[House Report 114-365] [From the U.S. Government Publishing Office] 114th Congress } { Report HOUSE OF REPRESENTATIVES 1st Session } { 114-365 ====================================================================== FEMALE VETERAN SUICIDE PREVENTION ACT _______ December 3, 2015.--Committed to the Committee of the Whole House on the State of the Union and ordered to be printed _______ Mr. Miller of Florida, from the Committee on Veterans' Affairs, submitted the following R E P O R T [To accompany H.R. 2915] [Including cost estimate of the Congressional Budget Office] The Committee on Veterans' Affairs, to whom was referred the bill (H.R. 2915) to amend title 38, United States Code, to direct the Secretary of Veterans Affairs to identify mental health care and suicide prevention programs and metrics that are effective in treating women veterans as part of the evaluation of such programs by the Secretary, having considered the same, report favorably thereon with amendments and recommend that the bill as amended do pass. CONTENTS Page Amendment........................................................ 2 Purpose and Summary.............................................. 3 Background and Need for Legislation.............................. 3 Hearings......................................................... 4 Subcommittee Consideration....................................... 5 Committee Consideration.......................................... 5 Committee Votes.................................................. 6 Committee Oversight Findings..................................... 6 Statement of General Performance Goals and Objectives............ 6 New Budget Authority, Entitlement Authority, and Tax Expenditures 6 Earmarks and Tax and Tariff Benefits............................. 6 Committee Cost Estimate.......................................... 6 Congressional Budget Office Estimate............................. 6 Federal Mandates Statement....................................... 7 Advisory Committee Statement..................................... 8 Constitutional Authority Statement............................... 8 Applicability to Legislative Branch.............................. 8 Statement on Duplication of Federal Programs..................... 8 Disclosure of Directed Rulemaking................................ 8 Section-by-Section Analysis of the Legislation................... 8 Changes in Existing Law Made by the Bill as Reported............. 9 Amendment The amendments are as follows: Strike all after the enacting clause and insert the following: SECTION 1. SHORT TITLE. This Act may be cited as the ``Female Veteran Suicide Prevention Act''. SEC. 2. SPECIFIC CONSIDERATION OF WOMEN VETERANS IN EVALUATION OF DEPARTMENT OF VETERANS AFFAIRS MENTAL HEALTH CARE AND SUICIDE PREVENTION PROGRAMS. Section 1709B(a)(2) of title 38, United States Code, is amended-- (1) in subparagraph (A), by inserting before the semicolon the following: ``, including specific metrics applicable to women''; (2) in subparagraph (D), by striking ``and'' at the end; (3) in subparagraph (E), by striking the period at the end and inserting ``; and''; and (4) by adding at the end the following new subparagraph: ``(F) identify the mental health care and suicide prevention programs conducted by the Secretary that are most effective for women veterans and such programs with the highest satisfaction rates among women veterans.''. SEC. 3. MENTAL HEALTH TREATMENT FOR VETERANS WHO SERVED IN CLASSIFIED MISSIONS. (a) Sense of Congress.--It is the sense of Congress that veterans who experience combat-related mental health wounds should have immediate, appropriate, and consistent access to comprehensive mental health care. (b) In General.--Subchapter II of chapter 17 of title 38, United States Code, is amended by adding at the end the following section: ``Sec. 1720H. Mental health treatment for veterans who served in classified missions ``(a) Establishment of Standards.--(1) The Secretary shall establish standards and procedures to ensure that each covered veteran may access mental health care provided by the Secretary in a manner that fully accommodates the obligation of the veteran to not improperly disclose classified information. ``(2) The Secretary shall disseminate guidance to employees of the Veterans Health Administration, including mental health professionals, on the standards and procedures established under paragraph (1) and how to best engage covered veterans during the course of mental health treatment with respect to classified information. ``(b) Identification.--In carrying out this section, the Secretary shall ensure that a veteran may elect to identify as a covered veteran on an appropriate form. ``(c) Definitions.--In this section: ``(1) The term `classified information' means any information or material that has been determined by an official of the United States pursuant to law, an Executive order, or regulation to require protection against unauthorized disclosure for reasons of national security. ``(2) The term `covered veteran' means a veteran who-- ``(A) is enrolled in the health care system established under section 1705(a) of this title; ``(B) is seeking mental health treatment; and ``(C) in the course of serving in the Armed Forces, participated in a sensitive mission or served in a sensitive unit. ``(3) The term `sensitive mission' means a mission of the Armed Forces that, at the time at which a covered veteran seeks treatment, is classified. ``(4) The term `sensitive unit' has the meaning given that term in section 130b(c)(4) of title 10.''. (c) Clerical Amendment.--The table of sections at the beginning of such chapter is amended by adding after the item relating to section 1720G the following new item: ``1720H. Mental health treatment for veterans who served in classified missions.''. Amend the title so as to read: A bill to amend title 38, United States Code, to direct the Secretary of Veterans Affairs to identify mental health care and suicide prevention programs and metrics that are effective in treating women veterans as part of the evaluation of such programs by the Secretary, and for other purposes. Purpose and Summary H.R. 2915, the Female Veteran Suicide Prevention Act, was introduced by Representative Julia Brownley of California on June 25, 2015. H.R. 2915, as amended, incorporates the text of H.R. 2915 and includes provisions from H.R. 421, which was introduced by Representative Kyrsten Sinema of Arizona on January 20, 2015. H.R. 2915, as amended, would: (1) direct the Department of Veterans Affairs (VA) to identify mental health care and suicide prevention programs that are most effective and have the highest satisfaction rates among women veterans; and, (2) require VA to establish and disseminate standards and procedures to ensure that a veteran who participated in a classified mission or served in a sensitive unit while in the Armed Forces may access VA mental health care in a manner that fully accommodates his/her obligation not to improperly disclose classified information. Background and Need for Legislation Section 2--Specific consideration of women veterans in evaluation of Department of Veterans Affairs mental health care and suicide prevention programs Congress has long recognized the unacceptable rates of suicide among the nation's veterans. Most recently, Congress passed the Clay Hunt Suicide Prevention for American Veterans Act (P.L. 114-2, 129 Stat. 30), which requires an independent third party to evaluate VA mental health care and suicide prevention programs, to include: (1) metrics that are common and useful for mental health and suicide prevention practitioners; (2) identify most effective programs; (3) identify the cost-effectiveness of each program; and (4) propose best practices. VA's most recent suicide data report was released on February 1, 2013.\1\ That report found that 18 to 22 veterans per day die as a result of suicide, a number that has remained stable since 1999 despite significant increases in VA's mental health and suicide prevention budget, programs, and staff. In January 2014, VA released an update to the 2012 Suicide Data Report that found increases in the suicide rate in female users of the VA health care system. Importantly, this update found increases in the suicide rate among female veterans who use the VA health care system.\2\ This finding echoes recent research that found female veterans commit suicide at nearly six times the rate of other women,\3\ and that women veterans are five times more likely to commit suicide than male veterans.\4\ These findings call into question the efficacy of VA's mental health and suicide prevention programs for female veterans and highlight the need for an increased focus on mental health care and suicide prevention efforts among women, who are one of the fastest growing subpopulations of veterans. However, most of VA's research regarding suicide has focused on male veterans, who account for more than 90% of the veteran population. --------------------------------------------------------------------------- \1\See, Suicide Data Report, 2012, Department of Veterans Affairs Mental Health Services Suicide Prevention Program, http://www.va.gov/ opa/docs/suicide-data-report-2012-final.pdf. \2\See, Suicide Rates in VHA Patients through 2011 with Comparisons with Other Americans and other Veterans through 2012, http:// www.mentalhealth.va.gov/docs/Suicide_Data_ Report_Update_January_2014.pdf. \3\See,``Suicide rate of female military veterans is called `staggering''', Los Angeles Times, June 8, 2015. http:// www.latimes.com/nation/la-na-female-veteran-suicide-20150608- story.html. \4\See, ``Changes in Suicide Mortality for Veterans and Nonveterans by Gender and History of VHA Service Use, 2000--2010'', Psychiatric Services, Volume 66, Issue 9, September 01, 2015. --------------------------------------------------------------------------- Section 2 would amend the Clay Hunt Suicide Prevention for American Veterans Act to include, within the independent third party evaluation, specific metrics applicable to women and to identify the VA mental health care and suicide prevention programs that are most effective and have the highest patient satisfaction rates among women veterans. Section 3--Mental health treatment of veterans who serve in classified missions The Committee believes that providing veterans in need with accessible, high-quality, and responsive mental health care is one of VA's most important missions. The Department alleges that VA mental health providers treating veterans who served on sensitive or classified missions during their military service ensure that the treatment that is provided to these veterans does not compromise their need for confidentiality. However, serious concerns have been raised about the provision of mental health care to these veterans following the suicide death of Sergeant Daniel Somers, who had served on a number of classified missions and was enrolled in VA group therapy sessions despite his fears about inadvertently sharing classified information in that setting. Sergeant Somers' military service was largely classified and could not be discussed with anyone lacking appropriate clearance. Enrolling him in group therapy sessions over his objections created an environment in which he felt that he was unable to seek care due to his national security obligations. Tragically, Sergeant Somers committed suicide in June 2013. Section 3 of the bill would direct VA to establish standards and procedures to ensure that veterans who participated in classified missions or served in sensitive units may access mental health care in a manner that fully accommodates their obligation to not improperly disclose classified information. The Committee urges the Secretary to develop procedures to ensure that mental health professionals caring for these veterans have appropriate security clearances, as needed. VA would also be required to disseminate guidance to VA employees--including mental health professionals--on these standards and procedures and on how to best engage veterans during the course of their mental health treatment with respect to classified information. This provision would require the Department to find alternative methods of mental health treatment for veterans who need to access care without being put in a position where they may reveal information that should not be disclosed. Hearings There were no full Committee hearings held on H.R. 2915. On July 14, 2015, the Subcommittee on Health conducted a legislative hearing on various bills introduced in the 114th Congress, including H.R. 2915 and H.R. 421. The following witnesses testified: The Honorable Tim Walberg, U.S. House of Representatives, 7th Congressional District, Michigan; The Honorable Sean Duffy, U.S. House of Representatives, 7th Congressional District, Wisconsin; The Honorable Steve Stivers, U.S. House of Representatives, 15th Congressional District, Ohio; The Honorable Kyrsten Sinema, U.S. House of Representatives, 9th Congressional District, Arizona; The Honorable Doug Collins, U.S. House of Representatives, 9th Congressional District, Georgia; The Honorable Mike Coffman, U.S. House of Representatives, 6th Congressional District, Colorado; The Honorable Jeff Denham, U.S. House of Representatives, 10th Congressional District, California; The Honorable Charles Boustany, U.S. House of Representatives, 3rd Congressional District, Louisiana; The Honorable Brad Wenstrup, U.S. House of Representatives, 2nd Congressional District, Ohio; Ian de Planque, Legislative Director, American Legion; Adrian Atizado, Assistant National Legislative Director, Disabled American Veterans; Carlos Fuentes, Senior Legislative Associate, National Legislative Service, Veterans of Foreign Wars of the United States; and, Madhulika Agarwal, MD, MPH, Deputy Under Secretary for Health for Policy and Services, Veterans Health Administration, U.S. Department of Veterans Affairs, who was accompanied by Janet P. Murphy, MBA, Acting Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration, U.S. Department of Veterans Affairs; and Jessica Tanner, General Attorney, Office of General Counsel, U.S. Department of Veterans Affairs. Statements for the Record were submitted by: The American Academy of Audiology and the American Speech- Language Association; the Children of Vietnam Veterans Health Alliance, the International Hearing Society; Iraq and Afghanistan Veterans of America; the National Medical Association; Paralyzed Veterans of America; VetsFirst, a program of the United Spinal Association: Vietnam Veterans of America; Warrior Canine Connection; the American Academy of Ophthalmology; and, the American Medical Association. Subcommittee Consideration On July 22, 2015, the Subcommittee on Health met in open markup session, a quorum being present, and favorably forwarded to the full Committee H.R. 2915 and H.R. 421, as amended, by voice vote. During consideration of the bills, the following amendment was considered: An amendment to H.R. 421 offered by Representative Julia Brownley of California, which provided a short title of ``The Sergeant Daniel Somers Classified Veterans Access to Care Act'' was agreed to by voice vote. Committee Consideration On September 17, 2015, the full Committee met in open markup session, a quorum being present, and ordered H.R. 2915, as amended, reported favorably to the House of Representatives, by voice vote. During consideration of the bill, the following amendment was considered: An amendment in the nature of a substitute by Representative Julia Brownley of California, which combined the text of H.R. 2915, as introduced, and H.R. 421, as amended. The amendment in the nature of a substitute was agreed to by voice vote. Committee Votes In compliance with clause 3(b) of rule XIII of the Rules of the House of Representatives, there were no recorded votes taken in connection with ordering H.R. 2915, as amended, reported to the House. A motion by Ranking Member Corrine Brown of Florida to report H.R. 2915, as amended, favorably to the House of Representatives was agreed to by voice vote. Committee Oversight Findings In compliance with clause 3(c)(1) of rule XIII and clause (2)(b)(1) of rule X of the Rules of the House of Representatives, the Committee's oversight findings and recommendations are reflected in the descriptive portions of this report. Statement of General Performance Goals and Objectives In accordance with clause 3(c)(4) of rule XIII of the Rules of the House of Representatives, the Committee's performance goals and objectives are that the Secretary will use these provisions to improve the mental health care provided to women veterans and to veterans who have served on classified missions or in sensitive units in the Armed Forces. New Budget Authority, Entitlement Authority, and Tax Expenditures In compliance with clause 3(c)(2) of rule XIII of the Rules of the House of Representatives, the Committee adopts as its own the estimate of new budget authority, entitlement authority, or tax expenditures or revenues contained in the cost estimate prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974. Earmarks and Tax and Tariff Benefits H.R. 2915, as amended, does not contain any Congressional earmarks, limited tax benefits, or limited tariff benefits as defined in clause 9 of rule XXI of the Rules of the House of Representatives. Committee Cost Estimate The Committee adopts as its own the cost estimate on H.R. 2915, as amended, prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974. Congressional Budget Office Cost Estimate Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House of Representatives, the following is the cost estimate for H.R. 2915, as amended, provided by the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974: U.S. Congress, Congressional Budget Office, Washington, DC, October 29, 2015. Hon. Jeff Miller, Chairman, Committee on Veterans' Affairs, House of Representatives, Washington, DC. Dear Mr. Chairman: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 2915, the Female Veterans Suicide Prevention Act. If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is Ann E. Futrell. Sincerely, Keith Hall. Enclosure. H.R. 2915--Female Veterans Suicide Prevention Act H.R. 2915 would revise the requirements for an annual independent assessment to include metrics on suicide among female veterans. The assessment was recently established under the Clay Hunt SAV Act (Public Law 114-2) and requires a nongovernment entity to review and report on the mental health care provided by the Department of Veterans Affairs (VA). The bill also would require VA to establish and disseminate standards for providing mental health treatment to veterans who served on classified missions. Based on information from VA and independent entities who have prepared similar assessments, CBO expects that adding an additional metric would increase the cost of preparing the report on mental health care by an insignificant amount, as would preparing and disseminating standards for mental health treatment. On that basis, CBO estimates that implementing H.R. 2915 would cost less than $500,000 over the 2016-2020 period. Any spending would be subject to the availability of appropriated funds. Enacting H.R. 2915 would not affect direct spending or revenues; therefore, pay-as-you-go procedures do not apply. CBO estimates that enacting H.R. 2915 would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2026. H.R. 2915 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act and would not affect the budgets of state, local, or tribal governments. The CBO staff contact for this estimate is Ann E. Futrell. The estimate was approved by H. Samuel Papenfuss, Deputy Assistant Director for Budget Analysis. Federal Mandates Statement The Committee adopts as its own the estimate of Federal mandates regarding H.R. 2915, as amended, prepared by the Director of the Congressional Budget Office pursuant to section 423 of the Unfunded Mandates Reform Act. Advisory Committee Statement No advisory committees within the meaning of section 5(b) of the Federal Advisory Committee Act would be created by H.R. 2915, as amended. Statement of Constitutional Authority Pursuant to Article I, section 8 of the United States Constitution, the reported bill is authorized by Congress' power to ``provide for the common Defense and general Welfare of the United States.'' Applicability to Legislative Branch The Committee finds that the legislation does not relate to the terms and conditions of employment or access to public services or accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act. Statement on Duplication of Federal Programs Pursuant to section 3(g) of H. Res. 5, 114th Cong. (2015), the Committee finds that no provision of H.R. 2915, as amended, establishes or reauthorizes a program of the Federal Government known to be duplicative of another Federal program, a program that was included in any report from the Government Accountability Office to Congress pursuant to section 21 of Public Law 111-139, or a program related to a program identified in the most recent Catalog of Federal Domestic Assistance. Disclosure of Directed Rulemaking Pursuant to section 3(i) of H. Res. 5, 114th Cong. (2015), the Committee estimates that H.R. 2915, as amended, contains no directed rule making that would require the Secretary to prescribe regulations. Section-by-Section Analysis of the Legislation Section 1--Short title Section 1 would provide a short title of H.R. 2915, as amended, as the ``Female Veteran Suicide Prevention Act.'' Section 2--Specific consideration of women veterans in evaluation of Department of Veterans Affairs mental health care and suicide prevention programs Section 2 would amend section 1709B(a)(2) of title 38 U.S.C., in subparagraph (A) by inserting ``, including specific metrics applicable to women'' before the semicolon; in subparagraph (E) by striking the period at the end and inserting ``; and''; and, by adding at the end a new subparagraph (F) to read ``(F) identify the mental health care and suicide prevention programs conducted by the Secretary that are most effective for women veterans and such programs with the highest satisfaction rates among women veterans.'' Section 3--Mental health treatment of veterans who serve in classified missions Section 3(a) would provide the sense of Congress that veterans who experience combat-related mental health wounds should have immediate, appropriate, and consistent access to comprehensive mental health care. Section 3(b) would amend subchapter II of chapter 17 of title 38 U.S.C., by adding at the end a new section entitled, ``Sec. 1720H. Mental health treatment for veterans who served in classified missions.'' Proposed sec. 1720H(a) would require the Secretary to establish standards and procedures to ensure that each covered veteran may access mental health care provided by the Secretary in a manner that fully accommodates the obligation of the veteran to not improperly disclose classified information and require the Secretary to disseminate guidance to Veterans Health Administration employees, including mental health professionals, on the standard and procedures established and how to best engage covered veterans during the course of mental health treatment with respect to classified information. Proposed sec. 1720H(b) would require the Secretary to ensure that a veteran may elect to identify as a covered veteran on an appropriate form. Proposed sec. 1720H(c) would define: the term ``classified information'' as any information or material that has been determined by an official of the United States pursuant to law, an Executive Order, or regulation to require protection against unauthorized disclosure for reasons of national security; the term ``covered veteran'' as a veteran enrolled in the health care system established under section 1705(a) of title 38 U.S.C., who is seeking mental health treatment and, in the course of serving in the Armed Forces, participated in a sensitive mission or services in a sensitive unit; the term ``sensitive mission'' as a mission of the Armed Forces that, at the time at which a covered veteran seeks treatment, is classified; and, the term ``sensitive unit'' as the meaning given that term in section 130b(c)(4) of title 10 U.S.C. Section 3(c) would amend the table of sections at the beginning of subchapter II of chapter 17 of title 38 U.S.C., by adding after the item relating to section 1720G the following new item, ``1720H. Mental health treatment for veterans who served in classified missions.'' Changes in Existing Law Made by the Bill, as Reported In compliance with clause 3(e) of rule XIII of the Rules of the House of Representatives, changes in existing law made by the 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): Changes in Existing Law Made by the Bill, as Reported In compliance with clause 3(e) of rule XIII of the Rules of the House of Representatives, changes in existing law made by the bill, as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, and existing law in which no change is proposed is shown in roman): TITLE 38, UNITED STATES CODE * * * * * * * PART II--GENERAL BENEFITS * * * * * * * CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE SUBCHAPTER I--GENERAL Sec. 1701. Definitions. * * * * * * * SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL TREATMENT * * * * * * * 1720H. Mental health treatment for veterans who served in classified missions. SUBCHAPTER I--GENERAL * * * * * * * Sec. 1709B. Evaluations of mental health care and suicide prevention programs (a) Evaluations.--(1) Not less frequently than once during each period specified in paragraph (3), the Secretary shall provide for the conduct of an evaluation of the mental health care and suicide prevention programs carried out under the laws administered by the Secretary. (2) Each evaluation conducted under paragraph (1) shall-- (A) use metrics that are common among and useful for practitioners in the field of mental health care and suicide prevention, including specific metrics applicable to women; (B) identify the most effective mental health care and suicide prevention programs conducted by the Secretary, including such programs conducted at a Center of Excellence; (C) identify the cost-effectiveness of each program identified under subparagraph (B); (D) measure the satisfaction of patients with respect to the care provided under each such program; [and] (E) propose best practices for caring for individuals who suffer from mental health disorders or are at risk of suicide, including such practices conducted or suggested by other departments or agencies of the Federal Government, including the Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services[.]; and (F) identify the mental health care and suicide prevention programs conducted by the Secretary that are most effective for women veterans and such programs with the highest satisfaction rates among women veterans. (3) The periods specified in this paragraph are the following: (A) The period beginning on the date on which the Secretary awards the contract under paragraph (4) and ending on September 30, 2018. (B) Each fiscal year beginning on or after October 1, 2018. (4) Not later than 180 days after the date of the enactment of this section, the Secretary shall seek to enter into a contract with an independent third party unaffiliated with the Department of Veterans Affairs to conduct evaluations under paragraph (1). (5) The independent third party that is awarded the contract under paragraph (4) shall submit to the Secretary each evaluation conducted under paragraph (1). (b) Annual Submission.--Not later than December 1, 2018, and each year thereafter, the Secretary shall submit to the Committee on Veterans' Affairs of the Senate and the Committee on Veterans' Affairs of the House of Representatives a report that contains the following: (1) The most recent evaluations submitted to the Secretary under subsection (a)(5) that the Secretary has not previously submitted to such Committees. (2) Any recommendations the Secretary considers appropriate. SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL TREATMENT * * * * * * * Sec. 1720H. Mental health treatment for veterans who served in classified missions (a) Establishment of Standards.--(1) The Secretary shall establish standards and procedures to ensure that each covered veteran may access mental health care provided by the Secretary in a manner that fully accommodates the obligation of the veteran to not improperly disclose classified information. (2) The Secretary shall disseminate guidance to employees of the Veterans Health Administration, including mental health professionals, on the standards and procedures established under paragraph (1) and how to best engage covered veterans during the course of mental health treatment with respect to classified information. (b) Identification.--In carrying out this section, the Secretary shall ensure that a veteran may elect to identify as a covered veteran on an appropriate form. (c) Definitions.--In this section: (1) The term ``classified information'' means any information or material that has been determined by an official of the United States pursuant to law, an Executive order, or regulation to require protection against unauthorized disclosure for reasons of national security. (2) The term ``covered veteran'' means a veteran who-- (A) is enrolled in the health care system established under section 1705(a) of this title; (B) is seeking mental health treatment; and (C) in the course of serving in the Armed Forces, participated in a sensitive mission or served in a sensitive unit. (3) The term ``sensitive mission'' means a mission of the Armed Forces that, at the time at which a covered veteran seeks treatment, is classified. (4) The term ``sensitive unit'' has the meaning given that term in section 130b(c)(4) of title 10. * * * * * * * [all]