49–010 

Calendar No. 284 

109TH CONGRESS REPORT " ! SENATE 1st Session 109–177 

VETERANS’ HEALTH CARE ACT OF 2005 

NOVEMBER 10, 2005.—Ordered to be printed 

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

submitted the following 

R E P O R T 

together with 

MINORITY VIEWS 

[To accompany S. 1182] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Veterans’ Affairs (hereinafter, ‘‘the Committee’’), to which was referred the bill (S. 1182) to amend title 38, 

United States Code, to improve and enhance the health care for 

veterans, and for other purposes, having considered the same, reports favorably thereon with an amendment in the nature of a substitute, and recommends that the bill, as amended, do pass. 

INTRODUCTION

On June 9, 2005, Committee Chairman Larry E. Craig introduced S. 1182, the Veterans Health Care Act of 2005. The bill, as 

introduced, would have: eliminated copayments for hospice care 

provided to veterans; repealed the requirement that the Department of Veterans Affairs (hereinafter ‘‘VA’’) maintain long-term 

care bed capacity at 1998 levels; exempted former POWs from certain long-term care copayments; authorized VA to reimburse insured veterans for emergency care provided at non-VA facilities; 

authorized VA to provide, or pay for, up to 14 days of care for a 

newborn child of a female VA patient; allowed providers of care to 

Spina Bifida-afflicted children of Vietnam Veterans to balance bill 

private insurers; permanently authorized grant and per diem payments to homeless assistance providers; authorized Senior ExecuVerDate Aug 31 2005 10:09 Nov 15, 2005 Jkt 049010 PO 00000 Frm 00001 Fmt 6659 Sfmt 6602 E:\HR\OC\A177SR.000 A177SR
2 

tive Service compensation to VA’s national Director, Nursing Services; repealed the ban on the use of appropriated funds to conduct 

cost-comparison studies; and required the expansion and improvement of mental health services and care for veterans suffering from 

Post-traumatic Stress Disorder (hereinafter ‘‘PTSD’’). The bill was 

referred to the Committee on Veterans’ Affairs. 

On June 7, 2005, Committee Ranking Member, Daniel K. Akaka, 

introduced S. 1177. The bill, as introduced, would have: required 

the VA to adjust funding for mental health services by adding inflation to the amount appropriated for such services each year 

starting in 1996; required VA’s Under Secretary for Health to ensure that 90 percent of VA’s community-based outpatient clinics 

(hereinafter ‘‘CBOCs’’) have the capacity to provide mental health 

services onsite, via contract referral, or through tele-health services; required that each VA primary medical facility have the capacity to provide not less than five days of inpatient detoxification 

services; required VA and the Department of Defense (hereinafter 

‘‘DoD’’) to develop a standardized pre-separation mental health and 

sexual trauma examination; required VA national guidelines for 

screening primary care patients for mental illness; and required a 

joint working group between VA and DoD to develop methods for 

combating the stigma of mental illness, improving the availability 

of treatment for mental illnesses, and advance family education for 

transition. Committee Members John D. Rockefeller, Patty Murray, 

and Ken Salazar along with Senator Richard Durbin were added 

as cosponsors. The bill was referred to the Committee on Veterans’

Affairs. 

On June 7, 2005, Senator Barack Obama introduced S. 1180. The 

bill as introduced would have: specified that per diem payments to 

providers of services to homeless veterans should be paid at the 

same as per diem payments to state veterans homes; expanded 

VA’s homeless reintegration program; extended to 2011 VA’s authorization to treat seriously mentally ill homeless veterans; made 

permanent VA’s program to transfer acquired properties to homelessness service providers; extended VA’s special needs homeless 

grant program through 2011; removed the 60 day limitation on 

homeless veterans’ dental care eligibility; authorized appropriations 

for VA’s technical assistance program for applicants for grants to 

assist homeless veterans; extended through 2011 VA’s Advisory 

Committee on Homeless Veterans; and required a study by VA on 

relationships between military sexual trauma and homelessness. 

Committee Member Patty Murray along with Senators Richard 

Durbin, Tim Johnson, and Byron Dorgan were added as cosponsors. 

The bill was referred to the Committee on Veterans’ Affairs. 

On June 7, 2005, Senator Ken Salazar introduced S. 1189, a bill 

to require the Secretary to develop a strategic plan for the provision of long-term care services to veterans and submit that plan to 

Congress. The bill was referred to the Committee on Veterans’ Affairs. 

On June 7, 2005, Senator Ken Salazar introduced S. 1190, a bill 

that would have: required the Secretary to establish the position of 

Blind Rehabilitation Outpatient Specialist (hereinafter ‘‘BROS’’) at 

each VA facility that treats more than 150 blind veterans; and authorized $5 million per year through 2010 to hire such specialists. 

3 

Senators Rick Santorum and Tim Johnson were added as cosponsors. The bill was referred to the Committee on Veterans’ Affairs. 

COMMITTEE HEARINGS

On June 9, 2005, the Committee held hearings on, among other 

bills: S. 716, S. 1177, S. 1180, S. 1189, and S. 1190. Testimony was 

heard from: The Honorable R. James Nicholson, Secretary of Veterans Affairs; The Honorable Jonathan B. Perlin, VA’s Under Secretary for Health; The Honorable Tim McClain, VA’s General 

Counsel; Mr. Donald Mooney, Assistant Director, The American Legion; Mr. Dennis Cullinan, Director of National Legislative Service, 

Disabled American Veterans; Mr. Adrian Atizado, Assistant National Legislative Director, Disabled American Veterans; Mr. Carl 

Blake, Associate National Legislative Director, Paralyzed Veterans 

of America; and Mr. Richard Jones, AMVETS. 

COMMITTEE MEETING

After carefully reviewing the testimony from the foregoing hearing, the Committee met in open session on September 15, 2005 to 

consider, among other legislation, S. 1182. The Committee voted by 

voice vote to report favorably S. 1182, as amended to incorporate 

provisions derived from S. 1177, S. 1180, S. 1189, and S. 1190 as 

well as an amendment offered by Committee Ranking Member 

Daniel K. Akaka and an amendment from Committee Ranking 

Member Daniel K. Akaka as amended by Committee Chairman 

Larry E. Craig. 

SUMMARY OF THE COMMITTEE BILL AS REPORTED

S. 1182, as reported (hereinafter the ‘‘Committee bill’’), consists 

of changes to current law that would: 

1. Authorize VA to provide up to 14 days of care for newborn 

children of female veterans who are receiving maternity care 

furnished by VA (section 2); 

2. Permit private sector providers of care to certain disabled 

children of Vietnam Veterans to balance bill private insurers 

for costs of that care not paid by the Secretary (section 3); 

3. Permanently authorize VA’s Homeless Grant and Per 

Diem Program, provide an authorization for $130,000,000 in 

funding for Fiscal Year 2006 and each year thereafter for the 

program, and re-authorize $1,000,000 for each of Fiscal Years 

2006—2011 for the Homeless Service Provider Technical Assistance Program (section 4); 

4. Authorize VA to employ licensed and credentialed Marriage and Family Therapists and Licensed Professional Mental 

Health Counselors (section 5); 

5. Authorize VA to pay the Chief Nursing Officer of the department at the Senior Executive Schedule rate of pay (section 

6); 

6. Repeal the statutory prohibition on VA spending any 

funds comparing the costs and efficiency of services provided 

by government employees with similar services provided in the 

private sector (section 7); 

7. Authorize $95,000,000 to: expand the number of clinical 

treatment teams principally dedicated to the treatment of 

4 

PTSD in VA facilities; expand and improve services available 

to diagnose and treat substance abuse; expand and improve 

tele-health initiatives to provide better access to mental health 

services in areas of the country that are determined to be underserved; improve educational programs for primary care clinicians to allow them to better recognize and treat mental illness in veterans; expand the number of VA CBOCs capable of 

providing on-site mental health services; and expand the number of Mental Health Intensive Case Management Teams to 

provide services to veterans with Serious Chronic Mental Illness (section 8(b)); 

8. Require the Under Secretary for Health to take appropriate steps and provide incentives to encourage Regional Directors of the Veterans Health Administration (hereinafter 

‘‘VHA’’) to: prioritize the provision of mental health services; 

foster collaborative working environments among clinicians for 

the provision of mental health services; and conduct mental 

health consultations during primary care appointments (section 8(c)); 

9. Require the Secretary to ensure that VA CBOCs have the 

capacity to provide, or monitor the provision of, mental health 

services to veterans through: a contract-provider, referral to 

another facility of the department, or an employee of the department (section 8(c)); 

10. Require the Secretaries of Defense and VA to enter into 

a Memorandum of Understanding to ensure that separating 

service-members receive standardized mental health and sexual trauma assessments and that the two Secretaries share 

guidelines on how to conduct such assessments (section 8(d)); 

11. Establish a Joint Working Group within DoD and VA to 

analyze the feasibility of initiatives related to: combating stigma associated with service-members who suffer from mental 

illness; VA making its expertise in the treatment of mental illness more readily available to DoD providers; the education of 

family members of veterans to assist them in recognizing and 

coping with readjustment issues; and the seamless transition 

of service-members who have been diagnosed with mental illness. The Joint Working Group would report on its findings 

and recommendations not later than June 30, 2007 (section 

8(d)); 

12. Require the Under Secretary for Health to establish system-wide guidelines for screening primary care patients for 

mental illness and ensure that VA clinicians are trained in the 

use of such guidelines (section 8(e)); 

13. Require the National Center on Post Traumatic Stress 

Disorder to collaborate with the Secretary of Defense to enhance the clinical skills of military clinicians and promote predeployment resilience and post-deployment re-adjustment for 

veterans of Operations Iraqi Freedom and Enduring Freedom 

(section 8(f)); 

14. Permit the exchange of certain health information between VA and DoD (section 9); 

15. Require the expansion of VA’s Global War on Terrorism 

Outreach Program (hereinafter ‘‘GWOT’’) and ensure the coordination with appropriate State officials to ensure members 

5 

of the National Guard receive accurate and timely information 

about VA’s benefits and services (section 10); 

16. Require the Secretary to expand the number of Veterans 

Readjustment Counseling Service facilities capable of providing 

services to veterans through tele-health linkages and to submit 

a report on accomplishing this expansion in Fiscal Years 2006 

and 2007 (section 11); 

17. Require the Secretary to submit a report to the Committees on Veterans’ Affairs of the Senate and House of Representatives containing: a description of the mental health 

data maintained by VA; an analysis as to whether the current 

method of collecting and storing the data is efficient and effective, and any recommendations for improving the collection, 

storage, and use of mental health data (section 12); 

18. Require the Secretary to publish a strategic plan for the 

provision of long-term care services to veterans (section 13); 

19. Require the establishment of Blind Rehabilitation Outpatient Specialist positions at not fewer than fifty facilities of 

VA that do not currently have such a position (section 14); 

20. Extend through 2006 the requirement that the Secretary 

submit a report to the Committees on Veterans’ Affairs of the 

Senate and House of Representatives detailing VA’s compliance with the specialized services capacity requirement (section 15); 

21. Authorize the Secretary to provide health care services to 

any veteran who lived in the catchments region of VA’s medical center in Gulfport or Biloxi, Mississippi or New Orleans, 

Louisiana and prohibit the Secretary from collecting any outof-pocket fees associated with that care until January 31, 2006 

(section 16); 

22. Allow the Secretary to cover out-of-pockets costs for certain insured veterans when such costs are related to care or 

treatment provided for an emergency health condition in a 

non-VA medical facility (section 17). 

BACKGROUND AND DISCUSSION

Section 2. Care for Newborn Children of Women Receiving Maternity Care 

Under current law, VA provides what it believes to be a ‘‘comprehensive package of health benefits for eligible veterans’’. Unfortunately, while a veteran’s care extends to maternity, prenatal, and 

postnatal care for female veterans, it does not permit the provision 

of, or payment for, any care for the newborn child of a female veteran-patient. In other words, for the increasing number of female 

veterans enrolling for VA care, the word ‘‘comprehensive’’ is not exactly accurate. 

VA has advised the Committee that newborn care is not provided 

because VA is only authorized to provide medical care and treatment to veterans. While that is true, it is also a disservice to our 

growing female veteran population and an inequity that must be 

addressed. 

As such, Section 2 of the Committee bill would authorize VA to 

provide, or pay for, up to the first 14 days of care for a newborn 

child of an enrolled, female veteran who delivers her baby under 

6 

VA provided, or VA financed, care. The Committee hopes that this 

limited but important step will help equalize the health care benefits package and ensure that it addresses the health needs of all 

veterans. 

Section 3. Enhancement of Payer Provisions for Health Care Furnished To Certain Children of Vietnam Veterans 

Under current law, VA provides, or pays for, care for certain children of Vietnam veterans. Generally, the payment provided by VA 

is considered payment in full for all services provided to the patient. However, it has come to the Committee’s attention that in 

rare circumstances it may be perfectly appropriate for a care provider to seek reimbursement for certain services not otherwise covered by VA. Yet, that action is not permitted. 

Section 3 of the Committee bill would designate VA as the primary payer for care or services furnished to certain children of 

Vietnam veterans under Title 38 U.S.C. § 1803. In so designating 

VA, the language expressly permits a provider (or his agent) who 

furnishes care to children under this program to seek payment for 

the difference between the amount billed and the amount paid by 

the Secretary from a third party payer if the beneficiary has a 

health care plan that would otherwise be responsible for payment. 

The Committee is concerned that express authority for so-called ‘‘balance billing’’ would permit providers to send such bills to veterans and their family members. In an effort to ensure that does 

not occur, Section 3 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. 

In addition, 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, under this section, VA would be required, upon request, to provide a third party 

with information concerning claims under this section. 

The Committee intends for this provision to encourage providers 

to work with VA to provide care to this very deserving and limited 

beneficiary population. 

Section 4. Improvements to Homeless Veterans Service Providers 

Programs 

VA operates a Homeless Providers Grant and Per Diem Program 

to fund community agencies providing services to homeless veterans. The program aims to help homeless veterans achieve residential stability, improve skill levels, and increase personal income. 

Only programs that offer supportive housing or service centers for 

case management, education, crisis intervention, and counseling 

are eligible for funds. In addition, VA maintains a small program 

to assist grant applicants in their efforts to submit in a timely 

fashion all of the complex paperwork associated with grants under 

this program. 

Since 1992, when this program was established, VA has been 

able to spur development of increased levels of assistance at the 

local level for homeless veterans living throughout the country. Indeed, grantees’ programs often fill existing gaps in the continuum 

7 

of VA care and services, thus serving as an effective complement 

to VA’s own efforts. 

VA has been successful at leveraging new resources to increase 

the overall supply of transitional housing and other effective assistance for homeless veterans throughout the country. In fact, the 

only programmatic shortcoming the Committee can identify is that 

there is more interest on the part of participating providers than 

there is grant money to support those efforts. 

As such, Section 4 of the Committee bill would permanently authorize the Homeless Grant and Per Diem Program and would increase the amount of money authorized for these efforts to 

$130,000,000 in each fiscal year. Further, the grantee assistance 

program would be authorized though 2011 with an authorized 

funding level of $1,000,000 for each fiscal year. 

Section 5. Additional Mental Health Providers 

Chapter 74 of Title 38, United States Code authorizes VA to hire 

a wide range of clinical care personnel to provide treatment to veterans who seek health services from the department. These include, but are not limited to: physicians, nurses, psychologists, and, 

social workers. Because the hiring authority is specific to listed 

medical professionals, VA is not permitted to employ any professional not mentioned in statute. 

Section 5 would add the professions of ‘‘Marriage and Family 

Therapist’’ and ‘‘Licensed Mental Health Counselor’’ to the list of 

clinical care providers VA is authorized to hire. This section does 

not require VA to hire any of the new clinicians. That decision is 

best left to the medical administrative professionals who operate 

VA’s medical centers and CBOCs across the United States. 

Still, the Committee believes that VA officials should have as 

much latitude as possible to hire the clinical professionals needed 

to ensure that the Nation’s veterans are provided with the right 

clinical care in the most cost-effective manner. The military is already offering Marriage and Family Therapy and Licensed Mental 

Health Counseling to those who are returning from overseas. And 

their programs are receiving good reviews from those in the mental 

health and counseling professions. It seems only logical that we extend successful ideas from the military experience to our veterans. 

Section 6. Pay Comparability for Chief Nursing Officer, Office of 

Nursing Services 

Section 6 would correct a long-time pay inequity for the VA’s 

Chief Nursing Officer. Under current law, this official is compensated at an annual salary far below that of all other VA service 

chiefs. 

Section 6 would ensure that any future holder of this important 

position is compensated as a salary level equal to the executive responsibilities of the job and equal to his or her other service chief 

counterparts. 

Section 7. Repeal of Cost Comparison Studies Prohibition 

Under current law, VA is prohibited from using any appropriated 

funds to carry out a study comparing the costs of a service provided 

by VHA with the same service provided under contract through a 

8 

private sector company. The Committee finds continuation of this 

strict prohibition to be unreasonable. 

America’s taxpayers have a right to expect that services offered 

by the Federal Government will be provided in the most cost efficient and effective manner possible. In order to provide that assurance to taxpayers, VA must be permitted to compare its performance with the experience of those conducting a similar business in 

the private sector. Section 7 would allow those comparison studies 

to be undertaken. 

It is important to note that the Committee does not believe that 

comparison studies will inevitably result in the reduction of government employment. Nor does the Committee believe that an increase in outside contracts is the only outcome possible. Rather, the 

Committee expects that such studies will, in many cases, verify the 

good work being done by VA’s employees. In cases where positive 

results are not shown, the Committee expects that appropriate 

changes, both inside and outside of VHA, will be implemented. 

Section 8. Improvement and Expansion of Mental Health Services 

The Committee has followed closely the studies which suggest 

that a number of men and women serving in Operations Enduring 

Freedom and Iraqi Freedom (hereinafter ‘‘OIF/OEF’’) will need assistance coping with the mental and physical scars war leaves. The 

Committee held a hearing on March 17, 2005 on this topic specifically as it relates to the transition from active duty to civilian life. 

In order to ensure that VA can adequately address the mental 

health needs of returning servicemen and women, Section 8 directs 

VA to expand and improve programs and services in a number of 

settings. 

Specifically, VA is directed to: expand the number of clinical 

treatment teams principally dedicated to the treatment of PTSD; 

expand treatment and diagnosis services for substance abuse; expand tele-health initiatives principally dedicated to mental health 

care in communities located great distances from current VA facilities; improve programs that provide education in mental health 

treatment to primary care clinicians; and expand the number of 

community based outpatient clinics capable of providing treatment 

for mental illness. 

The Committee bill would authorize $95 million to be dedicated 

to the implementation of this section. It is the Committee’s expectation that VA will take this opportunity to ensure that the treatment teams and the tools to provide care are in place before returning OIF/OEF veterans present themselves at VHA facilities. 

Section 8 also requires VA to ensure that it has the capacity to 

provide mental health services at every Community-Based Outpatient Clinic (CBOC) in the system. As part of this, VA is directed 

to establish performance standards and working environments that 

give appropriate recognition to the importance of mental health 

care. Based on the recommendations of VA’s Mental Health Strategic Plan, the Committee seeks to encourage greater collaboration 

among primary and mental health care providers. 

Additionally, the Committee is concerned that a provision of P.L. 

107–95 has yet to be properly implemented. The provision required 

VA to have a plan to meet the needs of any veteran who entered 

a VA health care facility seeking mental health or substance abuse 

9 

treatment. As such, Section 8 reiterates and expands on these requirements, by giving the option of using tele-mental health services or contracting. 

Another provision in this section seeks to address the transition 

of returning servicemembers from active duty to civilian life. The 

Committee found that there is currently no real collaborative body 

examining or developing ways for VA and the Department of Defense (DOD) to work together to provide for a smoother transition 

out of the military for those that may require mental health services. Section 8 establishes a joint VA–DOD workgroup that will 

consist of 7 experts in the fields of mental health and readjustment 

counseling from each Department. The workgroup will look at ways 

to combat stigmas associated with mental health, to better educate 

families of servicemembers on how to deal with such issues, and 

will report to Congress on their findings. 

Section 8 also requires the two Departments to enter into a 

Memorandum of Understanding to ensure that all separating 

servicemembers receive mental health and sexual trauma screening. The Committee believes that this will ensure that no 

servicemember who may require treatment or counseling leaves 

their military service without that being discovered, and ultimately 

going untreated. 

As part of the effort to encourage improved coordination of mental and primary health care, Section 8 directs the Secretary to establish systemwide guidelines for screening primary care patients 

for potential mental health issues or disorders, as well as properly 

training physicians to conduct the screening. 

Finally, Section 8 requires VA’s National Center on Post-Traumatic Stress Disorder (PTSD) to collaborate with the Secretary of 

Defense for the purposes of enabling DOD mental health care providers and clinicians to benefit from the unique and comprehensive 

expertise that VA has in the area of PTSD diagnosis and treatment. It also directs the two entities to develop joint training and 

protocols to ensure consistency. This is yet another facet of this 

Committee’s encouragement of the two Departments to collaborate 

on the mental health treatment of servicemembers. The Committee 

has authorized $2 million for the purpose of carrying out these requirements. 

Section 9. Data Sharing Improvements 

Each year, approximately 200,000 active duty personnel leave 

the Armed Forces and become veterans. A good portion of those 

men and women, approximately 20% by historical standards, will 

seek care or services from the Department of Veterans Affairs at 

some point during their lifetime. 

Unfortunately, due to requirements under the Health Insurance 

Portability and Accountability Act (hereinafter ‘‘HIPAA’’), VA must 

wait until the veteran actually enrolls for care at a VA facility before requesting that DoD send the veteran’s medical records from 

active duty service. This small delay in records processing seriously 

hinders the seamless transition from active duty to civilian life that 

many servicemembers have come to expect and this Committee demands. 

Section 9 of the Committee bill would ensure that DoD would not 

violate HIPAA regulation by providing VA with access to certain 

10 

medical records of servicemembers while the future VA beneficiary 

is still on active duty. The Committee does not intend this action 

to be a license for VA to request access to all active duty records 

maintained by DoD. Records transfer costs, privacy expectations, 

and basic fairness should guide the use of this authority. 

Section 10. Expansion of Global War on Terrorism Outreach Program 

On February 3, 2004, then-Secretary of Veterans Affairs, Anthony Principi, authorized the Veterans Readjustment Counseling 

Service to hire 50 veterans of OIF/OEF to conduct outreach to returning servicemembers and help ensure a smooth transition back 

to civilian life. Since that time, it is estimated that the Global War 

on Terrorism Outreach Program (hereinafter ‘‘GWOT’’) has served 

20,000 combat veterans from OIF/OEF. 

On March 17, 2005, the Committee held a hearing on the activities of this program and learned of its importance to ensuring that 

our new veterans obtain the benefits to which they are entitled and 

the help and services they and their families need. Especially noteworthy is the outreach done to our returning Guardsmen and Reservists at reserve and state guard facilities. 

Unlike active duty personnel, most members of the Guard and 

Reserves quickly begin rebuilding a private, civilian life after returning stateside. GWOT Outreach employees are taking their important message directly to Guardsmen and Reservists by speaking 

during weekend drilling periods and at special gatherings of Guard 

and Reserve troops. 

The Committee was truly impressed by the dedication of the 

GWOT staff and the passion with which each of them approached 

this important mission. 

As such, Section 10 directs the Secretary to expand the total 

number of persons employed by the GWOT program and to ensure 

that VA is collaborating to the maximum extent practicable with 

appropriate State officials in their outreach efforts. 

Section 11. Expansion of Tele-health Services 

As has been noted, the Veterans Readjustment Counseling Service has made great efforts to improve its outreach and services to 

combat veterans and their families to ensure a smooth and seamless transition from active duty to civilian life. However, Readjustment Counseling Centers (hereinafter ‘‘VET Centers’’) are often located only in the most urban settings around the country. As such, 

critically important transition assistance can be unavailable to veterans who reside in rural communities. 

Section 11 of the Committee bill would direct VA to expand the 

number of VET Center facilities capable of providing health services and counseling through tele-health linkages. It is the Committee’s belief that this important step will allow VA to reach more 

veterans in rural areas and provide more services in a setting closer to the veterans’ homes. 

Section 12. Mental Health Data Sources Report 

VA is one of the largest integrated providers of mental health 

care services in the United States. As a consequence, VA collects 

11 

and maintains extraordinary amounts of data and statistics on veterans who seek mental health treatment. 

Unfortunately, the Committee has little information on how 

much data is maintained by VA, where it is held, and at what cost. 

Therefore, Section 12 of the Committee bill requires VA to submit 

a report, not later than 180 days after the date of enactment of the 

Committee bill detailing the information needed by the Committee 

to better monitor VA’s data collection in this sensitive area. 

Section 13. Strategic Plan for Long-Term Care 

In 1999, Congress passed and the President signed Public Law 

106–117, the Veterans Millennium Health Care and Benefits Act of 

1999 (hereinafter the ‘‘Millennium Act’’). The Millennium Act, 

among other things, required VA to develop a program of non-institutional long-term care services and mandated that VA maintain 

the institutional staffing and level of extended care services at, or 

above, the level of staffing and services during Fiscal Year 1998. 

These two actions were taken simultaneously because, at the time, 

some felt that the development of a non-institutional care program 

would cause VA to discontinue a large portion of its institutional 

care capacity. 

Since that time, VA has increased the number of veterans it 

treats by nearly two million. Yet, VA reports that it does not have 

a need to maintain the number of nursing home beds it is required 

to maintain under the current law. VA asserts that this is because 

they have paralleled the progress of medicine and offered tens-ofthousands of veterans the non-institutional care services that will 

keep them at home rather than in a VA long-term care bed. 

S. 1182, as introduced, contained a provision that would have 

struck the institutional capacity requirement from current law. 

However, discussion at the Committee’s hearing of June 9, 2005, 

coupled with legislation introduced by Senator Ken Salazar and 

testimony from the Veterans Service Organizations convinced the 

Committee that a more measured approach would serve the interests of the veterans VA serves as well as VA itself. 

As such, Section 13 requires the Under Secretary for Health to 

publish a strategic plan for long-term care. The plan should address policies and strategies for: care delivery in institutional, noninstitutional, and domiciliary settings; maximizing the use of the 

State Home Program; identification of free-standing nursing homes 

for care; data collection on catastrophically disabled veterans and 

their geographic location; and providing a full spectrum of non-institutional care services. 

It is the Committee’s hope that this strategic plan will provide 

a clearer focus for the future of VA long-term care as well as a 

roadmap for veterans who rely on VA’s services. 

Section 14. Blind Rehabilitation Outpatient Specialists 

VA operates a robust program to provide medical and social assistance to visually impaired veterans. Typically, care is provided 

at one of VA’s ten residential Blind Rehabilitation facilities. These 

facilities provide intensive inpatient care services designed to allow 

blinded veterans to live, work, and socialize independently of outside assistance. 

12 

Often, following a stay at a residential program, follow-up care 

will occur through care coordination provided by a Visual Impairment Service Team (hereinafter ‘‘VIST’’) coordinator at a local VA 

medical facility. Care coordinators ensure that veterans’ prosthetics 

are properly maintained, benefits are explained, and specialized 

health care services are provided to visually impaired veterans. In 

FY 2006, VA will employ over 150 part-time and full-time VIST coordinators. Total VA expenditures on blind rehabilitation services 

will exceed $62 million. 

Recently, a new model of care has been developed known as 

BROS. BROS are well-trained, blind rehabilitation specialists who 

can provide many of the services on an outpatient basis that are 

normally reserved for the inpatient treatment program. This allows 

VA to treat a greater number of visually impaired veterans, closer 

to home, at a lower cost. 

Further, because travel to one of the ten inpatient facilities is 

often a limitation to participation in rehabilitation, many advocates 

suggest that more veterans will become self-sufficient and enjoy 

greater opportunities for independent living through the BROS program. 

Unfortunately, VA has not focused as much as the Committee 

would like on the expansion of the BROS program. As such, Section 

14 directs VA to employ 35 new BROS at facilities of the department over the next three years. It is the Committee’s belief that 

by expanding the total number of BROS to over 50 VA can make 

a true, meaningful improvement in the lives of blinded veterans 

and do so closer to their homes. 

Section 15. Extension of Compliance Reporting Requirement 

Under current law, 38 U.S.C. §1706(b)(5), VA is required to submit to the Committees on Veterans’ Affairs of the House and Senate a report on its compliance with the so-called ‘‘specialized services capacity requirement’’. The capacity requirement dictates that 

VA must maintain within each Veterans Integrated Service Network (hereinafter ‘‘VISN’’) the capacity to provide specialized services to veterans. VA’s specialized services include: spinal cord injury programs; blind rehabilitation programs; traumatic brain injury programs, and amputation rehabilitation programs. 

Clearly, the Committee believes that VA must continue to devote 

significant resources to these important efforts. Renewing the reporting requirement will ensure that the Committee can appropriately monitor VA’s efforts in this area and hold officials accountable. 

Section 16. Health Care and Services for Veterans Affected by Hurricane Katrina 

Hurricane Katrina had devastating effects on the citizens and infrastructure in the States of Mississippi, Louisiana, Alabama, and 

Texas. Facilities of the Department of Veterans Affairs and the veterans served by these facilities were not immune to the results of 

this destruction. 

Over one million veterans reside in Louisiana, Mississippi, and 

Alabama. Hundreds-of-thousands of them were significantly affected by Katrina. They were forced to relocate (in many cases to 

Texas and Florida), lost their homes, jobs, and unfortunately health 

13 

insurance coverage. To address some of these concerns, Section 16 

of the Committee bill seeks to ensure that those veterans who lost 

health insurance and primary income can be assured of health coverage in any facility of the department as they attempt to put their 

lives back together and recover from this historical storm. 

The bill would authorize VA to treat any veteran from one of the 

affected states in any facility of the department regardless of 

whether the veteran is enrolled in the VA health care system, or 

even eligible to enroll. This authority, which also waives any applicable copayments or fees, extends through the end of January 

2006. 

There were views expressed in Committee about extending the 

cost-free access to all veterans for a longer period of time than January 31, 2006. The Committee is prepared to consider an extension 

of the timeline if VA officials believe that a longer access period is 

needed. However, the Committee believes that the bill contains a 

reasonable period of time for recovery of the affected veterans. Any 

efforts to extend the time must be mindful of the fact that special 

geographically-based eligibility cannot continue in perpetuity without being unfair to similarly situated veterans who reside in states 

not affected by Hurricane Katrina. 

Section 17. Reimbursement for Certain Veterans’ Outstanding 

Emergency Treatment Expenses 

Under current law, VA is authorized to pay for emergency care 

services provided to veterans in non-VA facilities if the veteran 

seeking the services is an enrolled patient and has seen a VA care 

provider in the past two years. However, the payment is also contingent on the veteran not having any other health insurance coverage for the service. 

As a result of the ‘‘payor of last resort’’ contingency, privately insured veterans are often paying more out-of-pocket costs than those 

with no insurance. VA has some evidence to suggest that the outof-pocket expenditures are causing some veterans to attempt to 

‘‘make it’’ to a VA facility where only VA copayments would apply. 

A recent study undertaken for VA showed that the additional 

travel time to a VA facility for emergency care was having deleterious health affects on VA patients. Clearly, that is not the kind 

of behavior the Committee seeks to encourage in our veterans. Nor 

is it good medicine. 

The Committee bill clarifies that veterans will be treated equally 

regardless of where emergency care treatment is sought. 

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 spending by $193 million in 2006 

and by $1.2 billion over the 2006–2010 period. Enactment of the 

Committee bill would not affect direct spending or 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: 

14 

OCTOBER 14, 2005. 

Hon. LARRY E. CRAIG, 

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. 1182, the Veterans Health 

Care Act of 2005. 

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

to provide them. The CBO staff contact is Michelle S. Patterson. 

Sincerely, 

DOUGLAS HOLTZ-EAKIN, 

Director. 

Enclosure. 

CONGRESSIONAL BUDGET OFFICE COST ESTIMATE

S. 1182—Veterans Health Care Act of 2005 

S. 1182 would expand or establish a number of health care benefits for veterans. In particular, the bill would authorize the Secretary of the Department of Veterans Affairs (VA) to provide medical care to infants born in VA hospitals, to reimburse certain veterans who seek emergency care from non-VA medical facilities, and 

to hire additional specialists who provide care for blind veterans. 

The bill also would allow veterans in areas affected by Hurricane 

Katrina who otherwise would not be eligible for such care to obtain 

medical care from VA and would prohibit the collection of co-payments and third-party reimbursements for medical care given to 

veterans from these areas. 

CBO estimates that implementing this bill would cost $193 million in 2006 and about $1.2 billion over the 2006–2010 period, assuming appropriation of the authorized and estimated amounts. 

Enacting this bill would not affect direct spending or receipts. 

S. 1182 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA) 

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

The estimated budgetary impact of S. 1182 is shown in Table 1. 

The costs of this legislation fall within budget function 700 (veterans benefits and services). 

TABLE 1.—ESTIMATED BUDGETARY IMPACT OF S. 1182 

By fiscal year, in millions of dollars— 

2006 2007 2008 2009 2010 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 1

Estimated authorization level ....................................................................... 297 319 228 234 238 

Estimated outlays ......................................................................................... 193 303 236 236 237 

1 These amounts do not include the costs of implementing section 7 because CBO cannot estimate such costs at this time. 

S. 1182 would affect discretionary spending for veterans’ medical 

care and would decrease the amount of offsetting collections deposited to the Medical Care Collections Fund (MCCF). CBO estimates 

that implementing S. 1182 would cost $193 million in 2006 and 

about $1.2 billion over the 2006–2010 period (see Table 2), assuming appropriation of the authorized and estimated amounts. These 

amounts do not include the costs of implementing section 7, which 

15 

would allow VA to conduct cost-comparison studies, because CBO 

cannot estimate the costs at this time. For this estimate, CBO assumes the bill will be enacted before the end of calendar year 2005. 

Section 4 would reinstate and make permanent VA’s authority to 

provide grants to organizations that furnish services to homeless 

veterans. That authority expired on October 1, 2005. The provision 

also would authorize the appropriation of $130 million in fiscal 

year 2006 and each subsequent year for these grants. Finally, the 

provision would authorize the appropriation of $1 million a year 

over the 2006–2011 period for grants to organizations that give 

technical assistance to entities or organizations that assist nonprofit, community-based groups in applying for grants to furnish 

services to homeless veterans. 

In 2005, the Congress appropriated $75 million for grants to organizations that furnish services to homeless veterans and 

$750,000 for grants to provide technical assistance. Based on information from VA, CBO assumes that it would take the department 

about three years to expand the grant programs to the levels authorized for 2006. Thus, CBO estimates that implementing section 

4 would cost $67 million in 2006 and $565 million over the 2006– 2010 period, assuming appropriations of the authorized amounts. 

TABLE 1.—ESTIMATED CHANGES IN SPENDING SUBJECT TO APPROPRIATION UNDER S. 1182 1

Provision 

By fiscal year, in millions of dollars—

2006 2007 2008 2009 2010 

Grants for Helping Homeless Veterans: 

Authorization level ................................................................................ 131 131 131 131 131 

Estimated outlays ................................................................................ 67 105 131 131 131 

Expansion of Mental Health Services 

Authorization level ................................................................................ 97 95 0 0 0 

Estimated outlays ................................................................................ 65 112 9 4 0 

Reimbursement for Emergency Treatment at Non-VA Medical Facilities: 

Estimated authorization level .............................................................. 52 73 76 80 83 

Estimated outlays ................................................................................ 47 69 75 79 82 

Medical Care for Veterans Affected by Hurricane Katrina: 

Estimated authorization level .............................................................. 6 9 9 10 10 

Estimated outlays ................................................................................ 6 8 9 9 10 

Forgone Offsetting Collections: 

Estimated authorization level .............................................................. 3 0 0 0 0 

Estimated outlays ................................................................................ 2 * * 0 0 

Care for Newborns: 

Estimated authorization level .............................................................. 4 7 8 9 10 

Estimated outlays ................................................................................ 4 6 8 9 10 

Outpatient Specialists for Blind Rehabilitation: 

Authorization level ................................................................................ 4 4 4 4 4 

Estimated outlays ................................................................................ 2 3 4 4 4 

Total Changes: 2

Estimated authorization level ..................................................... 297 319 228 234 238 

Estimated outlays ....................................................................... 193 303 236 236 237 

1 Five-year costs in the text differ slightly from a summation of the annual costs shown here because of rounding. 

2 These amounts do not include the costs of implementing section 7 because CBO cannot estimate such costs at this time. 

Note: * = less than $500,000. 

Section 8 would direct VA to improve and expand mental health 

services offered by the department and would authorize the appropriation of $95 million in 2006 and 2007 for these purposes. The 

provision would direct VA to increase the number of clinical treatment teams dedicated to the treatment of post-traumatic stress disorder (PTSD), to expand the services available to diagnose and 

treat substance abuse, and to improve tele-health initiatives in 

16 

areas of the country that are far from VA facilities. The provision 

also would require the Department of Defense (DoD) to work with 

the National Center on Post Traumatic Stress Disorder to provide 

training medical care providers within DoD on PTSD and would 

authorize the appropriation of $2 million in 2006 to carry out this 

authority. Assuming outlays follow historical patterns, CBO estimates that implementing section 8 would cost $65 million in 2006 

and about $190 million over the 2006–2009 period, assuming appropriation of the authorized amounts. 

Section 17 would allow VA to reimburse certain veterans who 

seek emergency treatment from a non-VA medical facility. Under 

current law, a veteran who receives emergency care in the private 

sector for a nonservice-connected condition can only be reimbursed 

if he or she has no other insurance coverage. This provision would 

authorize VA to reimburse veterans who receive emergency treatment from a non-VA medical facility for costs that the veteran remains personally liable for if the veteran is enrolled in VA’s health 

care system, received medical care from VA during the 24-month 

period preceding emergency treatment, has health insurance that 

partially reimburses the cost of emergency treatment, is financially 

liable for the cost of treatment that is not reimbursed by his or her 

health insurance, and is not eligible for reimbursement under current law. 

According to VA, it expects about 250,000 veterans would qualify 

each year for reimbursement under this provision and that, on average, such veterans would be paid about $280 in 2006 to cover 

nonreimbursed treatment costs including net co-pays and 

deductibles. (VA indicates that it would deduct the co-payment a 

veteran would have paid if the treatment had been provided at a 

VA facility from any request for reimbursement.) Based on this information and adjusting for inflation, CBO estimates that implementing section 17 would cost $47 million in 2006 (accounting for 

a partial-year effect) and about $350 million over the 2006–2010 

period, assuming appropriation of the necessary amounts. 

Section 16 would require VA to treat certain veterans affected by 

Hurricane Katrina who would otherwise not be allowed to receive 

care from the agency’s medical system. Since January 2003, VA 

has not accepted new enrollments from priority 8 veterans, who are 

veterans without a service-connected disability and with income 

above certain thresholds. This provision would allow those priority 

8 veterans in the New Orleans, Louisiana, and Gulfport or Biloxi, 

Mississippi, regions who were previously excluded to receive care 

at VA medical facilities through January 31, 2006. 

Based on data from VA about the number of veterans in these 

regions and the projected population of potential priority 8 enrollees in each state, CBO estimates that there are about 5,700 veterans from the affected areas who would seek care from VA at an 

average annual cost of about $1,500 in 2006. Although the provision would limit such care to the period before January 31, 2006, 

CBO expects that VA would allow these veterans to continue to receive medical care beyond that date since it has grandfathered such 

priority 8 veterans in the past. Thus, after adjusting for expected 

inflation, CBO estimates that implementing this provision would 

cost $6 million in 2006 and almost $45 million over the 2006–2010 

period, assuming appropriation of the necessary amounts. 

17 

Section 16 also would prohibit VA from collecting co-payments 

and third-party co-payments and third-party reimbursements for 

medical care given to veterans from these areas until January 31, 

2006. Under current law, certain veterans must make co-payments 

when receiving health care from VA. In addition, VA can bill a veteran’s third-party insurance when the veteran is treated for nonservice-connected conditions. These payments are deposited into 

the MCCF and, under current law, are treated as offsets to discretionary spending. Spending from the MCCF is subject to appropriation. 

VA estimates that it will collect nationwide more than $2.1 billion in co-payments and reimbursements in 2006. Because the population for the affected area comprises less than 1 percent of all 

veterans using VA’s medical system and CBO expects that VA 

would waive co-payments and third-party reimbursements for only 

one month, CBO estimates that implementing this provision would 

reduce collections by about $3 million in 2006. 

Section 2 would allow VA to provide medical care for up to 14 

days to newborns of female veterans who are delivered in a VA facility. Under current law, VA may only provide medical benefits to 

the mother. VA estimates that about 1,000 newborns would receive 

medical care in the first year and that this number would grow to 

about 2,000 infants by 2011. Based on data from VA, CBO estimates that the cost of providing neonatal care to those infants 

would be about $5,900 per infant in 2006. (Providing neonatal care 

for most infants would cost much less; the high average cost is 

driven by those infants who require extensive care for longer periods of time.) After adjusting for expected inflation, CBO estimates 

that implementing this provision would cost $4 million in 2006 and 

$36 million over the 2006–2010 period, assuming appropriation of 

the necessary amounts. 

Section 14 would require VA to employ outpatient specialists for 

blind rehabilitation at no fewer than 35 of its facilities and would 

authorize the appropriation of $3.5 million a year over the 2006–

2011 period to carry out this provision. CBO estimates that implementing this provision would cost $2 million in 2006 and just over 

$16 million over the 2006–2010 period, assuming appropriation of 

the necessary amounts. 

Section 7 would repeal a provision in law that prohibits VA from 

using appropriated funds to conduct studies comparing the costs of 

allowing certain functions to be performed by private contractors 

instead of using VA personnel. CBO cannot estimate the budgetary 

impact of implementing this provision since VA has not provided 

information on the number of studies it would conduct or the potential cost per study. It is likely, however, that the costs of implementing section 7 would be small compared to the total cost of this 

bill. 

The following provisions would have an insignificant budgetary 

impact on spending subject to appropriation: 

• Section 6 would exempt the Chief Nursing Officer with the 

Office of Nursing Services from current-law restrictions to 

nurse pay and allow that officer to be paid at a rate up to the 

maximum rate established by the Senior Executive Service. 

Based on information provided by VA, CBO estimates that implementing this provision would cost less than $50,000 a year. 

18 

• Section 3 would allow medical care providers to collect 

payment for services from a third-party insurance company 

when they provide care to certain children of Vietnam veterans. Under current law, medical care providers who treat 

children of Vietnam veterans with spina bifida or birth defects 

can only receive payment from VA. This provision would allow 

providers to seek payment from a responsible third-party for 

the difference between the amount billed and the amount paid 

by VA. CBO estimates that implementing this provision would 

not affect VA payments to these providers. 

• Section 10 would direct VA to increase the number of personnel employed by VA as part of its Readjustment Counseling 

Service outreach program. Section 11 would direct VA to increase the number of Veterans Readjustment Counseling Service facilities that can provide tele-health linkages with other 

VA facilities. VA indicates that it is already implementing such 

increases. As such, CBO estimates that implementing these 

provisions would result in no additional costs. 

S. 1182 contains no intergovernmental or private-sector mandates as defined in UMRA and would impose no costs on state, 

local, or tribal governments. 

The CBO staff contacts are Michelle Patterson, Melissa Merrell, 

and Allison Percy. This estimate was approved by Peter H. 

Fontaine, Deputy Assistant Director for Budget Analysis. 

REGULATORY IMPACT STATEMENT

In compliance with paragraph 11(b) of rule XXVI of the Standing 

Rules of the Senate, the Committee on Veterans’ Affairs has made 

an evaluation of the regulatory impact that would be incurred in 

carrying out the Committee bill. The Committee finds that the 

Committee bill would not entail any regulation of individuals or 

businesses or result in any impact on the personal privacy of any 

individuals and that the paperwork resulting from enactment 

would be minimal. 

TABULATION OF VOTES CAST IN COMMITTEE

In compliance with paragraph 7 of rule XXVI of the Standing 

Rules of the Senate, the following is a tabulation of votes cast in 

person or by proxy by members of the Committee on Veterans’ Affairs at its September 15, 2005 meeting. 

On that date, the Committee, by voice vote, ordered S. 1182 reported favorably to the Senate, with related measures included 

from the following: provisions of S. 1177, a bill by Committee Ranking Member Daniel K. Akaka; provisions of S. 1189, a bill by Committee Member Senator Ken Salazar; and provisions of S. 1190, a 

bill by Committee Member Senator Salazar. 

In addition, the Committee adopted two amendments to S. 1182. 

One amendment by Committee Ranking Member Akaka concerning 

the provision of emergency care services to veterans was adopted 

by unanimous consent. A second amendment offered by Committee 

Ranking Member Akaka concerning health care services for veterans affected by Hurricane Katrina was adopted by voice vote 

after a second degree amendment to the Akaka amendment, offered 

19 

by Chairman Larry E. Craig, was adopted by a vote of 8 yeas and 

6 nays. 

AGENCY REPORT

On June 9, 2005, Secretary of Veterans’ Affairs, the Honorable 

R. James Nicholson, appeared before the Committee on Veterans’

Affairs and submitted testimony on, among other things, a draft 

version of the Veterans Health Care Improvements Act of 2005. Excerpts from this statement are reprinted below: 

STATEMENT OF THE VIEWS OF THE 

ADMINISTRATION 

STATEMENT OF THE HONORABLE R. JAMES NICHOLSON

SECRETARY OF VETERANS’ AFFAIRS

Good Afternoon Mr. Chairman and Members of the Committee: 

I am pleased to be here this morning to present the Department’s views on several different bills being considered 

by the Committee. They cover a wide range of subjects related to VA’s provision of health care services to veterans. 

VETERANS HEALTH CARE IMPROVEMENTS ACT OF 2005

Mr. Chairman, I will begin by commenting on your draft 

bill that includes an array of provisions, many of which 

would carry out proposals that were included in the President’s budget submitted to Congress earlier this year. We 

strongly support enactment of this measure and we appreciate your inclusion of provisions to carry out the President’s plans for assisting veterans and for assisting the 

Department to carry out its mission. 

One major provision in the bill would expand VA’s authority to assist with payment for emergency-care costs 

that veterans incur in private hospitals. As you may know, 

a major study found that veterans with cardiac emergencies, despite having health insurance, often deliberately 

forgo emergency treatment at the closest community hospital (where they might incur out-of-pocket expenses) in 

favor of receiving care from the nearest VA facility at no 

or minimal cost. Delaying needed emergency medical treatment can jeopardize their health status and hinder the Department’s ability to timely and successfully manage their 

emergent medical conditions. Under current law, a veteran 

who obtains emergency care in the private sector for a 

nonservice-connected condition is not eligible for VA reimbursement for the related expenses if the veteran has any 

insurance or other coverage for the cost of the care, in 

whole or in part. Your proposal would amend the law to 

enable the Department to reimburse a veteran for out-ofpocket expenses not covered by insurance or other coverage, thereby ensuring that veterans, whether insured or 

not, have consistent access to optimal care for emergency 

health conditions. 

20 

Unfortunately, the stress of combat leaves scars on 

many veterans. Your bill contains several new authorities 

that will help assist us in caring for those returning from 

overseas who are suffering from PTSD and other mental 

health disorders. The bill also contains a provision to exempt former POWs from having to pay copayments in connection with the receipt of extended-care services, and a 

second provision to exempt veterans from copayments for 

hospice care in a hospital or at home. These provisions will 

be extremely beneficial to the affected veterans. The bill 

would also authorize time-limited care for newborn children when veterans deliver the children under VA auspices. 

Finally, Mr. Chairman, your bill contains two provisions 

that would repeal laws that have seriously hindered our 

efforts at VA to provide veterans with high-quality care by 

the best and most cost-effective means. The bill would repeal a law that requires VA to maintain at least the same 

staffing and level of extended-care services in Department 

facilities as was provided in fiscal year 1998. That law has 

seriously limited our ability to provide or pay for extended 

care services for veterans in a variety of institutional and 

non-institutional settings outside VA, including private 

nursing homes in the community and State nursing home 

facilities. As you know, many veterans prefer to remain in 

their homes and communities, and it is often cost-effective 

to provide care in those settings. Your bill would also repeal an old law that generally bars the Department from 

using appropriated funds to compare the costs of providing 

services directly, or by contract, which impedes our ability 

to obtain the best possible value for veterans. On a government-wide basis, public-private competitions completed in 

FYs 2003 and 2004 are estimated to generate savings, or 

cost avoidances, for the taxpayer of more than $2.5 billion 

over the next three to five years. The tailored and responsible use of competitive sourcing at VA will help the Department free up resources that can be dedicated to our 

veterans. 

(21) 

MINORITY VIEWS OF RANKING MEMBER AKAKA 

The underlying legislation is a step forward in improving care for 

veterans. I am especially pleased that the bill now includes my legislation to provide a measure of financial relief for those veterans 

affected by Hurricane Katrina. 

Where this legislation falls short, however, is that it does not do 

enough to improve care for veterans living in rural areas. In addition, the legislation would eliminate the long-standing prohibition 

against the Veterans Health Administration conducting costly private-public cost comparison studies without a separate appropriation. 

Let me present my concerns. 

RURAL CARE IS NOT ADDRESSED

While the underlying legislation contains varying provisions on 

such subjects as mental health care, emergency care, and homeless 

veterans, none are specifically designed to help veterans living in 

rural areas. 

The Committee rejected an amendment I offered that would have 

provided VA with a viable set of tools with which to address the 

unique needs of veterans living in rural areas. The amendment was 

partially based on legislation I introduced in June to improve 

things for rural veterans in Hawaii. In addition, provisions from 

worthy legislation introduced by Senators Thune and Salazar on 

rural health initiatives were also included in the amendment. This 

amendment received bipartisan support but failed on a tie vote. 

Specific to Hawaii, we know that the level of care provided to 

those living on what we call the ‘‘Neighbor Islands’’—Kauai, 

Molokai, Lanai, Maui, and the Big Island is not at the optimal 

level. My amendment called for a pilot program to test the operation of two satellite clinics, as well as expanding services at those 

already in existence. 

This pilot would focus on the islands of Molokai and Lanai, 

which currently lack VA facilities altogether. A veteran living on 

either of these remote islands must either wait for a VA provider 

to visit—which is only nine to ten times a year for Molokai and 

four times a year for Lanai—or take it upon himself to get to Maui 

for clinical care or to Oahu for treatment for a more serious condition. 

Filling up the car with a tank of gas and driving across the State 

is obviously not even an option. Inter-island airfare is more than 

$200. VA does not reimburse for this. Add in various other travel 

costs, such as rental car and lodging expenses, and a veteran may 

choose to forgo care rather than pay these sizeable out-of-pocket 

costs. Even when a VA provider finally comes to one of these remote islands, they have no computer or telemedicine equipment—

22 

this from a Department which touts their computerized medical 

records and technologies. 

At the Committee’s legislative hearing in early June, VA couldn’t 

comment on these Hawaii-specific rural access components. However, VA now has had four months to comment. And they have still 

not done so. One could assume that the needs of Hawaii’s veterans 

do not rank high on the list of Department priorities. 

Let us not be under the illusion that State-specific projects are 

not important and have not been moved upon by this Committee. 

For those who would argue that this amendment is too prescriptive, I would argue that it absolutely needs to be. 

For example, clinic personnel have asked for home care nurses 

to fulfill the long-term mandate this Committee passed six years 

ago. Veterans on Molokai are literally rallying for better care. Even 

when the Network and the local VA sends up proposals to Headquarters they are not acted upon. In the meantime, veterans are 

suffering. 

With respect to this bill including benefits for veterans in rural 

areas in my state, let me state that these are legitimate needs of 

Hawaii veterans and, if these demonstration projects are successful, could be used as models for other rural areas in our nation. 

At times, Members need to write prescriptive legislation, when it 

is clear that an agency or Department is not doing what is required. Because of the distance to the mainland, and because of the 

view that Hawaii is a paradise—which it is—it is difficult for us 

to get policymakers to travel to Hawaii to actually witness firsthand the challenges faced by veterans living on these geographically remote islands. As a result, the needs of neighbor island veterans are being ignored. 

This amendment seeks to fix some of the access problems, while 

giving VA another opportunity to work with veterans to see which 

approach is best for all. 

Also included in this amendment was Senator Thune’s rural pilot 

program which would give us more data about how best to treat 

veterans living in highly rural areas. In addition, again based on 

Senator Thune’s bill, VA needs to revamp its beneficiary travel program. This benefit is one that is highly valued by many veterans, 

especially those on fixed incomes. Unfortunately, there has not 

been an increase in the benefit for some time. In 2001, VA found 

that the current allowances under this program were not sufficient 

to begin to deal with high gas prices. Yet, four years later, the increase was never put forward. 

This beneficiary travel increase would go hand in hand with another provision—an innovative grant program to provide options 

for transportation that Senator Salazar originally introduced. Although some ad hoc veterans travel programs have community support, many suffer from underfunding. Relatively small investments 

in transportation services can result in significantly better care for 

our Nation’s most vulnerable veterans. 

While this legislation still does not contain any provisions aimed 

at rural health, I will be working to ensure that these provisions 

come to fruition. For example, the Committee will be holding field 

hearings in my State. The main focus of these hearings will be on 

the unique access issues. 

23 

BLANKET APPROVAL FOR COST COMPARISON STUDIES: UNPROVEN AND

EXPENSIVE

The Committee Bill would eliminate the longstanding prohibition 

against the Veterans Health Administration (VHA) conducting private-public cost comparison studies without a separate appropriation. This is the wrong course for VA at this time. 

VHA has experienced serious shortfalls this year in the funding 

account for veterans’ health care. As the cost of health care continues to rise to adjust for medical inflation and burgeoning demand, VHA resources are stretched thin. Yet, the Committee would 

give VHA this authority without any idea of the costs of the studies 

and the expenses associated with implementing the findings. 

VA has yet to provide detailed estimates on how much will be 

spent doing these studies. The annual report on President Bush’s 

‘‘competitive sourcing’’ initiative says that the government spent 

$110 million in 2004 on private-public cost comparison studies. 

These studies reviewed, in total, more than 12,000 positions 

throughout the Federal government. In the end, about 1,000 jobs 

were contracted out, at a cost to the taxpayer of close to $100,000 

per position. VA has identified 36,000 positions which could be affected by cost-comparison studies. Given the results from the ‘‘competitive sourcing’’ initiative, it is unrealistic to expect that VA 

would spend hundreds of millions to conduct its own cost comparison studies. In reality, VA would likely spend much, much more. 

At the Committee markup, the Chairman argued that this bill 

would generate, ‘‘$1.3 billion over five years, that this would be the 

opportunity for this Committee to reinvest that money in care services.’’ Unfortunately, to date, VA has been unable to document any 

substantial savings through its previous outsourcing initiatives or 

the creation of any significant new hires of full-time employees 

(FTE) as a result. 

The Committee Report above states, ‘‘It is important to note that 

the Committee does not believe that comparison studies will inevitably result in the reduction of government employment.’’ In reality, VA’s own estimates for FTE reinvestment are based upon the 

potential elimination or outsourcing of some or all of 36,000 jobs 

currently being performed by government workers. 

The provision would likely have a disastrous effect on VA workers, many of whom are also veterans. VA’s own plan calls for the 

first 12,000 VHA employees affected by these cost-comparison studies to be laundry, canteen, nutrition, and food service workers. According to VA’s own figures, 75 percent of the laundry workers and 

57 percent of the food service workers are veterans. In addition, 

there are 3,400 veterans participating in VA’s compensated work 

therapy program working in these same fields. It makes no sense 

for the Committee to pursue legislation that disregards the unique 

characteristics of VHA’s workforce and jeopardizes the employment 

of veterans currently employed in these wage-grade jobs. 

The provision in the legislation also lacks any mechanism for effective oversight of these studies. If enacted, there would be no 

transparency, and ergo, no accountability to Congress on this issue. 

Before we blindly proceed, we should have a clear idea of how 

and where these savings will occur and what impact they will have 

24 

on VA’s existing workforce. A much more prudent course of action 

would allow VA to use its own internal management analyses. VA 

through its own internal program should first be given the opportunity to realize its goal for management efficiencies without the 

disruption and uncertainty to its workforce created by cost-comparison studies and without the unnecessary expenditure of millions of unappropriated dollars needed to conduct them. 

In summary, given the current shortfalls in VHA funding, it is 

inappropriate for VHA to spend millions on cost-comparison studies 

without any evidence there are substantial savings to be gained 

from such an endeavor. The legislation would give VA blanket approval to spend millions on conducting these studies without any 

provisions for Congressional oversight. 

CHANGES IN EXISTING LAW MADE BY THE COMMITTEE BILL, AS

REPORTED

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, UNITED STATES CODE 

* * * * * * * 

CHAPTER 17—HOSPITAL, NURSING HOME, 

DOMICILIARY, AND MEDICAL CARE 

* * * * * * * 

Subchapter II—Hospital, Nursing Home, or Domiciliary and 

Medical Treatment 

* * * * * * * 

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

* * * * * * * 

(f)(1) The Secretary may not furnish hospital care or nursing 

home care other than 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) of this subsection. 

(g)(1) The Secretary may not furnish medical services other than 

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. 

* * * * * * * 

25 

§ 1710B. Extended care services 

* * * * * * * 

(a) * * * 

ø(b) The Secretary shall ensure that the staffing and level of extended care services provided by the Secretary nationally in facilities of the Department during any fiscal year is not less than the 

staffing and level of such services provided nationally in facilities 

of the Department during fiscal year 1998.¿ 

ø(c)¿(b)(1) Except as provided in paragraph (2), the Secretary 

may not furnish extended care services for a non-service-connected 

disability other than in the case of a veteran who has a compensable service-connected disability unless the veteran agrees to pay 

to the United States a copayment (determined in accordance with 

subsection (d)) for any period of such services in a year after the 

first 21 days of such services provided that veteran in that year. 

(2) Paragraph (1) shall not apply— (A) to a veteran whose annual income (determined under 

section 1503 of this title) is less than the amount in effect 

under section 1521(b) of this title; 

(B) to a veteran who is a former prisoner of war; 

ø(B)¿(C) to a veteran being furnished hospice care under this 

section; or 

ø(C)¿(D) with respect to an episode of extended care services 

that a veteran is being furnished by the Department on November 30, 1999. 

ø(d)¿(c)(1) A veteran who is furnished extended care services 

under this chapter and who is required under subsection ø(c)¿(b) 

to pay an amount to the United States in order to be furnished 

such services shall be liable to the United States for that amount. 

(2) In implementing subsection ø(c)¿(b), the Secretary shall develop a methodology for establishing the amount of the copayment 

for which a veteran described in subsection ø(c)¿(b) is liable. That 

methodology shall provide for—

(A) establishing a maximum monthly copayment (based on 

all income and assets of the veteran and the spouse of such 

veteran); 

(B) protecting the spouse of a veteran from financial hardship by not counting all of the income and assets of the veteran 

and spouse (in the case of a spouse who resides in the community) as available for determining the copayment obligation; 

and 

(C) allowing the veteran to retain a monthly personal allowance. 

ø(e)¿(d)(1) There is established in the Treasury of the United 

States a revolving fund known as the Department of Veterans Affairs Extended Care Fund (hereinafter in this section referred to as 

the ‘‘fund’’). Amounts in the fund shall be available, without fiscal 

year limitation and without further appropriation, exclusively for 

the purpose of providing extended care services under subsection 

(a). 

(2) All amounts received by the Department under this section 

shall be deposited in or credited to the fund. 

* * * * * * * 

26 

Subchapter III—Miscellaneous Provisions Relating to Hospital and Nursing Home Care and Medical Treatment of 

Veterans 

* * * * * * * 

§ 1725. Reimbursement for Emergency Treatment 

* * * * * * * 

(a) GENERAL AUTHORITY.—(1) Subject to subsections (c) øand 

(d)¿, the Secretary may reimburse a veteran described in subsection (b) for øthe reasonable value of¿ expenses resulting from 

emergency treatment furnished the veteran in a non-Department 

facility for which the veteran remains personally liable. 

(2) In any case in which reimbursement is authorized under subsection (a)(1), the Secretary, in the Secretary’s discretion, may, in 

lieu of reimbursing the veteran, make payment øof the reasonable 

value of the furnished emergency treatment directly¿—

(A) to a hospital or other health care provider that furnished 

the treatment; or 

(B) to the person or organization that paid for such treatment on behalf of the veteran. 

(b) ELIGIBILITY.—ø(1)¿ A veteran referred to in subsection 

(a)ø(1)¿ is an individual who—øis an active Department healthcare participant who is personally liable for emergency treatment 

furnished the veteran in a non-Department facility.¿ 

(1) is enrolled in the health care system established under section 1705(a) of this title; 

ø(2) A veteran is an active Department health-care participant 

if—

(A) the veteran is enrolled in the health care system established under section 1705(a) of this title; and 

(B) the veteran received care under this chapter within the 

24-month period preceding the furnishing of such emergency 

treatment.¿ 

(2) received care under this chapter during the 24-month period preceding the furnishing of such emergency treatment; 

ø(3) veteran is personally liable for emergency treatment furnished the veteran in a non-Department facility if the veteran—

(A) is financially liable to the provider of emergency treatment for that treatment; 

(B) has no entitlement to care or services under a healthplan 

contract (determined, in the case of a health-plan contract as 

defined in subsection (f)(2)(B) or (f)(2)(C), without regard to 

any requirement or limitation relating to eligibility for care or 

services from any department or agency of the United States); 

(C) has no other contractual or legal recourse against a third 

party that would, in whole or in part, extinguish such liability 

to the provider; and 

(D) is not eligible for reimbursement for medical care of services under section 1728 of this title.¿ 

(3) is entitled to care or services under a health-plan contract 

that partially reimburses the cost of the veteran’s emergency 

treatment; 

27 

(4) is financially liable to the provider of emergency care 

treatment for costs not covered by the veteran’s health-plan contract, including copayments and deductibles; and 

(5) is not eligible for reimbursement for medical care or services under section 1725 or 1728 of this title. 

(c) LIMITATIONS ON REIMBURSEMENT.—(1) øThe Secretary, in accordance with regulations prescribed by the Secretary, shall—¿ Any 

amount paid by the Secretary under subsection (a) shall exclude the 

amount of any payment the veteran would have been required to 

make to the United States under this chapter if the veteran had received the emergency treatment from the Department. 

ø(A) establish the maximum amount payable under subsection (a); 

ø(B) delineate the circumstances under which such payments 

may be made, to include such requirements on requesting reimbursement as the Secretary shall establish; and 

ø(C) provide that in no event may a payment under that subsection include any amount for which the veteran is not personally liable.¿ 

(2) øSubject to paragraph (1)¿ øt¿ The Secretary may not provide 

reimbursement under this section with respect to any item or service øonly after the veteran or the provider of emergency treatment 

has exhausted without success all claims and remedies reasonably 

available to the veteran or provider against a third party for payment of such treatment.¿—

(A) provided or for which payment has been made, or can 

reasonably be expected to be made, under the veteran’s healthplan contract; or 

(B) for which payment has been made or can reasonably be 

expected to be made by a third party. 

(3) (A) Payment by the Secretary under this section on behalf of 

a veteran to a provider of emergency treatment shall, unless rejected and refunded by the provider within 30 days of receipt, extinguish any liability on the part of the veteran for that treatment. 

øNeither the absence of a contract or agreement between the Secretary and the provider nor any provision of a contract, agreement, 

or assignment to the contrary shall operate to modify, limit, or negate the requirement in the preceding sentence¿. 

(B) The absence of a contract or agreement between the Secretary 

and the provider, any provision of a contract or agreement, or an 

assignment to the contrary shall not operate to modify, limit, or negate the requirement under subparagraph (A). 

(4) In accordance with regulations prescribed by the Secretary, the 

Secretary shall (A) establish criteria for determining the amount of 

reimbursement (which may include a maximum amount) payable 

under this section; and 

(B) delineate the circumstances under which such payment may 

be made, including requirements for requesting reimbursement. 

(d) INDEPENDENT RIGHT OF RECOVERY.—(1) In accordance with 

regulations prescribed by the Secretary, the United States shall 

have the independent right to recover any amount paid under this 

section øwhen¿ if, and to the extent that, a third party subsequently makes a payment for the same emergency treatment. 

28 

(2) Any amount paid by the United States to the veteran, ø(or¿ 

the veteran’s personal representative, successor, dependents, or 

survivorsø)¿, 

or to any other person or organization paying for such treatment 

shall constitute a lien in favor of the United States against any recovery the payee subsequently receives from a third party for the 

same treatment. 

(3) Any amount paid by the United States to the provider that 

furnished the veteran’s emergency treatment shall constitute a lien 

against any subsequent amount the provider receives from a third 

party for the same emergency treatment for which the United 

States made payment. 

(4) The veteran ø(¿ or the veteran’s personal representative, successor, dependents, or survivors ø)¿ shall— (A) ensure that the Secretary is promptly notified of any payment received from any third party for emergency treatment 

furnished to the veteran ø.¿; 

øThe veteran (or the veteran’s personal representative, successor, dependents, or survivors) shall¿ (B) immediately forward all documents relating to øsuch¿ a payment described in 

subparagraph (A) 

(C) cooperate with the Secretary in the investigation of 

øsuch¿ a payment described in subparagraph (A); and 

(D) assist the Secretary in enforcing the United States right 

to recover any payment made under subsection (c)(3). 

(e) WAIVER.—The Secretary ø, in the Secretary’s discretion,¿ may 

waive recovery of a payment made to a veteran under this section 

that is otherwise required by subsection (d)(1) when the Secretary 

determines that such waiver would be in the best interest of the 

United States, as defined by regulations prescribed by the Secretary. 

(f) DEFINITIONS.—For purposes of this section ø:¿— ø(2)¿ (1) The term ø’’¿ ‘healthplan contractø’’¿’ includes øany 

of the following:¿—

(A) An insurance policy or contract, medical or hospital 

service agreement, membership or subscription contract, or 

similar arrangement under which health services for individuals are provided or the expenses of such services are 

paid ø.¿; 

(B) An insurance program described in section 1811 of 

the Social Security Act (42 U.S.C. 1395c) or established by 

section 1831 of that Act (42 U.S.C. 1395j) ø.¿; 

(C) A State plan for medical assistance approved under 

title XIX of such Act (42 U.S.C. 1396 et seq.) ø.¿; and 

(D) A workers’ compensation law or plan described in 

section 1729(a)(2)(A) of this title ø.¿; 

ø(E) A law of a State or political subdivision described 

in section 1729(a)(2)(B) of this title.¿ 

ø(3)¿ (2) The term ø’’¿ ‘third partyø’’¿’ means øany of the following:¿; 

(A) A Federal entityø.¿; 

(B) A State or political subdivision of a State ø.¿; 

(C) An employer or an employer’s insurance carrierø.¿; 

and 

29 

ø(D) An automobile accident reparations insurance carrier.¿ 

ø(E)¿ (D) A person or entity obligated to provide, or to 

pay the expenses of, øhealth services under a healthplan 

contract.¿ such emergency treatment; and 

ø(1)¿ (3) The term ø’’¿ ‘emergency treatmentø’’¿’ ømeans 

medical care or services furnished, in the judgment of the Secretary—¿ has the meaning given such term in section 1725 of 

this title. 

ø(A) when Department or other Federal facilities are not 

feasibly available and an attempt to use them beforehand 

would not be reasonable; 

ø(B) when such care or services are rendered in a medical emergency of such nature that a prudent layperson 

reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health; and 

ø(C) until such time as the veteran can be transferred 

safely to a Department facility or other Federal facility.¿ 

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

of chapter 17 is amended by inserting after the item relating to section 1725 the following: 

Sec. 1725A. Reimbursement for emergency treatment expenses for which certain veterans remain personally liable 

* * * * * * * 

Subchapter VIII—Health Care of Persons Other Than 

Veterans 

* * * * * * * 

§ 1785. * * * 

* * * * * * * 

§ 1786. Care for newborn children of women veterans receiving maternity care 

(a) The Secretary may furnish care to a newborn child of a 

woman veteran, who is receiving maternity care furnished by the 

Department, for not more than 14 days after the birth of the child 

if the veteran delivered the child in a Department contract for the 

delivery services. 

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

of chapter 17 is amended by inserting after the item relating to section 1785 the following: 

SEC. 1786. Care for newborn children of women veterans receiving maternity care 

* * * * * * * 

CHAPTER 18—BENEFITS FOR CHILDREN OF VIETNAM 

VETERANS 

* * * * * * * 

§ 1803. Health care 

* * * * * * * 

(b) * * * 

30 

(c)(1) If a payment made by the Secretary for health care under 

this section is less than the amount billed for such health care, the 

health care provider or agent of the health care provider may, in accordance with paragraphs (2) through (4), 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 would be eligible to receive payment for such health care 

from such third party. 

(2) The health care provider or agent may not impose any additional charge on the beneficiary who received the health care, or the 

family of such beneficiary, for any service or item for which the Secretary has made payment under this section; 

(3) The total amount of payment a health care provider or agent 

may receive for health care furnished under this section may not exceed the amount billed to the Secretary. 

(4) The Secretary, upon request, shall disclose to such third party 

information received for the purposes of carrying out this section.. 

øc¿ (d) For the purposes of this section—

(1) The term ‘‘health care’’—

(A) means home care, hospital care, nursing home care, 

outpatient care, preventive care, habilitative and rehabilitative care, case management, and respite care; and 

(B) includes—

(i) the training of appropriate members of a child’s 

family or household in the care of the child; and 

(ii) the provision of such pharmaceuticals, supplies, 

equipment, devices, appliances, assistive technology, 

direct transportation costs to and from approved 

sources of health care, and other materials as the Secretary determines necessary. 

(2) The term ‘‘health care provider’’ includes specialized 

spina bifida clinics, health care plans, insurers, organizations, 

institutions, and any other entity or individual furnishing 

health care services that the Secretary determines are authorized under this section. 

(3) The term ‘‘home care’’ means outpatient care, habilitative 

and rehabilitative care, preventive health services, and healthrelated services furnished to an individual in the individual’s 

home or other place of residence. 

(4) The term ‘‘hospital care’’ means care and treatment for a 

disability furnished to an individual who has been admitted to 

a hospital as a patient. 

(5) The term ‘‘nursing home care’’ means care and treatment 

for a disability furnished to an individual who has been admitted to a nursing home as a resident. 

(6) The term ‘‘outpatient care’’ means care and treatment of 

a disability, and preventive health services, furnished to an individual other than hospital care or nursing home care. 

(7) The term ‘‘preventive care’’ means care and treatment 

furnished to prevent disability or illness, including periodic examinations, immunizations, patient health education, and such 

other services as the Secretary determines necessary to provide 

effective and economical preventive health care. 

31 

(8) The term ‘‘habilitative and rehabilitative care’’ means 

such professional, counseling, and guidance services and treatment programs (other than vocational training under section 

1804 of this title) as are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of a 

disabled person. 

(9) The term ‘‘respite care’’ means care furnished on an intermittent basis for a limited period to an individual who resides 

primarily in a private residence when such care will help the 

individual to continue residing in such private residence. 

* * * * * * * 

§ 1813. Health care 

(b) * * * 

(c)(1) If payment made by the Secretary for health care under this 

section is less than the amount billed for such health care, the 

health care provider or agent of the health care provider may, in accordance with paragraphs (2) through (4), 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 would be eligible to receive payment for such health care 

from such third party. 

(2) The health care provider or agent may not impose any additional charge on the beneficiary who received health care, or the 

family of such beneficiary, for any service or item for which the Secretary has made payment under this section; 

(3) The total amount of payment a health care provider or agent 

may receive for health care furnished under this section may not exceed the amount billed to the Secretary; and 

(4) The Secretary, upon request, shall disclose to such third party 

information received for the purposes of carrying out this section. 

ø(c)¿ (d) DEFINITIONS.—For purposes of this section, the definitions in section 1803(c) of this title shall apply with respect to the 

provision of health care under this section, except that for such 

purposes—

(1) the reference to ‘‘specialized spina bifida clinic’’ in paragraph (2) of that section shall be treated as a reference to a 

specialized clinic treating the birth defect concerned under this 

section; and 

(2) the reference to ‘‘vocational training under section 1804 

of this title’’ in paragraph (8) of that section shall be treated 

as a reference to vocational training under section 1814 of this 

title. 

* * * * * * * 

CHAPTER 20—BENEFITS FOR HOMELESS VETERANS 

* * * * * * * 

Subchapter II—Comprehensive Service Programs 

* * * * * * * 

32 

§ 2011. Grants 

(a) AUTHORITY TO MAKE GRANTS.—ø(1)¿ Subject to the availability of appropriations provided for such purpose, the Secretary 

shall make grants to assist eligible entities in establishing programs to furnish, and expanding or modifying existing programs 

for furnishing, the following to homeless veterans: 

(A) Outreach. 

(B) Rehabilitative services. 

(C) Vocational counseling and training 

(D) Transitional housing assistance. 

ø(2) The authority of the Secretary to make grants under this 

section expires on September 30, 2005.¿ 

* * * * * * * 

§ 2013. Authorization of appropriations 

There are authorized to be appropriated $130,000,000 for fiscal 

year 2006 and each subsequent fiscal year to carry out this subchapter øamounts as follows:¿. 

ø(1) $60,000,000 for fiscal year 2002. 

ø(2) $75,000,000 for fiscal year 2003. 

ø(3) $75,000,000 for fiscal year 2004. 

ø(4) $75,000,000 for fiscal year 2005.¿ 

* * * * * * * 

CHAPTER 74—VHA—PERSONNEL 

* * * * * * * 

Subchapter I—Appointments 

* * * * * * * 

§ 7402. Qualifications of appointees 

(b)(9) * * * 

(b)(10) Marriage and family therapist—To be eligible to be appointed to a marriage and family therapist position, a person 

must—

(A) hold a master’s degree in marriage and family therapy, 

or a comparable degree in mental health, from a college or university approved by the Secretary; and 

(B) be licensed or certified to independently practice marriage 

and family therapy in a State, except that the Secretary may 

waive the requirement of licensure or certification for an individual marriage and family therapist for a reasonable period of 

time recommended by the Under Secretary for Health. 

(b)ø10¿(11) CHIROPRACTOR.—To be eligible to be appointed to a 

chiropractor position, a person must—

(A) hold the degree of doctor of chiropractic, or its equivalent, 

from a college of chiropractic approved by the Secretary; and 

(B) be licensed to practice chiropractic in a State. 

(b)ø11¿(12) OTHER HEALTHCARE POSITIONS.—To be appointed as 

a physician assistant, expanded-function dental auxiliary, certified 

or registered respiratory therapist, licensed physical therapist, licensed practical or vocational nurse, occupational therapist, dietiVerDate Aug 31 2005 10:09 Nov 15, 2005 Jkt 049010 PO 00000 Frm 00032 Fmt 6604 Sfmt 6602 E:\HR\OC\A177SR.013 A177SR
33 

tian, microbiologist, chemist, biostatistician, medical technologist, 

dental technologist, or other position, a person must have such 

medical, dental, scientific, or technical qualifications as the Secretary shall prescribe. 

(c) Except as provided in section 7407(a) of this title, a person 

may not be appointed in the Administration to a position listed in 

section 7401(1) of this title unless the person is a citizen of the 

United States. 

(d) A person may not be appointed under section 7401(1) of this 

title to serve in the Administration in any direct patient-care capacity unless the Under Secretary for Health determines that the 

person possesses such basic proficiency in spoken and written 

English as will permit such degree of communication with patients 

and other healthcare personnel as will enable the person to carry 

out the person’s healthcare responsibilities satisfactorily. Any determination by the Under Secretary for Health under this subsection shall be in accordance with regulations which the Secretary 

shall prescribe. 

(e) A person may not serve as Chief of Staff of a Department 

healthcare facility if the person is not serving on a full-time basis. 

(f) A person may not be employed in a position under subsection 

(b) (other than under paragraph (4) of that subsection) if—

(1) the person is or has been licensed, registered, or certified 

(as applicable to such position) in more than one State; and 

(2) either—

(A) any of those States has terminated such license, registration, 

or certification for cause; or 

(B) the person has voluntarily relinquished such license, 

registration, or certification in any of those States after 

being notified in writing by that State of potential termination for cause. 

* * * * * * * 

§ 7404. Grades and pay scales 

(c) * * * 

(d) Except as provided under øsubchapter III¿ paragraph (e), 

subchapter III and in section 7457 of this title, pay may not be paid 

at a rate in excess of the rate of basic pay for an appropriate level 

authorized by section 5315 or 5316 of title 5 for positions in the Executive Schedule, as follows: 

(1) Level IV for the Deputy Under Secretary for Health. 

(2) Level V for all other positions for which such basic pay 

is paid under this section. 

(e) The position of Chief Nursing Officer, Office of Nursing Services, shall be exempt from the provisions of section 7451 of this title 

and shall be paid at a rate not to exceed the maximum rate established for the Senior Executive Service under section 5382 of title 5 

United States Code, as determined by the Secretary. 

* * * * * * * 

34 

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 

* * * * * * * 

§ 8110. Operation of Medical Facilities 

(a)(4) * * * 

ø(5) Notwithstanding any other provision of this title or of any 

other law, funds appropriated for the Department under the appropriation accounts for medical care, medical and prosthetic research, 

and medical administration and miscellaneous operating expenses 

may not be used for, and no employee compensated from such 

funds may carry out any activity in connection with, the conduct 

of any study comparing the cost of the provision by private contractors with the cost of the provision by the Department of commercial 

or industrial products and services for the Veterans Health Administration unless such funds have been specifically appropriated for 

that purpose.¿ 

ø(6)¿ (5) (A) Temporary research personnel of the Veterans 

Health Administration shall be excluded from any ceiling on fulltime equivalent employees of the Department or any other personnel ceiling otherwise applicable to employees of the Department. 

(B) For purposes of subparagraph (A) of this paragraph, the term 

‘‘temporary research personnel’’ means personnel who are employed 

in the Veterans Health Administration in other than a career appointment for work on a research activity and who are not paid by 

the Department or are paid from funds appropriated to the department to support such activity. 

Æ