director and chief medical officer of each Veterans 
        Health Administration medical facility for the actions 
        of physicians in such facility.
    (b) Quality Assurance Officers for VISNs.--(1) The Regional 
Director of each Veterans Integrated Services Network (VISN) 
shall appoint an official of the Network to act as the quality 
assurance officer of the Network.
    (2) The quality assurance officer for a Veterans Integrated 
Services Network shall report to the Regional Director of the 
Veterans Integrated Services Network, and to the National 
Quality Assurance Officer, regarding the discharge of the 
responsibilities and duties of the officer under this section.
    (3) The quality assurance officer for a Veterans Integrated 
Services Network shall--
          (A) direct the quality assurance office in the 
        Network; and
          (B) coordinate, monitor, and oversee the quality 
        assurance programs and activities of the Administration 
        medical facilities in the Network in order to ensure 
        the thorough and uniform discharge of quality assurance 
        requirements under such programs and activities 
        throughout such facilities.
    (c) Quality Assurance Officers for Medical Facilities.--(1) 
The director of each Veterans Health Administration medical 
facility shall appoint a quality assurance officer for that 
facility.
    (2) The official appointed as a quality assurance officer 
for a facility under this subsection shall be a practicing 
physician at the facility. If the official appointed as quality 
assurance officer for a facility has other clinical or 
administrative duties, the director of the facility shall 
ensure that those duties are sufficiently limited in scope so 
as to ensure that those duties do not prevent the officer from 
effectively discharging the responsibilities and duties of 
quality assurance officer at the facility.
    (3) The quality assurance officer for a facility shall 
report directly to the director of the facility, and to the 
quality assurance officer of the Veterans Integrated Services 
Network in which the facility is located, regarding the 
discharge of the responsibilities and duties of the quality 
assurance officer under this section.
    (4) The quality assurance officer for a facility shall be 
responsible for designing, disseminating, and implementing 
quality assurance programs and activities for the facility that 
meet the requirements established by the National Quality 
Assurance Officer under subsection (a).

           *       *       *       *       *       *       *

              Subchapter III. Protection of Patient Rights

SEC. 7332. CONFIDENTIALITY OF CERTAIN MEDICAL RECORDS

           *       *       *       *       *       *       *

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

           *       *       *       *       *       *       *

          (F)(i) To a representative of a patient who lacks 
        decision-making capacity, when a practitioner deems the 
        content of the given record necessary for that 
        representative to make an informed decision regarding 
        the patient's treatment.
          (ii) In this subparagraph, the term 
        ``representative'' means an individual, organization, 
        or other body authorized under section 7331 of this 
        title and its implementing regulations to give informed 
        consent on behalf of a patient who lacks decision-
        making capacity.
          (G) To a third party, as defined in section 
        1729(i)(3)(D) of this title, to collect reasonable 
        charges under section 1729(a)(2)(E) of this title for 
        care or services provided for a non-service-connected 
        disability.

           *       *       *       *       *       *       *

                  Subchapter IV. Research Corporations

SEC. 7361. AUTHORITY TO ESTABLISH; STATUS

    (a) The Secretary may authorize the establishment at any 
Department medical center of a nonprofit corporation to provide 
a flexible funding mechanism for the conduct of approved 
research and education at the medical center. [Except as 
otherwise required in this subchapter or under regulations 
prescribed by the Secretary, any such corporation, and its 
directors and employees, shall be required to comply only with 
those Federal laws, regulations, and executive orders and 
directives which apply generally to private nonprofit 
corporations.] Such a corporation may be established to 
facilitate either research or education or both research and 
education.
    (b)(1) Subject to paragraph (2), a corporation established 
under this subchapter may facilitate the conduct of research, 
education, or both at more than one medical center. Such a 
corporation shall be known as a ``multi-medical center research 
corporation''.
    (2) The board of directors of a multi-medical center 
research corporation under this subsection shall include the 
official at each Department medical center concerned who is, or 
who carries out the responsibilities of, the medical center 
director of such center as specified in section 
7363(a)(1)(A)(i) of this title.
    (3) In facilitating the conduct of research, education, or 
both at more than one Department medical center under this 
subchapter, a multi-medical center research corporation may 
administer receipts and expenditures relating to such research, 
education, or both, as applicable, performed at the Department 
medical centers concerned.
    (c) Any corporation established under this subchapter shall 
be established in accordance with the nonprofit corporation 
laws of the State in which the applicable Department medical 
center is located and shall, to the extent not inconsistent 
with any Federal law, be subject to the laws of such State. In 
the case of any multi-medical center research corporation that 
facilitates the conduct of research, education, or both at 
Department medical centers located in different States, the 
corporation shall be established in accordance with the 
nonprofit corporation laws of the State in which one of such 
Department medical centers is located.
    (d)(1) Except as otherwise provided in this subchapter or 
under regulations prescribed by the Secretary, any corporation 
established under this subchapter, and its officers, directors, 
and employees, shall be required to comply only with those 
Federal laws, regulations, and executive orders and directives 
that apply generally to private nonprofit corporations.
    (2) A corporation under this subchapter is not--
          (A) owned or controlled by the United States; or
          (B) an agency or instrumentality of the United 
        States.
    (e) [(b)] If by the end of the four-year period beginning 
on the date of the establishment of a corporation under this 
subchapter the corporation is not recognized as an entity the 
income of which is exempt from taxation under section 501(c)(3) 
of the Internal Revenue Code of 1986, the Secretary shall 
dissolve the corporation.
    (f) A corporation established under this subchapter may act 
as a multi-medical center research corporation under this 
subchapter in accordance with subsection (b) if--
          (1) the board of directors of the corporation 
        approves a resolution permitting facilitation by the 
        corporation of the conduct of research, education, or 
        both at the other Department medical center or medical 
        centers concerned; and
          (2) the Secretary approves the resolution of the 
        corporation under paragraph (1).

SEC. 7362. PURPOSE OF CORPORATIONS

    (a) [Any corporation established under this subchapter 
shall be established solely to facilitate] A corporation 
established under this subchapter shall be established to 
provide a flexible funding mechanism for the conduct of 
approved research and education at one or more Department 
medical centers and to facilitate functions related to the 
conduct of research as described in section 7303(a) of this 
title and education and training as described in sections 7302, 
7471, 8154, and 1701(6)(B) of this title in conjunction with 
the applicable Department medical center or centers. [Any funds 
received by the Secretary for the conduct of research or 
education at the medical center other than funds appropriated 
to the Department may be transferred to and administered by the 
corporation for these purposes.]
    (b) For purposes of this section, the term [``education and 
training''] ``education'' includes education and training and 
means the following:
          (1) In the case of employees of the Veterans Health 
        Administration, such term means work-related 
        instruction or other learning experiences to--
                  (A) improve performance of current duties;
                  (B) assist employees in maintaining or 
                gaining specialized proficiencies; and
                  (C) expand understanding of advances and 
                changes in patient care, technology, and health 
                care administration.
          [Such term includes (in the case of such employees) 
        education and training conducted as part of a residency 
        or other program designed to prepare an individual for 
        an occupation or profession.]
          (2) In the case of veterans under the care of the 
        Veterans Health Administration, such term means 
        instruction or other learning experiences related to 
        improving and maintaining the health of veterans [to 
        patients and to the families] and includes education 
        and training for patients and families and guardians of 
        patients.

SEC. 7363. BOARD OF DIRECTORS; EXECUTIVE DIRECTOR

    (a) The Secretary shall provide for the appointment of a 
board of directors for any corporation established under this 
subchapter. The board shall include--
          (1) [the director of the medical center, the chief of 
        staff of the medical center, and as appropriate, the 
        assistant chief of staff for research for the medical 
        center and the assistant chief of staff for education 
        for the medical center, or, in the case of a facility 
        at which such positions do not exist, those officials 
        who are responsible for carrying out the 
        responsibilities of the medical center director, chief 
        of staff, and, as appropriate, the assistant chief of 
        staff for research and the assistant chief of staff for 
        education; and] with respect to the Department medical 
        center--
                  (A)(i) the director (or directors of each 
                Department medical center, in the case of a 
                multi-medical center research corporation);
                  (ii) the chief of staff; and
                  (iii) as appropriate for the activities of 
                such corporation, the associate chief of staff 
                for research and the associate chief of staff 
                for education; or
                  (B) in the case of a Department medical 
                center at which one or more of the positions 
                referred to in subparagraph (A) do not exist, 
                the official or officials who are responsible 
                for carrying out the responsibilities of such 
                position or positions at the Department medical 
                center; and
          (2) subject to subsection (c), not less than two 
        members who are not officers or employees of the 
        Federal Government [and who are familiar with issues 
        involving medical and scientific research or education, 
        as appropriate] and who have backgrounds, or business, 
        legal, financial, medical, or scientific expertise, of 
        benefit to the operations of the corporation.
    (b) * * *
    (c) An individual appointed under subsection (a)(2) to the 
board of directors of a corporation established under this 
subchapter may not be affiliated with[, employed by, or have 
any other financial relationship with] or employed by any 
entity that is a source of funding for research or education by 
the Department unless that source of funding is a governmental 
entity or an entity the income of which is exempt from taxation 
under the Internal Revenue Code of 1986.

SEC. 7364. GENERAL POWERS

    [(a) A corporation established under this subchapter may--
          [(1) accept gifts and grants from, and enter into 
        contracts with, individuals and public and private 
        entities solely to carry out the purposes of this 
        subchapter; and
          [(2) employ such employees as it considers necessary 
        for such purposes and fix the compensation of such 
        employees.
    [(b) A corporation established under this subchapter may 
not spend funds for a research project unless the project is 
approved in accordance with procedures prescribed by the Under 
Secretary for Health for research carried out with Department 
funds. Such procedures shall include a peer review process.
    [(c)(1) A corporation established under this subchapter may 
not spend funds for an education activity unless the activity 
is approved in accordance with procedures prescribed by the 
Under Secretary for Health.
    [(2) The Under Secretary for Health shall prescribe 
policies and procedures to guide the expenditure of funds by 
corporations under paragraph (1) consistent with the purpose of 
such corporations as flexible funding mechanisms.]
    (a)(1) A corporation established under this subchapter may, 
solely to carry out the purposes of this subchapter--
          (A) accept, administer, retain, and spend funds 
        derived from gifts, contributions, grants, fees, 
        reimbursements, and bequests from individuals and 
        public and private entities;
          (B) enter into contracts and agreements with 
        individuals and public and private entities;
          (C) subject to paragraph (2), set fees for education 
        and training facilitated under section 7362 of this 
        title, and receive, retain, administer, and spend funds 
        in furtherance of such education and training;
          (D) reimburse amounts to the appropriation account of 
        the Department for the Office of General Counsel for 
        any expenses of that Office in providing legal services 
        attributable to research and education agreements under 
        this subchapter; and
          (E) employ such employees as the corporation 
        considers necessary for such purposes and fix the 
        compensation of such employees.
    (2) Fees charged under paragraph (1)(C) for education and 
training described in that paragraph to individuals who are 
officers or employees of the Department may not be paid for by 
any funds appropriated to the Department.
    (3) Amounts reimbursed to the Office of General Counsel 
under paragraph (1)(D) shall be available for use by the Office 
of the General Counsel only for staff and training, and related 
travel, for the provision of legal services described in that 
paragraph.
    (b)(1) Except as provided in paragraph (2), any funds 
received by the Secretary for the conduct of research or 
education at a Department medical center or centers, other than 
funds appropriated to the Department, may be transferred to and 
administered by a corporation established under this subchapter 
for such purposes.
    (2) A Department medical center may reimburse the 
corporation for all or a portion of the pay, benefits, or both 
of an employee of the corporation who is assigned to the 
Department medical center if the assignment is carried out 
pursuant to subchapter VI of chapter 33 of title 5.
    (c) Except for reasonable and usual preliminary costs for 
project planning before its approval, a corporation established 
under this subchapter may not spend funds for a research 
project unless the project is approved in accordance with 
procedures prescribed by the Under Secretary for Health for 
research carried out with Department funds. Such procedures 
shall include a scientific review process.
    (d) Except for reasonable and usual preliminary costs for 
activity planning before its approval, a corporation 
established under this subchapter may not spend funds for an 
education activity unless the activity is approved in 
accordance with procedures prescribed by the Under Secretary 
for Health.
    (e) The Under Secretary for Health may prescribe policies 
and procedures to guide the spending of funds by corporations 
established under this subchapter that are consistent with the 
purpose of such corporations as flexible funding mechanisms and 
with Federal and State laws and regulations, and executive 
orders, circulars, and directives that apply generally to the 
receipt and expenditure of funds by nonprofit organizations 
exempt from taxation under section 501(c)(3) of the Internal 
Revenue Code of 1986.

SEC. 7365. [7364A.] COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT 
                    CLAIMS LAWS

           *       *       *       *       *       *       *

[SEC. 7365. APPLICABLE STATE LAW

    [Any corporation established under this subchapter shall be 
established in accordance with the nonprofit corporation laws 
of the State in which the applicable medical center is located 
and shall, to the extent not inconsistent with any Federal law, 
be subject to the laws of such State.]

SEC. 7366. ACCOUNTABILITY AND OVERSIGHT

    (a) * * *
    [(b) Each such corporation shall submit to the Secretary an 
annual report providing a detailed statement of its operations, 
activities, and accomplishments during that year. A corporation 
with revenues in excess of $300,000 for any year shall obtain 
an audit of the corporation for that year. A corporation with 
annual revenues between $10,000 and $300,000 shall obtain an 
independent audit of the corporation at least once every three 
years. Any audit under the preceding sentences shall be 
performed by an independent auditor. The corporation shall 
include the most recent such audit in the corporation's report 
to the Secretary for that year.]
    (b)(1) Each corporation shall submit to the Secretary each 
year a report providing a detailed statement of the operations, 
activities, and accomplishments of the corporation during that 
year.
    (2)(A) A corporation with revenues in excess of $300,000 
for any year shall obtain an audit of the corporation for that 
year.
    (B) A corporation with annual revenues between $10,000 and 
$300,000 shall obtain an audit of the corporation at least once 
every three years.
    (C) Any audit under this paragraph shall be performed by an 
independent auditor.
    (3) The corporation shall include in each report to the 
Secretary under paragraph (1) the following:
          (A) The most recent audit of the corporation under 
        paragraph (2).
          (B) The most recent Internal Revenue Service Form 990 
        ``Return of Organization Exempt from Income Tax'' or 
        equivalent and the applicable schedules under such 
        form.
    (c)(1) Each member of the board of directors of a 
corporation established under this subchapter, each officer and 
each employee of such a corporation[, and each employee of the 
Department who is involved in the functions of the corporation 
during any year] shall be subject to Federal [laws and] 
regulations applicable to Federal employees with respect to 
conflicts of interest in the performance of official functions.
    (2) Each corporation established under this subchapter 
shall each year submit to the Secretary a statement signed by 
the executive director of the corporation verifying that each 
officer, director and employee has certified awareness of the 
laws and regulations referred to in paragraph (1) and of the 
consequences of violations of those [laws and] regulations [in 
the same manner as Federal employees are required to so 
certify].
    (d) * * *

           *       *       *       *       *       *       *

          (3) * * *

           *       *       *       *       *       *       *

                  (C) if the amount expended with respect to 
                any payee exceeded [$35,000] $50,000, 
                information that identifies the payee.

[SEC. 7368. EXPIRATION OF AUTHORITY

    [No corporation may be established under this subchapter 
after December 31, 2008.]

         CHAPTER 74. VETERANS HEALTH ADMINISTRATION--PERSONNEL

                       SUBCHAPTER I. APPOINTMENTS

SEC.

7401. * * *

7402. * * *

7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS.

           *       *       *       *       *       *       *

SUBCHAPTER IV. PAY FOR NURSES AND OTHER HEALTH-CARE PERSONNEL

           *       *       *       *       *       *       *

7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY.

           *       *       *       *       *       *       *

Subchapter I. Appointments

           *       *       *       *       *       *       *

SEC. 7401. APPOINTMENTS IN VETERANS HEALTH ADMINISTRATION

           *       *       *       *       *       *       *

          (3) Audiologists, speech pathologists, and 
        audiologist-speech pathologists, biomedical engineers, 
        certified or registered respiratory therapists, 
        dietitians, licensed physical therapists, licensed 
        practical or vocational nurses, nurse assistants, 
        medical instrument technicians, medical records 
        administrators or specialists, medical records 
        technicians, medical technologists, dental hygienists, 
        dental assistants, nuclear medicine technologists, 
        occupational therapists, occupational therapy 
        assistants, kinesiotherapists, orthotist-prosthetists, 
        pharmacists, pharmacy technicians, physical therapy 
        assistants, prosthetic representatives, psychologists, 
        diagnostic radiologic technologists, therapeutic 
        radiologic technologists, social workers, marriage and 
        family therapists, licensed professional mental health 
        counselors, blind rehabilitation specialists, [and 
        blind rehabilitation outpatient specialists] blind 
        rehabilitation outpatient specialists, and such other 
        classes of health care occupations as the Secretary 
        considers necessary for the recruitment and retention 
        needs of the Department subject to the following 
        requirements:
                  (A) Not later than 45 days before the 
                Secretary appoints any personnel for a class of 
                health care occupations that is not 
                specifically listed in this paragraph, the 
                Secretary shall submit to the Committee on 
                Veterans' Affairs of the Senate, the Committee 
                on Veterans' Affairs of the House of 
                Representatives, and the Office of Management 
                and Budget notice of such appointment.
                  (B) Before submitting notice under 
                subparagraph (A), the Secretary shall solicit 
                comments from any labor organization 
                representing employees in such class and 
                include such comments in such notice.

           *       *       *       *       *       *       *

SEC. 7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS

    (a) In General.--The Secretary shall, acting through the 
Under Secretary for Health, prescribe standards to be met by 
individuals in order to qualify for appointment in the Veterans 
Health Administration in the position of physician and to 
practice as a physician in medical facilities of the 
Administration. The standards shall incorporate the 
requirements of this section.
    (b) Disclosure of Certain Information Before Appointment.--
Each individual seeking appointment in the Veterans Health 
Administration in the position of physician shall do the 
following:
          (1) Provide the Secretary a full and complete 
        explanation of the following:
                  (A) Each lawsuit, civil action, or other 
                claim (whether open or closed) brought against 
                the individual for medical malpractice or 
                negligence (other than a lawsuit, action, or 
                claim closed without any judgment against or 
                payment by or on behalf of the individual).
                  (B) Each payment made by or on behalf of the 
                individual to settle any lawsuit, action, or 
                claim covered by subparagraph (A).
                  (C) Each investigation or disciplinary action 
                taken against the individual relating to the 
                individual's performance as a physician.
          (2) Submit a written request and authorization to the 
        State licensing board of each State in which the 
        individual holds or has held a license to practice 
        medicine to disclose to the Secretary any information 
        in the records of such State on the following:
                  (A) Each lawsuit, civil action, or other 
                claim brought against the individual for 
                medical malpractice or negligence covered by 
                paragraph (1)(A) that occurred in such State.
                  (B) Each payment made by or on behalf of the 
                individual to settle any lawsuit, action, or 
                claim covered by subparagraph (A).
                  (C) Each medical malpractice judgment against 
                the individual by the courts or administrative 
                agencies or bodies of such State.
                  (D) Each disciplinary action taken or under 
                consideration against the individual by an 
                administrative agency or body of such State.
                  (E) Any change in the status of the license 
                to practice medicine issued the individual by 
                such State, including any voluntary or 
                nondisciplinary surrendering of such license by 
                the individual.
                  (F) Any open investigation of the individual 
                by an administrative agency or body of such 
                State, or any outstanding allegation against 
                the individual before such an administrative 
                agency or body.
                  (G) Any written notification by the State to 
                the individual of potential termination of a 
                license for cause or otherwise.
    (c) Disclosure of Certain Information Following 
Appointment.--(1) Each individual appointed in the Veterans 
Health Administration in the position of physician after the 
date of the enactment of this section shall, as a condition of 
service under the appointment, disclose to the Secretary, not 
later than 30 days after the occurrence of such event, the 
following:
          (A) A judgment against the individual for medical 
        malpractice or negligence.
          (B) A payment made by or on behalf of the individual 
        to settle any lawsuit, action, or claim disclosed under 
        paragraph (1) or (2) of subsection (b).
          (C) Any disposition of or material change in a matter 
        disclosed under paragraph (1) or (2) of subsection (b).
    (2) Each individual appointed in the Veterans Health 
Administration in the position of physician as of the date of 
the enactment of this section shall do the following:
          (A) Not later than the end of the 60-day period 
        beginning on the date of the enactment of that Act and 
        as a condition of service under the appointment after 
        the end of that period, submit the request and 
        authorization described in subsection (b)(2).
          (B) Agree, as a condition of service under the 
        appointment, to disclose to the Secretary, not later 
        than 30 days after the occurrence of such event, the 
        following:
                  (i) A judgment against the individual for 
                medical malpractice or negligence.
                  (ii) A payment made by or on behalf of the 
                individual to settle any lawsuit, action, or 
                claim disclosed pursuant to subparagraph (A) or 
                under this subparagraph.
                  (iii) Any disposition of or material change 
                in a matter disclosed pursuant to subparagraph 
                (A) or under this subparagraph.
    (3) Each individual appointed in the Veterans Health 
Administration in the position of physician shall, as part of 
the biennial review of the performance of the physician under 
the appointment, submit the request and authorization described 
in subsection (b)(2). The requirement of this paragraph is in 
addition to the requirements of paragraph (1) or (2), as 
applicable.
    (d) Investigation of Disclosed Matters.--(1) The Director 
of the Veterans Integrated Services Network (VISN) in which an 
individual is seeking appointment in the Veterans Health 
Administration in the position of physician shall perform an 
investigation (in such manner as the standards required by this 
section shall specify) of each matter disclosed under 
subsection (b) with respect to the individual.
    (2) The Director of the Veterans Integrated Services 
Network in which an individual is appointed in the Veterans 
Health Administration in the position of physician shall 
perform an investigation (in a manner so specified) of each 
matter disclosed under subsection (c) with respect to the 
individual.
    (3) The results of each investigation performed under this 
subsection shall be fully documented.
    (e) Approval of Appointments by Directors of VISNs.--(1) An 
individual may not be appointed in the Veterans Health 
Administration in the position of physician without the 
approval of the Director of the Veterans Integrated Services 
Network in which the individual will first serve under the 
appointment.
    (2) In approving the appointment under this subsection of 
an individual for whom any matters have been disclosed under 
subsection (b), a Director shall--
          (A) certify in writing the completion of the 
        performance of the investigation under subsection 
        (d)(1) of each such matter, including the results of 
        such investigation; and
          (B) provide a written justification why any matters 
        raised in the course of such investigation do not 
        disqualify the individual from appointment.
    (f) Enrollment of Physicians With Practice Privileges in 
Proactive Disclosure Service.--Each medical facility of the 
Department at which physicians are extended the privileges of 
practice shall enroll each physician extended such privileges 
in the Proactive Disclosure Service of the National 
Practitioners Data Base.
    (g) Encouraging Hiring of Physicians With Board 
Certification.--(1) The Secretary shall, for each performance 
contract with a Director of a Veterans Integrated Services 
Network (VISN), include in such contract a provision that 
encourages such director to hire physicians who are board 
eligible or board certified in the specialty in which the 
physicians will practice.
    (2) The Secretary may determine the nature and manner of 
the provision described in paragraph (1).

SEC. 7403. PERIOD OF APPOINTMENTS; PROMOTIONS

           *       *       *       *       *       *       *

    (b)(1) [Appointments] Except as otherwise provided in this 
subsection, appointments described in subsection (a) shall be 
for a probationary period of two years.
    (2) An appointment of a registered nurse under this 
chapter, whether on a full-time basis or a part-time basis, 
shall be for a probationary period ending upon the completion 
by the person so appointed of a number of hours of work 
pursuant to such appointment that the Secretary considers 
appropriate for such appointment but not more than 4,180 hours.
    (3) An appointment described in subsection (a) on a part-
time basis of a person who has previously served on a full-time 
basis for the probationary period for the position concerned 
shall be without a probationary period.
    (4) [(2)] The record of each person serving under such an 
appointment in the Medical, Dental, and Nursing Services shall 
be reviewed from time to time by a board, appointed in 
accordance with regulations of the Secretary. If such a board 
finds that such person is not fully qualified and satisfactory, 
such person shall be separated from the service.

           *       *       *       *       *       *       *

SEC. 7404. GRADES AND PAY SCALES

    (a)(1) The annual [The annual] rates or ranges of rates of 
basic pay for positions provided in section 7306 of this title 
shall be prescribed from time to time by Executive order as 
authorized by chapter 53 of title 5 or as otherwise authorized 
by law.
    (2) The pay [The pay] of physicians and dentists serving in 
positions to which an Executive order applies [under the 
preceding sentence] under paragraph (1) shall be determined 
under subchapter III of this chapter instead of such Executive 
order.
    (3) The minimum rate of basic pay for a position to which 
an Executive order applies under paragraph (1) and is not 
described by paragraph (2) may not be less than the lowest rate 
of basic pay payable for a Senior Executive Service position 
under section 5382 of title 5.

           *       *       *       *       *       *       *

SEC. 7405. TEMPORARY FULL-TIME APPOINTMENTS, PART-TIME APPOINTMENTS, 
                    AND WITHOUT-COMPENSATION APPOINTMENTS

           *       *       *       *       *       *       *

    (g)(1) Employment of a registered nurse on a temporary 
part-time basis under subsection (a)(1) shall be for a 
probationary period ending upon the completion by the person so 
employed of a number of hours of work pursuant to such 
employment that the Secretary considers appropriate for such 
employment but not more than 4,180 hours.
    (2) Upon completion by a registered nurse of the 
probationary period described in paragraph (1)--
          (A) the employment of such nurse shall--
                  (i) no longer be considered temporary; and
                  (ii) be considered an appointment described 
                in section 7403(a) of this title; and
          (B) the nurse shall be considered to have served the 
        probationary period required by section 7403(b).
    (h)(1) The Secretary may waive the application of sections 
8344 and 8468 of title 5 (relating to annuities and pay on 
reemployment) or any other similar provision of law under a 
Government retirement system on a case-by-case basis for an 
annuitant reemployed on a temporary basis under the authority 
of subsection (a) in a position described under paragraph (1) 
of that subsection.
    (2) An annuitant to whom a waiver under paragraph (1) is in 
effect shall not be considered an employee for purposes of any 
Government retirement system.
    (3) An annuitant to whom a waiver under paragraph (1) is in 
effect shall be subject to the provisions of chapter 71 of 
title 5 (including all labor authority and labor representative 
collective bargaining agreements) applicable to the position to 
which appointed.
    (4) In this subsection:
          (A) The term ``annuitant'' means an annuitant under a 
        Government retirement system.
          (B) The term ``employee'' has the meaning under 
        section 2105 of title 5.
          (C) The term ``Government retirement system'' means a 
        retirement system established by law for employees of 
        the Government of the United States.

           *       *       *       *       *       *       *

SEC. 7410. ADDITIONAL PAY AUTHORITIES

    (a) In General.--The Secretary may [The Secretary may] 
authorize the Under Secretary for Health to pay advance 
payments, recruitment or relocation bonuses, and retention 
allowances to the personnel described in paragraph (1) of 
section 7401 of this title, or interview expenses to candidates 
for appointment as such personnel, in the same manner, and 
subject to the same limitations, as in the case of the 
authority provided under sections 5524a, 5706b, 5753, and 5754 
of title 5.
    (b) Comparability Pay for Appointees to the Office of the 
Under Secretary for Health.--(1) The Secretary may authorize 
the Under Secretary for Health to provide comparability pay of 
not more than $100,000 per year to individuals of the Veterans 
Health Administration appointed under section 7306 of this 
title who are not physicians or dentists and to individuals who 
are appointed to Senior Executive Service positions (as such 
term is defined in section 3132(a) of title 5) to achieve 
annual pay levels for such individuals that are comparable with 
annual pay levels of individuals with similar positions in the 
private sector.
    (2) Comparability pay under paragraph (1) for an individual 
is in addition to all other pay, awards, and performance 
bonuses paid to such individual under this title.
    (3) Except as provided in paragraph (4), comparability pay 
under paragraph (1) for an individual shall be considered basic 
pay for all purposes, including retirement benefits under 
chapters 83 and 84 of title 5, and other benefits.
    (4) Comparability pay under paragraph (1) for an individual 
shall not be considered basic pay for purposes of adverse 
actions under subchapter V of this chapter.
    (5) Comparability pay under paragraph (1) may not be 
awarded to an individual in an amount that would result in an 
aggregate amount of pay (including bonuses and awards) received 
by such individual in a year under this title that is greater 
than the annual pay of the President.
    (c) Special Incentive Pay for Department Pharmacist 
Executives.--(1) In order to recruit and retain highly 
qualified Department pharmacist executives, the Secretary may 
authorize the Under Secretary for Health to pay special 
incentive pay of not more than $40,000 per year to an 
individual of the Veterans Health Administration who is a 
pharmacist executive.
    (2) In determining whether and how much special pay to 
provide to such individual, the Under Secretary shall consider 
the following:
          (A) The grade and step of the position of the 
        individual.
          (B) The scope and complexity of the position of the 
        individual.
          (C) The personal qualifications of the individual.
          (D) The characteristics of the labor market 
        concerned.
          (E) Such other factors as the Secretary considers 
        appropriate.
    (3) Special incentive pay under paragraph (1) for an 
individual is in addition to all other pay (including basic 
pay) and allowances to which the individual is entitled.
    (4) Except as provided in paragraph (5), special incentive 
pay under paragraph (1) for an individual shall be considered 
basic pay for all purposes, including retirement benefits under 
chapters 83 and 84 of title 5, and other benefits.
    (5) Special incentive pay under paragraph (1) for an 
individual shall not be considered basic pay for purposes of 
adverse actions under subchapter V of this chapter.
    (6) Special incentive pay under paragraph (1) may not be 
awarded to an individual in an amount that would result in an 
aggregate amount of pay (including bonuses and awards) received 
by such individual in a year under this title that is greater 
than the annual pay of the President.

           *       *       *       *       *       *       *

            Subchapter III. Pay for Physicians and Dentists

SEC. 7431. PAY

           *       *       *       *       *       *       *

    (b) * * *

           *       *       *       *       *       *       *

          (5) The non-foreign cost of living adjustment 
        allowance authorized under section 5941 of title 5 for 
        physicians and dentists whose pay is set under this 
        section shall be determined as a percentage of base pay 
        only.

           *       *       *       *       *       *       *

    (c) * * *

           *       *       *       *       *       *       *

          (4)(A) * * *
          (B)(i) In determining the amount of the market pay 
        for a particular physician or dentist under this 
        subsection, and in determining a tier (if any) to apply 
        to a physician or dentist under subsection (e)(1)(B), 
        the Secretary shall consult with and consider the 
        recommendations of an appropriate panel or board 
        composed of physicians or dentists (as applicable). The 
        Secretary may exempt physicians and dentists occupying 
        administrative or executive leadership positions from 
        the requirements of the previous sentence.

           *       *       *       *       *       *       *

          (7) No adjustment of the amount of market pay of a 
        physician or dentist under paragraph (6) may result in 
        a reduction of the amount of market pay of the 
        physician or dentist while in the same position or 
        assignment at the medical facility of the Department 
        [concerned.] concerned, unless there is a change in 
        board certification or reduction of privileges.

           *       *       *       *       *       *       *

     Subchapter IV. Pay for Nurses and Other Health-Care Personnel

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

           *       *       *       *       *       *       *

    (c)(1) * * *
    (2) The maximum rate of basic pay for any grade for a 
covered position may not exceed the maximum rate of basic pay 
established for positions in [level V] level IV of the 
Executive Schedule under section 5316 of title 5. The maximum 
rate of basic pay for a grade for the position of certified 
registered nurse anesthetist pursuant to an adjustment under 
subsection (d) may exceed the maximum rate otherwise provided 
in the preceding sentence.

           *       *       *       *       *       *       *

    (d)(3)(A) * * *

           *       *       *       *       *       *       *

    (F) The Under Secretary for Health shall provide 
appropriate education, training, and support to directors of 
Department health care facilities in the conduct and use of 
surveys, including the use of third-party surveys, under this 
paragraph.

           *       *       *       *       *       *       *

    (e)(4) * * *

           *       *       *       *       *       *       *

          (D) In any case in which the director conducts such a 
        wage survey during the period covered by the report and 
        makes adjustment in rates of basic pay applicable to 
        one or more covered positions at the facility, 
        information on the methodology used in making such 
        adjustment or adjustments.
          (E) [(D)] In any case in which the director, after 
        finding that there is, or is likely to be, in 
        accordance with criteria established by the Secretary, 
        a significant pay-related staffing problem at that 
        facility for any covered position, determines not to 
        conduct a wage survey with respect to that position, a 
        statement of the reasons why the director did not 
        conduct such a survey.

           *       *       *       *       *       *       *

    (e)(5) * * *
    (6)(A) Upon the request of an individual described in 
subparagraph (B) for a report provided under paragraph (4) with 
respect to a Department health-care facility, the Under 
Secretary for Health or the director of such facility shall 
provide to the individual the most current report for such 
facility provided under such paragraph.
    (B) An individual described in this subparagraph is--
          (i) an individual in a covered position at a 
        Department health-care facility; or
          (ii) a representative of the labor organization 
        representing that individual who is designated by that 
        individual to make the request.

           *       *       *       *       *       *       *

    [(f) Not later than March 1 of each year, the Secretary 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report regarding any pay 
adjustments under the authority of subsection (d) effective 
during the 12 months preceding the submission of the report. 
Each such report shall set forth, by health-care facility, the 
percentage of such increases and, in any case in which no 
increase was made, the basis for not providing an increase.]
    (f) [(g)] For the purposes of this section, the term 
``health-care facility'' means a medical center, an independent 
outpatient clinic, or an independent domiciliary facility.

SEC. 7452. NURSES AND OTHER HEALTH-CARE PERSONNEL: ADMINISTRATION OF 
                    PAY

           *       *       *       *       *       *       *

    (g)(1) * * *
    (2) The amount of special pay paid to a nurse executive 
under paragraph (1) shall be not less than $10,000 or more than 
[$25,000] $100,000.

           *       *       *       *       *       *       *

SEC. 7453. NURSES: ADDITIONAL PAY

    (a) In addition to the rate of basic pay provided for 
nurses, [a nurse] a full-time nurse or part-time nurse shall 
receive additional pay as provided by this section.
    (b) A nurse performing service [on a tour of duty], any 
part of which is within the period commencing at 6 postmeridian 
and ending at 6 antemeridian, shall receive additional pay for 
each hour of [service on such tour] such service at a rate 
equal to 10 percent of the nurse's hourly rate of basic pay if 
at least four hours [of such tour] of such service fall between 
6 postmeridian and 6 antemeridian. When less than four hours 
[of such tour] of such service fall between 6 postmeridian and 
6 antemeridian, the nurse shall be paid the differential for 
each hour of service performed between those hours.
    (c) A nurse performing service [on a tour of duty], any 
part of which is within the period commencing at midnight 
Friday and ending at midnight Sunday, shall receive additional 
pay for each hour of [service on such tour] such service at a 
rate equal to 25 percent of such nurse's hourly rate of basic 
pay.
    (d) * * *
    (e)(1) A nurse performing officially ordered or approved 
hours of service in excess of 40 hours in an administrative 
workweek, or in excess of [eight hours in a day] eight 
consecutive hours, shall receive overtime pay for each hour of 
such additional service. The overtime rates shall be one and 
one-half times such nurse's hourly rate of basic pay.

           *       *       *       *       *       *       *

    (5) * * *
          (A) such travel occurs during such nurse's [tour of 
        duty] period of service; or

           *       *       *       *       *       *       *

SEC. 7454. PHYSICIAN ASSISTANTS AND OTHER HEALTH CARE PROFESSIONALS: 
                    ADDITIONAL PAY

    (b)(1) * * *

           *       *       *       *       *       *       *

    (3) Employees appointed under section 7408 of this title 
[shall be entitled to additional pay on the same basis as 
provided for nurses in section 7453(c) of this title.] 
performing service on a tour of duty, any part of which is 
within the period commencing at midnight Friday and ending at 
midnight Sunday, shall receive additional pay in addition to 
the rate of basic pay provided such employees for each hour of 
service on such tour at a rate equal to 25 percent of such 
employee's hourly rate of basic pay.
    (c) * * *

SEC. 7455. INCREASES IN RATES OF BASIC PAY

           *       *       *       *       *       *       *

    (c)(1) The amount of any increase under subsection (a) in 
the maximum rate for any grade may not (except in the case of 
nurse anesthetists, licensed practical nurses, licensed 
vocational nurses, and nursing positions otherwise covered by 
title 5, pharmacists, and licensed physical therapists) exceed 
by two times the amount by which the maximum for such grade 
(under applicable provisions of law other than this subsection) 
exceeds the minimum for such grade (under applicable provisions 
of law other than this subsection), and the maximum rate as so 
increased may not exceed the rate paid for individuals serving 
as Assistant Under Secretary for Health.

           *       *       *       *       *       *       *

SEC. 7456. NURSES: SPECIAL RULES FOR WEEKEND DUTY

           *       *       *       *       *       *       *

    [(c) A nurse described in subsection (b)(1) who is absent 
on approved sick leave or annual leave during a regularly 
scheduled 12-hour tour of duty shall be charged for such leave 
at a rate of five hours of leave for three hours of absence.]
    (c) [(d)] The Secretary shall prescribe regulations for the 
implementation of this section.

SEC. 7456A. NURSES: ALTERNATE WORK SCHEDULES

    (a) * * *
    (b) [36/40] 72/80 work schedule.
          (1)(A) Subject to paragraph (2), if the Secretary 
        determines it to be necessary in order to obtain or 
        retain the services of registered nurses at any 
        Department health-care facility, the Secretary may 
        provide, in the case of nurses employed at such 
        facility, that such nurses who work [three regularly 
        scheduled 12-hour tours of duty within a work week 
        shall be considered for all purposes to have worked a 
        full 40-hour basic work week.] six regularly scheduled 
        12-hour periods of service within a pay period shall be 
        considered for all purposes to have worked a full 80-
        hour pay period.
          (B) A nurse who works under the authority in 
        subparagraph (A) shall be considered a 0.90 full-time 
        equivalent employee in computing full-time equivalent 
        employees for the purposes of determining compliance 
        with personnel ceilings.
          (2)(A) Basic and additional pay for a nurse who is 
        considered under paragraph (1) to have worked a full 
        [40-hour basic work week] 80-hour pay period shall be 
        subject to subparagraphs (B) and (C).
          (B) The hourly rate of basic pay for a nurse covered 
        by this paragraph for service performed as part of a 
        [regularly scheduled 36-hour tour of duty within the 
        work week] scheduled 72-hour period of service within 
        the bi-weekly pay period shall be derived by dividing 
        the nurse's annual rate of basic pay by 1,872.
          (C) The Secretary shall pay overtime pay to a nurse 
        covered by this paragraph who--
                  (i) performs a period of service in excess of 
                such nurse's [regularly scheduled 36-hour tour 
                of duty within an administrative work week] 
                scheduled 72-hour period of service within an 
                administrative pay period;
                  (ii) for officially ordered or approved 
                service, performs a period of service in excess 
                of 8 hours on a day other than a day on which 
                such nurse's [regularly scheduled 12-hour tour 
                of duty] scheduled 12-hour period of service 
                falls;
                  (iii) performs a period of service in excess 
                of 12 hours for any day included in the 
                [regularly scheduled 36-hour tour of duty work 
                week] scheduled 72-hour period of service pay 
                period; or
                  (iv) performs a period of service in excess 
                of 40 hours during an administrative work week.
          (D) The Secretary may provide a nurse to whom this 
        subsection applies with additional pay under section 
        7453 of this title for any period included in a 
        [regularly scheduled 12-hour tour of duty] scheduled 
        12-hour period of service.
          (3) A nurse who works a work schedule described in 
        this subsection who is absent on approved sick leave or 
        annual leave during a [regularly scheduled 12-hour tour 
        of duty] scheduled 12-hour period of service shall be 
        charged for such leave at a rate of ten hours of leave 
        for every nine hours of absence.

7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY

    (a) Limitation.--Except as provided in subsection (c), the 
Secretary may not require nursing staff to work more than 40 
hours (or 24 hours if such staff is covered under section 7456 
of this title) in an administrative work week or more than 
eight consecutive hours (or 12 hours if such staff is covered 
under section 7456 or 7456A of this title).
    (b) Voluntary Overtime.--(1) Nursing staff may on a 
voluntary basis elect to work hours otherwise prohibited by 
subsection (a).
    (2) The refusal of nursing staff to work hours prohibited 
by subsection (a) shall not be grounds to discriminate (within 
the meaning of section 704(a) of the Civil Rights Act of 1964 
(42 U.S.C. 2000e-3(a))) against the staff, dismissal or 
discharge of the staff, or any other adverse personnel action 
against the staff.
    (c) Overtime Under Emergency Circumstances.--(1) Subject to 
paragraph (2), the Secretary may require nursing staff to work 
hours otherwise prohibited by subsection (a) if--
          (A) the work is a consequence of an emergency that 
        could not have been reasonably anticipated;
          (B) the emergency is non-recurring and is not caused 
        by or aggravated by the inattention of the Secretary or 
        lack of reasonable contingency planning by the 
        Secretary;
          (C) the Secretary has exhausted all good faith, 
        reasonable attempts to obtain voluntary workers;
          (D) the nurse staff have critical skills and 
        expertise that are required for the work; and
          (E) the work involves work for which the standard of 
        care for a patient assignment requires continuity of 
        care through completion of a case, treatment, or 
        procedure.
    (2) Nursing staff may not be required to work hours under 
this subsection after the requirement for a direct role by the 
staff in responding to medical needs resulting from the 
emergency ends.
    (d) Nursing Staff Defined.--In this section, the term 
``nursing staff'' includes the following;
          (1) A registered nurse.
          (2) A licensed practical or vocational nurse.
          (3) A nurse assistant appointed under this chapter or 
        title 5.
          (4) Any other nurse position designated by the 
        Secretary for purposes of this section.

           *       *       *       *       *       *       *

CHAPTER 76. HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM

           *       *       *       *       *       *       *

Subchapter II. Scholarship Program

           *       *       *       *       *       *       *

SEC. 7612. ELIGIBILITY; APPLICATION; AGREEMENT

           *       *       *       *       *       *       *

    (b)(1) * * *
    (2) A qualifying field of education or training for 
purposes of this subchapter is education or training leading to 
employment [(under section 7401 of this title) as any of the 
following:] as an appointee under paragraph (1) or (3) of 
section 7401 of this title.
          [(A) A physician, dentist, podiatrist, optometrist, 
        nurse, physician assistant, or expanded function dental 
        auxiliary.
          [(B) A psychologist described in section 7401(3) of 
        this title or a certified or registered respiratory 
        therapist, licensed physical therapist, or licensed 
        practical or vocational nurse.]

           *       *       *       *       *       *       *

SEC. 7618. EXPIRATION OF PROGRAM

    The Secretary may not furnish scholarships to new 
participants in the Scholarship Program after [December 31, 
1998] December 31, 2013.

           *       *       *       *       *       *       *

            Subchapter VII. Education Debt Reduction Program

SEC. 7681. AUTHORITY FOR PROGRAM

    (a) In general.--
          (1) * * *
          (2) The purpose of the Education Debt Reduction 
        Program is to assist in the recruitment and retention 
        of qualified health care professionals for positions in 
        the Veterans Health Administration for which 
        recruitment or retention of an adequate supply of 
        qualified personnel is difficult.
    (b) * * *

SEC. 7682. ELIGIBILITY

    (a) Eligibility.--An individual is eligible to participate 
in the Education Debt Reduction Program if the individual--
          (1) is [a recently appointed] an employee in the 
        Veterans Health Administration serving in a position 
        (as determined by the Secretary) providing direct-
        patient care services or services incident to direct-
        patient care services for which recruitment or 
        retention of qualified health-care personnel (as so 
        determined) is difficult; and

           *       *       *       *       *       *       *

    [(c) Recently appointed individuals.--For purposes of 
subsection (a), an individual shall be considered to be 
recently appointed to a position if the individual has held 
that position for less than 6 months.]

SEC. 7683. EDUCATION DEBT REDUCTION

           *       *       *       *       *       *       *

    (d) Maximum annual amount.--(1) Subject to paragraph (2), 
the amount of education debt reduction payments made to a 
participant under the Education Debt Reduction Program may not 
exceed [$44,000] $60,000 over a total of five years of 
participation in the Program, of which not more than [$10,000] 
$12,000 of such payments may be made in each of the fourth and 
fifth years of participation in the Program.

           *       *       *       *       *       *       *

            PART VI. ACQUISITION AND DISPOSITION OF PROPERTY

   CHAPTER 81. ACQUISITION AND OPERATION OF HOSPITAL AND DOMICILIARY 
    FACILITIES; PROCUREMENT AND SUPPLY; ENHANCED-USE LEASES OF REAL 
                                PROPERTY

     SUBCHAPTER I. ACQUISITION AND OPERATION OF MEDICAL FACILITIES

SEC.

           *       *       *       *       *       *       *

[8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES.]

           *       *       *       *       *       *       *

   SUBCHAPTER III. STATE HOME FACILITIES FOR FURNISHING DOMICILIARY, 
NURSING HOME, AND HOSPITAL CARE

           *       *       *       *       *       *       *

8133A. TRIBAL ORGANIZATIONS.

           *       *       *       *       *       *       *

              Subchapter I. Acquisition and Operation of 
Medical Facilities

           *       *       *       *       *       *       *

SEC. 8104. CONGRESSIONAL APPROVAL OF CERTAIN MEDICAL FACILITY 
                    ACQUISITIONS

    (a)(1) * * *
    (2) * * *
    (3) * * *
          (A) * * *
          (B) The term ``major medical facility lease'' means a 
        lease for space for use as a new medical facility at an 
        average annual rental of more than [$600,000] 
        $1,000,000.

           *       *       *       *       *       *       *

[SEC. 8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES

    [(a) In order to promote effective planning for the 
efficient provision of care to eligible veterans, the 
Secretary, based on the analysis and recommendations of the 
Under Secretary for Health, shall submit to each committee an 
annual report regarding long-range health planning of the 
Department. The report shall be submitted each year not later 
than the date on which the budget for the next fiscal year is 
submitted to the Congress under section 1105 of title 31.
    [(b) Each report under subsection (a) shall include the 
following:
          [(1) A five-year strategic plan for the provision of 
        care under chapter 17 of this title to eligible 
        veterans through coordinated networks of medical 
        facilities operating within prescribed geographic 
        service-delivery areas, such plan to include provision 
        of services for the specialized treatment and 
        rehabilitative needs of disabled veterans (including 
        veterans with spinal cord dysfunction, blindness, 
        amputations, and mental illness) through distinct 
        programs or facilities of the Department dedicated to 
        the specialized needs of those veterans.
          [(2) A description of how planning for the networks 
        will be coordinated.
    [(c) The Secretary shall submit to each committee not later 
than January 31 of each year a report showing the location, 
space, cost, and status of each medical facility (1) the 
construction, alteration, lease, or other acquisition of which 
has been approved under section 8104(a) of this title, and (2) 
which was uncompleted as of the date of the last preceding 
report made under this subsection.
    [(d)(1) The Secretary shall submit to each committee, not 
later than January 31 of each year, a report showing the 
current priorities of the Department for proposed major medical 
construction projects. Each such report shall identify the 20 
projects, from within all the projects in the Department's 
inventory of proposed projects, that have the highest priority 
and, for those 20 projects, the relative priority and rank 
scoring of each such project and the projected cost of such 
project (including the projected operating costs, including 
both recurring and nonrecurring costs). The 20 projects shall 
be compiled, and their relative rankings shall be shown, by 
category of project (including the categories of ambulatory 
care projects, nursing home care projects, and such other 
categories as the Secretary determines).
    [(2) The Secretary shall include in each report, for each 
project listed, a description of the specific factors that 
account for the relative ranking of that project in relation to 
other projects within the same category.
    [(3) In a case in which the relative ranking of a proposed 
project has changed since the last report under this subsection 
was submitted, the Secretary shall also include in the report a 
description of the reasons for the change in the ranking, 
including an explanation of any change in the scoring of the 
project under the Department's scoring system for proposed 
major medical construction projects.]

           *       *       *       *       *       *       *

   Subchapter III. State Home Facilities for Furnishing Domiciliary, 
Nursing Home, and Hospital Care

           *       *       *       *       *       *       *

SEC. 8131. DEFINITIONS

           *       *       *       *       *       *       *

          (5) The term ``tribal organization'' has the meaning 
        given such term in section 3765 of this title.

SEC. 8132. DECLARATION OF PURPOSE

    The purpose of this subchapter is to assist the several 
States and tribal organizations to construct State home 
facilities (or to acquire facilities to be used as State home 
facilities) for furnishing domiciliary or nursing home care to 
veterans, and to expand, remodel, or alter existing buildings 
for furnishing domiciliary, nursing home, adult day health, or 
hospital care to veterans in State homes.

SEC. 8133. AUTHORIZATION OF APPROPRIATIONS

           *       *       *       *       *       *       *

SEC. 8133A. TRIBAL ORGANIZATIONS

    (a) Authority to Award Grants.--The Secretary may award a 
grant to a tribal organization under this subchapter in order 
to carry out the purposes of this subchapter.
    (b) Manner and Condition of Grant Awards.--(1) Grants to 
tribal organizations under this section shall be awarded in the 
same manner, and under the same conditions, as grants awarded 
to the several States under the provisions of this subchapter, 
subject to such exceptions as the Secretary shall prescribe for 
purposes of this subchapter to take into account the unique 
circumstances of tribal organizations.
    (2) For purposes of according priority under subsection 
(c)(2) of section 8135 of this title to an application 
submitted under subsection (a) of such section, an application 
submitted under such subsection (a) by a tribal organization of 
a State that has previously applied for award of a grant under 
this subchapter for construction or acquisition of a State 
nursing home shall be considered under subparagraph (C) of such 
subsection (c)(2) an application from a tribal organization 
that has previously applied for such a grant.

           *       *       *       *       *       *       *

SEC. 8138. TREATMENT OF CERTAIN HEALTH FACILITIES AS STATE HOMES

           *       *       *       *       *       *       *

    (d) * * *
    (e)(1) A health facility (or certain beds in a health 
facility) of a tribal organization is treatable as a State home 
under subsection (a) in accordance with the provisions of that 
subsection.
    (2) Except as provided in paragraph (3), the provisions of 
this section shall apply to a health facility (or certain beds 
in such facility) treated as a State home under subsection (a) 
by reason of this subsection to the same extent as health 
facilities (or beds) treated as a State home under subsection 
(a).
    (3) Subsection (f) shall not apply to the treatment of 
health facilities (or certain beds in such facilities) of 
tribal organizations as a State home under subsection (a).
    (f) [(e)] The Secretary may not treat any new health 
facilities (or any new certain beds in a health facility) as a 
State home under subsection (a) after September 30, 2009.

           *       *       *       *       *       *       *

              VETERANS' BENEFITS AND SERVICES ACT OF 1988

         (Public Law 100-322, as amended; 38 U.S.C. 7333 Note)

TITLE I. HEALTH-CARE PROGRAMS

           *       *       *       *       *       *       *

Part C. Matters Relating to AIDS

           *       *       *       *       *       *       *

[SEC. 124. RESTRICTION ON TESTING FOR INFECTION WITH THE HUMAN 
                    IMMUNODEFICIENCY VIRUS.

    [(a) General rule.--Except as provided in subsection (b), 
the Secretary of Veterans Affairs may not during any fiscal 
year conduct a widespread testing program to determine 
infection of humans with the human immunodeficiency virus 
unless funds have been appropriated to the Department of 
Veterans Affairs specifically for such a program during the 
fiscal year.
    [(b) Voluntary testing.--(1) The Secretary shall provide 
for a program under which the Department of Veterans Affairs 
offers each patient to whom the Department is furnishing health 
care or services and who is described in paragraph (2) the 
opportunity to be tested to determine whether such patient is 
infected with the human immunodeficiency virus.
    [(2) Patients referred to in paragraph (1) are--
          [(A) patients who are receiving treatment for 
        intravenous drug abuse,
          [(B) patients who are receiving treatment for a 
        disease associated with the human immunodeficiency 
        virus, and
          [(C) patients who are otherwise at high risk for 
        infection with such virus.
    [(3) Subject to the consent requirement in paragraph (4) 
and unless medically contraindicated, the test shall be 
administered to each patient requesting to be tested for 
infection with such virus.
    [(4) A test may not be conducted under this subsection 
without the prior informed and separate written consent of the 
patient tested. The Secretary shall provide pre- and post-test 
counseling regarding the acquired immune deficiency syndrome 
and the test to each patient who is administered the test.]

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              PERSIAN GULF WAR VETERANS' HEALTH STATUS ACT

(Public Law 102-585; 106 Stat. 4943; 38 U.S.C. 527 Note)

           *       *       *       *       *       *       *

TITLE VII. PERSIAN GULF WAR VETERANS' HEALTH STATUS

           *       *       *       *       *       *       *

SEC. 707. COORDINATION OF HEALTH-RELATED GOVERNMENT ACTIVITIES ON THE 
                    PERSIAN GULF WAR

           *       *       *       *       *       *       *

    (c) Reports.--
          (1) [Not later than March 1 of each year] Not later 
        than July 1, 2008, and July 1 of each of the 
        fivefollowing years, the head of the department or 
        agency designated under subsection (a) shall submit to 
        the Committees on Veterans' Affairs of the Senate and 
        House of Representatives a report on--
                  (A) the status and results of all such 
                research activities undertaken by the executive 
                branch during the previous year; and
                  (B) research priorities identified during 
                that year.

           *       *       *       *       *       *       *

 VETERANS BENEFITS, HEALTH CARE, AND INFORMATION TECHNOLOGY ACT OF 2006

(Public Law 109-461; 38 U.S.C. 1710B Note)

           *       *       *       *       *       *       *

TITLE II. HEALTH MATTERS

           *       *       *       *       *       *       *

SEC. 214. PILOT PROGRAM ON IMPROVEMENT OF CAREGIVER ASSISTANCE 
                    SERVICES.

           *       *       *       *       *       *       *

    (d) Authorization of Appropriations.--There are authorized 
to be appropriated to the Department of Veterans Affairs 
$5,000,000 for [each of fiscal years 2007 and 2008] each of the 
fiscal years 2007 through 2009 to carry out the pilot program 
authorized by this section.

           *       *       *       *       *       *       *

                 CONSOLIDATED APPROPRIATIONS ACT, 2008

(Public Law 110-161; 121 Stat. 2276)

           *       *       *       *       *       *       *

  DIVISION I. MILITARY CONSTRUCTION AND VETERANS AFFAIRS AND RELATED 
AGENCIES APPROPRIATIONS ACT, 2008

           *       *       *       *       *       *       *

TITLE IV. GENERAL PROVISIONS

           *       *       *       *       *       *       *

SEC. 410. CONVEYANCE OF CERTAIN NON-FEDERAL LAND.

    [(a) In this section:
          [(1) The term ``City'' means the City of Aurora, 
        Colorado.
          [(2) The term ``deed'' means the quit claim deed--
                  [(A) conveyed by the Secretary to the City; 
                and
                  [(B) dated May 24, 1999.
          [(3) The term ``non-Federal land'' means--
                  [(A) parcel I of the Fitzsimons Army Medical 
                Center, Colorado; and
                  [(B) the parcel of land described in the 
                deed.
          [(4) The term ``Secretary'' means the Secretary of 
        the Interior.
    [(b)(1) In accordance with paragraph (2), to allow the City 
to convey by donation to the United States the non-Federal land 
to be used by the Secretary of Veterans Affairs for the 
construction of a veterans medical facility.
    [(2) In carrying out paragraph (1), with respect to the 
non-Federal land, the Secretary shall forego exercising any 
rights provided by the--
          [(A) deed relating to a reversionary interest of the 
        United States; and
          [(B) any other reversionary interest of the United 
        States.
    [This division may be cited as the ``Military Construction 
and Veterans Affairs and Related Agencies Appropriations Act, 
2008''.]
    (a) Definitions.--In this section:
          (1) City.--The term ``City'' means the City of 
        Aurora, Colorado.
          (2) Deed.--The term ``deed'' means the quit-claim 
        deed--
                  (A) conveyed to the City by the Secretary 
                (acting through the Director of the National 
                Park Service); and
                  (B) dated May 24, 1999.
          (3) Non-federal land.--The term ``non-Federal land'' 
        means--
                  (A) parcel I of the former United States Army 
                Garrison Fitzsimons, Adams County, Colorado, as 
                more specifically described in the deed; and
                  (B) the parcel of land described in the deed.
          (4) Secretary.--The term ``Secretary'' means the 
        Secretary of the Interior.
    (b) Duty of Secretary.--To allow the City to convey by 
donation to the United States the non-Federal land to be used 
by the Secretary of Veterans Affairs for the construction of a 
veterans medical facility, not later than 60 days after the 
date of enactment of this section, the Secretary shall execute 
each instrument that is necessary to release all rights, 
conditions, and restrictions re-tained by the United States in 
and to the non-Federal land conveyed in the deed.

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