[Senate Report 107-229]
[From the U.S. Government Publishing Office]
Calendar No. 534
107th Congress Report
SENATE
2nd Session 107-229
======================================================================
DEPARTMENT OF VETERANS AFFAIRS EMERGENCY PREPAREDNESS ACT OF 2002
_______
July 31, 2002.--Ordered to be printed
_______
Mr. Rockefeller, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany S. 2132]
The Committee on Veterans' Affairs, to which was referred
the bill S. 2132, to amend title 38, United States Code, to
provide for the establishment of medical emergency preparedness
centers in the Veterans Health Administration, to provide for
the enhancement of the medical research activities of the
Department of Veterans Affairs, and for other purposes, having
considered the same, reports favorably thereon with an
amendment in the nature of a substitute and an amendment to the
title, and recommends that the bill, as amended, do pass.
Introduction
On October 16, 2001, the Committee held a hearing to
consider VA's readiness and capacity to care for veterans,
active duty servicemembers, and the public during conflicts and
national emergencies, and its role in the Federal response to
disasters. Those testifying at the hearing included: The
Honorable Anthony J. Principi, Secretary, Department of
Veterans Affairs (hereinafter, ``VA''); The Honorable Claude A.
Allen, Deputy Secretary of Health and Human Services; The
Honorable David Chu, Ph.D., Under Secretary of Defense for
Personnel and Readiness; and Bruce P. Baughman, Director,
Planning and Readiness Division, Readiness, Response, and
Recovery Directorate, Federal Emergency Management Agency.
On April 16, 2002, Committee Chairman John D. Rockefeller
IV introduced S. 2132. S. 2132, as introduced, would have
amended provisions of title 38, United States Code, to
authorize the establishment of four medical emergency
preparedness centers in VA's Veterans Health Administration
(hereinafter, ``VHA''); to modify the authorities of VA non-
profit research and education corporations to transfer
appropriated funds and to act as affiliated institutions for
sharing of health care resources; and to allow employees of
these corporations assigned to approved VA projects to be
considered VA employees for the purposes of Federal Tort Claims
Act and medical malpractice coverage.
On April 17, 2002, Chairman Rockefeller introduced S. 2186
at the request of the Administration. S. 2186 would have
amended title 38 to establish a new Assistant Secretary to
coordinate functions relating to emergency preparedness,
continuity of operations, security, and law enforcement.
On April 17, 2002, Chairman Rockefeller introduced S. 2187
with the co-sponsorship of Committee member Daniel K. Akaka.
Ranking Member Arlen Specter later cosponsored the bill. S.
2187 would have authorized the Secretary of Veterans Affairs to
furnish hospital care and medical services to affected
individuals during and immediately following a disaster or
emergency declared by the President or in which the National
Disaster Medical System is activated.
On May 2, 2002, Chairman Rockefeller held a hearing to
receive testimony on the aforementioned bills and other
measures. Those testifying at the hearing included the
following VA witnesses: The Honorable Tim McClain, General
Counsel; The Honorable Claude M. Kicklighter, Assistant
Secretary for Policy and Planning and Acting Director, Office
of Operations, Security and Preparedness; Frances M. Murphy,
MD, Deputy Under Secretary for Health, Veterans Health
Administration; Robert Epley, Associate Deputy Under Secretary
for Policy and Program Management, Veterans Benefits
Administration; John Thompson, Deputy General Counsel; and
Vincent Barile, Deputy Under Secretary for Management, National
Cemetery Administration. Also testifying were James Fischl,
Director, National Veterans Affairs and Rehabilitation
Commission, The American Legion; Joseph Violante, National
Legislative Director, Disabled American Veterans; David Tucker,
Associate Legislative Director, Paralyzed Veterans of America;
and Dennis Cullinan, Director, National Legislative Service,
Veterans of Foreign Wars.
After carefully reviewing the testimony from the foregoing
hearing, the Committee met in open session on June 6, 2002, and
voted unanimously to report favorably S. 2132, with an
amendment in the nature of a substitute incorporating
provisions from S. 2132, S. 2186, and S. 2187. Present were
Chairman Rockefeller, Ranking Member Specter, and Senators
Jeffords, Wellstone, Murray, Miller, Nelson, Thurmond,
Murkowski, Hutchinson, and Hutchison.
Summary of the Committee Bill as Reported
S. 2132 as reported (hereinafter, ``Committee bill'')
contains various amendments to title 38 of United States Code
and other freestanding provisions that would:
(a) create four medical emergency preparedness
research and education centers within VHA to prepare
for the potential medical consequences of terrorism;
(b) authorize an additional Assistant Secretary for
Operations, Preparedness, Security, and Law
Enforcement;
(c) increase the number of authorized deputy
assistant secretaries from 18 to 20;
(d) authorize VA to furnish medical care to any
individual affected by a major disaster or emergency
declared by the President under the Stafford Act, or by
a medical crisis that requires the activation of the
National Disaster Medical System;
(e) permit VA to transfer appropriated research
funding to a VA nonprofit research corporation in order
to conduct research, training, or education;
(f) allow VA to treat these nonprofit corporations as
affiliated institutions when negotiating the sharing of
health care resources for VA-approved projects;
(g) allow employees of these nonprofit corporations
assigned to VA-approved projects to be considered VA
employees for the purposes of Federal Tort Claims Act
and medical malpractice coverage; and
(h) permanently extend VA's authority to establish
nonprofit research and education corporations.
Committee Bill
TITLE I: MEDICAL EMERGENCY PREPAREDNESS
In 1982, Congress assigned a new responsibility to VA that
built upon its three primary duties--caring for our nation's
veterans, training health care personnel, and fostering
scientific and clinical research to improve future medical
care. Public Law 97-174 defined VA as the primary medical back-
up system to the Department of Defense during conflicts or
domestic emergencies, and required that VA maintain a state of
readiness to care for a large number of active duty military
casualties with little notice.
As Federal plans to protect public health during disasters
have evolved over the last two decades, this ``Fourth Mission''
has grown to encompass more than just supporting the military
during crises. Through the National Disaster Medical System--
formed as an interagency agreement by VA, the Federal Emergency
Management Agency (hereinafter, ``FEMA''), the Department of
Defense (hereinafter, ``DOD''), and the Department of Health
and Human Services (hereinafter, ``HHS'') in 1984 and recently
codified in Public Law 107-188--VA conducts training exercises
and coordinates a network of Federal and community health care
providers to prepare for domestic disasters. VA provides
medical and logistical support through the Federal Response
Plan for domestic disasters, developed according to the amended
Robert T. Stafford Disaster Relief and Assistance Act, Public
Law 93-288, and maintains a deployable Medical Emergency
Radiological Response Team as part of the Federal Radiological
Emergency Response Plan. Presidential Decision Directive 62 on
combating terrorism (May 1998) tasked VA to provide medical
support to HHS, including management of the National
Pharmaceutical Stockpile.
The assets that VA, the Nation's largest integrated health
care system, brings to domestic emergency preparedness include
its clinical infrastructure, its medical education programs,
and its basic and clinical research programs. VA operates
medical facilities in every State, the District of Columbia,
and Puerto Rico, staffed by over 14,000 physicians and 37,000
registered nurses. More than half of the physicians practicing
in the United States received part of their professional
education in the VA health care system through affiliations
with 107 medical schools and more than 1,200 other schools
across the country. VA's Medical and Prosthetic Research
Program--which funded more than 15,000 projects last year--
includes large multi-center clinical trials, studies in
clinical outcomes and health care delivery methods,
rehabilitation development, and investigator-initiated research
in areas that include mental illnesses, chronic disorders,
aging, and the long-term consequences of exposures to chemical
and biological hazards.
The Committee strongly believes that these considerable
resources should be efficiently incorporated into Federal
strategies to protect the Nation during domestic disasters,
including potential terrorist attacks. Through its geographic
reach, education programs, and research capacity, VA stands
ready to make a significant contribution to protecting veterans
and the public from the medical consequences of a terrorist
attack. At the same time, VA must receive the recognition and
the resources necessary to accomplish its ``Fourth Mission''
without sacrificing its capacity to serve veterans and their
families. The provisions incorporated in the Committee bill
would create a new VA function within the nation's preparedness
plans, strengthen VA's existing emergency response mission, and
help VA preserve its ability to serve veterans during crises.
SECTION 101: MEDICAL EMERGENCY PREPAREDNESS CENTERS IN VHA
Background
The attacks of September 11th and the subsequent anthrax
assaults on media and government figures demonstrated our
national vulnerability to asymmetric warfare by terrorists
willing to employ weapons of mass destruction against civilian
targets. Fortunately, the anthrax exposures resulted in
relatively few casualties. However, their aftermath illustrated
vividly that the nation's public health and medical communities
would be quickly overwhelmed in the face of a larger attack
with biological, chemical, radiological, or even explosive or
incendiary weapons. In addition, the anthrax incidents
highlighted the dearth of knowledge regarding best medical
practices--or even accurate diagnostic tools--to detect and
cope with deliberately induced disease outbreaks.
Although other research entities, such as the National
Institutes of Health, also incorporate the talent and resources
necessary to develop diagnostic, preventive, and therapeutic
modes to counter the medical effects of biological or chemical
attacks, VA possesses unparalleled strength in large-scale
clinical management research. VA's Medical and Prosthetic
Research Program has developed clinical practice models for
many diseases, ranging from treatments for tuberculosis
following World War II to a recently launched study to
determine the best way to treat HIV/AIDS. Successful multi-
center VA clinical trials have yielded improved treatment for
conditions that include schizophrenia, diabetes, cancer,
depression, heart disease and stroke. VA's Centers of
Excellence allow researchers from different disciplines to
concentrate their research, education, and clinical programs on
a single focus, such as hepatitis, geriatric medicine, mental
illnesses, or Parkinson's disease.
The military history of the last century has required VA to
develop expertise in the consequences of exposure to
radiological and chemical agents. In addition to long-standing
research and clinical programs in these areas, Public Law 105-
368--passed subsequent to the Persian Gulf War--charged VA to
investigate potential long-term health effects of biological
and chemical warfare agents, including one-time and low-dose
exposures. This program is currently divided between two VA
research centers and an interagency collaboration with the
Departments of Defense and Health and Human Services.
VA demonstrated its ability to disseminate clinical
information quickly after the September 11th attacks, using its
powerful telemedicine network to bring a DOD-sponsored course
on medical management of biological and chemical casualties to
professionals throughout the VA healthcare system, and to its
military and community partners. Three-quarters of VA
researchers are practicing clinicians who can efficiently
translate their research findings into general clinical
practice through collaborations with researchers in other
Federal agencies, academia, and the private sector.
The medical emergency preparedness centers authorized by
the Committee bill would build upon VA's expertise in both
health care delivery and biological, chemical, and radiological
exposures to ready VA health care professionals, and the
medical community, for the potential medical consequences of a
terrorist attack. Further, the centers would enable VA
researchers to explore new technologies and medical
applications that could be used to care for victims of such
exposures, such as the use of umbilical cord stem cells to
treat neural damage or the blood cell disorders that frequently
occur in individuals exposed to large doses of radiation.
Although VA might be able to identify enough established
scientific programs at one site to constitute a single-field--
e.g., radiological response--center, the medical community
generally accepts that strategies to manage mass casualties
will most likely overlap and benefit from an all-hazards
approach. As stated in a medical policy paper co-authored by
VA's Deputy Under Secretary for Health:
In order to combat acts of mass terror, contingency
planning has to involve more than just emergency
response. An effective strategy will have to consider a
broader array of immediate and long-term consequences,
which will arise regardless of the type of toxic
exposure or number of casualties.\1\
---------------------------------------------------------------------------
\1\ Hyams, K.C., Murphy, F.M., and S. Wessely. (2002) Responding to
Chemical, Biological, or Nuclear Terrorism: The Indirect and Long-Term
Health Effects May Present the Greatest Challenge. Journal of Health
Politics, Policy, and Law 27(2):273-291.
---------------------------------------------------------------------------
As the Nation's public health and medical communities
struggle with the dual problems of measuring and maintaining
surge capacity, research into the best way to manage mass
casualties is desperately needed. Regardless of the agency
finally appointed to oversee homeland security research, the
Committee expects that VA's valuable research and clinical
resources will be integrated productively into national
preparedness strategies.
Committee Bill
Section 101 of the Committee bill is based on S. 2132 as
introduced. This section would authorize VA to establish four
centers for medical emergency preparedness research, training,
and clinical activities. These centers would develop strategies
to detect, diagnose, prevent, and treat the injuries or
illnesses that could arise from a terrorist attack with
chemical, biological, radiological, incendiary, or other
explosive weapons.
Section 101 would direct the Secretary to select sites for
centers through a peer-reviewed competitive process open to VA
medical centers affiliated with at least one accredited school
of medicine, school of public health, and graduate program in
epidemiology, in order to select sites with considerable
resident expertise and potential to train health care
professionals. The Committee bill does not limit each center to
a specific topic of study (e.g., radiological incidents), but
leaves the appropriate mix of research in this new and
interdisciplinary field of medical preparedness to VA, peer
reviewers, and researchers.
Section 101 would direct that techniques or practices
identified at these centers be used to educate and train health
care professionals within VHA. Section 101 would also allow VA
to extend these training activities, at the direction of the
Secretary and through interagency agreements such as the
National Disaster Medical System, to non-VA care providers.
Section 101 would also authorize VA to offer laboratory,
epidemiological, medical, or other appropriate assistance to
other agencies--whether Federal, State, or local--that request
assistance during a medical emergency. This mission is
consistent with VA's current role as a support agency to the
Federal response to disasters, and would still allow individual
VA medical centers to respond to local disasters as an integral
part of the communities they serve.
The Committee bill would require that research and response
activities undertaken under this section be compatible with
research strategies coordinated by the Office of Homeland
Security (or equivalent agency) and similar research undertaken
by the Departments of Defense and Health and Human Services.
Cost: CBO estimates that enacting this provision would
increase spending by $12 million in 2003 and by $87 million
over the 2003-2007 period.
SECTION 201: AUTHORIZED FUNCTIONS OF ASSISTANT SECRETARIES FOR VETERANS
AFFAIRS
Background
In the wake of the September 11th terrorist attacks, senior
staff representing VA's three administrations and other major
offices identified a pressing need for a single office within
VA headquarters to coordinate all preparedness and Federal
response activities.
On October 26, 2001, the Secretary authorized assignment of
detailed employees from other VA offices to an office charged
with ensuring department-wide operational readiness. VA then
requested authorization of a new office to carry out
operations, preparedness, security, and law enforcement
functions on a dedicated basis. This new office would be
directed by an Assistant Secretary responsible for providing
appropriate executive leadership and accountability, and for
representing VA in interagency homeland security planning
efforts.
The Committee intends that the new Assistant Secretary of
Operations, Preparedness, and Security would coordinate
department-wide planning, training, and exercises to ensure
that VA can effectively serve veterans during emergencies.
Critical tasks would include planning to protect veterans and
staff within VA facilities, integrating emergency preparedness
and consequence management strategies within VA, and developing
and maintaining effective relationships with other agencies
responsible for homeland security. This office should build
upon, rather than supplant, existing medical preparedness
programs within VA.
Committee Bill
Section 201 would increase the number of authorized VA
assistant secretaries from six to seven, and expand authorized
functions to include operations, preparedness, security, and
law enforcement.
Cost: CBO did not estimate any cost to be associated with
section 201.
SECTION 202: ADDITIONAL DEPUTY ASSISTANT SECRETARIES FOR VETERANS
AFFAIRS
Background
VA's internal assessment of its readiness to respond to
disasters and the experience of staff responsible for emergency
preparedness have established the need for an office dedicated
to preparedness activities, as described in Section 201. In
order to provide appropriate executive level assistance, the
Committee bill would authorize two new deputy assistant
secretaries for this office. To the existing Deputy Assistant
Secretary for Security and Law Enforcement, whose authorities
will be transferred to the new office, Section 202 would
authorize VA to add a Principal Deputy Assistant Secretary to
support the Assistant Secretary and a Deputy Assistant
Secretary to assist in contingency and mass care planning.
Committee Bill
Section 202 would increase the number of authorized deputy
assistant secretaries from 18 to 20.
Cost: CBO did not estimate any cost to be associated with
section 202.
SECTION 301: AUTHORITY TO FURNISH HEALTH CARE DURING MAJOR DISASTERS
Background
The Federal Response Plan for domestic disasters outlines
specific ``emergency support functions'' that may be required
during and following a national emergency and assigns primary
responsibility for each of these functions to a specific agency
or entity. VA's tasks under this plan include supporting
several emergency functions, most significantly Emergency
Support Function #8 (ESF #8), the Health and Medical Services
Annex. Under this plan, HHS ``coordinates the provision of
Federal health and medical assistance to fulfill the
requirements identified by the affected State and local
authorities having jurisdiction. Included in ESF #8 are overall
public health response; triage, treatment, and transportation
of victims of the disaster; and evacuation of patients out of
the disaster area, as needed, into a network of Military
Services, Veterans Affairs, and pre-enrolled non-Federal
hospitals located in the major metropolitan areas of the United
States.''
This plan gives HHS authority to call upon VA for
assistance directly following a Presidentially declared
emergency or major disaster, or after activation of the
National Disaster Medical System (hereinafter, ``NDMS''), a
network of Federal and non-Federal care providers. VA has
responded quickly when called, working within the NDMS to
provide care and supplies during every major domestic disaster
of the last two decades, including in New York and at the
Pentagon following the September 11th attacks.
VA's NDMS obligations were undertaken subsequent to its
assignment as primary contingency medical back-up system to the
military in Public Law 97-174. Under 38 U.S.C. Sec. 1784, the
Secretary is authorized to ``furnish hospital care or medical
services as a humanitarian service in emergency cases, but the
Secretary shall charge for such care and services at rates
prescribed by the Secretary.'' Neither of these authorities
acknowledges VA's considerable commitment and obligation to
providing emergency care and support to the public as part of
its Federal response plan duties, which may be expected to
escalate in light of the Nation's increasing commitment to
homeland security.
In addition to the role VA fills as a Federal resource
during disasters, VA medical centers contribute to disaster
management within their communities. Even before September
11th, more than 80 percent of VA medical centers had been
included in local community emergency response plans. At the
Committee's May 2, 2002, hearing on pending legislation, Deputy
Under Secretary for Health Murphy stated:
I would just add that one of the misperceptions is
that because we are a Federal agency and an executive
branch department, that we are not part of the local
communities. In fact, VA is different than many of the
departments, in that we are integrated into every city,
every community in the country, and VA needs to be
there to be part of that Federal public health
infrastructure, and we can play a very valuable role if
we are given the mission to do so.
The dual obligation of VA's medical facilities--serving
collectively as the major pre-deployed Federal clinical
resource and individually as an integral part of the
communities in which they are placed--demands appropriate
authority not now explicit in law.
Committee Bill
Section 301 authorizes VA to extend medical services to
individuals affected by a Presidentially declared major
disaster or a public health emergency in which the National
Disaster Medical System is activated. VA would be authorized to
offer care at VA medical facilities, including hospital
treatment, to veterans (regardless of enrollment status),
active duty military personnel, local and community emergency
response providers, or other individuals responding to or
involved in the disaster. Veterans with service-connected
disabilities would retain the highest priority for care and
services, followed by active duty military casualties during
activation of the VA/DOD contingency medical system, after
which VA could grant the next level of priority to individuals
affected by a disaster.
This section would also allow VA to receive reimbursement
for the cost of services provided to employees of other Federal
agencies or departments, to be credited to the facility that
provided care. VA would not be required to charge other
individuals for emergency care offered during a disaster.
Cost: CBO was unable to provide a cost estimate associated
with section 301.
SECTIONS 401-403: RESEARCH CORPORATIONS
Background
VA-affiliated nonprofit research and education corporations
(hereinafter, ``NPCs'') were established under 38 U.S.C.
Sec. Sec. 7361-7368 to facilitate VA's research and education
missions. In 2001, non-profit corporations at 84 VA medical
centers (hereinafter, ``VAMCs'') reported previous-year
revenues of nearly $174 million. These revenues would never
have been available to VA without the special rules under which
these corporations operate.
Currently, VAMCs are prohibited from entering into
contracts, or other agreements involving payments, with their
affiliated NPCs. Further, a 1989 VA Office of General Counsel
opinion ruled that VAMCs and NPCs may not enter into sharing
agreements. However, two later opinions, dated April 4, 1990,
and February 16, 1996, concluded that agreements were
permissible. The result of this web of conflicting legal
opinions and statutory prohibitions is that VAMCs cannot
acquire services that they may need from the NPCs, even when it
could be cost-effective and efficient to do so.
Several VA researchers described examples of possible VA-
NPC contracting opportunities to the Committee. In one example,
a project funded through a VA merit review award in VISN 3
required patients to travel long distances to the VAMC to
participate in the study. The grant included funding for such
travel; however, the principal investigator lacked the staff
and the expertise to provide for such travel arrangements.
Hence, the investigator sought to enter into a contract with
the affiliated NPC to make all the necessary arrangements. This
arrangement, however, was prohibited. Other examples
highlighted the benefits for VA researchers to contract with
NPCs for conference management; technical services; use of
expensive, high-tech equipment; and organization of training
programs.
VA's inability to contract with NPCs is not the only
limitation under the current statutory scheme. A recent legal
interpretation by the Department of Justice determined that
certain employees of NPCs are not covered under the Federal
Tort Claims Act (hereinafter, ``FTCA''). The opinion noted that
physicians employed by the VA-affiliated NPCs cannot be
considered Federal employees for purposes of FTCA even though
they have VA ``without compensation'' (WOC) appointments. Prior
to this opinion, the common understanding had been that
corporation employees were covered by FTCA, subject to the
Attorney General's certification that their work was within the
scope of government employment. In order to assure such
certification, NPC employees have been required to have VA WOC
appointments, to work only on VA-approved research and
education, and to work under the supervision of VA personnel.
On October 15, 2001, the VA Office of General Counsel
requested reconsideration of the conclusion reached by the
Department of Justice in its March 29, 2000, letter. However,
the Committee understands that such a reconsideration, if it is
granted at all, might take up to four years to be resolved. In
the meantime, NPC physicians, nurses, technicians, and allied
health care professionals are personally liable for suits
alleging negligence or malpractice while working on VA-approved
research.
Authority for VA to establish nonprofit research and
education corporations expires on December 31, 2003.
Committee Bill
Section 401 of the Committee bill clarifies that VA medical
centers may use VA's existing contracting authorities to
acquire research or education services from NPCs. In testimony
before the Committee on May 2, 2002, VA General Counsel Tim
McClain objected to these clarifications on ``the grounds that
they would alter the fundamental nature of the relationship
between VA and the non-profits, which is analogous to that
created in a trust.'' While the Committee agrees that the
relationship between NPCs and VAMCs would change, the Committee
believes such changed would be for the better--the NPCs will be
able to do more for VA, not less, and only after potential
agreements are approved by VA. As a result, VA will retain full
responsibility for the conduct of NPC research assistance.
Section 402 provides FTCA coverage for certain employees of
VA-affiliated NPCs. Since 1989, both VA and the NPCs have
operated under the belief that corporation employees with WOC
appointments, working on VA-approved research under the
supervision of VA employees, would be covered under FTCA. While
no negligence or malpractice suits have been filed against a
corporation employee, prudence dictates that these employees
with VA appointments be covered by the FTCA. VA strongly
supports this provision.
Section 403 permanently extends the authority to establish
nonprofit VA research and education corporations.
Cost: CBO did not estimate any cost to be associated with
sections 401-403.
Agency Report
On May 2, 2002, the Honorable Tim McClain, General Counsel,
Department of Veterans Affairs, appeared before the Committee
and submitted testimony on, among other things, S. 2132, S.
2186, and S. 2187. Excerpts from this statement are reprinted
below:
STATEMENT OF TIM McCLAIN, GENERAL COUNSEL, DEPARTMENT OF VETERANS
AFFAIRS
Mr. Chairman and Members of the Committee, Thank you for
the opportunity to testify on a number of legislative items of
interest to veterans.
* * * * * * *
S. 2132
Section 1 of S. 2132 would require the Secretary to
establish four Emergency Medical Preparedness Centers within
the Veterans Health Administration (VHA). VA employees would
staff the proposed Centers, and the Centers would be
administered jointly by the offices within the Department that
are responsible for directing research and for directing
medical emergency preparedness.
The Centers would have four specific purposes. First, they
would carry out research and develop methods in detection,
diagnosis, vaccination, protection, and treatment of injuries
arising from the use of chemical, biological, radiological
agents or incendiary or other explosive weapons or devices.
Second, they would provide education, training, and advice on
the medical consequences of the use of CBR agents or incendiary
or other explosive weapons or devices. Third, the Centers would
provide that same education, training, and advice to non-VA
health-care professionals. These activities would be
accomplished through either the National Disaster Medical
System or interagency agreements. Fourth, in the event of a
national emergency, they would provide laboratory,
epidemiological, medical, or other assistance, as the Secretary
considers appropriate, to Federal, State, and local health care
agencies and personnel involved in, or responding to, the
national emergency.
Each Center would be authorized to solicit and accept
contributions of funds and other resources, including grants,
to carry out their purposes and activities, subject to the
Secretary's approval. Section 1 of this bill would also
authorize to be appropriated $20 million for these Centers for
each of fiscal years 2003 through 2007. By the bill's terms,
such authorization is valid only for funds appropriated
separately and solely for purposes of the Centers; otherwise,
the authorization is null and void.
Section 1 of S. 2132 is similar to H.R. 3253 on which the
Deputy Secretary testified on April 10, 2002, before the House
Committee on Veterans' Affairs, Subcommittee on Health.
However, it incorporates the recommendations VA suggested in
its April testimony concerning H.R. 3253 and adds a number of
improvements to the House version of the bill. We are grateful
to this Committee for having incorporated our recommendations.
We strongly support the goals of section 1 of S. 2132 and
prefer it to H.R. 3253. However, the Executive Office of the
President, through the Homeland Security Council (HSC), is
currently crafting a comprehensive coordinated Federal policy
on Homeland Security. VA is actively participating in this HSC
effort. It is expected that HSC will deliver this policy to the
President this July. The precise roles and responsibilities VA
will be assigned in the area of Homeland Security will be
reflected in that policy. We expect that we will have much to
contribute in this area based on our depth of expertise and
infrastructure, as alluded to above.
Because the President's Homeland Security Policy is
forthcoming, we would like to work with the Committee to ensure
that section 1 of S. 2132 is consistent with the comprehensive
Federal plan.
In addition, S. 2132 contains two provisions that would
expand the purpose and operations of VA non-profit
corporations. VA non-profit corporations function as flexible
funding mechanisms that support VA research and education. VA
non-profits receive and administer funds from outside sources,
e.g., NIH grants and donations made by private sponsors, in
support of approved VA research projects and education
activities. However, the current statute expressly provides
that VA may not transfer appropriated funds to the
corporations. Section 2(a) of the bill would amend section 7362
of title 38 to permit the transfer of appropriated dollars from
VA to a corporation pursuant to a contract or other agreement,
including an agreement for actual research. In addition,
section 2(b) of the bill would amend VA's sharing authority to
treat VA non-profits like affiliated institutions for the
purpose of sharing health-care resources related to research,
education and training. These changes would broadly enable the
corporations to sell services to the Department. The bill also
provides that these arrangements would be outside the scope of
Federal procurement law and, therefore, would not be subject to
full and open competition.
VA objects to these proposals on the grounds that they
would alter the fundamental nature of the relationship between
VA and the non-profits, which is analogous to that created in a
trust. Under current law the corporations exist as a flexible
funding mechanism solely to support approved VA research and
education. The amendments in section 2 of the bill would make
the relationship between Department health-care facilities and
VA non-profits more like that with outside contractors or
university affiliates; more of an arms-length negotiation
rather than one of incontrovertible fiduciary support. This
change would also shift the emphasis of VA non-profits away
from the primary focus of providing flexible funding support
for VA research, education and training to conducting and
selling these services to VA. This shift would present a
troubling risk of ceding Department control of VA approved
research or education to the non-profits.
Section 3 of the bill would amend the title 38 authorities
related to VA non-profits by adding a new section 7364A to
specifically state that corporation employees assigned to work
on approved VA research or education and training shall be
considered employees for purposes of Federal tort claim and
medical malpractice coverage. VA strongly favors this
provision. We note, however, that the phrase, ``carried out
with Department funds'' in the proposed section 7364A(b)(2)
might be interpreted to limit this coverage. Much of VA-
approved research, or education and training is supported by
external funds.
S. 2186
Mr. Chairman, thank you for introducing S. 2186 at our
request. This legislation would establish a new Assistant
Secretary to perform operations, preparedness, security and law
enforcement and a new VA office of Operations Security and
Preparedness. We believe this new office is essential if we are
to meet our responsibilities of protecting veterans, employees,
and visitors to our facilities.
S. 2187
S. 2187 would permit VA, on its own initiative, to care for
those affected by a disaster or emergency and those responding
to the emergency. The disaster or emergency must be either
declared by the President or involve activation of the National
Defense Medical System. The bill would also require other
Federal agencies to reimburse VA for care provided to their
officers, employees, and active duty members at rates agreed
upon by the agencies. VA would not be required to charge for
care provided to other individuals. Finally, the bill would
allow VA to provide care in response to disasters and emergency
situations before caring for all other beneficiaries except
service-connected veterans and active duty military members
referred during war or national emergency or who are responding
or involved in a disaster or emergency.
We are very interested in this measure, but we need to work
with both the committee and other Federal departments and
agencies to fully understand the implications of the bill. We
anticipate providing further views on the measure at a later
time. We would note, however, that the bill also proposes to
amend 38 U.S.C. Sec. 1711(b). That provision is now codified at
38 U.S.C. Sec. 1784. Finally, the bill would conflict with an
administrative provision that appears in VA's annual
appropriation act that requires reimbursement of costs except
in specified situations. For the provision to be effective that
provision of the appropriations act will also need amendment.
Congressional Budget Office Cost Estimate
U.S. Congress,
Congressional Budget Office,
Washington, DC, June 13, 2002.
Hon. John D. Rockefeller IV,
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. 2132, the Department
of Veterans Affairs Emergency Preparedness Act of 2002.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sam
Papenfuss.
Sincerely,
Barry B. Anderson,
for Dan L. Crippen, Director.
Enclosure.
S. 2132, Department of Veterans Affairs Emergency Preparedness Act of
2002
SUMMARY
S. 2132 would establish four centers for medical emergency
preparedness that would carry out research and development,
provide education and training, and provide assistance in the
case of a national emergency with regard to chemical,
biological, radiological, incendiary or other explosive weapons
threats. These emergency centers would be located in hospitals
operated by the Department of Veterans Affairs (VA). S. 2132
would authorize appropriations of $20 million a year over the
2003-2007 period to operate the centers. S. 2132 also would
allow VA to provide medical care to individuals who are
affected by a major disaster or emergency.
In addition, S. 2132 would increase the number of assistant
secretaries within the VA from six to seven with the new
assistant secretary being responsible for operations,
preparedness, security, and law enforcement functions. The bill
also would increase the number of deputy assistant secretaries
within VA from 18 to 20. Finally, S. 2132 would allow research
corporations established under current law by the Secretary of
VA to use appropriated funds to conduct their research and
would consider some employees of those research corporations to
be employees of the federal government for purposes of certain
federal tort claims laws.
CBO estimates that implementing S. 2132 would cost $12
million in 2003 and $87 million over the 2003-2007 period,
assuming appropriation of the authorized amounts, for
establishing and operating the new emergency centers. CBO
cannot estimate the potential additional discretionary spending
that could occur under S. 2132 for providing VA medical care to
individuals needing assistance in a national emergency. CBO
also expects that enacting this bill could increase direct
spending for settlement of tort claims over the 2003-2012
period but we cannot provide a specific estimate. Because the
bill could affect direct spending, pay-as-you-go procedures
would apply.
S. 2132 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would impose no costs on state, local, or tribal
governments.
ESTIMATED COST TO THE FEDERAL GOVERNMENT
The estimated budgetary impact of S. 2132 is shown in the
following table. The costs of this legislation fall within
budget functions 700 (veterans benefits and services) and 800
(general government).
Changes in Spending Subject to Appropriation a, b
[By Fiscal Year, in Millions Dollars]
------------------------------------------------------------------------
2003 2004 2005 2006 2002
------------------------------------------------------------------------
Spending for VA Emergency
Preparedness Centers Under S.
2132:
Authorization Level........... 20 20 20 20 20
Estimated Outlays............. 12 16 19 20 20
------------------------------------------------------------------------
a No funds were appropriated for these purposes in 2002.
b In addition to the bill's impact on discretionary spending, CBO
estimates that S. 2132 could increase direct spending for settlement
of tort claims over the 2003-2012 period but is unable to provide a
specific estimate given the uncertain events and the nature of these
claims.
BASIS OF ESTIMATE
For this estimate, CBO assumes that the bill will be
enacted by October 1, 2002, and that the authorized amounts
will be appropriated for each year. In addition to the bill's
discretionary cost, enacting S. 2132 could affect direct
spending; but CBO cannot estimate those potential effects, if
any.
Spending Subject to Appropriation
Emergency Preparedness Centers. VA has some limited
responsibilities to provide assistance in the event of a
chemical, biological, radiological, incendiary or other
explosive weapons threat under current law. Under section 101,
VA would have expanded responsibility to assist with these
threats with the creation of four medical emergency
preparedness centers that would carry out VA's
responsibilities. S. 2132 would specifically authorize
appropriations of $20 million a year over the 2003-2007 period
for the operation of these centers. Assuming normal delays in
beginning new programs and appropriation of the authorized
amounts, CBO estimates that implementing S. 2132 would increase
spending by $12 million in 2003 and by $87 million over the
2003-2007 period.
The bill would require VA to establish four centers for
medical emergency preparedness that would have three different
responsibilities. The first would be to conduct research and
development on detection, diagnosis, protection, and treatment
for the specified threats to the public health and safety. The
second responsibility would be to provide training and advice
to health care professionals outside of VA with regard to these
threats. The third responsibility would be to provide
contingent rapid response assistance including laboratory
assistance in the event of national emergencies.
Assistance in a National Emergency. Section 301 would allow
VA to provide medical care to individuals needing assistance,
regardless of their VA enrollment status, in the event of a
major disaster or medical emergency. Depending on the scope of
the assistance provided in response to a major disaster or
emergency, CBO believes that implementing this provision could
prove costly. CBO cannot estimate the cost of implementing this
provision, however, because we cannot predict the frequency or
seriousness of national emergencies, nor the extent to which VA
assistance would be used in any such emergency.
Direct Spending
Under current law, there is a question whether or not
employees of research corporations established by the VA who do
research are considered employees of the federal government for
purposes of certain federal tort claims laws. Section 402 would
resolve this question by specifying that these employees would
be considered federal employees for purposes of tort claims.
Consequently, any judgments against these employees would be
paid by the federal government. The allowable tort claims are
for injury, loss of property, personal injury, or death caused
by negligence, wrongful acts, or omissions by a federal
employee acting within the scope of the employee's office or
employment. Those payments would be considered direct spending.
If these employees are, on the one hand, already covered
under the relevant federal tort claims laws, then this section
would have no cost. If, on the other hand, these employees are
not covered under the relevant tort claims laws, then the
federal government would face a potential increase in its
liability under these laws upon enactment of this bill. Given
the uncertainty surrounding future events and the nature of
tort claims, CBO cannot estimate the cost--if any--of future
tort claims against the federal government.
PAY-AS-YOU-GO CONSIDERATIONS
The Balanced Budget and Emergency Deficit Control Act sets
up pay-as-you-go procedures for legislation affecting direct
spending or receipts. CBO estimates that enacting this bill
could increase direct spending for settlement of tort claims,
but we cannot provide a specific estimate.
INTERGOVERNMENTAL AND PRIVATE-SECTOR IMPACT
S. 2132 contains no intergovernmental or private-sector
mandates as defined in UMRA and would impose no costs on state,
local, or tribal governments.
PREVIOUS CBO ESTIMATE
On May 10, 2002, CBO transmitted a cost estimate for H.R.
3253, the Department of Veterans Affairs Emergency Preparedness
Research, Education, and Bio-Terrorism Prevention Act of 2002,
as ordered reported by the House Committee on Veterans' Affairs
on May 9, 2002. H.R. 3253 and S. 2132 would both establish four
centers for medical emergency preparedness and authorize $20
million a year over the 2003-2007 period to operate those
centers. Both bills would increase the number of VA assistant
secretaries from six to seven, but only S. 2132 would increase
the number of deputy assistant secretaries from 18 to 20.
Finally, S. 2132 contains provisions affecting research
corporations established by VA and assistance in a national
emergency, while H.R. 3253 does not.
Estimate prepared by: Federal Costs: Sam Papenfuss; Impact
on State, Local, and Tribal Governments: Elyse Goldman; Impact
on the Private Sector: Sally S. Maxwell.
Estimate approved by: Peter H. Fontaine, Deputy Assistant
Director for Budget Analysis.
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, the following provides a print of the
statute or the part or section thereof to be amended or
replaced (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
* * * * * * *
Sec. 308. Assistant Secretaries; Deputy Assistant Secretaries
(a) There shall be in the Department not more than [six]
seven Assistant Secretaries. Each Assistant Secretary shall be
appointed by the President, by and with the advice and consent
of the Senate.
(b) The Secretary shall assign to the Assistant Secretaries
responsibility for the administration of such functions and
duties as the Secretary considers appropriate, including the
following functions:
* * * * * * *
(11) Operations, preparedness, security, and law
enforcement functions.
* * * * * * *
(d)(1) There shall be in the Department such number of Deputy
Assistant Secretaries, not exceeding [18] 20, as the Secretary
may determine. Each Deputy Assistant Secretary shall be
appointed by the Secretary and shall perform such functions as
the Secretary prescribes.
* * * * * * *
* * * * * * *
1785. CARE AND SERVICES DURING MAJOR DISASTERS AND MEDICAL EMERGENCIES.
Sec. 1784. Humanitarian care
The Secretary may furnish hospital care or medical services
as a humanitarian service in emergency cases, but , except as
provided in section 1785 of this title with respect to a
disaster or emergency covered by that section, the Secretary
shall charge for such care and services at rates prescribed by
the Secretary.
* * * * * * *
CHAPTER 11--COMPENSATION FOR SERVICE-CONNECTED DISABILITY OR DEATH???
* * * * * * *
SUBCHAPTER II--WARTIME DISABILITY COMPENSATION????
* * * * * * *
CHAPTER 11--COMPENSATION FOR SERVICE-CONNECTED DISABILITY OR DEATH???
subchapter i--general???
Sec.
* * * * * * *
subchapter ii--wartime disability compensation
* * * * * * *
7320A. MEDICAL EMERGENCY PREPAREDNESS CENTERS.
* * * * * * *
Sec. 7320A. Medical emergency preparedness centers
(a) The Secretary shall establish and maintain within the
Veterans Health Administration four centers for research and
activities on medical emergency preparedness.
(b) The purposes of each center established under subsection
(a) shall be as follows:
(1) To carry out research on the detection,
diagnosis, prevention, and treatment of injuries,
diseases, and illnesses arising from the use of
chemical, biological, radiological, or incendiary or
other explosive weapons or devices, including the
development of methods for the detection, diagnosis,
prevention, and treatment of such injuries, diseases,
and illnesses.
(2) To provide to health-care professionals in the
Veterans Health Administration education, training, and
advice on the treatment of the medical consequences of
the use of chemical, biological, radiological, or
incendiary or other explosive weapons or devices.
(3) Upon the direction of the Secretary, to provide
education, training, and advice described in paragraph
(2) to health-care professionals outside the Department
through the National Disaster Medical System or through
interagency agreements entered into by the Secretary
for that purpose.
(4) In the event of a national emergency, to provide
such laboratory, epidemiological, medical, or other
assistance as the Secretary considers appropriate to
Federal, State, and local health care agencies and
personnel involved in or responding to the national
emergency.
(c)(1) Each center established under subsection (a) shall be
established at an existing Department medical center, whether
at the Department medical center alone or at a Department
medical center acting as part of a consortium of Department
medical centers for purposes of this section.
(2) The Secretary shall select the sites for the centers from
among competitive proposals that are submitted by Department
medical centers seeking to be sites for such centers.
(3) The Secretary may not select a Department medical center
as the site of a center unless the proposal of the Department
medical center under paragraph (2) provides for--
(A) an arrangement with an accredited affiliated
medical school and an accredited affiliated school of
public health (or a consortium of such schools) under
which physicians and other health care personnel of
such schools receive education and training through the
Department medical center;
(B) an arrangement with an accredited graduate
program of epidemiology under which students of the
program receive education and training in epidemiology
through the Department medical center; and
(C) the capability to attract scientists who have
made significant contributions to innovative approaches
to the detection, diagnosis, prevention, and treatment
of injuries, diseases, and illnesses arising from the
use of chemical, biological, radiological, or
incendiary or other explosive weapons or devices.
(4) In selecting sites for the centers, the Secretary shall--
(A) utilize a peer review panel (consisting of
members with appropriate scientific and clinical
expertise) to evaluate proposals submitted under
paragraph (2) for scientific and clinical merit; and
(B) to the maximum extent practicable, ensure the
geographic dispersal of the sites throughout the United
States.
(d)(1) Each center established under subsection (a) shall be
administered jointly by the offices within the Department that
are responsible for directing research and for directing
medical emergency preparedness.
(2) The Secretary and the heads of the agencies concerned
shall take appropriate actions to ensure that the work of each
center is carried out--
(A) in close coordination with the Department of
Defense, Department of Health and Human Services,
Office of Homeland Security, and other departments,
agencies, and elements of the Federal Government
charged with coordination of plans for United States
homeland security; and
(B) in accordance with any applicable recommendations
of the Working Group on Bioterrorism and Other Public
Health Emergencies, or any other joint interagency
advisory groups or committees designated to coordinate
Federal research on weapons of mass destruction.
(e)(1) Each center established under subsection (a) shall be
staffed by officers and employees of the Department.
(2) Subject to the approval of the head of the department or
agency concerned and the Director of the Office of Personnel
Management, an officer or employee of another department or
agency of the Federal Government may be detailed to a center if
the detail will assist the center in carrying out activities
under this section. Any detail under this paragraph shall be on
a non-reimbursable basis.
(f) In addition to any other activities under this section, a
center established under subsection (a) may, upon the request
of the agency concerned and with the approval of the Secretary,
provide assistance to Federal, State, and local agencies
(including criminal and civil investigative agencies) engaged
in investigations or inquiries intended to protect the public
safety or health or otherwise obviate threats of the use of a
chemical, biological, radiological, or incendiary or other
explosive weapon or device.
(g) Notwithstanding any other provision of law, each center
established under subsection (a) may, with the approval of the
Secretary, solicit and accept contributions of funds and other
resources, including grants, for purposes of the activities of
such center under this section.
* * * * * * *
Sec. 7362. Purpose of corporations
(a) Any corporation established under this subchapter shall
be established solely to facilitate research as described in
section 7303(a) of this title and education and training as
described in sections 7302, 7471, 8154, and 1701(6)(B) of this
title in conjunction with the applicable Department medical
center. [Any funds received by the Secretary for the conduct of
research or education at the medical center other than funds
appropriated to the Department may be transferred to and
administered by the corporation for these purposes.]
(b)(1) Any funds, other than funds appropriated for the
Department, that are received by the Secretary for the conduct
of research or education and training may be transferred to and
administered by a corporation established under this subchapter
for the purposes set forth in subsection (a).
(2) Funds appropriated for the Department are available for
the conduct of research or education and training by a
corporation, but only pursuant to the terms of a contract or
other agreement between the Department and such corporation
that is entered into in accordance with applicable law and
regulations.
(3) A contract or agreement executed pursuant to paragraph
(2) or section 8153 of this title may facilitate only research
or education and training described in subsection (a). Such
contract or agreement may not be executed for the provision of
a health-care resource unless such health-care resource is
related to such research or education and training.
[(b)] (c) For purposes of this section, the term ``education
and training'' means the following:
* * * * * * *
Sec. 8111A. Furnishing of health-care services to members of the Armed
Forces during a war or national emergency
[(a)(1) During and immediately following a period of war, or
a period of national emergency declared by the President or the
Congress that involves the use of the Armed Forces in armed
conflict, the Secretary may furnish hospital care, nursing home
care, and medical services to members of the Armed Forces on
active duty. The Secretary may give a higher priority to the
furnishing of care and services under this section than to the
furnishing of care and services to any other group of persons
eligible for care and services in medical facilities of the
Department with the exception of veterans with service-
connected disabilities.]
[(2) For the purposes of this section, the terms ``hospital
care'', ``nursing home care'', and ``medical services'' have
the meanings given such terms by sections 1701(5), 101(28), and
1701(6) of this title, respectively, and the term ``medical
services'' includes services under sections 1782 and 1783 of
this title.]
(a)(1) During and immediately following a period of war, or a
period of national emergency declared by the President or
Congress that involves the use of the Armed Forces in armed
conflict, the Secretary may furnish hospital care, nursing home
care, and medical services to members of the Armed Forces on
active duty.
(2)(A) During and immediately following a disaster or
emergency referred to in subparagraph (B), the Secretary may
furnish hospital care and medical services to members of the
Armed Forces on active duty responding to or involved in such
disaster or emergency, as the case may be.
(B) A disaster or emergency referred to in this subparagraph
is any disaster or emergency follows:
(i) A major disaster or emergency declared by the
President under the Robert B. Stafford Disaster Relief
and Emergency Assistance Act (42 U.S.C. 5121 et seq.).
(ii) A disaster or emergency in which the National
Disaster Medical System is activated.
(3) The Secretary may give a higher priority to the
furnishing of care and services under this section than to the
furnishing of care and services to any other group of persons
eligible for care and services in medical facilities of the
Department with the exception of veterans with service-
connected disabilities.
(4) In this section, the terms ``hospital care'', ``nursing
home care'', and ``medical services'' have the meanings given
such terms by sections 1701(5), 101(28), and 1701(6) of this
title, respectively.
* * * * * * *
Sec. 8153. Sharing of health-care resources
(a)(1) * * *
* * * * * * *
(3)(A) * * *
* * * * * * *
(C) If the resource required is research or education and
training (as that term is defined in section 7362(c) of this
title) and is to be acquired from a corporation established
under subchapter IV of chapter 73 of this title, the Secretary
may make arrangements for acquisition of the resource without
regard to any law or regulation (including any Executive order,
circular, or other administrative policy) that would otherwise
require the use of competitive procedures for acquiring the
resource.
[(C)] (D) Any procurement of health-care resources other than
those covered by subparagraph [(A) or (B)] (A), (B), or (C)
shall be conducted in accordance with all procurement laws and
regulations.
[(D)] (E) For any procurement to be conducted on a sole
source basis other than a procurement covered by subparagraph
[(A)] (A) or (B), a written justification shall be prepared
that includes the information and is approved at the levels
prescribed in section 303(f) of the Federal Property and
Administrative Services Act of 1949 (41 U.S.C. 253(f)).
[(E)] (F) As used in this paragraph, the term ``commercial
service'' means a service that is offered and sold
competitively in the commercial marketplace, is performed under
standard commercial terms and conditions, and is procured using
firm-fixed price contracts.
* * * * * * *
7364A. COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT CLAIMS LAWS.
* * * * * * *
7368. [REPEALED.]
* * * * * * *
Sec. 7364A. Coverage of employees under certain Federal tort claims
laws
(a) An employee of a corporation established under this
subchapter who is described by subsection (b) shall be
considered an employee of the government, or a medical care
employee of the Veterans Health Administration, for purposes of
the following provisions of law:
(1) Section 1346(b) of title 28.
(2) Chapter 171 of title 28.
(3) Section 7316 of this title.
(b) An employee described in this subsection is an employee
who--
(1) has an appointment with the Department, whether
with or without compensation;
(2) is directly or indirectly involved or engaged in
research or education and training that is approved in
accordance with procedures established by the Under
Secretary for Health for research or education and
training; and
(3) performs such duties under the supervision of
Department personnel.
* * * * * * *
Sec. 7368. [Repealed]
* * * * * * *
TITLE 5, UNITED STATES CODE
* * * * * * *
PART III--EMPLOYEES
* * * * * * *
Subpart D--Pay and Allowances
* * * * * * *
CHAPTER 53--PAY RATES AND SYSTEMS
* * * * * * *
SUBCHAPTER II--EXECUTIVE SCHEDULE PAY RATES
* * * * * * *
Sec. 5315. Positions at level IV
Level IV of the Executive Schedule applies to the following
positions, for which the annual rate of basic pay shall be the
rate determined with respect to such level under chapter 11 of
title 2, as adjusted by section 5318 of this title:
* * * * * * *
[Assistant Secretaries, Department of Veterans
Affairs (6).]
Assistant Secretaries, Department of Veterans Affairs
(7)
* * * * * * *