[Senate Report 110-281]
[From the U.S. Government Publishing Office]
Calendar No. 632
110th Congress Report
SENATE
2d Session 110-281
======================================================================
VETERANS MENTAL HEALTH IMPROVEMENTS ACT OF 2007
_______
April 8, 2008.--Ordered to be printed
_______
Mr. Akaka, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany S. 2162]
The Committee on Veterans' Affairs (hereinafter, ``the
Committee''), to which was referred the bill (S. 2162), to
improve the treatment and services provided by the Department
of Veterans Affairs to veterans with post-traumatic stress
disorder and substance use disorders, and for other purposes,
having considered the same, reports favorably thereon with an
amendment, and recommends that the bill (as amended) do pass.
Introduction
On April 25, 2007, the Committee held an oversight hearing
on mental health issues. Testimony was offered by: Tony Bailey,
father of Justin Bailey, accompanied by Mary Kaye Bailey;
Randall Omvig, father of Joshua Omvig, accompanied by Ellen
Omvig; Patrick Campbell, Congressional Liaison, Iraq and
Afghanistan Veterans of America; Connie L. Best, PhD, Senior
Faculty Member, National Crime Victims Research and Treatment
Center, Medical University of South Carolina; David Oslin, MD,
Director, VISN 4 Mental Illness Research Education and Clinical
Center, Department of Veterans Affairs; Jan Kemp, RN, PhD,
Associate Director for Education, VISN 19 Mental Illness
Research Education and Clinical Center, Department of Veterans
Affairs; Patricia Resick, PhD, Director, Women's Division,
National Center for Post Traumatic Stress Disorder, Department
of Veterans Affairs, accompanied by Ira Katz, MD, PhD, Deputy
Chief Patient Care Services Officer for Mental Health,
Department of Veterans Affairs; and Ralph Ibson, Vice President
for Government Relations, Mental Health America.
On May 23, 2007, the Committee held a hearing on pending
veterans' health legislation at which testimony was offered by:
Gerald M. Cross, MD, FAAFP, Acting Principal Deputy Under
Secretary for Health, Department of Veterans Affairs; Carl
Blake, National Legislative Director, Paralyzed Veterans of
America; Dennis M. Cullinan, Director, National Legislative
Service, Veterans of Foreign Wars of the United States; Joy J.
Ilem, Assistant National Legislative Director, Disabled
American Veterans; Shannon Middleton, Deputy Director for
Health, Veterans Affairs and Rehabilitation Commission, The
American Legion; Bernard Edelman, Deputy Director for Policy
and Government Affairs, Vietnam Veterans of America; Jerry
Reed, Executive Director, Suicide Prevention Action Network USA
(SPAN USA); John Booss, MD, American Academy of Neurology; and
Meredith Beck, National Policy Director, Wounded Warrior
Project.
On October 15, 2007, following these two hearings, Chairman
Akaka introduced S. 2162, the proposed ``Veterans Mental Health
Improvements Act of 2007.'' S. 2162, as introduced, would
establish peer outreach and peer support for veterans of
Operation Enduring Freedom and Operation Iraqi Freedom, ensure
adequate substance use disorder treatments in VA facilities,
expand research on comorbid post-traumatic stress disorder and
substance use disorders, and expand services for veterans'
families. S. 2162 is cosponsored by the Committee's Ranking
Member Senator Burr, and Senators Ensign, and Mikulski.
On October 24, 2007, the Committee held a hearing on
pending veterans' health legislation, including S. 2162, at
which testimony was offered by, among others: the Honorable
Michael J. Kussman, MD, MS, MACP, Under Secretary for Health,
Department of Veterans Affairs, accompanied by Walter Hall,
Assistant General Counsel, Department of Veterans Affairs; Carl
Blake, National Legislative Director, Paralyzed Veterans of
America; Joy J. Ilem, Assistant National Legislative Director,
Disabled Veterans of America; Brenda Murdough, MSN, RN-C,
Military/Veterans Initiative Coordinator, American Pain
Foundation; and Capt. Constance Walker, USN (Ret.), President,
Southern Maryland Chapter of the National Alliance on Mental
Illness.
Committee Meeting
After carefully reviewing the testimony from the foregoing
hearings, the Committee met in open session on November 14,
2007, to consider, among other legislation, S. 2162. The
Committee voted unanimously to report favorably S. 2162 with an
amendment in the nature of a substitute.
Summary of S. 2162 as Reported
S. 2162, as reported, (hereinafter, ``the Committee bill'')
would make numerous enhancements and expansions to VA mental
health care and services.
TITLE I--SUBSTANCE USE DISORDER AND MENTAL HEALTH CARE
Section 101 would express the sense of Congress on
substance use disorders (SUD) and mental health.
Section 102 would require that a minimum set of services
and treatments for SUD be available to all veterans enrolled in
the VA health care system who need such services.
Section 103 would require that veterans receiving care for
SUD and a comorbid mental health disorder from VA receive such
care concurrently from professionals with appropriate
expertise.
Section 104 would establish national centers of excellence
on post-traumatic stress disorder (PTSD) and SUD.
Section 105 would require the Secretary to carry out a
review of all VA residential mental health care facilities and
report to Congress on the results of that review.
Section 106 provides that title I is a tribute to Justin
Bailey, a veteran of the Iraq war, who died in a VA
domiciliary.
TITLE II--MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS
Section 201 would establish a pilot program of peer
outreach and support, and on the use of community mental health
centers, the Indian Health Service and other entities to
provide mental health services in rural areas.
TITLE III--RESEARCH
Section 301 would establish a research program on comorbid
PTSD and SUD.
Section 302 would extend the authorization for the Special
Committee on Post-Traumatic Stress Disorder.
TITLE IV--ASSISTANCE FOR FAMILIES OF VETERANS
Section 401 would clarify and expand the authority of the
Secretary of Veterans Affairs to provide mental health services
to families of veterans.
Section 402 would establish a pilot program for the
provision of readjustment and transition assistance to veterans
and their families in cooperation with Readjustment Counseling
Centers.
Background and Discussion
S. 2162 would establish peer outreach and peer support for
veterans of Operation Enduring Freedom and Operation Iraqi
Freedom, ensure adequate substance use disorder treatments in
VA facilities, expand research on comorbid post-traumatic
stress disorder and substance use disorders, and expand
services for veterans' families.
In testimony before the Committee on October 24, 2007, Carl
Blake, National Legislative Director, Paralyzed Veterans of
America (PVA), and Joy J. Ilem, Assistant National Legislative
Director, Disabled Veterans of America (DAV), indicated that
the organizations which they represent support the bill in its
entirety. S. 2162 is also supported by the American Federation
of Government Employees. In testimony before the Committee on
October 24, 2007, Michael J. Kussman, Under Secretary for
Health of the Department of Veterans Affairs, submitted the
views of the Administration on S. 2162. VA had concerns about
certain provisions of the bill as introduced, and the reported
version of the bill, as amended, addresses a number of those
concerns.
TITLE I--SUBSTANCE USE DISORDERS AND MENTAL HEALTH CARE
Section 101 of the Committee bill would express the sense
of Congress on substance use disorders, mental health, and on
VA's capability and capacity to treat these conditions.
The dangers and costs of SUD can hardly be overstated. In
the words of Dr. David Oslin, Director of VISN 4 Mental Illness
Research Education and Clinical Center, from testimony before
the Committee on April 25, 2007, ``Alcohol misuse creates more
financial burden to our society than any other health behavior,
including smoking and obesity. Addiction is also a deadly
disease. The toll on families, friends, and coworkers is
incalculable.'' Other witnesses at that hearing presented
personal stories of struggles with SUD, PTSD, and readjustment
to civilian life after deployment abroad.
While VA provides exemplary treatment for substance-related
disorders at some facilities, access to quality comprehensive
care is inconsistent. In general, VA's capacity to treat
veterans with SUD has not kept pace with the needs of the
veteran population. Testimony at the Committee hearings on
April 25 and October 24, 2007, spoke to this issue.
The findings in this section of the Committee bill are
derived from the 2005 Department of Defense ``Survey of Health
Related Behaviors Among Active Duty Personnel,'' the December
2006 GAO report entitled ``Spending for Mental Health Strategic
Plan Was Substantially Less than Planned,'' and consultation
with VA and veterans' community experts.
The findings provide information on a number of the issues
addressed by this legislation. In particular, the findings
point out that while the Veterans Health Administration has
significantly increased health services for veterans from 1996
through 2006, the number of veterans receiving specialized
substance abuse treatment services decreased 18 percent during
that time. No comparable decrease in the national rate of
substance abuse has been observed during that time.
Furthermore, according to the Government Accountability Office,
the Department of Veterans Affairs significantly reduced its
substance use disorder treatment and rehabilitation services
between 1996 and 2006, and has made little progress since in
restoring these services to their pre-1996 levels.
Section 102 of the Committee bill would require that a
minimum level of services and treatments be available to each
veteran enrolled in VA health care who is in need of treatment
or services for SUD. The services required are derived from
VA's Clinical Practice Guidelines for Substance Use Disorders,
a 1999 NIH publication entitled ``Principles of Drug Addiction
Treatment,'' and from consultation with SUD experts.
As discussed above, under section 101, VA has the
capability to offer exemplary SUD treatment, but these services
are not consistently available throughout the system. Dr. Oslin
testified before the Committee on April 25, 2007, that
``[t]here is a clear evidence base that this type of broad-
based public health initiative can identify veterans earlier in
the addiction process and prevent substantial burden in the
future.'' Some Veteran's Integrated Service Networks already
provide comprehensive services, and this should be the norm
throughout the VA system.
As set forth in section 102(b) of the Committee bill, the
services and treatments set forth in section 102(a) may be
provided in a VA facility, or by contract or fee-basis payments
with community based organizations.
It is the Committee's view that VA has not moved quickly
enough to take a comprehensive and systemic approach to SUD
treatment. As previously mentioned, no consistent level of SUD
services exist throughout the system. This section of the
Committee bill, in addition to later sections which would
expand treatment and research programs, addresses this
deficiency.
Section 103 of the Committee bill would require that
veterans with a mental health disorder and comorbid SUD be
treated concurrently by clinicians with appropriate expertise.
SUD is frequently experienced concurrently with other mental
and physical disorders, and is strongly associated with PTSD.
Treatments addressing these disorders concurrently are more
effective, especially when administered by clinicians with
experience in both disorders.
In testimony before the Committee on April 25, 2007, Dr.
David Oslin stated that the concurrent treatment of PTSD and
SUD has dramatically improved outcomes at the Philadelphia VA
Medical Center. The Committee believes that this model should
be replicated throughout the VA health care system. Studies
have found that patients with psychological trauma, including
PTSD, are often susceptible to alcohol and drug abuse.
According to the National Institute on Drug Abuse, patients
subjected to chronic stress, as experienced by those with PTSD,
are prone to drug use. Research by Sinha, Fuse, Aubin and
O'Malley in Psychopharmacology (2000), and by Brewer et al. in
Addiction (1998) further emphasize this point.
Section 104 of the Committee bill would add a new section
to title 38, 7330A, entitled ``National centers of excellence
on post-traumatic stress disorder and substance use
disorders,'' which would require VA to establish six national
centers of excellence on PTSD and SUD. The Committee's intent
is that veterans diagnosed with both of these disorders receive
comprehensive inpatient or residential care from facilities
with exceptional therapeutic capabilities. In addition, under
new section 7330A, VA would be required to establish a process
to refer and aid the transition of veterans from these national
centers to programs that provide step down rehabilitation
treatment specific to these disorders.
The requirement for national centers of excellence is
predicated on the need for geographically dispersed centers
with exceptional capabilities to provide inpatient or
residential treatment for both PTSD and SUD. It also responds
to the trends described in section 101 of the Committee bill.
As thousands of servicemembers return from combat with PTSD,
many will be at risk for SUD. By quickly intervening, VA may be
able to reduce chronic PTSD and SUD among the veteran
population.
Section 105 of the Committee bill would require VA to
conduct a review of all VA residential mental health care
facilities, including domiciliary facilities, and to report on
the results of that review. The report would be required to
include, among other information, an assessment of the
supervision and support provided in the residential mental
health care facilities of VA, the ratio of staff members to
patients at each facility, and an assessment of the
appropriateness of rules and procedures for the prescription
and administration of medications to patients.
The requirements of this section respond to testimony
offered at the Committee's April 25, 2007, hearing on mental
health care in VA. The testimony of Tony Bailey about the care
provided to his son, Justin, described inattentive staff and
lax control of medications, among other issues.
Justin Bailey was receiving treatment in a VA domiciliary
facility for PTSD, SUD, and a groin injury when he died of an
apparent overdose of medications prescribed to him by VA
clinicians. Justin's parents, Tony and Mary Kaye Bailey,
believe that the lack of appropriate staff supervision and
support at the domiciliary, coupled with the facility's
disregard for VA rules and procedures for the management of
prescription medication, contributed to his death.
The testimony of Justin Bailey's parents, excerpted below,
inspired many of the provisions in the proposed legislation.
I would like to tell you about my son, Justin Bailey,
who died on January 26, 2007, at the West LA VA
Hospital. He was 27 years old. Justin was seeking
treatment for PTSD and drug abuse.
Justin joined the Marine Corps in December 1998,
approximately 6 months after graduating from high
school. He was in the infantry and was due to separate
from the Marines in January 2003, but was involuntarily
extended due to the impending war. Justin was with the
first wave of troops that arrived in Iraq when the war
started in 2003. He fought in Nasarija and returned to
Camp Pendleton in June, 2003.
On the night of January 26th I learned that Justin
was being taken to the ER at the hospital. He had just
received his new prescriptions the day before. And now
he had died of an apparent overdose of his prescription
drugs.
According to the Baileys, the report that would be required
by this section would ensure a full accounting of VA
domiciliary facilities and practices, with a goal of helping to
avert future tragedies.
TITLE II--MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS
Section 201 of the Committee bill would require VA to carry
out a pilot program to assess the feasibility and advisability
of providing certain services to veterans of Operation Iraqi
Freedom and Operation Enduring Freedom. The first component of
the pilot program would provide peer outreach and peer support,
and a second component would assess the use of community mental
health centers, the Indian Health Service and other entities to
provide mental health services in rural areas.
Peer outreach and support, conducted with appropriate
training as discussed below, may be effective in connecting
veterans with mental health services. Vet Centers and
individual VISNs have been especially successful in conducting
this type of outreach and support. Given the unprecedented
number of National Guard and Reserve forces from rural areas
deployed in current conflicts, these outreach and support
services may now be more helpful.
The benefits of peer outreach and support need to be
assessed. While clinicians provide essential treatments and
therapies, they are not expected to provide the social support
that peers can offer. The support of a strong social network of
peers with similar experiences may complement and augment
clinical treatment. A study by Davidson, Chinman, Sells, and
Rowe, published in Schizophrenia Bulletin (July, 2006),
concluded that ``peer support is still early in its development
as a form of mental health service provision,'' and recommends
further exploration of this ``promising, if yet unproven,
practice.'' A number of medical facilities and VISNs are
already conducting this type of outreach and support, and this
pilot will build upon existing capabilities.
The training that would be required to be provided to
veterans conducting outreach and support under this section is
essential. In this program, peers would not be intended to act
in a clinical capacity, but would receive basic training in
skills necessary for working with veterans with mental health
concerns. VA may have the capacity to conduct this training, or
may choose to conduct training through a non-Department entity.
During the Committee's hearing on May 23, 2007, Carl Blake,
of PVA, discussed successful peer outreach and support
conducted by PVA to help veterans recovering from and adjusting
to life after catastrophic injuries. It is the view of PVA that
the model of veteran peers with common experiences and
backgrounds providing non-clinical outreach and support has
proven to be effective among this group of disabled veterans.
The Committee believes broader use of peer outreach and support
should be explored and assessed.
The second component of this pilot program would be the
provision of readjustment counseling and mental health services
to Operation Enduring Freedom and Operation Iraqi Freedom
veterans through community mental health centers, the
facilities of the Indian Health Service, and other entities.
The Committee recognizes that access to VA mental health
services varies significantly across the country. The second
part of the pilot program would target rural veteran
populations whose needs are not being met. Community mental
health centers and the Indian Health Service provide services
in many areas where VA does not have facilities. By permitting
veterans to receive treatment from these entities, under
contract or agreement in the case of community mental health
centers or other community providers, or under an existing
memorandum of understanding in the case of the Indian Health
Service, VA will be better able to meet the needs of rural
veterans.
In a number of locations, VA has already partnered with
community mental health centers to reach rural populations.
This part of the pilot program would build upon previous
success.
Capt. Constance Walker, President of the Southern Maryland
Chapter of the National Alliance on Mental Illness, testified
before the Committee on October 24, 2007, that ``[t]he
likelihood of obtaining specialized services [for PTSD and
serious mental illnesses] on a consistent basis is very small
for veterans living in rural and frontier areas beyond a
reasonable commute to a VA Medical Center or without access to
an appropriately and consistently staffed VA Community Based
Outpatient Clinic.'' The provisions of section 201 of the
Committee bill would address this gap.
The Committee believes that this pilot effort will preserve
the integrity of the VA health care system while expanding
options for veterans who cannot access VA facilities. Joy Ilem,
of DAV, testified that non-VA entities are, on occasion,
necessary for the provision of care, but that proper training
and oversight of those entities is essential. The provisions in
this section of the Committee bill would ensure VA has
sufficient control and oversight of quality of care and patient
privacy, among other requirements. The Committee notes that the
American Federation of Government Employees has expressed
strong preference for this provision of the Committee bill.
TITLE III--RESEARCH
Section 301 of the Committee bill would require VA to carry
out a research program on comorbid PTSD and SUD. This program
would be conducted through the National Center for Post
Traumatic Stress Disorder. The Committee bill would authorize
$2,000,000 for the program in each fiscal year 2008 through
2011 to fund research on PTSD and comorbid SUD.
Research has demonstrated the destructive confluence of
these two disorders, but research on treatments has not
advanced sufficiently. According to recent research conducted
by Dr. Lisa M. Najavits of Harvard Medical School, while there
are studies that have directly compared various treatments,
including cognitive behavioral therapy, such studies have not
yet been conducted in substance abuse samples. The field is
still developing its understanding of the complex issues of
comorbid mental health and substance use disorders.
A recent Institute of Medicine (IOM) study, entitled
``Treatment of Posttraumatic Stress Disorder: An Assessment of
the Evidence,'' describes the current status of research on
treatments of PTSD. The study indicates that insufficient high
quality and focused research has been conducted to draw
conclusions on the efficacy of pharmacotherapies and
psychotherapies, with the exception of exposure therapies.
Among other points, IOM recommends that research on
treatments for PTSD be more systematic and clearly focused with
established definitions and goals. Furthermore, IOM recommends
that research focus on specific veteran populations who suffer
from PTSD in addition to other disorders, such as SUD. This
legislation would place the National Center on PTSD in a
position to effectively guide research in this area, and
authorizes the necessary funding.
The emphasis in this section of the Committee bill is not
without precedent. Section 122 of Public Law 102-405 calls for
VA to place a high priority on treatment programs for mental
health care, including for PTSD and comorbid SUD. This area of
research continues to be a priority.
Section 302 of the Committee bill would modify section
110(e)(2) of the Veterans' Health Care Act of 1984, P.L. 98-
528, to extend the reporting requirement for the Special
Committee on Post-Traumatic Stress Disorder. Currently, the
reporting requirement is set to expire in 2008; this provision
would extend it through 2012.
The Special Committee has served an important role in
overseeing and guiding the treatment of PTSD within VA, and has
become a major resource in and out of government for expertise
on PTSD. The Committee believes that it is essential for the
Special Committee to continue in operation beyond 2008.
TITLE IV--ASSISTANCE FOR FAMILIES OF VETERANS
Section 401 of the Committee bill would amend section 1701
(5)(B) of title 38 United States Code to clarify the authority
of the Secretary of Veterans Affairs to provide mental health
services to families of veterans.
The Committee recognizes that a veteran's family or legal
guardian often plays a central role in his or her recovery
from, or management of, mental health disorders, SUDs, and in
the transition to civilian life. In this context, and given the
long term trend in VA toward expanding home-based care, this
section makes clear VA's authority to offer care to veterans'
families, including mental health care, as well as training and
other forms of assistance and support.
Through oversight activities and hearings, the Committee
has identified marked irregularity in the application of
existing authority to offer services to veterans' families.
This section would amend existing law to explicitly require
that marriage and family counseling be offered to veterans'
families.
Testimony received by the Committee during hearings has
repeatedly demonstrated the need for greater support for
families. For example, at the October 2007 hearing, Capt.
Walker testified that ``it is impossible to overstate the
stressors that rural and frontier family caregivers are bearing
on a daily basis as they search for limited treatment and
rehabilitative services.''
During the Committee's April 25, 2007, hearing, a number of
witnesses testified to the importance of education, training,
support, and care for families in a veteran's recovery and
readjustment process. Two parents, Tony Bailey and Randall
Omvig, father of Spc. Joshua Omvig, who committed suicide after
returning from Iraq, emphasized the need to help families.
Ralph Ibson, of Mental Health America, also testified on the
importance of families in helping a veteran readjust, noting
that ``VA health care, and particularly mental health care,
would often be more effective if barriers to family involvement
were eliminated.'' The Committee concurs with this statement.
During the Committee's hearing in May 2007, Dennis M.
Cullinan of Veterans of Foreign Wars of the United States,
Shannon Middleton of The American Legion, and Jerry Reed of
Suicide Prevention Action Network USA testified to the
importance of providing a broader range of support and clinical
services to families of veterans.
Section 402 of the Committee bill would establish a pilot
program to assess the feasibility and advisability of providing
additional readjustment and transition assistance to veterans
and their families in cooperation with Readjustment Counseling
Centers. The pilot would be similar to family assistance
programs previously conducted at ten Army facilities around the
country. The programs have been effective in helping families
prepare for deployments, and adjust to the deployment and
return of servicemembers. These programs have helped families
strengthen their relationships, resolve disagreements through
discussion, balance professional and family responsibilities,
and make better financial decisions. Readjustment assistance
geared towards military families has equipped them with tools
useful in coping with deployments and the return of
servicemembers, especially those who have suffered physical or
mental injuries.
The Committee believes that similar programs, tailored to
the needs of veterans, may prove helpful to veterans and their
families. Targeted assistance in handling the stress of
readjusting to civilian life, coping with physical and mental
injuries, and maintaining family support may have the potential
to preemptively address many of the more serious challenges
facing veterans and their families.
Committee Bill Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the
Standing Rules of the Senate, the Committee, based on
information supplied by the CBO, estimates that enactment of
the Committee bill would, relative to current law, increase
discretionary spending by $880,000,000 over the 2008-2013
period, assuming appropriation of the necessary amounts. The
Committee bill would not increase direct spending, based on
information supplied by the CBO. Enactment of the Committee
bill would not affect receipts, and would not affect the budget
of state, local or tribal governments.
The cost estimate provided by CBO, setting forth a detailed
breakdown of costs, follows:
Congressional Budget Office,
Washington, DC, April 7, 2008.
Hon. Daniel K. Akaka,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 2162, the Mental
Health Improvements Act of 2007.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sunita
D'Monte.
Sincerely,
Peter R. Orszag,
Director.
Enclosure.
S. 2162--Mental Health Improvements Act of 2007
Summary: S. 2162 would require the Department of Veterans
Affairs (VA) to expand the treatments and services available to
veterans suffering from disorders related to post-traumatic
stress, substance abuse, and other mental health problems. In
total, CBO estimates that implementing S. 2162 would cost about
$880 million over the 2008-2013 period, assuming appropriation
of the specified and estimated amounts. Enacting the bill would
not affect direct spending or revenues.
S. 2162 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA);
any costs to state, local, or tribal governments would be
incurred voluntarily.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 2162 is shown in Table 1. The costs of
this legislation fall within budget function 700 (veterans
benefits and services).
Basis of estimate: CBO assumes that the legislation will be
enacted by the middle of calendar year 2008, that the specified
and estimated amounts will be appropriated each year, and that
outlays will follow historical spending patterns for the VA
medical services program. (Funding for 2008 would have to be
provided in a supplemental appropriations act.)
TABLE 1.--ESTIMATED BUDGETARY IMPACT OF S. 2162
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------
2008 2009 2010 2011 2012 2013
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Estimated Authorization Level................................... 42 168 165 170 174 182
Estimated Outlays............................................... 36 155 164 168 174 180
----------------------------------------------------------------------------------------------------------------
Clinician teams
Section 103 would require VA to ensure that veterans being
treated for both substance use disorder and another mental
health disorder receive treatment by a health professional
trained in both disorders, a team of clinicians with the
appropriate expertise, or coordinated but separate services for
each disorder. According to VA, the average annual cost of its
five existing teams for substance use and post-traumatic stress
disorders (PTSD) is about $520,000. CBO estimates that
establishing similar teams in the remaining 148 medical centers
would cost $439 million over the 2008-2013 period, assuming
appropriation of the necessary amounts (see Table 2).
Treatment for substance use disorders
Section 102 would require VA to provide certain services
and treatments to veterans suffering from substance use
disorders, either at VA medical facilities or through contracts
at community-based organizations. After adjusting for
anticipated inflation, CBO estimates that implementing this
provision would cost $378 million over the 2008-2013 period,
assuming appropriation of the necessary amounts.
According to VA, some of the services and treatments
specified under the bill are already being provided. Most of
the costs of this provision stem from providing detoxification
and stabilization services, residential care, and intensive
outpatient care, which are discussed below. Other services,
such as counseling, opiate substitution therapy, other
pharmacological treatments, and relapse prevention, would
result in additional costs of about $20 million over the 2008-
2013 period, assuming appropriation of the necessary amounts.
Detoxification and Stabilization Services. Based on
information from VA, CBO estimates that to provide the
detoxification and stabilization services specified in the
bill, VA would need to hire 153 advanced practice nurses (one
at each medical center) at an annual cost of $135,000 each (in
2008 dollars). CBO estimates that implementing this provision
would cost $118 million over the 2008-2013 period, assuming
appropriation of the necessary amounts.
TABLE 2.--COMPONENTS OF THE ESTIMATED CHANGES IN SPENDING SUBJECT TO APPROPRIATION UNDER S. 2162
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------
2008 2009 2010 2011 2012 2013
----------------------------------------------------------------------------------------------------------------
Clinician Teams:
Estimated Authorization Level............................... 19 80 83 86 90 93
Estimated Outlays........................................... 17 73 82 85 89 93
Treatment for Substance Use Disorders:
Estimated Authorization Level............................... 19 71 70 73 76 79
Estimated Outlays........................................... 17 65 70 72 75 79
Centers of Excellence:
Estimated Authorization Level............................... 1 13 8 8 8 9
Estimated Outlays........................................... 1 12 8 8 8 9
Research Program on Comorbid Disorders:
Authorization Level......................................... 2 2 2 2 0 0
Estimated Outlays........................................... * 2 2 2 2 *
Pilot Programs:
Estimated Authorization Level............................... 1 2 1 * 0 0
Estimated Outlays........................................... * 2 1 1 * 0
Report on Residential Facilities:
Estimated Authorization Level............................... 0 1 1 0 0 0
Estimated Outlays........................................... 0 1 1 * * 0
Total Changes:
Estimated Authorization Level........................... 42 168 165 170 174 182
Estimated Outlays....................................... 36 155 164 168 174 180
----------------------------------------------------------------------------------------------------------------
Notes: Components may not sum to totals because of rounding.
* = less than $500,000.
Residential Care. Based on information from VA, CBO
estimates that to provide residential care under the bill, VA
would require an additional 110 beds nationwide at an annual
cost of $16 million and have start-up costs of $5 million. CBO
estimates that implementing this provision would cost $97
million over the 2008-2013 period, assuming appropriation of
the necessary amounts.
Intensive Outpatient Care. According to VA, the intensive
outpatient care required under the bill could be provided at
both community-based outpatient clinics (CBOCs) and VA medical
centers. Based on information from VA, CBO estimates that VA
would hire the equivalent of 185 full-time counselors to work
in over 1,000 CBOCs. Each counselor would provide group
treatment (therapy of three hours a week over three months to
50 patients at a time) to about 200 patients a year, and would
be paid an average of $71,500 a year (in 2008 dollars).
Based on information from VA, CBO estimates that
establishing similar intensive outpatient care in VA medical
centers would require VA to upgrade programs in 50 medical
centers by hiring three additional employees at each center, at
an average annual cost of $71,500. In addition, CBO estimates
that VA would require additional appropriations of $1 million a
year to initiate specialty care for substance use disorders at
one medical center.
In total, and after adjusting for anticipated inflation,
CBO estimates that implementing this provision at CBOCs and
medical centers would cost $142 million over the 2008-2013
period, assuming appropriation of the necessary amounts.
Centers of excellence
Section 104 would require VA to establish at least six
centers of excellence on PTSD and substance use disorders at
its health care facilities. The centers would provide inpatient
or residential treatment and recovery services to veterans.
Based on information from VA and after adjusting for inflation,
CBO estimates that each of the six centers would have 11
employees, annual operating costs of about $1.3 million, and
start-up costs of $1 million. CBO estimates that implementing
this provision would cost $46 million over the 2008-2013
period, assuming appropriation of the necessary amounts.
Research program on comorbid disorders
Section 301 would authorize the appropriation of $2 million
a year over the 2008-2011 period for research into comorbid
(i.e., occurring concurrently) substance use disorders and PTSD
in veterans. CBO estimates that implementing this provision
would cost $8 million over the 2008-2013 period, assuming
appropriation of the authorized amounts.
Pilot programs
Two sections of the bill would authorize new pilot programs
to provide counseling, outreach, and other services to certain
veterans. Based on information from VA, CBO estimates that
implementing these pilot programs would cost $5 million over
the 2008-2013 period, assuming appropriation of the specified
and estimated amounts. Section 201 would require VA to study
the feasibility of providing counseling, peer outreach, peer
support, and other mental health services to veterans of
Operation Iraqi Freedom and Operation Enduring Freedom,
including the use of community health centers and the Indian
Health Service to reach rural veterans. Section 402 would
require VA to assess the feasibility of providing readjustment
and transition assistance through private organizations, in
collaboration with Vet Centers (community-based centers that
provide counseling and outreach services to combat veterans and
their families) and would authorize the appropriation of $1
million a year over the 2008-2010 period.
Report on residential facilities
Section 106 would require VA to conduct reviews of all its
residential facilities for mental health care and report to the
Congress. Based on information from VA, CBO estimates VA would
require two employees to review 134 facilities at a cost of $2
million over the 2008-2013 period, assuming the availability of
appropriated funds.
Intergovernmental and private-sector impact: S. 2162
contains no intergovernmental or private-sector mandates as
defined in UMRA. State, local, and tribal governments that
provide counseling and mental health services to veterans would
benefit from program activities authorized in the bill. Any
costs those governments incur to comply with service agreements
would be incurred voluntarily.
Estimate prepared by: Federal Costs: Sunita D'Monte, Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum,
Impact on the Private Sector: Victoria Liu.
Estimate approved by: Peter H. Fontaine, 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 November 14, 2007 meeting. On that
date, the Committee ordered S. 2162, as amended, reported
favorably to the Senate by voice vote.
Agency Report
On October 24, 2007, the Honorable Michael J. Kussman,
Under Secretary for Health, Department of Veterans Affairs,
appeared before the Committee and submitted testimony on, among
other things, an earlier version of S. 2162. Excerpts of this
statement are reprinted below:
Statement of the Views of the Administration
Michael J. Kussman, MD, MS, MACP, Under Secretary for Health for the
Department of Veterans Affairs
Good morning Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to present the
Administration's views on several bills that would affect
Department of Veterans Affairs (VA) programs that provide
veterans benefits and services. With me today is Walter A.
Hall, Assistant General Counsel. I will address the five bills
on today's agenda and then I would be happy to answer any
questions you and the Committee members may have.
s. 2162 ``mental health improvements act of 2007''
Title I. Substance use disorders and mental health care
Mr. Chairman, title I of this bill focuses on VA treatment
programs for substance use disorders and mental health
disorders, particularly PTSD. Section 102 would require the
Secretary to ensure the provision of the following services for
substance use disorders at every VA medical center:
Short term motivational counseling services.
Intensive outpatient care services.
Relapse prevention services.
Ongoing aftercare and outpatient counseling
services.
Opiate substitution therapy services.
Pharmacological treatments aimed at reducing
cravings for drugs and alcohol.
Detoxification and stabilization services.
Such other services as the Secretary deems
appropriate.
The Secretary could, however, exempt an individual medical
center or Community-Based Outpatient Clinic (CBOC) from
providing all of the mandated services. Annually the Department
would have to report to Congress on the facilities receiving an
exemption under this provision, including the reason for the
exemption.
Section 103 would require the Secretary to ensure that VA
treatment for a veteran's substance use disorder and a co-
morbid mental health disorder is provided concurrently by a
team of clinicians with appropriate expertise.
Section 104 would require the Secretary to carry out a
program to enhance VA's treatment of veterans suffering from
substance use disorders and PTSD through facilities that
compete for funds for this purpose. Funding awarded to a
facility would be used for the six purposes specified in the
bill, in addition to the conduct of peer outreach programs
through Vet Centers to re-engage OEF/OIF veterans who miss
multiple appointments for PTSD or a substance use disorder.
Another specified purpose for the funds would be to establish
collaboration between VA's urgent care clinicians and substance
use disorder and PTSD professionals to ensure expedited
referral of veterans who are diagnosed with these disorders.
Not later than one year after the bill's enactment, the
Secretary would need to submit a report to Congress on this
program and the facilities receiving funding.
S. 2162 would provide for funding by requiring the
Secretary to allocate $50 million from appropriated funds
available for medical care for each of fiscal years 2008, 2009,
and 2010. The bill would require the total expenditure for PTSD
and substance use disorder programs to not be less than $50
million in excess of a specified baseline amount. (The bill
would define the baseline as the amount of the total
expenditures on VA's treatment programs for PTSD and substance
use disorders for the most recent fiscal year for which final
expenditure amounts are known, as adjusted to reflect any
subsequent increase in applicable costs to deliver those
programs.)
Section 105 would require the Secretary to establish not
less than six national centers of excellence on PTSD and
substance use disorders. These centers would provide
comprehensive inpatient treatment and recovery services to
veterans newly diagnosed with these disorders. Sites for the
centers would be limited to VA medical centers that provide
inpatient care; that are geographically situated in an area
with a high number of veterans that have been diagnosed with
both PTSD and substance use disorder; and that are capable of
treating PTSD and substance use disorders. This provision would
also direct the Secretary to establish a process to refer and
aid the transition of veterans receiving treatment in these
centers to programs that provide step down rehabilitation
treatment.
Section 106 would require the Secretary, acting through the
Office of the Medical Inspector (MI), to review all of VA's
residential mental health care facilities and to submit to
Congress a detailed report on the MI's findings.
Section 107 would provide for title I of this bill to be
enacted in tribute to Justin Bailey, an OIF veteran who died
while under VA treatment for PTSD and a substance use disorder.
While VA respects the attention this Committee is giving
these critical issues, Title I is overly prescriptive and
attempts to mandate the type of treatments to be provided to
covered veterans, the treatment settings, and the composition
of treatment teams. Treatment decisions should be based on
professional medical judgments in light of an individual
patient's needs, and experienced health care managers are in
the best position to decide how best to deliver needed health
care services at the local level. With regard to the proposed
centers of excellence, we reiterate our concerns about disease-
specific treatment centers and models, although we appreciate
the Committee's efforts thereby to hasten the eradication of
those particular diseases. For all of the above reasons, we do
not support this title.
Title II. Mental health accessibility enhancements
Section 201 would require the Secretary to establish a
three-year pilot program to assess the feasibility and
advisability of providing eligible OEF/OIF veterans with peer
outreach services, peer support services, and readjustment
counseling services, and other mental health services. This
pilot would begin not later than 180 days after the bill's
enactment. Eligible veterans would include those who are
enrolled in VA's health care system and who, for purposes of
the pilot program, receive a referral from a VHA health
professional to a community mental health center or to a
facility of the Indian Health Service (IHS).
In providing readjustment counseling services and other
mental health services to rural veterans who do not have
adequate access to VA services, section 201 would require the
Secretary, acting through the Office of Rural Health, to
contract for those services with community mental health
centers (as defined in 42 CFR 410.2) and IHS facilities.
Sites for the pilot would need to include at least two
Veterans Integrated Service Networks (selected by the
Secretary), and at least two of the sites would have to be
located in rural areas that lack access to comprehensive VA
mental health services.
A center or IHS facility that participates in the pilot
program must, to the extent practicable, provide readjustment
counseling services and other mental health services to
eligible veterans through the use of telehealth services. It
would also need to provide the services using best practices
and technologies and meet any other requirements established by
the Secretary. A participating center or IHS facility would
also have to comply with applicable VA protocols before
incurring any liability on behalf of the Department and provide
clinical information on each veteran to whom it furnishes
services.
The Secretary would be required to carry out a national
program of training for (1) veterans who would provide peer
outreach and peer support services under the pilot program; and
(2) clinicians of participating centers or IHS facilities to
ensure they can furnish covered services and that such services
will be provided in a manner that accounts for factors unique
to OEF/OIF veterans. This provision would also establish
detailed annual reporting requirements for participating
centers and facilities.
As we discussed in connection with section 2 of S. 38, all
of these services are already available to OEF/OIF veterans,
including those who served in the National Guard or the
Reserves. As such, no demonstrated need exists for the pilot
program or these additional authorities, which are duplicative
of currently existing authorities. And VA is already working
with other entities to provide treatment to veterans at the
local level if VA is not able to provide the needed care;
therefore, the requirement to contract specifically with a
community health center or IHS facility would limit the local
VA providers' flexibility in finding the most appropriate care
for our veterans.
Title III. Research
Section 301 would require the Secretary to carry out a
program of research into co-morbid PTSD and substance use
disorder. The purpose of this program would be to address co-
morbid PTSD and substance use disorder; provide systematic
integration of treatment for these two disorders; develop
protocols to evaluate VA's care of veterans with these
disorders; and, facilitate the cumulative clinical progress of
these veterans. This provision would charge VA's National
Center for PTSD with responsibility for carrying out and
overseeing this program, developing the protocols and goals,
and coordinating the research, data collection, and data
dissemination.
Section 301 would also authorize $2 million to be
appropriated for each of fiscal years 2008 through 2011 to
carry out this program and specifically require these funds be
allocated to the National PTSD Center. The funds made available
to the Center would be in addition to any other amounts made
available to it under any other provision of law.
Section 302 would continue the Special Committee on PTSD
(which is established within VHA) through 2012; otherwise the
Committee's mandate would terminate after 2008.
While well-intended, this title is overly prescriptive and
more importantly altogether unnecessary. Therefore, with the
exception of the extension of the Special Committee, VA does
not support the provisions in title III. VA is a world-
recognized leader in the care of both PTSD and substance use
disorders, particularly when these conditions co-exist in an
individual. The activities required by title III are
essentially duplicative of VHA's ongoing efforts in this area,
particularly the research efforts being carried out by VA's
National PTSD Center. We would welcome the opportunity to brief
the Committee on VA's achievements and efforts in this area,
plus the role of the Office of Mental Health in overseeing the
PTSD and substance abuse programs.
Title IV. Assistance for families of veterans
In connection with the family support services authorized
in chapter 17 of title 38, United States Code (i.e., mental
health services, consultation, professional counseling, and
training), section 401 would amend the statutory definition of
``professional counseling'' to expressly include marriage and
family counseling. This provision would also ease eligibility
requirements for these family support services by authorizing
the provision of these services when considered appropriate (as
opposed to essential) for the effective treatment and
rehabilitation of the veteran. Section 401 would further
clarify that these services are available to family members in
Vet Centers, VA medical centers, CBOCs, or other VA facilities
the Secretary considers necessary.
Section 402 would require the Secretary to carry out,
through a non-VA entity, a three-year pilot program to assess
the feasibility and advisability of providing ``readjustment
and transition assistance'' to veterans and their families in
cooperation with Vet Centers. Readjustment and transition
assistance would be defined as readjustment and transition
assistance that is preemptive, proactive, and principle-
centered. It would also include assistance and training for
veterans and their families in coping with the challenges
associated with making the transition from military to civilian
life.
This provision would require services furnished under the
pilot program to be furnished by a for-profit or non-profit
organization(s) selected by the Secretary (pursuant to an
agreement). To participate in the pilot, a participating
organization(s) must have demonstrated expertise and experience
in providing those types of services.
The pilot program would have to be carried out in
cooperation with 10 geographically distributed Vet Centers,
which would be responsible for promoting awareness of the
assistance available to veterans and their families through the
Vet Centers, the non-VA organization(s) conducting the pilot,
and other appropriate mechanisms.
Section 403 would establish detailed reporting requirements
and authorize $1 million to be appropriated for each of fiscal
years 2008 through 2010 to carry out the pilot program. Such
amounts would remain available until expended.
VA does not support title IV. First, it is unclear how
these ``readjustment and transition assistance'' services are
intended to differ from, or interact with, the readjustment
counseling services and related mental health services already
made available to veterans and their families through the Vet
Centers. In our view, this provision would conflict in many
respects with VA's existing authorities to provide readjustment
counseling and related mental health services and lend
confusion to what is otherwise a highly successful program
(particularly with respect to client outreach). Indeed, client
satisfaction with the Vet Centers is the highest of VA's
programs (98%). The services they provide already include
marriage and counseling services to family members as necessary
to further the veteran's readjustment.
We also do not understand the perceived need for reliance
on non-VA organizations for the provision of these services.
Let me again assure you that our Vet Centers readily contract
with appropriate organizations and providers to ensure veterans
and their families receive covered family support services. In
sum, we do not see how this provision would effectively enhance
current authorities or Vet Center activities; rather, we see
that it has serious potential to create confusion and
disruption for both VA and our beneficiaries.
* * * * * * *
Changes in Existing Law Made by the Committee Bill, as Reported
In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, changes in existing law made by the
Committee bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
TITLE 38. VETERANS' BENEFITS
PART II. GENERAL BENEFITS
CHAPTER 17. HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
Subchapter I. General
SEC. 1701. DEFINITIONS.
* * * * * * *
(5) * * *
(B) such mental health services,
consultation, professional counseling, marriage
and family counseling, and training for the
members of the immediate family or legal
guardian of a veteran, or the individual in
whose household such veteran certifies an
intention to live, [as may be essential to] as
the Secretary considers appropriate for the
effective treatment and rehabilitation of a
veteran or dependent or survivor of a veteran
receiving care under the last sentence of
section 1781(b) of this title and
* * * * * * *
Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical
Treatment
* * * * * * *
SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL
HEALTH SERVICES.
* * * * * * *
(e)(1) * * *
(2) Not later than May 1 of each year [through 2008]
through 2012, the Secretary shall submit to the Committees on
Veterans' Affairs of the Senate and House of Representatives a
report containing information updating the reports submitted
under this subsection since the enactment of the Veterans
Millennium Health Care and Benefits Act.
* * * * * * *
Subchapter VIII. Health Care of Persons other than Veterans
* * * * * * *
SEC. 1782. COUNSELING, TRAINING, AND MENTAL HEALTH SERVICES FOR
IMMEDIATE FAMILY MEMBERS
(a) Counseling for family members of veterans receiving
service-connected treatment. In the case of a veteran who is
receiving treatment for a service-connected disability pursuant
to paragraph (1) or (2) of section 1710(a) of this title [38
USCS Sec. 1 A1710(a)], the Secretary shall provide to
individuals described in subsection (c) such consultation,
professional counseling, marriage and family counseling,
training, and mental health services as are necessary in
connection with that treatment.
(b) Counseling for family members of veterans receiving
non-service-connected treatment. In the case of a veteran who
is eligible to receive treatment for a non-service-connected
disability under the conditions described in paragraph (1),
(2), or (3) of section 1710(a) of this title [38 USCS Sec. 1
A1710(a)], the Secretary may, in the discretion of the
Secretary, provide to individuals described in subsection (c)
such consultation, professional counseling, marriage and family
counseling, training, and mental health services as are
necessary in connection with that treatment if--
(1) those services were initiated during the veteran's
hospitalization; and
(2) the continued provision of those services on an
outpatient basis is essential to permit the discharge of the
veteran from the hospital.
* * * * * * *
PART V. BOARDS, ADMINISTRATIONS, AND SERVICES
CHAPTER 73. VETERANS HEALTH ADMINISTRATION-ORGANIZATION AND FUNCTIONS
Subchapter II. General Authority and Administration
* * * * * * *
SEC.
7330A. NATIONAL CENTERS OF EXCELLENCE ON POST-TRAUMATIC STRESS DISORDER
AND SUBSTANCE USE DISORDERS.
* * * * * * *
7330A. NATIONAL CENTERS OF EXCELLENCE ON POST-TRAUMATIC STRESS DISORDER
AND SUBSTANCE USE DISORDERS.
(a) Establishment of Centers.--(1) The Secretary shall
establish not less than six national centers of excellence on
post-traumatic stress disorder and substance use disorders.
(2) The purpose of the centers established under this
section is to serve as Department facilities that provide
comprehensive inpatient or residential treatment and recovery
services for veterans diagnosed with both post-traumatic stress
disorder and a substance use disorder.
(b) Location.--Each center established in accordance with
subsection (a) shall be located at a medical center of the
Department that--
(1) provides specialized care for veterans with post-
traumatic stress disorder and a substance use disorder;
and
(2) is geographically situated in an area with a high
number of veterans that have been diagnosed with both
post-traumatic stress disorder and substance use
disorder.
(c) Process of Referral and Transition To Step Down
Diagnosis Rehabilitation Treatment Programs.--The Secretary
shall establish a process to refer and aid the transition of
veterans from the national centers of excellence on post-
traumatic stress disorder and substance use disorders
established pursuant to subsection (a) to programs that provide
step down rehabilitation treatment for individuals with post-
traumatic stress disorder and substance use disorders.
(d) Collaboration With the National Center for Post-
Traumatic Stress Disorder.--The centers established under this
section shall collaborate in the research of the National
Center for Post-Traumatic Stress Disorder.