[Senate Report 107-231]
[From the U.S. Government Publishing Office]
Calendar No. 536
107th Congress Report
SENATE
2nd Session 107-231
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VETERANS LONG-TERM CARE AND MENTAL HEALTH PROGRAMS ENHANCEMENT ACT OF
2002
_______
August 1, 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. 2043]
The Committee on Veterans' Affairs, to which was referred
the bill S. 2043, to amend title 38, United States Code, to
extend by five years the period for the provision by the
Secretary of Veterans Affairs of noninstitutional extended care
services and required nursing home care, and for other
purposes, having considered the same, reports favorably thereon
with an amendment in the nature of a committee substitute and
an amendment to the title, and recommends that the bill, as
amended, do pass.
Introduction
On April 25, 2002, the Committee held a hearing to review
factors underlying the lack of action by the Department of
Veterans Affairs (hereinafter, ``VA'') in implementing the
long-term care provisions of the Veterans Millennium Health
Care and Benefits Act of 1999 (Public Law 106-117 (hereinafter,
Millennium Act)). Those testifying at the hearing included:
Robert Roswell, MD, Under Secretary for Health, VA; Marsha E.
Goodwin, RN, MSN, Acting Chief Consultant, Geriatrics and
Extended Care, and Director, Geriatrics Program, VA; Cynthia A.
Bascetta, Director, Health Care, Veterans' Health and Benefits
Issues, United States General Accounting Office (hereinafter,
``GAO''); Jim Musselwhite, Assistant Director, Health Care,
GAO; Gladys Dickerson, RN, Home Based Primary Care Coordinator,
Dallas VA Medical Center; Paula Hemmings, RN, Geriatrics and
Extended Care Line Manager, Veterans Integrated Service Network
#2, representing the Alzheimer's Association; Thomas McClure,
LCSW, Coordinator, VA Medical Foster Home Program, Little Rock
VA Medical Center; and Jennifer Moye, PhD, Director, Geriatric
Mental Health Clinic/UPBEAT, Brockton VA Medical Center, and
Associate Professor of Psychology, Department of Psychiatry,
Harvard Medical School.
Prior to this hearing, on March 21, 2002, Committee
Chairman John D. Rockefeller IV introduced S. 2043, which would
extend by five years the period for the provision by VA of
noninstitutional extended care services and required nursing
home care.
On September 6, 2001, Chairman Rockefeller introduced S.
1408, with Committee Members Daniel Akaka, Paul Wellstone, Ben
Nelson, and Zell Miller joining later as cosponsors. S. 1408
would standardize the income threshold for copayments for
outpatient medications with the income threshold currently used
to determine a veteran's inability to defray necessary expenses
of care.
On October 25, 2001, Chairman Rockefeller introduced S.
1576, which would extend for ten years the special eligibility
for health care provided to veterans who served in Southwest
Asia during the Persian Gulf War.
On March 21, 2002, Chairman Rockefeller introduced S. 2044,
which would expand and improve programs for the provision of
specialized mental health services to veterans.
On April 18, 2002, Chairman Rockefeller introduced S. 2205,
which would provide VA with permanent authority to offer
veterans counseling and treatment for sexual trauma suffered
during active duty in service.
On April 23, 2002, Chairman Rockefeller introduced S. 2227,
with Senator Max Cleland joining later as a cosponsor. S. 2227
would clarify the effective date of the modification of
treatment for retirement annuity purposes of part-time service
before April 7, 1986, of certain VA health-care professionals.
On April 30, 2002, Chairman Rockefeller introduced S. 2228,
which would authorize VA to operate up to 15 centers for mental
illness research, education, and clinical activities.
On May 2, 2002, the Committee held a hearing to receive
testimony on the aforementioned bills, and on other measures.
Those testifying at the hearing included: Tim McClain, General
Counsel, VA; Frances M. Murphy, MD, Deputy Under Secretary for
Health, Veterans Health Administration, VA; Robert Epley,
Associate Deputy Under Secretary for Policy and Program
Management, Veterans Benefits Administration, VA; John
Thompson, Deputy General Counsel, VA; Claude Kicklighter,
Assistant Secretary for Policy and Planning/Acting Director,
Office of Operations, Security and Preparedness, VA; Vincent
Barile, Deputy Under Secretary for Management, National
Cemetery Administration, VA; James Fischl, Director, National
Veterans Affairs and Rehabilitation Commission, The American
Legion; Joseph A. 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.
Committee Meeting
On June 6, 2002, the Committee met in open session to
consider, among other matters, S. 2043 with an amendment in the
nature of a substitute incorporating provisions from Section 2
of S. 1408, S. 1576, S. 2044, Section 2 of S. 2205, S. 2227,
and S. 2228, and amendments offered by Senator Frank H.
Murkowski regarding a State Home grant of $16 million to the
State of Alaska for the Pioneers' Homes, and by Senator Patty
Murray requiring VA to establish two medical outreach programs
in the State of Washington.
Present were Chairman Rockefeller, Ranking Member Arlen
Specter, and Senators James M. Jeffords, Wellstone, Murray,
Miller, Ben Nelson, Strom Thurmond, Murkowski, Tim Hutchinson
and Kay Bailey Hutchison. The Committee voted unanimously to
report favorably S. 2043, as amended, to the Senate.
Summary of S. 2043 as Reported
S. 2043, as reported (hereinafter, ``Committee bill'')
consists of three titles, summarized below.
TITLE I--LONG-TERM CARE AND MENTAL HEALTH ENHANCEMENTS
Subtitle A--Long-term Care
Section 101 extends for five years the provision set forth
in the Millennium Act requiring that VA provide non-
institutional extended care services and nursing home care
services to certain veterans.
Subtitle B--Mental Health Programs
Section 111 increases from $15 million (as specified in
Section 116 of Public Law 107-135) to $25 million per year
funding set aside for a program designed to expand and improve
services relating to the treatment of post-traumatic stress
disorder (PTSD) and substance use disorders; requires VA to
ensure that this funding is in excess of a baseline amount;
clarifies that these funds are to be provided on an annual
basis for a three-year period; and requires the Secretary to
ensure that not less than $10 million be allocated by direct
grants to programs identified by the Mental Health Strategic
Health Care Group and the Committee on Care of Severely
Chronically Mentally Ill Veterans, not less than $5 million be
allocated for PTSD programs, and not less than $5 million be
allocated for substance use disorder programs.
Section 112 provides permanent authority for counseling and
treatment of sexual trauma. Authority for this program is
currently scheduled to expire on December 31, 2004.
Section 113 authorizes VA to operate up to 15 centers for
mental illness research, education and clinical activities. The
current authority provides for up to five such centers.
TITLE II--CONSTRUCTION AUTHORIZATION
Section 201 authorizes the following Administration-
requested construction projects: seismic corrections to
Building 2 at the Palo Alto VAMC in the amount of $14 million;
seismic corrections to Building 4 at the Palo Alto VAMC in the
amount of $22 million; seismic corrections to the West Los
Angeles VAMC in the amount of $27 million; and seismic
corrections to the San Francisco VAMC in the amount of $31
million. In addition, the Committee bill includes a
modification to a prior authorization for a nursing home
project at the Beckley, West Virginia VAMC and extends a prior
authorization for the nursing home project at the Lebanon,
Pennsylvania VAMC.
Section 211 changes to $9 million the monetary threshold
used for determining when a construction project will be
classified as a major construction project.
Section 212 allows VA to make a grant of not more than $16
million to the State of Alaska for the purpose of expanding,
remodeling or altering space in six separate Pioneers' Homes
and specifies that following such grant, the space be treated
as a single State home facility for the purposes of subchapter
III of chapter 81 of title 38, United States Code.
TITLE III--GENERAL HEALTH CARE MATTERS
Subtitle A--Prescription Copayment Adjustment
Section 311 modifies the income threshold amount for
prescription drug copayments by specifying that that income
threshold amount be the same as the income threshold used to
determine a veteran's qualification for free outpatient and
inpatient care.
Subtitle B--Extensions of Authorities
Section 321 provides that the effective date of the
amendment made by Section 132 of Public Law 107-135 shall be
January 23, 2002, and requires that the Office of Personnel
Management recompute the annuities of each covered health care
professional who retired before January 23, 2002, but after
April 7, 1986.
Section 322 extends for ten years the eligibility for
health care services of veterans who served in Southwest Asia
during the Persian Gulf War.
Subtitle C--Other Matters
Section 331 provides hourly-rate employees of the Veterans
Canteen Service with transfer rights to title 5 positions.
Section 332 requires that VA establish a two-year pilot
project on medical care outreach at two locations in the State
of Washington.
Background and Discussion
TITLE I--LONG-TERM CARE AND MENTAL HEALTH ENHANCEMENTS
Long-Term Care Authorities
There is clearly an expanding need for long-term care in
our country, and in VA that demand is even more pressing.
Approximately 37 percent of the veteran population is 65
years of age or older; the veteran population exceeding age 65
will grow dramatically in the next few years. In an effort to
respond to the burgeoning need for long-term care services,
Congress enacted comprehensive long-term care legislation for
veterans in November 1999 as part of the Millennium Act.
Section 101 of the Millennium Act directed that VA provide
nursing home care to any veteran who is in need of such care
for a service-connected condition, or who is more than 70
percent disabled due to a service-connected condition. In
addition, VA was directed to provide non-institutional care,
such as respite and adult day health care, to all enrolled
veterans requiring such services. Within three years of the
bill's enactment, VA was required to evaluate and report to the
House and Senate Committees on Veterans' Affairs on VA's
experience in providing services under both of these
provisions, and to make recommendations on extending or making
permanent these provisions. These programs were given an
expiration date of four years from the date of enactment so
that the effects on the VA health care system and its patients
could be adequately studied and, if need be, the programs
modified.
A key element of the Millennium Act is a provision that
requires VA to furnish non-institutional long-term care as part
of VA's standard benefits package. While the Millennium Act was
signed into law at the end of 1999, VA did not issue interim
guidance on new long term care benefits until October 2001--
nearly two years later. This interim guidance, VHA Directive
2001-061, required facilities either to have non-institutional
long-term care services available or to develop a plan for
providing such services. In order to assess whether facilities
had made non-institutional services universally available,
Chairman Rockefeller and House Veterans' Affairs Committee
Ranking Member Lane Evans requested that the GAO inventory non-
institutional long-term care programs then existing within VA.
At the Committee's hearing on April 25, 2002, GAO witnesses
testified that:
. . . more than two years after enactment, VA has not
completed its response to the Millennium Act . . . we
have found that several facilities reported offering at
least eight of the non-institutional long-term care
services, but some offered one non-institutional
service or none at all. The results of our survey are
similar to the distribution of services noted almost
four years ago by the Advisory Committee on the Future
of VA Long-Term Care.
Veterans Service Organizations shared their concerns at the
Committee's May 2, 2002, hearing on pending legislation. Dennis
Cullinan testified that, ``[t]he VFW is deeply disappointed
that these services, as provided for [in the Millennium Act]
almost three years ago, have yet to be properly implemented by
VA.''
Following the hearing, on May 17, 2002, VA issued
regulations authorizing non-institutional long-term care
services. In addition to designating non-institutional adult
day care, non-institutional geriatric evaluation, and non-
institutional respite care as a part of the medical benefits
package, the regulations also established copayments for
extended care services.
Since Millennium Act provisions relating to both non-
institutional and inpatient long term care services are due to
expire next year, Section 101 of the Committee bill would
extend the expiration dates of both long-term care authorities
for an additional five years, until December 31, 2008.
Mental Health Enhancements
As the Committee has previously sought to improve and
expand the provision of veterans' long-term care, so too has
the Committee worked to improve mental health services provided
by VA. Historically, as many as one-third of veterans seeking
care at VA have received mental health treatment, and research
suggests that serious mental illnesses affect at least one-
fifth of veterans who use the VA health care system.\1\ About
450,000 of the approximately 2.3 million veterans who receive
compensation from VA have service-connected psychiatric and
neurological disorders.\2\ These statistics do not reflect
problems that affect veterans alone; in 1999, the Surgeon
General of the United States reported that mental disorders
account for more than 15 percent of the overall burden of
disease from all causes--slightly more than all forms of
cancer.\3\ Major depression alone ranked second only to heart
disease in impact.
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\1\ E. P. Fischer, S. R. Mardner, G. R. Smith, R. R. Owen, L.
Rubenstein, S. C. Hedrick, and G. M. Curran. Quality Enhancement
Research Initiative in Mental Health. Medical Care, June 2000; 38(6
Suppl. 1): 170-81.
\2\ Department of Veterans Affairs, Veteran Data and Information.
Program Statistics: FY 1999 Annual Accountability Report Statistical
Appendix, September 30, 1999.
\3\ U.S. Department of Health and Human Services. Mental Health: A
Report of the Surgeon General. Rockville, MD: Substance Abuse and
Mental Health Services Administration, Center for Mental Health
Services, National Institutes of Health, National Institute of Mental
Health, 1999.
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Grants to Improve Specialized Mental Health Programs
From its inception, the VA health care system has been
challenged to meet the special needs of veterans, such as
spinal cord injuries, injuries requiring prosthetic devices,
blindness, traumatic brain injury, homelessness, and post-
traumatic stress disorders (PTSD), as well as substance use
disorders that frequently accompany these other afflictions.
Over the years, VA has developed widely-commended expertise in
providing specialized services to meet these needs.
Unfortunately, these programs have been negatively affected by
budget constraints, a shift in focus from inpatient to
outpatient care, and the introduction by VA of a new resource
allocation system. In 1996, Congress recognized that VA efforts
to serve more veterans with a limited budget made these costly
specialized services disproportionately vulnerable to
reductions, and it took steps to protect them. The Veterans'
Health Care Eligibility Reform Act of 1996, Public Law 104-262,
required the Secretary of Veterans Affairs to maintain VA's
capacity to treat specific special needs of disabled veterans
at then-current levels, and to report to Congress annually on
the maintenance of those specialized services.
Subsequently, internal VA advisory committees and the GAO
reported that these protections did not go far enough.\4\ Many
specialized programs particularly for substance use disorders
and PTSD were closed, reduced in size, or understaffed,
offering little or no care to veterans suffering from these
seriously debilitating disorders which can result from combat
experiences. VA's own annual capacity reports evidenced that
these programs had failed to provide services to veterans at
the needed levels. They also evidenced that VA had failed to
preserve equal access to such services throughout the VA
system.\5\
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\4\ U.S. Department of Veterans Affairs. Special Committee on Post-
Traumatic Stress Disorder. Report to the Under Secretary for Health,
2002, pp. 6, 7, 11, and 13; and U.S. Department of Veterans Affairs.
Committee on the Care of Veterans with Serious Mental Illness. Report
to the Under Secretary for Health, 2002, pp. 4, 6, and 16.
\5\ U.S. Department of Veterans Affairs. Report to the Committees
on Veterans' Affairs of the Senate and House of Representatives, as
required by Public Law 104-262, 2002, pp. 11-12.
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In December 2001, Congress strengthened protection of
specialized services through the Department of Veterans Affairs
Health Care Programs Enhancement Act of 2002, Public Law 107-
135, which described the manner in which VA is to maintain
capacity. In addition to protecting VA's capacity to treat
veterans' special needs, Public Law 107-135 contained a
designated $15 million in VA funding specifically to assist
medical facility efforts to improve care for veterans with
substance use disorders and PTSD. The funds for these mental
health grant programs will soon revert to a general medical
care fund.
In order to distribute these designated funds, VA sought
proposals from facilities interested in expanding and improving
their substance use disorder and PTSD treatment programs. VA
began to release these funds at the end of 2001. As of March
2002, eight of the sixteen PTSD treatment programs awarded
funding were operational, but only one-third of these had hired
a full complement of authorized and funded staff.\6\ Of the
substance use disorder programs funded through this act, 18 of
31 have not completed staffing.\7\
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\6\ U.S. Department of Veterans Affairs. Program Evaluation
Resources Center, VA Palo Alto, California. Millennium Bill
Implementation for Substance Abuse Programs as of July 15, 2001.
\7\ Ibid.
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Despite a slow start, funding has resulted in new PTSD and
substance use disorder treatment programs being made available
to veterans. More than 100 staff members have been hired in 18
of VA's 21 service networks to treat substance use disorders.
Nine new programs in Baltimore, Atlanta, San Francisco, Dayton
and elsewhere have initiated or intensified opioid substitution
programs for veterans who have not responded well to drug-free
treatment regimens. Other new programs, such as those in Tampa,
Cincinnati, Columbia, Missouri and Loma Linda, California, put
special emphasis on treating veterans with more complex
conditions that include PTSD and substance use disorders.
Additional funding has also enabled VA to develop better
outpatient substance use disorder and PTSD treatment programs,
outpatient dual-diagnosis programs, more PTSD community
clinical teams, and more residential substance use disorder
rehabilitation programs.
Due to these grants, VA has made improvements. However,
many VA medical center directors have been reluctant to hire
specialized substance use disorder or PTSD treatment staff
when, in fiscal year 2003, funding for these programs will be
subject to a population-based resource allocation system that
would likely cause funding to disappear. Section 111 ensures
that this funding will remain ``protected'' for three more
years. In addition, Section 111 would increase the total amount
of funding identified specifically for treatment of substance
use disorders and PTSD from $15 million to $25 million.
Of the $25 million authorized for this program, $15 million
would be allocated to individual medical facilities responding
to calls for proposals. The remaining $10 million would be
provided as direct grants to VA treatment facilities, based on
veterans' needs as identified by VA's Mental Health Strategic
Health Care Group and the Committee on Care of the Severely
Chronically Mentally Ill.
Veterans Service Organizations have impressed upon the
Committee the need to set aside funding for specialized
services, especially for PTSD and substance use disorder
programs. Joseph Violante, National Legislative Director of the
Disabled American Veterans, testified at the Committee hearing
on S. 2044. During his testimony, he noted:
As part of The Independent Budget,\8\ DAV has urged
Congress to improve specialized mental health services,
particularly programs for the treatment of post-
traumatic stress disorder and substance abuse . . . The
treatment and rehabilitation of veterans with mental
disorders is among the highest priorities for the
Veterans Health Administration. This bill will begin to
address necessary programmatic expansion and funding
needs of these important mental health programs.
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\8\ A publication published jointly by AMVETS, Disabled American
Veterans, Paralyzed Veterans of America and the Veterans of Foreign
Wars to present policy positions and make budget recommendations on
programs conducted by the Department of Veterans Affairs.
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Sexual Trauma Counseling
Almost a decade ago, the Committee on Veterans' Affairs
held a hearing on the needs of the Nation's growing numbers of
women veterans. Subsequent to that hearing, investigations
revealed that women veterans are eight times more likely to
report having experienced sexual assault during service than
women civilians of the same age.
In 1992, Congress authorized VA to provide counseling to
women who had experienced sexual trauma during active service.
Two years later, recognizing that sexual trauma is not limited
to women, Congress expanded VA's mandate to offer counseling
and treatment to victims of sexual harassment or sexual assault
without regard to gender. The Millennium Act broadened VA's
responsibilities toward victims of sexual trauma further,
strengthening outreach efforts and extending the programs
through December 2004.
VA has worked--internally and with the Department of
Defense--to educate health care professionals about the
physical and emotional legacies of sexual trauma. Those who
have endured such trauma need counseling and appropriate
treatment, both during and following service. While we must
hope that sexual violence will be eliminated from our forces,
the programs that VA has established will likely continue to be
needed. Section 112 would authorize VA to continue its
counseling and treatment programs for veterans who have
experienced military sexual trauma beyond 2004.
The Committee on Veterans' Affairs continues to await a VA
report, mandated by the Millennium Act and due in March 2001,
on rates of sexual trauma among National Guard members and
Reservists. Upon receipt of that report, the Committee will be
better equipped to decide whether authority for counseling and
treatment services to members of the Armed Forces who might
have experienced sexual trauma while on active duty for
training will be needed.
Mental Illness Research, Education, and Clinical Centers
In 1996, Congress authorized VA to establish five centers
dedicated to mental illness research, education, and clinical
activities. These Mental Illness Research, Education, and
Clinical Centers (hereinafter, ``MIRECCs'') integrate basic and
clinical research with a training mission that allows VA to
translate new findings into improved patient care. Research
undertaken within these centers has helped to increase
fundamental understanding of mental illnesses, and has given VA
care givers more and better tools to treat patients with mental
disorders so they can function more easily within their
communities.
Because they have proved so effective at fostering
scientific, clinical, and educational improvements in mental
health care, Section 113 authorizes VA to expand the number of
MIRECCs from five to fifteen. VA researchers have already
started three more centers--expanding the number of existing
programs to eight--and have demonstrated their willingness to
open more in the near future.
While the Committee bill contains no legislative
initiatives to assist the National Center for PTSD, the
Committee commends the Center for its work at the forefront of
research and education on the etiology, diagnosis, and
treatment of PTSD and other adverse consequences of exposure to
stress. Its consistent record of accomplishment is one reason
VA has emerged as a national and world leader in this field.
National Center programs supporting VA clinicians, benefits
personnel, researchers and other officials result in improved
treatment and claims adjudication for veterans. The Committee
believes that the National Center for PTSD is a unique and
valuable resource that deserves continued strong support from
VA.
TITLE II--CONSTRUCTION MATTERS
Subtitle A--Construction Authorization
Sections 201-203. Major Medical Facility Construction
VA may not obligate or expend funds on any ``major medical
facility project'' unless that project has been specifically
authorized by law. A major medical facility project is one that
would involve the construction, alteration, or acquisition of a
medical facility involving the total expenditure of more than
$4 million.
Section 201 of the Committee bill would authorize the
following major medical facility projects: seismic corrections
to Building 2 at the Palo Alto VAMC in the amount of $14
million; seismic corrections to Building 4 at the Palo Alto
VAMC in the amount of $22 million; seismic corrections to the
West Los Angeles VAMC in the amount of $27 million; and seismic
corrections to the San Francisco VAMC in the amount of $31
million.
The Committee bill also increases the amount of the
authorization for a previously-authorized project at the
Beckley, West Virginia VAMC. It also extends a previously-
enacted authorization for a long-term care project at the
Lebanon, Pennsylvania VAMC.
VA identifies--in accordance with 38 U.S.C.
Sec. 8107(d)(1), (2), and (3)--the major construction projects
that have the highest priority within the Department. Utilizing
guidance contained in the Office of Management and Budget's
Circular A-11, Planning, Budgeting, and Acquisition of Capital
Assets, the VA's Strategic Management Council prioritized the
major medical construction projects for FY 2003. The top
fifteen projects, in order of priority, are:
1. Palo Alto, CA, Building 2, Seismic Corrections
2. Cleveland, OH, Ambulatory Surgery and Clinical
Consolidation
3. San Francisco, CA, Building 203, Seismic Corrections
4. Anchorage, AK, VA Health Care System and Regional Office
Construction
5. West Los Angeles, CA, Building 500, Seismic Corrections
6. West Haven, CT, Ward Renovation
7. Long Beach, CA, Building 7, Seismic Corrections
8. Palo Alto, CA, Building 4, Seismic Corrections
9. Tampa, FL, Ambulatory Care Expansion
10. VISN 4 Outpatient Improvements
11. Beckley, WV, Nursing Home Construction
12. Lebanon, PA, Building 2 Renovations
13. San Diego, CA, Building 1, Seismic Corrections
14. Hines, IL, Spinal Cord Injury and Blind Rehabilitation
Construction
15. San Juan, PR, Main Building, Seismic Corrections
While the Committee bill includes authorizations for each
project requested by the Administration in the President's
Fiscal Year 2003 Budget, the Committee is concerned about the
methodology used by VA to rank projects and how that ranking
relates to the Administration's requests for funding. The four
seismic correction projects requested by the Administration
appear on various points along VA's priority list, namely,
first, third, fifth, and eighth. Funding and authorization for
other projects which appear, in some cases, as higher priority
projects is not sought by the Administration. For example, the
Cleveland, Ohio ambulatory surgery and clinical consolidation
project appears as the Department's second-highest rated
project; yet, the project does not appear in the
Administration's budget request. The Committee intends to
monitor the process closely during the next budget cycle and
urges the Department to review its construction request
methodology.
Subtitle B--Other Matters
Sec. 211. Increase in Threshold for Major Medical Facility
Projects
Section 211 of the Committee bill increases the threshold
for major construction projects from $4 million to $9 million.
Currently, VA medical center projects with a minor improvement
component of less than $4 million are funded from the Minor
Construction appropriation and need not be authorized
individually by Congress. However, all such projects are
subjected to internal review and approval by VA's Strategic
Management Council. The application process includes an
assessment of needs; a ten-year cost-effectiveness analysis; a
study of the impact on Capital Asset Realignment for Enhanced
Services activities; risk analysis; and alternative analysis of
issues such as quality, access, waiting times and increased
benefits. Projects are first screened by the Capital Asset
Board in the Veterans Health Administration. They are then
prioritized and referred by the Under Secretary for Health to
the Department's Strategic Management Council, chaired by the
Department's Deputy Secretary. Minor improvement projects
include structural changes, space utilization changes, and
construction of new or additional space.
Initially, 38 U.S.C. Sec. 8104 made no distinction between
major and minor construction projects. In 1988, Public Law 100-
322 defined major construction projects as those costing more
than $2 million and required that those projects be authorized
and individually appropriated by Congress. In 1993, Public Law
103-79 changed the threshold for a major project from $2
million to $3 million, and in 1996, Public Law 104-262
increased the threshold to $4 million. Over a period of 14
years, the threshold has only increased an average of less than
$150,000 per year.
The Independent Budget for Fiscal Year 2003 addressed the
issue of minor construction by noting:
. . . the $4 million limit on minor construction
projects imposed by Congress continues to be a major
problem. Realignment and consolidation and the CARES
initiative will call for extensive construction
investments in many facilities in all VISNs.
Accordingly, the current ceiling on minor construction
projects is too low to finance the scope of many of
these projects . . . Network Directors are forced to
string together a series of minor construction projects
to make the architectural changes that are needed to
realign facilities to new missions. Project scheduling
is dictated by financing gimmicks rather than by good
design and engineering principles. Facility operations
are disrupted and veterans are inconvenienced by drawn-
out construction activities.
An example of the how VA ``works around'' the current minor
construction limit is the Augusta VAMC's Spinal Cord Injury
(hereinafter, ``SCI'') unit. VA needed to replace the unit
because current privacy and infrastructure (plumbing,
electrical, AC and ventilation) standards were not met. A
replacement unit would have cost approximately $14 million--an
amount well above the minor construction limit. Rather than
pursuing approval for major construction project funding,
facility and VISN management decided to remodel the current SCI
unit in two phases using funding for two minor construction
projects (totaling around $7 million). The first phase, which
was a renovation of inpatient areas, was approved and
construction has begun. Another minor construction project will
be requested in fiscal year 2003 to complete the remodeling of
the outpatient areas. By doing the project in two phases, VA
will take 50 percent longer to complete the project. Additional
inconvenience to veterans and disruptions during construction
will result.
Sec. 212. State Home Facilities for Furnishing Care to
Veterans in the State of Alaska
Section 212, provides VA the authority to grant to the
State of Alaska up to $16 million to improve space in six
existing Pioneer Homes.
Since 1888, the Federal government has provided funding to
States to assist in the care of elderly veterans. 38 U.S.C.
Sec. 8135(a) requires any State desiring assistance with the
construction of State home facilities to submit an application
to the Secretary, certifying that the State has funding of not
less than 35 percent of the costs needed with respect to such
construction and that such funding will be available by July 1
of the fiscal year in which the application is made.
The State of Alaska is one of three States that currently
does not have a State Veterans Home. However, the State does
maintain a residential housing program, known as Pioneers'
Homes, for elderly citizens, including veterans and their
spouses, in six different locations within the State.
The grant provided under this section would exempt the
State from meeting the 35 percent funding requirement and would
treat the space in the aggregate as a State home facility.
TITLE III--GENERAL HEALTH CARE MATTERS
Subtitle A--Prescription Copayment Adjustment
Sec. 311. Standardization of Income Thresholds for
Copayment for Outpatient Medications and for
Inability to Defray Necessary Expenses of Care
Under current law, veterans who are eligible for Medicaid,
or those who meet an income threshold established by law, are
eligible to receive free health care at VA facilities.
Additionally, veterans who are--or would be--eligible for a VA
pension receive free prescription drugs. However, the income
threshold for pension eligibility is much lower than that set
for Medicaid eligibility or the means test established by
statute for free health care.
The prescription drug copayment was initially established
by Public Law 101-508, the Omnibus Budget Reconciliation Act of
1990. The charge was $2 for each 30-day supply of medication
prescribed by a VA physician. Public Law 101-508 also
established the means test for determining the ability to pay
copayments for outpatient medical care. The means test
considers annual income (setting a threshold at approximately
$24,300) and net property worth (setting a threshold at
$80,000). Public Law 101-508 did not, however, include an
income threshold for prescription drug copayments. As a
consequence, all veterans, except those with a 50 percent or
greater service-connected disability, were charged the $2
medication copayment prescribed for drugs to treat nonservice-
connected conditions. Later, Public Law 102-568, exempted
veterans whose annual income did not exceed the maximum annual
rate of VA pension (approximately $9,500 today) from paying the
prescription drug copayment.
For veterans with financial hardships, VHA Directive 2002-
005, dated January, 2002, provides authority and guidance to
field facilities for processing waiver requests for medical
care and prescription drug copayment debts.
On February 4, 2002, VA raised the prescription copayment
from $2 to $7--a 350 percent increase. This increase has been
particularly burdensome for lower-income veterans. To
illustrate the new financial burden imposed on those with low
incomes, the Committee considered the case of a veteran who
required ten prescriptions and had an income of approximately
$10,000 a year. Because of VA's increase in the prescription
drug copayment, such a veteran must now allocate 8.4 percent of
his or her annual income, rather than 1.2 percent, on
prescription medications.
Robert E. Wallace, Executive Director, Veterans of Foreign
Wars, wrote in a letter to the VA Secretary, Anthony J.
Principi:
That scenario will probably result in one of two
things for our category 5 veterans: they will either
stop seeking needed medical care because the increased
costs will soon ``price'' them out of the system or we
will be faced with an inordinate increase in the number
of waiver requests . . . the substantial increase of
unintentional patient noncompliance will, in the long
run, invariably result in overall higher medical costs
than what would be recovered by the increased
prescription copayment.
On May 2, 2002, the American Legion testified before the
Committee about the need to modify the income threshold for
prescription drugs.
The American Legion has heard--loud and clear--the
negative reactions of veterans to the recent medication
copayment increase. . . . Clearly, the sizable percent
of this increase has presented difficulties for certain
veterans, especially those with low fixed incomes and
those who are barely above the threshold for
exemption--the pension rate of $9,556--as well as those
veterans who require multiple or maintenance
medications. Veterans also find the complex and arcane
rules that govern eligibility difficult to understand.
Standardizing the thresholds, as proposed, would help
to simplify the copayment criteria, but most
importantly, it would assist those least able to afford
the increase in their prescription copayments.
Section 311 of the Committee bill standardizes the income
threshold limitation for prescription copayments with the
income threshold for outpatient medical care. The primary
purpose for this modification is to reduce the financial burden
of the VA's new $7 copayment imposed upon veterans in the lower
income levels (between $9,500 and $24,300); however, there are
administrative benefits associated with this provision as well.
The number of waivers requested by veterans has increased
dramatically, as the Veterans of Foreign Wars predicted. For
the first three months of the increase, $4.7 million more in
copayment charges have been waived than during the same time
period last year. One VA medical center reported that waiver
applications had increased from only 4 in April 2001 to 48 in
April 2002. Because the Committee expects that the number of
waivers requested by veterans will be nearly eliminated by this
provision, there would be a corresponding decrease in the
manpower associated with filing, processing, and reviewing each
claim.
Subtitle B--Extensions of Authorities
Sec. 321. Retirement Annuities for Part-Time VA Nurses
Section 321 of the Committee bill addresses an issue of
fairness in retirement annuity benefits promised to part-time
VA nurses prior to 1986. In December 2001, Congress enacted the
Department of Veterans Affairs Health Care Programs Enhancement
Act of 2001, Public Law 107-135. This legislation gave VA
several tools to respond to the looming nurse crisis. In
addition, it altered the way part-time service performed by
certain title 38 employees would be considered when granting
retirement credit.
Previously, the law required that title 38 employees' part-
time service prior to April 7, 1986, be prorated when
calculating retirement annuities, resulting in lower annuities
for these employees. Section 132 of Public Law 107-135 was
intended to exempt all previously-retired registered nurses,
physician assistants, and expanded-function dental auxiliaries
from this limitation. However, the Office of Personnel
Management has interpreted this provision to apply only to
those health care professionals who retire after the measure's
date of enactment.
Section 321 of the Committee bill would require OPM to
recalculate the annuities for these retired health care
professionals. This clarification would not extend retirement
benefits retroactively to the date of retirement. It would,
however, ensure that annuities are calculated fairly from now
on for eligible employees who retired between April 7, 1986,
and January 23, 2002.
Sec. 322. Eligibility for Persian Gulf War Veterans
Section 322, which is drawn from S. 1576, as introduced by
Chairman Rockefeller, extends eligibility for health care to
veterans who served in Southwest Asia during the Persian Gulf
War.
Service members returning from the Gulf in 1991 reported a
range of unexplained illnesses that many believed might have
resulted from service. Investigations by Congress, the
Departments of Defense and Veterans Affairs, and the Institute
of Medicine showed that the men and women who served in
Operation Desert Storm might have been exposed to many
battlefield hazards, including smoke from oil-well fires,
pesticides, organic solvents, the drug pyridostigmine bromide,
numerous vaccinations, and sarin nerve gas.
Success in determining whether any or all of these hazards
might be linked to specific symptoms has been limited by poor
data, a lack of research into the long-term effects of low-dose
exposures, and incomplete military record keeping. In response
to concerns about the health of Gulf War veterans, Congress
enacted Public Law 102-585, authorizing health examinations,
tasking the National Academy of Sciences to evaluate scientific
evidence regarding potential Gulf War exposures, and
establishing the Gulf War Veterans Health Registry. In
addition, Congress enacted Public Law 102-310, authorizing VA
to provide health care services on a priority basis to Gulf War
veterans through December 31, 2001. Public Law 107-135 extended
this provision granting access to health care on a priority
basis through December 31, 2002.
More than a decade after the war, scientific research still
has not determined the causes of veterans' symptoms, or the
long-term health consequences of Gulf War exposures. The
Department of Defense recently released new estimates of the
number and locations of service personnel exposed to nerve
agents. To meet the medical needs of Gulf War veterans, now and
in the future, Section 322 of the Committee bill would extend
this period for providing health care services on a priority
basis for 10 more years.
Subtitle C--Other Matters
Sec. 331. Transfer Rights for VA Canteen Workers
Section 331 of the Committee bill would provide transfer
rights for hourly rate Veterans Canteen Service (hereinafter,
``VCS'') employees to title 5 VA positions through internal
competitive procedures. VCS hourly-rate employees are Federal
employees hired under authority of 38 U.S.C. Sec. 7802. And
while this authority provides many of the same benefits that
title 5 federal employees enjoy, (e.g., workers compensation,
health benefits, retirement, and veterans' preference) there
are benefits to which they are not entitled. For example, VCS
hourly employees do not have the same transfer rights to other
VA positions that VCS managers have.
VCS hires through a merit system; however, VA may hire
canteen workers without regard to title 5 competitive civil
service procedures. As a result, VCS hourly employees applying
for VA food service positions, VA housekeeping positions, and
other VA positions are not treated as internal competitive
service candidates. Their years of service are irrelevant, as
they cannot easily transfer to another job at VA without first
going through civil service competitions.
In 1979, the Office of Personnel Management (hereinafter,
``OPM'') approved an interchange agreement with VA that
permitted two-way movement between the two hiring authorities.
VA attempted to establish an interchange agreement for the
hourly employees in 1984, 1987 and 1998, but OPM did not
approve these proposals.
Sec. 332. Pilot Project on Medical Care Outreach for
Veterans in the State of Washington Through
Outreach Clinics
Section 332 requires VA to establish a program, during
fiscal years 2003 and 2004, to provide health care services for
veterans in the State of Washington through two outreach
clinics. The clinics would be located in Whatcom County,
Washington and in north central Washington, in or near
Leavenworth, Washington.
Each clinic would provide basic health care services,
including diagnosis and referral to other VA facilities, at
least one day per week. VA would be required, by June 1, 2004,
to provide to the Veterans Committees of the Senate and the
House a report on the program describing personnel utilized,
patient workload and costs, and making recommendations
regarding the modification or expansion of the pilot project.
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 CBO, estimates that, compared to the
CBO baseline, there would be costs resulting from enactment of
the Committee bill.
The cost estimate provided by CBO follows:
Congressional Budget Office Cost Estimate
U.S. Congress,
Congressional Budget Office,
Washington, DC, June 24, 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. 2043, the Veterans
Long-Term Care and Mental Health Programs Enhancement 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. 2043 Veterans Long-Term Care and Mental Health Programs Enhancement
Act of 2002 (As ordered reported by the Senate Committee on Veterans'
Affairs on June 6, 2002)
SUMMARY
S. 2043 contains several provisions that would affect
health care provided by the Department of Veterans Affairs
(VA). CBO estimates that enacting the bill would increase
direct spending by $6 million in 2003, $30 million over the
2003-2007 period, and $64 million over the 2003-2012 period.
Because the bill would affect direct spending, pay-as-you-go
procedures would apply. In addition, S. 2043 would modify
provisions governing discretionary spending for veterans'
health care programs, which CBO estimates would result in
outlays of $28 million in 2003 and $880 million over the 2003-
2007 period, assuming appropriation of the estimated amounts.
The bill would extend for five years certain requirements
that specify how VA is to provide long-term care to veterans.
S. 2043 also would increase the amount of appropriated funds
spent on mental health services and would increase the number
of centers at VA hospitals that focus on mental health research
and services. In addition, the bill would permanently extend
the authority to provide counseling and treatment for veterans
who suffer from sexual trauma and establish a pilot program of
outreach clinics in the state of Washington. S. 2043 also would
require retirement annuities to be recalculated for certain
former VA employees.
S. 2043 also would allow more veterans to become eligible
for free prescription drugs by raising the income threshold for
determining which veterans need to make a prescription drug
copayment. Because the bill would not extend the authority to
collect prescription drug copayments, which expires on
September 30, 2002, enacting this provision would have no
budgetary effect over the 2003-2007 period. The provision could
increase direct spending in fiscal year 2002, however, if the
bill is enacted soon. If the bill is enacted before the end of
the fiscal year, CBO estimates that raising the income
thresholds for eligibility for free prescription drugs could
increase direct spending by no more than $9 million in 2002,
and that this increase would be offset by savings of $7 million
in 2003 and $2 million in 2004.
Finally, the bill would authorize appropriations for
construction projects and would raise the threshold for
projects to be financed out of the appropriation for major
medical facility construction from $4 million to $9 million.
(Thus, under the bill projects costing up to $9 million would
be considered minor construction.)
S. 2043 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. 2043 is shown in Table
1. For this estimate CBO assumes that the bill will be enacted
near the beginning of fiscal year 2003, and that both the
authorized and estimated amounts will be appropriated each
year. The costs of this legislation fall within budget
functions 600 (income security) and 700 (veterans benefits and
services).
Table 1.--Estimated Budgetary Impact of S. 2043
[By Fiscal Year, in Millions Dollars]
------------------------------------------------------------------------
2003 2004 2005 2006 2007
------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Estimated Budget Authority...... 6 6 6 6 6
Estimated Outlays............... 6 6 6 6 6
CHANGES IN SPENDING SUBJECT TO
APPROPRIATION
Estimated Authorization Level... 150 192 197 179 186
Estimated Outlays............... 28 208 237 213 194
------------------------------------------------------------------------
a Enacting S. 2043 could also increase direct spending in fiscal year
2002 if the bill is enacted before the end of the fiscal year. In that
case, CBO estimates raising the income threshold for determining which
veterans are eligible for free prescription drugs could increase
direct spending by no more than $9 million in 2002, depending on the
date of enactment, but that this increase would be offset by savings
of $7 million in 2003 and $2 million in 2004.
BASIS OF ESTIMATE
Direct Spending
The legislation would affect direct spending in all future
years for retirement annuities to certain former VA employees.
The bill could also affect direct spending in 2002 by allowing
more veterans to become eligible for free prescription drugs,
but those potential effects are not included in Table 1 because
we assume the bill will be enacted near the beginning of fiscal
year 2003 for the purposes of this cost estimate.
Retirement Annuities for Certain Retirees with Part-time
Service. S. 2043 would require retirement annuities to be
recalculated for federal retirees who performed part-time
service as registered nurses, physician's assistants, and
certain dental technicians at VA prior to April 7, 1986. The
Department of Veterans Affairs Health Care Programs Enhancement
Act of 2001 (Public Law 107-135), enacted on January 23, 2002,
made changes to the way retirement benefits are determined for
those workers who retired on or after the date that legislation
was enacted. That legislation treated pre-April 7, 1986, part-
time service as full-time service for the purpose of
calculating retirement annuities. S. 2043 would extend these
changes to the types of workers covered by Public Law 107-135,
but who retired between April 6, 1986, and January 23, 2002.
Retirement benefits for these workers currently are set
according to a formula that prorates all part-time service
performed in these positions. For most other federal workers,
including those covered by Public Law 107-135, part-time
service performed prior to April 7, 1986, is treated as full-
time service when calculating retirement annuities. In most
cases, the changes result in higher retirement benefits.
Information about retirees who would be covered by S. 2043
is limited, but based on data provided by VA and the Office of
Personnel Management, CBO estimates that about 1,500 current
retirees would have their benefits increased by the bill. CBO
estimates that the new formula would increase benefits for
affected retirees by 13 percent to 22 percent, depending on how
much part-time service was performed prior to April 7, 1986. As
a result, enacting S. 2043 would increase direct spending by $6
million in 2003, $30 million over the 2003-2007 period, and $64
million over the 2003-2012 period.
Prescription Copayments. Under current law, veterans who
are eligible for a VA pension, eligible for Medicaid, or meet a
certain income threshold are eligible to receive free health
care at VA hospitals and clinics. That income threshold is
currently $24,305 for a veteran with no dependents. Some
veterans also can receive free prescription drugs, but the
income threshold is much lower, currently $9,556 for a veteran
with no dependents. (Both thresholds are adjusted annually for
inflation.) Section 311 would raise the income threshold for
receiving free prescription drugs to the same level needed to
receive free health care and would allow all veterans with
incomes less than the annually adjusted amount to be eligible
for free prescription drugs.
Today, veterans who do not meet the income threshold for
free prescription drugs must make a copayment when they have
their prescriptions filled. VA currently collects a $7
copayment for each outpatient prescription it fills and
deposits the first $2 of this copayment into the Medical Care
Collections Fund (MCCF). Under current law, amounts deposited
into the MCCF are considered to be offsets to discretionary
appropriations and spending from the MCCF is subject to annual
appropriation. The remaining $5 is deposited into the Health
Services Improvement Fund (HSIF). Deposits into the HSIF are
considered offsets to direct spending, and VA may spend amounts
in the HSIF without appropriation action. That is, both the
receipts and outlays of the HSIF constitute direct spending.
Using information from VA, CBO estimates that raising the
income threshold for determining which veterans make
prescription drug copayments would reduce copayment collections
by about 35 percent. Because the authority to collect
prescription drug copayments expires on September 30, 2002, the
impact of providing free prescription drugs to a larger number
of veterans would only affect fiscal year 2002 and have no
budgetary effect over the 2003-2012 period.
If S. 2043 were enacted before the end of the fiscal year,
CBO estimates that collections deposited into the HSIF would
decline by no more than $23 million. Because VA has the
authority to spend the money in the HSIF without appropriation,
any drop in collections would be matched by a drop in spending
from the fund. Accounting for a lag in spending of HSIF
deposits, we estimate that there could be a net increase in
direct spending of up to $9 million in 2002. That increase
would be offset exactly by savings of $7 million in 2003 and $2
million in 2004. Thus, enacting S. 2043 would have no net
direct spending costs or savings over the 2002-2007 period.
Spending Subject to Appropriation
Table 2 shows the estimated effects of S. 2043 on
discretionary spending for veterans' health care programs,
assuming that appropriations are provided in the authorized and
estimated amounts. Individual provisions that would affect
discretionary spending are described below.
Table 2.--Changes in Spending Subject to Appropriation for S. 2043
[By Fiscal Year, Outlays in Millions of Dollars]
----------------------------------------------------------------------------------------------------------------
2003 2004 2005 2006 2007
----------------------------------------------------------------------------------------------------------------
VETERANS' MEDICAL CARE
Long-Term Care:
Estimated Authorization Level.................................... 0 166 171 177 184
Estimated Outlays................................................ 0 151 169 176 182
Mental Health Care:
Estimated Authorization Level.................................... 23 24 26 2 2
Estimated Outlays................................................ 21 24 26 4 2
Pilot Project on Medical Care Outreach:
Estimated Authorization Level.................................... 2 2 0 0 0
Estimated Outlays................................................ 2 2 0 0 0
Subtotal for Veterans' Medical Care:
Estimated Authorization Level.................................... 25 192 197 179 186
Estimated Outlays................................................ 23 177 195 180 184
MAJOR CONSTRUCTION OF VETERANS MEDICAL FACILITIES
Authorization Level................................................ 109 0 0 0 0
Estimated Outlays.................................................. 5 29 35 26 10
GRANTS FOR CONSTRUCTION OF EXTENDED CARE FACILITIES
Authorization Level................................................ 16 0 0 0 0
Estimated Outlays.................................................. 0 2 7 7 0
TOTAL CHANGES
Estimated Authorization Level...................................... 150 192 197 179 186
Estimated Outlays.................................................. 28 208 237 213 194
----------------------------------------------------------------------------------------------------------------
Veterans Medical Care. Federal spending for all veterans
medical care totals more than $22 billion a year. Several
sections of the bill would affect medical care for veterans. In
total, CBO estimates that implementing these provisions would
cost $23 million in 2003 and $759 million over the 2003-2007
period.
Long-Term Care. Section 101 would extend a requirement in
current law that VA provide nursing home care to veterans that
have a disability rating of 70 percent or greater. Under
current law, this requirement expires on December 31, 2003.
This provision would extend the requirement for five more years
through December 31, 2008. Section 101 also would extend an
authorization to treat noninstitutional extended care services
as regular medical care. According to VA, the department
currently spends about $3.5 billion a year providing long-term
care services to veterans. Of that amount, VA spends more than
$2 billion for nursing home care and less than $0.5 billion for
noninstitutional extended care.
According to VA, it currently spends about $150 million a
year out of the $3.5 billion to conform with the above
requirements. Accordingly, CBO estimates that requiring VA to
continue these services would cost $151 million in 2004 and
$678 million over the 2004-2007 period, assuming appropriation
of the estimated amounts.
Mental Health Care. Section 113 would require VA to
establish not more than 15 centers for mental illness research,
education, and clinical activities. VA can establish no more
than five centers under current law. According to VA, there are
eight such centers operating today, however. Thus, for this
estimate, CBO assumes that VA would establish seven more
centers for mental illness research, education, and clinical
activities to implement this provision. Based on data from VA,
CBO estimates that each center would cost about $2 million a
year to operate. Assuming normal delays in organizing new
centers and appropriation of the estimated amounts, CBO
estimates that establishing seven new centers would cost $12
million in 2003 and $70 million over the 2003-2007 period.
Section 111 would require VA to spend an additional $25
million a year on mental health care over the 2003-2005 period.
Under current law, VA is required to spend $15 million more
each year than what they otherwise would have spent on post-
traumatic stress disorder and substance use disorders; there is
no expiration date associated with this requirement. Under
section 111, VA would be required to spend $10 million more
than specified under current law over the 2003-2005 period, but
would then not be required to spend any additional amounts
after 2005. Thus, CBO estimates that implementing this section
would cost $9 million in 2003, cost $29 million over the 2003-
2005 period, and save $28 million over the 2006-2007 period.
Section 112 would permanently extend VA's authority to
provide counseling and treatment for veterans who suffered
sexual trauma while a member of the armed services. Under
current law, this provision expires on December 31, 2004. VA
currently spends about $2 million a year providing this
counseling and treatment. CBO estimates that extending this
provision would cost $2 million in 2005 and $6 million over the
2005-2007 period, assuming appropriation of the estimated
amounts.
Prescription Drug Copayments. Section 311 would raise the
income threshold for receiving free prescription drugs to the
same level needed to receive free health care and would allow
all veterans with incomes less than the annually adjusted
amount to be eligible for free prescription drugs. The
specifics of this proposal were discussed above under the
heading of ``Direct Spending.'' As mentioned earlier, CBO
estimates the impact of providing free prescription drugs to a
larger number of veterans would have no budgetary effect over
the 2003-2007 period because the authority to collect
prescription drug copayments expires on September 30, 2002. (As
noted below, costs would be triggered if future legislation
extends that authority.)
If S. 2043 were enacted before the end of the fiscal year,
CBO estimates that this provision would decrease spending from
the MCCF by no more than $10 million. Because spending from the
MCCF is subject to appropriation, this reduction would
represent a real cost to VA that would need to be paid for out
of increased appropriations if the level of medical care were
not reduced. CBO estimates that implementing S. 2043 could
increase spending by as much as $10 million, if the bill were
enacted before October 1, 2002, assuming the availability of
appropriated funds.
In addition, if the authority to collect prescription drug
copayments were extended through September 30, 2007, CBO
estimates that VA would collect $634 million from prescription
drug copayments in 2003 and almost $4 billion over the 2003-
2007 period. If the collection authority is extended, CBO
estimates that those collections would be reduced by about 35
percent or $222 million in 2003 and about $1.4 billion over the
2003-2007 period under S. 2043.
Pilot Project on Medical Care Outreach. Section 322 would
authorize VA to establish and operate two VA clinics for fiscal
years 2003 and 2004 as a pilot project in the state of
Washington to provide outreach on health care and services for
veterans in that state. These clinics would provide basic
health care services to veterans in areas that do not currently
have VA facilities and would be open at least one day a week.
Based on information from VA, CBO estimates that each clinic
would cost about $1 million a year to operate. Thus CBO
estimates that implementing this provision would cost $4
million over the 2003-2004 period, assuming appropriation of
the estimated amounts.
Major Construction of Veterans Medical Facilities. Sections
201 would authorize specific construction projects for seismic
corrections along with one construction project for a long-term
care facility, and would set spending limits for each project.
Section 202 would authorize the appropriation of $108.5 million
in 2003 for major construction projects. Finally, section 211
would raise the threshold for projects to be financed out of
the appropriation for major medical facility construction from
$4 million to $9 million. (Thus, under the bill projects
costing up to $9 million would be considered minor
construction.) CBO estimates that implementing these provisions
would cost $5 million in 2003 and $105 million over the 2003-
2007 period, assuming appropriation of the authorized amounts.
Grants for Construction of Extended Care Facilities.
Section 212 would authorize up to $16 million to expand,
remodel, or alter space in six Pioneer Homes in the state of
Alaska that are dedicated to providing care for veterans. Under
section 212, these modified Pioneer Homes would be considered a
state home facility for the state of Alaska for the purpose of
laws administered by the Secretary of VA. CBO estimates that
this provision would have no cost in 2003 but would cost $16
million over the 2004-2007 period, assuming appropriation of
the authorized amounts.
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. The net changes in outlays that are subject to pay-
as-you-go procedures are shown in Table 3. For the purposes of
enforcing pay-as-you-go procedures, only the effects through
fiscal year 2006 are counted.
Table 3.--Estimated Impact of S. 2043 on Direct Spending and Receipts
[By Fiscal Year, in Millions of Dollars]
----------------------------------------------------------------------------------------------------------------
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
----------------------------------------------------------------------------------------------------------------
Changes in outlays................. 0 6 6 6 6 6 6 7 7 7 7
Changes in receipts *
----------------------------------------------------------------------------------------------------------------
* Not applicable.
INTERGOVERNMENTAL AND PRIVATE-SECTOR IMPACT
S. 2043 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 October 29, 2001, CBO transmitted a cost estimate for S.
1408, the Veterans' Copayment Adjustment Act, as introduced on
September 6, 2001. S. 2043 and S. 1408 would both allow more
veterans to become eligible for free prescription drugs by
raising the income threshold for determining which veterans
need to make a prescription drug copayment. Because neither
bill would extend the authority to collect prescription drug
copayments, which expires on September 30, 2002, the estimated
costs of this provision are limited to fiscal year 2002 for
both bills. CBO's estimate for S. 2043 does not include any
costs for fiscal year 2002 because we assume the bill will be
enacted near the beginning of fiscal year 2003. Differences in
the cost estimates stem primarily from different assumed
enactment dates.
Estimate prepared by: Federal Costs: Sam Papenfuss and
Geoffrey Gerhardt. 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.
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 June 6, 2002 meeting. On that date,
the Committee, by unanimous voice vote, ordered S. 2043, as
amended, reported favorably to the Senate.
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. 1408, S.
1576, S. 2043, S. 2044, S. 2227, and S. 2228. 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. 1408
This bill would increase the income threshold used to
define the group of low-income veterans who are exempted from
paying the outpatient pharmacy co-payment. The exempted group
would be expanded to include veterans who, for purposes of
receiving VA health care, are deemed unable to defray necessary
expenses of care, i.e., those with incomes below VA's ``means-
test'' threshold. A provision of the bill would also prohibit
the Secretary from increasing the pharmacy co-payment until VA
begins collecting co-payments for outpatient care.
Currently, the low-income exemption applies only to those
veterans whose incomes do not exceed the maximum annual rate of
pension payable under 38 U.S.C. Sec. 1521 were they eligible
for such pension. This is a much smaller group composed of very
low-income veterans. Although VA appreciates the desire to
standardize the definition of ``low-income'' veteran for
purposes of both health care eligibility and the pharmacy co-
payment exemption, VA cannot support S. 1408. The proposal
would significantly reduce much-needed revenue upon which the
Department relies to continue providing services. We also
recommend deletion of the provision deferring increases in the
amount of the pharmacy co-payment. VA is already implementing
new regulations pertaining to both the pharmacy co-payment and
the outpatient co-payment.
We estimate the PAYGO costs of S. 1408 to be $300 million
dollars annually.
* * * * * * *
S. 1576
S. 1576 would extend through December 31, 2011, VA's
special authority to treat Gulf War veterans for any
disability, notwithstanding there is insufficient medical
evidence to conclude that such disability may be associated
with such service. That authority will expire after December
31, 2002. VA supports this proposal.
* * * * * * *
S. 2043
S. 2043 would extend by five years (through December 31,
2008) VA's authority to provide non-institutional extended care
services as part of the medical benefits package furnished to
veterans. The bill would also extend through December 31, 2008,
mandatory eligibility for nursing home care for veterans with a
service-connected disability rated 70% or greater. Finally, S.
2043 would extend by five years the date by which the Secretary
must report to Congress on the operation of its long-term care
programs established under the Millennium Act. VA supports S.
2043 and the continuation of the Millennium Act non-
institutional long-term care provisions.
* * * * * * *
S. 2044
S. 2044 would amend section 116 of the Millennium Act to
direct that we increase funding for specialized mental health
services for veterans. The measure directs that we expend $25
million for these programs, but it is not clear whether it
would require $25 million for each of three successive years,
or over a three-year period. The additional $25 million must
also be over and above the baseline amount now being expended
for these programs. However, it is unclear if we must expend an
additional $25 million over the baseline each year for three
successive years, or only over a three-year period. Finally,
the measure directs that we consider these funds to be special-
purpose funds that we must allocate outside the VERA allocation
system.
Although VA appreciates the need to ensure adequate funding
for these highly valuable and essential health-care programs,
we strongly oppose this bill. We do not believe any individual
health service should be treated differently from other
essential treatment programs for allocation of appropriated
resources. We also believe it is inappropriate to direct that
we allocate funds for programs like this outside of the VERA
system.
* * * * * * *
S. 2227
S. 2227 would clarify the effective date of changes to the
method of computing retirement annuities for certain VA health-
care personnel. Last January the Department of Veterans Affairs
Health Care Programs Enhancement Act of 2001 (P.L. 107-135)
became law. That bill changed the way part-time service
performed before April 7, 1986, by certain VA health-care
personnel is credited for annuity purposes. VA had recruitment
and retention problems based upon the prior methodology of the
annuity computation for VA nurses. These difficulties were
addressed by the enactment of section 132 of P.L. 107-135. S.
2227 would extend the benefits of section 132 of P.L. 107-135
to individuals who retired before the law's enactment. The
Administration opposes legislation that modifies the
retirement-benefit computations for employees who are already
retired.
* * * * * * *
S. 2228
This bill would provide that the Secretary may establish
not more than 15 Centers for Mental Illness Research,
Education, and Clinical Activities under 38 U.S.C. Sec. 7320.
VA has no objection to this provision.
Additional Views of Chairman John D. Rockefeller IV
Section 212 of the Committee bill sets a precedent which is
cause for concern. The State Veterans Home program--run by the
Department of Veterans Affairs--is a partnership between the
states and VA to meet the needs of veterans through the
establishment and maintenance of custodial facilities,
hospitals, and nursing homes. This partnership has existed for
more than 60 years.
In order to gain access to VA funds, which total 65 percent
of the construction or renovation of existing buildings, a
state must certify the availability of the remaining 35
percent. This financial commitment allows VA's limited
resources to benefit more states and ultimately more veterans,
and it is the cornerstone of the State Veterans Home Program.
Section 212 of the Committee bill creates an exception for
the State of Alaska and would allow the Secretary of VA to hand
over $16 million to Alaska without any corresponding State
appropriation.
Every state, save Alaska, Delaware and Hawaii, have
previously enacted legislation to appropriate their share for
participation in the program. Many states have done so multiple
times, so that veterans could have access to more than one
facility. Currently, both Alaska and Delaware legislatures have
taken up the issue.
Most recently, the legislatures in West Virginia, Colorado,
Texas, Pennsylvania, and Idaho, have each set aside funds
totaling more than $25 million dollars. Had these States sought
a route similar to the one taken by section 212 of the
Committee bill, the cost to the Federal government would be
more than $46 million. The chart below details the funding for
each State Veterans Home project.
Construction Grants for State Extended Care Facilities
[dollars in thousands]
----------------------------------------------------------------------------------------------------------------
State Appropriated
State Home Total Cost VA Share Share
----------------------------------------------------------------------------------------------------------------
Alexander City, AL............................ 7,629 4,959 2,670
Anderson, SC.................................. 12,520 7,516 5,004
Anna, IL...................................... 4,510 2,932 1,578
Armore, OK.................................... 9,501 6,176 3,325
Augusta, GA................................... 1,956 978 978
Augusta, ME................................... 4,472 2,907 1,565
Aurora, CO.................................... 23,843 15,498 8,345
Bangor, ME.................................... 10,154 6,600 3,554
Barstow, CA................................... 30,500 19,825 10,675
Batavia, NY................................... 15,000 8,633 6,367
Bay Minette, AL............................... 10,035 6,523 3,512
Bennington, VT................................ 11,960 7,006 4,954
Big Springs, TX............................... 11,770 7,650 4,120
Boise, ID..................................... 6,795 4,292 2,503
Bonham, TX.................................... 11,770 7,650 4,120
Boulder City, NV.............................. 20,930 13,604 7,326
Bristol, RI................................... 8,377 5,264 3,113
Buffalo, NY................................... 3,633 2,254 1,379
Cape Girardeau, MO............................ 8,364 5,436 2,928
Cameron, MO................................... 20,356 13,604 6,752
Caribou, ME................................... 1,850 1,187 663
Charlotte Hall, MD............................ 33,885 20,432 13,453
Chelsea, MA................................... 7,999 4,593 3,406
Chula Vista, CA............................... 34,803 22,100 12,703
Claremore, OK................................. 22,769 14,364 8,405
Clarksburg, WV................................ 13,500 8,775 4,725
Clinton, OK................................... 10,223 6,568 3,655
Collins, MS................................... 9,451 6,143 3,308
Columbia Falls, MT............................ 1,711 1,040 671
Columbia, SC.................................. 1,982 687 1,295
Daytona Beach, FL............................. 11,646 7,764 3,882
Erie, PA...................................... 6,862 3,550 3,312
Fayetteville, NC.............................. 8,801 692 8,109
Fergus Falls, MN.............................. 8,000 5,200 2,800
Florence, CO.................................. 1,410 894 516
Floresville, TX............................... 11,746 7,635 4,111
Ft. Dodge, KS................................. 830 415 415
Glendive, MT.................................. 5,691 3,699 1,992
Grand Island, NB.............................. 3,299 1,333 1,966
Grand Rapids, MI.............................. 22,005 12,993 9,012
Hanson, KY.................................... 13,635 8,863 4,772
Hastings, MN.................................. 4,888 3,292 1,596
Hazard, KY.................................... 15,457 10,047 5,410
Hollidaysburg, PA............................. 26,569 16,567 10,002
Holyoke, MA................................... 4,062 2,130 1,932
Homelake, CO.................................. 2,822 1,864 958
Hot Springs, SD............................... 1,330 829 501
Humboldt, TN.................................. 7,538 4,900 2,638
Huntsville, AL................................ 10,308 6,701 3,607
Jackson, LA................................... 8,675 5,000 3,675
Jackson, MS................................... 6,198 3,931 2,267
Juana Diaz, PR................................ 13,667 8,884 4,783
King, WI...................................... 34,801 20,385 14,416
Kosciusko, MS................................. 9,172 5,962 3,210
Lafayette, IN................................. 12,532 6,126 6,406
Lake City, FL................................. 6,739 4,376 2,363
Land O'Lakes, FL.............................. 11,944 7,764 4,180
LaSalle, IL................................... 7,200 4,643 2,557
Lawson, OK.................................... 38,226 24,847 13,379
Lewiston, ID.................................. 6,012 3,908 2,104
Lisbon, ND.................................... 5,381 3,498 1,883
Little Rock, AR............................... 2,182 1,418 764
Luverne, MN................................... 7,457 4,847 2,610
Manteno, IL................................... 18,094 11,761 6,333
Marquette, MI................................. 10,639 6,915 3,724
Marshalltown, IA.............................. 42,557 27,205 15,352
Menlo Park, NJ................................ 47,284 30,058 17,226
Mexico, MO.................................... 8,027 5,204 2,823
Milledgeville, GA............................. 12,284 6,808 5,476
Minneapolis, MN............................... 43,831 28,358 15,473
Monroe, LA.................................... 11,849 7,279 4,570
Montrose, NY.................................. 43,856 28,506 15,350
Murfreesboro, TN.............................. 5,126 3,226 1,900
Norman, OK.................................... 29,737 19,255 10,482
Norfolk, NB................................... 16,516 10,527 5,989
Omaha, NB..................................... 1,913 1,243 670
Orting, WA.................................... 4,382 2,805 1,577
Oxford, MS.................................... 9,537 6,199 3,338
Paramus, NJ................................... 28,677 18,251 10,426
Pembroke Pines, FL............................ 15,344 9,924 5,420
Philadelphia, PA.............................. 20,930 13,605 7,325
Phoenix, AZ................................... 14,189 9,223 4,966
Pittsburgh, PA................................ 27,339 17,770 9,569
Pocatello, ID................................. 5,277 3,430 1,847
Quincy, IL.................................... 3,976 2,772 1,204
Retsil, WA.................................... 5,989 3,871 2,118
Rifle, CO..................................... 3,571 2,321 1,250
Roanoke, VA................................... 17,846 9,161 8,685
Rocky Hill, CT................................ 4,656 2,843 1,813
Salisbury, NC................................. 3,371 2,191 1,180
Salt Lake City, UT............................ 6,792 4,415 2,377
St. Albans, NY................................ 28,919 18,798 10,121
St. James, MO................................. 27,754 16,829 10,925
Sandusky, OH.................................. 47,762 30,008 17,754
Scarborough, ME............................... 11,226 6,858 4,368
Scotts Bluff, NB.............................. 4,520 2,854 1,666
Scranton, PA.................................. 23,143 13,477 9,666
Silver Bay, MN................................ 2,481 1,613 868
South Paris, ME............................... 7,619 4,953 2,666
Spring City, PA............................... 17,936 11,653 6,283
Stony Brook, NY............................... 25,400 16,510 8,890
Sulfur, OK.................................... 5,077 3,300 1,777
Talihina, OK.................................. 9,438 5,999 3,439
Temple, TX.................................... 11,770 7,650 4,120
The Dllas, OR................................. 14,218 9,242 4,976
Tilton, NH.................................... 7,022 4,414 2,608
Truth or Consequence, NM...................... 5,662 3,636 2,026
Union Grove, WI............................... 2,857 1,857 1,000
Vineland, NJ.................................. 16,432 8,663 7,769
Walsenburg, CO................................ 7,741 5,404 2,337
Warrensburg, CO............................... 20,960 13,624 7,336
Wilmore, KY................................... 14,923 10,315 4,609
Winfield, KS.................................. 17,171 10,641 6,530
Yountville, CA................................ 94,694 61,384 33,310
----------------------------------------------------------------------------------------------------------------
On June 6, 2002, John Johnson, President of the National
Association of State Veterans Homes wrote:
We feel giving one state preference would be unjust
to all other states. We have worked long and hard with
the Department of Veterans Affairs and members of both
Houses to create a fair and equitable program. If any
changes are made, they should not favor one state over
another, but should be equally applied to all states
and veterans. Forty-seven states have had to use the
process that has been in place, and to waive rules and
regulations for one state would be an injustice to all
other states who have followed the process.
Joseph A. Violante, National Legislative Director, Disabled
American Veterans, expressed similar reservations. In his
letter of June 6, 2002, Mr. Violante argued that section 212
``bypasses the Department of Veterans Affairs State Home
authority currently in place.''
The proponent of this provision, Senator Murkowski, made
the case that the uniqueness of Alaska mandates a different
approach, and that may well be true. Alaska has six Pioneers'
Homes, in which the elderly reside. Of the current 500
residents, 97 are veterans. Rather than building one new home,
it was argued that renovation of these existing homes would be
more practical. Not only does the statute allow for the
renovation of multiple facilities, but it actually favors these
types of projects over new construction. Through the normal
course--appropriation of funds by the Alaskan legislature,
certification of the funds, and applications made to VA--Alaska
could have multiple State Veterans Homes. Each stage of the
process, including submitting a basic application, was
disregarded.
Applying this type of change equally to all states would
unfortunately mean a total erosion of the partnership which has
made the State Home Program a success. Allowing an exception
for only one State is unfair to all others.
------
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. 1701. Definitions
For the purposes of this chapter--
* * * * * * *
(10)(A) During the period beginning on [the date of the
enactment of the Veterans Millennium Health Care and Benefits
Act and ending on December 31, 2003,] November 30, 1999, and
ending on December 31, 2008, the term ``medical services''
includes noninstitutional extended care services.
* * * * * * *
Sec. 1710. Eligibility for hospital, nursing home, and domiciliary care
* * * * * * *
(e)(1)(A) `` * *
* * * * * * *
(3) * * *
* * * * * * *
(B) in the case of care for a veteran described in
paragraph (1)(C), after [December 31, 2002] December
31, 2012; and
* * * * * * *
Sec. 1710A. Required nursing home care
* * * * * * *
(c) The provisions of subsection (a) shall terminate on
[December 31, 2003] December 31, 2008.
* * * * * * *
Sec. 1720D. Counseling and treatment for sexual trauma
(a)(1) [During the period through December 31, 2004, the
Secretary] The Secretary shall operate a program under which
the Secretary provides counseling and appropriate care and
services to veterans who the Secretary determines require such
counseling and care and services to overcome psychological
trauma, which in the judgment of a mental health professional
employed by the Department, resulted from a physical assault of
a sexual nature, battery of a sexual nature, or sexual
harassment which occurred while the veteran was serving on
active duty.
(2) In furnishing counseling to a veteran under this
subsection, the Secretary may[, during the period through
December 31, 2004,] provide such counseling pursuant to a
contract with a qualified mental health professional if (A) in
the judgment of a mental health professional employed by the
Department, the receipt of counseling by that veteran in
facilities of the Department would be clinically inadvisable,
or (B) Department facilities are not capable of furnishing such
counseling to that veteran economically because of geographical
inaccessibility.
(b)(1) The Secretary shall give priority to the
[establishment and] operation of the program to provide
counseling and care and services under subsection (a). In the
case of a veteran eligible for counseling and care and services
under subsection (a), the Secretary shall ensure that the
veteran is furnished counseling and care and services under
this section in a way that is coordinated with the furnishing
of such care and services under this chapter.
(2) In [establishing a program] operating a program to
provide counseling under subsection (a), the Secretary shall--
* * * * * * *
Sec. 1722A. Copayment for medications
(a)(1) * * *
* * * * * * *
(3) Paragraph (1) does not apply--
* * * * * * *
[(B) to a veteran whose annual income (as determined
under section 1503 of this title) does not exceed the
maximum annual rate of pension which would be payable
to such veteran if such veteran were eligible for
pension under section 1521 of this title.]
(B) to a veteran whose attributable income is not
greater than the amount provided for in subsection (b)
of section 1722 of this title, as adjusted from time to
time under subsection (c) of that section.
* * * * * * *
Sec. 7320. Centers for mental illness research, education, and clinical
activities
* * * * * * *
(b)(1) * * *
* * * * * * *
(3) Not more than [five centers] 15 centers may be designated
under this section.
* * * * * * *
Sec. 7802. Duties of Secretary with respect to Service
The Secretary shall--
* * * * * * *
(5) employ such persons as are necessary for the
establishment, maintenance, and operation of the
Service, and pay the salaries, wages, and expenses of
all such employees from the funds of the Service.
Personnel necessary for the transaction of the business
of the Service at canteens, warehouses, and storage
depots shall be appointed, compensated from funds of
the Service, and removed by the Secretary without
regard to the provisions of title 5 governing
appointments in the competitive service and chapter 51
and subchapter III of chapter 53 of title 5. Those
employees are subject to the provisions of title 5
relating to a preference eligible described in section
2108(3) of title 5, subchapter I of chapter 81 of title
5, and subchapter III of chapter 83 of title 5.
Employees and personnel under this clause may be
considered for appointment in Department positions in
the competitive service in the same manner that
Department employees in the competitive service are
considered for transfer to such positions. An employee
or individual appointed as personnel under this clause
who is appointed to a Department position under the
authority of the preceding sentence shall be treated as
having a career appointment in such position once such
employee or individual meets the three-year requirement
for career tenure (with any previous period of
employment or appointment in the Service being counted
toward satisfaction of such requirement);
* * * * * * *
Sec. 8104. Congressional approval of certain medical facility
acquisitions
(a)(1) * * *
* * * * * * *
(3) For the purpose of this subsection:
(A) The term *major medical facility project'' means
a project for the construction, alteration, or
acquisition of a medical facility involving a total
expenditure of more than [$4,000,000] $9,000,000, but
such term does not include an acquisition by exchange.
* * * * * * *
VETERANS MILLENNIUM HEALTH CARE AND BENEFITS ACT
* * * * * * *
TITLE I--ACCESS TO CARE
Subtitle A--Long-Term Care
SEC. 101. REQUIREMENT TO PROVIDE EXTENDED CARE SERVICES.
* * * * * * *
(i) Report.--Not later than [January 1, 2003,] January 1,
2008, the Secretary shall submit to the Committees on Veterans'
Affairs of the Senate and House of Representatives a report on
the operation of this section (including the amendments made by
this section). The Secretary shall include in the report--
* * * * * * *
SEC. 116. SPECIALIZED MENTAL HEALTH SERVICES.
* * * * * * *
(c) Funding.--(1) In carrying out the program described in
subsection (a), the Secretary shall identify, from funds
available to the Department for medical care, an amount of not
less than [$15,000,000] $25,000,000 in each of fiscal years
2003, 2004, and 2005 to be available to carry out the program
and to be allocated to facilities of the Department pursuant to
subsection (d).
(2) In identifying available amounts pursuant to paragraph
(1), the Secretary shall ensure that, after the allocation of
those funds under subsection (d), the total expenditure for
programs relating to (A) the treatment of post-traumatic stress
disorder, and (B) substance use disorders is not less than
[$15,000,000] $25,000,000 in excess of the baseline amount.
(3)(A) For purposes of paragraph (2), the baseline amount is
the amount of the total expenditures on such programs for the
most recent fiscal year for which final expenditure amounts are
known, adjusted to reflect any subsequent increase in
applicable costs to deliver such services in the Veterans
Health Administration, as determined by the Committee on Care
of Severely Chronically Mentally Ill Veterans.
(B) For purposes of this paragraph, in fiscal years 2003,
2004, and 2005, the fiscal year utilized to determine the
baseline amount shall be fiscal year 2002.
* * * * * * *
(d) Allocation of Funds to Department Facilities.--[The
Secretary] (1) In each of fiscal years 2003, 2004, and 2005,
the Secretary shall allocate funds identified pursuant to
subsection (c)(1) to individual medical facilities of the
Department as the Secretary determines appropriate based upon
proposals submitted by those facilities for the use of those
funds for improvements to specialized mental health services.
(2) In allocating funds to facilities in a fiscal year under
paragraph (1), the Secretary shall ensure that--
(A) not less than $10,000,000 is allocated by direct
grants to programs that are identified by the Mental
Health Strategic Health Care Group and the Committee on
Care of Severely Chronically Mentally Ill Veterans;
(B) not less than $5,000,000 is allocated for
programs on post-traumatic stress disorder; and
(C) not less than $5,000,000 is allocated for
programs on substance abuse disorder.
(3) The Secretary shall provide that the funds to be
allocated under this section during each of fiscal years 2003,
2004, and 2005 are funds for a special purpose program for
which funds are not allocated through the Veterans Equitable
Resource Allocation system.
* * * * * * *
VETERANS BENEFITS AND HEALTH CARE IMPROVEMENT ACT OF 2000
* * * * * * *
TITLE II--HEALTH PROVISIONS
* * * * * * *
Subtitle D--Construction Authorization
SEC. 231. AUTHORIZATION OF MAJOR MEDICAL FACILITY PROJECTS.
(a) Fiscal Year 2001 Projects.--The Secretary of Veterans
Affairs may carry out the following major medical facility
projects, with each project to be carried out in an amount not
to exceed the amount specified for that project:
* * * * * * *
(2) Construction of a nursing home at the Department
of Veterans Affairs Medical Center, Beckley, West
Virginia, [$9,500,000] $18,200,000.
* * * * * * *
SEC. 232. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--There are authorized to be appropriated to
the Secretary of Veterans Affairs for the Construction, Major
Projects, account--
(1) for fiscal years 2001 and 2002, a total of
[$87,800,000] $96,500,000 for the projects authorized
in paragraphs (1), (2), and (3) of section 231(a);
* * * * * * *