Senate Report 114-395 - HOMELESS VETERANS' REINTEGRATION PROGRAMS REAUTHORIZATION ACT OF 2015

[Senate Report 114-395]
[From the U.S. Government Publishing Office]

Calendar No. 716
114th Congress } { Report
SENATE
2d Session } { 114-395

======================================================================

HOMELESS VETERANS' REINTEGRATION PROGRAMS
REAUTHORIZATION ACT OF 2015

_______

December 7, 2016.--Ordered to be printed

_______

Mr. Isakson, from the Committee on Veterans' Affairs,
submitted the following

R E P O R T

together with

SUPPLEMENTAL VIEWS

[To accompany S. 425]

The Committee on Veterans' Affairs (hereinafter,
``Committee''), to which was referred the bill (S. 425) to
amend title 38, United States Code (hereinafter, ``U.S.C.''),
to provide for a five-year extension to the homeless veterans
reintegration programs and to provide clarification regarding
eligibility for services under such programs, having considered
the same, reports favorably thereon with an amendment in the
nature of a substitute and an amendment to the title, and
recommends that the bill, as amended, do pass.

Introduction

On February 10, 2015, Senator Boozman introduced S. 425,
the proposed Homeless Veterans' Reintegration Programs
Reauthorization Act of 2015. S. 425 would reauthorize homeless
veterans' reintegration programs through fiscal year 2020 and
expand eligibility for those reintegration programs to veterans
participating in the Department of Housing and Urban
Development-Veterans Affairs Supportive Housing (hereinafter,
``HUD-VASH'') program, Indian veterans receiving assistance
under the Native American Housing Assistance and Self
Determination Act of 1996 (hereinafter, ``NAHASDA''), and
veterans transitioning from being incarcerated. Senator Tester
is an original cosponsor. Senators Inhofe and Schumer were
later added as cosponsors. The bill was referred to the
Committee.
On February 26, 2015, Senator Wyden introduced S. 602, the
proposed GI Bill Fairness Act of 2015. S. 602 would consider
certain time spent by members of the reserves while receiving
medical care from the Secretary of Defense as active duty for
purposes of eligibility for Post-9/11 Educational Assistance
and would make that change apply retroactively as if it were
enacted immediately after the enactment of the Post-9/11
Veterans Educational Assistance Act of 2008. Senator Boozman is
an original cosponsor. Senators Markey and McCain were later
added as cosponsors of the bill. The bill was referred to the
Committee.
On March 10, 2015, Senator Burr introduced S. 684, the
proposed Homeless Veterans Prevention Act of 2015. S. 684 would
increase per diem payments for transitional housing for
homeless veterans placed in housing that will become permanent,
authorize per diem payments for entities furnishing care for
dependents of certain homeless veterans, authorize the
Department of Veterans Affairs (hereinafter, ``VA'' or
``Department'') to partner with public or private entities to
provide legal services to homeless veterans, expand VA
authority to provide dental care to certain veterans, repeal
the sunset on referral and counseling programs for veterans at
risk of homelessness and transitioning from certain
institutions, extend supportive services assistance for low-
income veteran families in permanent housing, direct VA to
assess comprehensive service programs for homeless veterans,
require a Government Accountability Office (hereinafter,
``GAO'') study of VA homeless programs, and repeal a
requirement for annual reports from VA on assistance to
homeless veterans. Senator Manchin is an original cosponsor.
Senator King was later added as a cosponsor. The bill was
referred to the Committee.
On April 23, 2015, Senator Murray introduced S. 1085, the
proposed Military and Veteran Caregiver Services Improvement
Act of 2015. S. 1085 would expand eligibility for the program
of comprehensive assistance for family caregivers to include
veterans who were injured or fell ill in the line of duty prior
to September 11, 2001; include child care, financial planning,
and legal services in the program of comprehensive assistance
for family caregivers; authorize the transfer of entitlement to
Post-9/11 education assistance to family members by veterans
who are in the program of comprehensive assistance for family
caregivers, without regard to length-of-service requirements;
expand eligibility for special compensation for members of the
uniformed services with catastrophic injuries or illnesses
requiring assistance in everyday living; authorize VA to
provide certain caregiver assistance to family caregivers of a
member in receipt of monthly special compensation; authorize
flexible work schedules or telework for Federal employees who
are caregivers of veterans; designate a veteran participating
in the program of comprehensive assistance for family
caregivers as an adult with a special need for purposes of the
lifespan respite care program; establish an interagency working
group to review policies relating to the caregivers of veterans
and members of the Armed Forces; and require studies on members
of the Armed Forces who commenced service after September 11,
2001, and veterans who have incurred a serious injury or
illness, including a mental health injury, and their
caregivers. Senators Brown, Collins, Coons, Durbin, and Tester
are original cosponsors. Senators Baldwin, Bennet, Blumenthal,
Boxer, Cantwell, Franken, Hirono, King, Markey, Menendez,
Peters, Sanders, Schatz, Schumer, and Warner were later added
as cosponsors. The bill was referred to the Committee.
On May 21, 2015, Senator Hirono introduced S. 1450, the
proposed Department of Veterans Affairs Emergency Medical
Staffing Recruitment and Retention Act. S. 1450 would authorize
VA to modify the hours of employment for a physician or
physician assistant appointed in VA on a full-time basis to
more or less than 80 hours in a biweekly pay period provided
the employee's total hours of employment in a calendar year do
not exceed 2,080. The bill was referred to the Committee.
On May 21, 2015, Senator Hirono introduced S. 1451, the
proposed Veterans' Survivors Claims Processing Automation Act
of 2015. S. 1451 would authorize VA to provide certain benefits
to a survivor of a veteran who has not filed a formal claim, if
VA determines that the record contains sufficient evidence to
establish the survivor's entitlement to such benefits. The bill
was referred to the Committee.
On May 22, 2015, Senator Brown introduced S. 1460, the
proposed Fry Scholarship Enhancement Act of 2015. S. 1460 would
include under the Yellow Ribbon G.I. Education Enhancement
Program (hereinafter, ``Yellow Ribbon Program'') the child of
an individual who, on or after September 11, 2001, dies in the
line of duty while serving on active duty. Senator Tillis is an
original cosponsor. Senators Blumenthal and Coons were later
added as cosponsors. The bill was referred to the Committee.
On June 22, 2015, Senator Baldwin introduced S. 1641, the
proposed Jason Simcakoski Memorial Opioid Safety Act. S. 1641
would direct VA and the Department of Defense (hereinafter,
``DOD'') to jointly update the VA/DOD Clinical Practice
Guideline for Management of Opioid Therapy for Chronic Pain;
establish a working group on pain management and opioid therapy
for individuals receiving VA or DOD health care within the
Health Executive Committee (hereinafter, ``HEC'') of the VA/DOD
Joint Executive Committee (hereinafter, ``JEC''); require GAO
to report to Congress on VA's Opioid Safety Initiative
(hereinafter, ``OSI'') and VA's opioid prescribing practices
and the Patient Advocacy Program; and require VA to request
information on medical license violations during the past 20
years and on whether the health care provider has entered into
any settlement agreement for a medical-related disciplinary
charge. Senators Blumenthal, Brown, Capito, Hirono, Johnson,
Kaine, Manchin, Markey, Moran, Murray, Sanders, and Tester are
original cosponsors. Senators Durbin, Feinstein, Franken, Kirk,
Klobuchar, McCaskill, Schumer, and Warner were later added as
cosponsors. The bill was referred to the Committee.
On June 24, 2015, Senator Tester introduced S. 1676, the
proposed Delivering Opportunities for Care and Services for
Veterans Act of 2015. S. 1676 would prohibit the U.S.
Department of Health and Human Services from including in
determining the limitation on the total number of residents the
residents for allopathic or osteopathic medicine who count
towards meeting VA's obligation under the Veterans Access,
Choice, and Accountability Act of 2014 (Public Law 113-146) to
increase the number of graduate medical education (hereinafter,
``GME'') residency positions at VA; extend the period for VA to
increase graduate medical education residency positions to 10
years; require VA and the Department of Health and Human
Services to conduct a pilot program on graduate behavioral
medicine residency programs; include education and training of
marriage and family therapists and mental health professionals
in VA education and training programs; allow appointment of
mental health counseling doctors to be eligible for appointment
to VA counselor positions; offer competitive pay for physician
assistants at VA; provide at least 30 percent of annual debt
reduction payments to rural medical practices; address the pay
for VA's Directors of Veterans Integrated Service Networks
(hereinafter, ``VISNs''); and conduct a pilot program to assess
the feasibility of implementing a nurse advice line for rural
areas. Senator McCaskill is an original cosponsor. Senators
Bennet, Blumenthal, Brown, Durbin, Schatz, and Udall were later
added as cosponsors. The bill was referred to the Committee.
On July 14, 2015, Senator Shaheen introduced S. 1754, which
would make permanent the temporary increase in the maximum
number of judges presiding over the U.S. Court of Appeals for
Veterans Claims (hereinafter, ``Veterans Court''). Senator
Blumenthal was later added as a cosponsor. The bill was
referred to the Committee.
On July 23, 2015, Senator Blumenthal introduced S. 1856,
the proposed Department of Veterans Affairs Equitable Employee
Accountability Act of 2015. S. 1856 would allow VA to suspend
employees without pay based on performance or misconduct and
remove such suspended individuals if it is determined necessary
after investigation and review; allow suspended or removed
individuals to appeal to the Merit Systems Protection Board and
receive back pay if the suspension or removal is found to be
unwarranted. Senators Brown, Hirono, Murray, Sanders, and
Tester are original cosponsors. Senators Baldwin, Bennet,
Booker, Boxer, Cantwell, Cardin, Casey, Durbin, Franken,
Gillibrand, Heinrich, Kaine, Leahy, Markey, Menendez, Mikulski,
Peters, Schumer, Shaheen, Stabenow, Udall, Warren, and
Whitehouse were later added as cosponsors. The bill was
referred to the Committee.
On July 29, 2015, Senator Blumenthal introduced S. 1885,
the proposed Veteran Housing Stability Act of 2015. S. 1885
would expand VA's definition of homeless veteran to include
those fleeing domestic violence; direct VA to provide intensive
case management interventions for veterans enrolled in the
homeless registry and the annual patient enrollment system;
provide case management services to improve housing retention
for transitioning or previously homeless veterans; expand the
VA housing assistance program to include assistance for at risk
and low-income veterans and their families transitioning to
permanent housing; direct VA to conduct community outreach on
the housing needs of veterans; codify the National Center on
Homelessness Among Veterans; and require an annual review of
each grant recipient and eligible entity that receives per diem
payments for homeless services to evaluate its performance.
Senators Brown, Hirono, and Sanders are original cosponsors.
Senators Boxer and Schumer were later added as cosponsors. The
bill was referred to the Committee.
On August 5, 2015, Senator Blumenthal introduced S. 1938,
the proposed Career-Ready Student Veterans Act of 2015. S. 1938
would modify the criteria for approving educational
institutions providing programs leading to licensure or
certification to require that they meet certain state
requirements or are approved by an appropriate state board or
agency. Senators Brown, Carper, Cassidy, Coons, Durbin,
Feinstein, Gillibrand, Merkley, Murphy, Reed, Schumer, Shaheen,
and Tillis are original cosponsors. Senator Warren was later
added as a cosponsor. The bill was referred to the Committee.
On August 5, 2015, Senator Hoeven introduced S. 2000, the
proposed Veterans Access to Long Term Care and Health Services
Act. S. 2000 would authorize VA to enter into a Veterans Care
Agreement with an eligible provider to furnish certain care and
services if VA is unable to do so, establish a process for
certification of eligible providers, monitor the quality of
care furnished to veterans, and allow the agreements to be made
to provide veterans with nursing home care. Senator Manchin is
an original cosponsor. Senator Rounds was later added as a
cosponsor. The bill was referred to the Committee.
On September 10, 2015, Senator Graham introduced S. 2022,
which would increase the special monthly pension for living
Medal of Honor recipients. Senators Blumenthal and Markey were
later added as cosponsors. The bill was referred to the
Committee.
On October 5, 2015, Senator Tester introduced S. 2134, the
proposed Grow Our Own Directive: Physician Assistant Employment
and Education Act of 2015. S. 2134 would direct VA to carry out
a pilot program to provide educational assistance to certain
former members of the Armed Forces for education and training
as a VA physician assistant, provide educational assistance to
program participants for the cost of obtaining a master's
degree in physician assistant studies or a similar master's
degree, ensure mentors are available for program participants
at each VA facility where a participant is employed, partner
with specified government programs and appropriate educational
institutions that offer degrees in physician assistant studies,
establish standards to improve education and hiring of
physician assistants, and implement a national plan for
retention and recruitment that includes adoption of competitive
pay standards. Senator Moran is an original cosponsor. Senators
Baldwin and Brown were later added as cosponsors. The bill was
referred to the Committee.
On November 5, 2015, Senator Blumenthal introduced S. 2253,
the proposed Department of Veterans Affairs Veterans Education
Relief and Restoration Act of 2015. S. 2253 would provide that,
if a veteran is forced to discontinue a course as a result of
an educational institution's permanent closure and did not
receive credit or lost time training toward completion of the
educational program, VA educational assistance payments will
not be charged against the individual's entitlement to
educational assistance or against the aggregate period for
which such assistance may be provided (for school closures
beginning with fiscal year 2015), and allow VA to continue
paying a monthly housing stipend following a permanent school
closure for a limited period of time. Senators Baldwin, Brown,
Durbin, Gillibrand, Hirono, Murphy, Reed, Tillis, Warren, and
Wyden are original cosponsors. Senators Boxer, Carper, Heller,
Klobuchar, McCaskill, Murray, Peters, Sanders, and Schumer were
later added as cosponsors. The bill was referred to the
Committee.

Committee Hearings

On May 13, 2015, the Committee held a hearing on
legislation pending before the Committee. Testimony was
received from David R. McLenachen, Acting Deputy Under
Secretary for Disability Assistance, U.S. Department of
Veterans Affairs; Anthony Kurta, Deputy Assistant Secretary of
Defense, Military Personnel Policy, U.S. Department of Defense;
Teresa W. Gerton, Deputy Assistant Secretary for Policy,
Veterans' Employment and Training Service, U.S. Department of
Labor; Alphonso Maldon, Jr., Chairman, Military Compensation
and Retirement Modernization Commission; Jeffrey E. Phillips,
Executive Director, Reserve Officers Association; and Aleks
Morosky, Deputy Legislative Director, National Legislative
Service, Veterans of Foreign Wars.
On June 3, 2015, the Committee held a hearing on
legislation pending before the Committee. Testimony was
received from Thomas Lynch, Assistant Deputy Under Secretary
for Health Clinical Operations, Veterans Health Administration,
U.S. Department of Veterans Affairs; Adrian Atizado, Assistant
National Legislative Director, Disabled American Veterans; Fred
Benjamin, Vice President and Chief Operating Officer,
Medicalodges, Inc.; Thomas J. Snee, National Executive
Director, Fleet Reserve Association; and Sergeant First Class
Victor Medina, U.S. Army, Retired.
On June 24, 2015, the Committee held a hearing on
legislation pending before the Committee. Testimony was
received from Dr. Rajiv Jain, Assistant Deputy Under Secretary
for Health for Patient Care Services, Veterans Health
Administration, U.S. Department of Veterans Affairs; Ian de
Planque, Legislative Director, The American Legion; Pete
Hegseth, CEO, Concerned Veterans of America; Adrian Atizado,
Assistant National Legislative Director, Disabled American
Veterans; Carl Blake, Associate Executive Director, Paralyzed
Veterans of America; Max Stier, President and CEO, Partnership
for Public Service; and John Rowan, National President, Vietnam
Veterans of America.
On September 16, 2015, the Committee held a hearing on
legislation pending before the Committee. Testimony was
received from Thomas Lynch, Assistant Deputy Under Secretary
for Health Clinical Operations, Veterans Health Administration,
U.S. Department of Veterans Affairs; Joseph W. Wescott II,
Legislative Director, National Association of State Approving
Agencies; Roscoe G. Butler, Deputy Director for Health Care,
The American Legion; Aleks Morosky, Deputy Director, National
Legislative Service, Veterans of Foreign Wars; and Donald F.
Kettl, Professor, School of Public Policy, University of
Maryland.
On October 6, 2015, the Committee held a hearing on
legislation pending before the Committee. Testimony was
received from Thomas Lynch, Assistant Deputy Under Secretary
for Health Clinical Operations, Veterans Health Administration,
U.S. Department of Veterans Affairs; Lauren Augustine,
Legislative Associate, Iraq and Afghanistan Veterans of
America; Lou Celli, Director, Veterans Affairs and
Rehabilitation Division, The American Legion; Elisha Harig-
Blaine, Principal Associate, Housing (Veterans and Special
Needs), National League of Cities; and David Norris, National
Legislative Committee Vice-Chairman, Veterans of Foreign Wars.
On November 18, 2015, the Committee held a hearing on
legislation pending before the Committee. Testimony was
received from Curtis L. Coy, Deputy Under Secretary for
Economic Opportunity, Veterans Benefits Administration, U.S.
Department of Veterans Affairs; Elizabeth Hempowicz, Public
Policy Associate, Project on Government Oversight; William
Hubbard, Vice President of Government Affairs, Student Veterans
of America; Aleks Morosky, Deputy Director, National
Legislative Service, Veterans of Foreign Wars; Thomas Porter,
Legislative Director, Iraq and Afghanistan Veterans of America;
and Diane Zumatto, National Legislative Director, AMVETS.

Committee Meeting

After reviewing the testimony from the foregoing hearings,
the Committee met in open session on December 9, 2015, to
consider, among other legislation, an amended version of
S. 425, including provisions derived from S. 425 as introduced
and provisions derived from the other legislation noted above.
The Committee voted by voice vote, without objection, to report
favorably to the Senate S. 425 as amended and as subsequently
amended at the Committee meeting.*
---------------------------------------------------------------------------
*The Committee notes that the information outlined in this report
was current as of the December 2015 Committee meeting at which the
Committee bill was ordered favorably reported. With regard to sections
416, 417, 418, 422, 423, 425, 431, 432, 433, 434, 441, and 442, the
Committee also notes that, after that Committee meeting, Public Law
114-198 was enacted, which incorporated in title IX numerous provisions
derived from the Committee bill and from S. 2921 as favorably reported
by the Committee regarding opioid therapy and pain management at VA.
For purposes of explaining the Committee's December 2015 actions, the
Committee generally opted to retain the then-current background
information in this report.
---------------------------------------------------------------------------

Summary of S. 425 as Reported

S. 425, as reported (hereinafter, ``the Committee bill''),
consists of 57 sections, summarized below.
Section 1 provides a short title and a table of contents.

TITLE I--BENEFITS

Section 101 would amend section 5101 of title 38, U.S.C.,
to provide that VA may pay benefits under chapter 13
(dependency and indemnity compensation) and chapter 15
(pension) and sections 2302 (funeral expenses), 2307 (burial
benefits), and 5121 (accrued benefits) of title 38, U.S.C., to
a survivor of a veteran who has not filed a formal claim, if VA
determines that the record contains sufficient evidence to
establish the survivor's entitlement to those benefits.
Section 102 would amend section 1562 of title 38, U.S.C.,
to increase from $1,299 to $3,000 the monthly special pension
VA provides to Medal of Honor recipients.

TITLE II--EDUCATION MATTERS

Section 201(a) would amend section 3312 of title 38,
U.S.C., to provide that any payment of educational assistance
to an individual for pursuit of a course or courses under the
Post-9/11 GI Bill, if VA finds that the individual was forced
to discontinue pursuit as a result of permanent closure of the
institution and did not receive credit or lost training time
toward completion of the program for that course or courses,
will not be charged against the individual's entitlement to
benefits under the Post-9/11 GI Bill or counted against the
aggregate period for which section 3695 of title 38, U.S.C.,
limits the individual's receipt of educational assistance.
Section 201(b) would amend section 3680(a) of title 38,
U.S.C., to provide that VA may continue to pay educational
allowances to certain veterans and other education
beneficiaries in order to pay the Post-9/11 GI Bill housing
allowance during periods following a permanent closure of an
educational institution, except that the payments may be
continued only until the earlier of the date of the end of the
term during which the closure occurred and the date 4 months
after the school closure.
Section 202 would modify section 3319 of title 38, U.S.C.,
so that a servicemember must serve 10 years and agree to serve
an additional 2 years in order to be eligible to transfer
unused Post-9/11 GI Bill benefits.
Section 202 would amend section 3319 of title 38, U.S.C.,
to cap monthly housing allowance payments at 50 percent of the
housing allowance that would otherwise be payable to a child
using transferred Post-9/11 GI Bill benefits.
Section 203 would codify in a new section 3326 of title 38,
U.S.C., the provisions now found in section 5003(c) of Public
Law 110-252 and would add a provision to that new section
providing that, in the case of an individual who on or after
January 1, 2016, submits to VA an election of which program to
use that VA determines is clearly against the interests of the
individual or who fails to make an election, VA may make an
alternative election on behalf of the individual that VA
determines is in the best interests of the individual. This
section would also provide that VA must promptly notify the
veteran of such alternate election and allow the veteran 30
days to modify the election.
Section 204 would modify section 3684 of title 38, U.S.C.,
so that an ``educational institution'' for purposes of
reporting to VA enrollments in education programs would include
a group, district, or consortium of separately accredited
educational institutions located in the same state that are
organized in a manner that facilitates the centralized
reporting of enrollments in the group, district, or consortium
of institutions.
Section 205 would amend section 3672 of title 38, U.S.C.,
so that an education program would be deemed approved for
purposes of VA education benefits only if a state approving
agency determines that the program meets the deemed-approved
criteria. It would also modify section 3675 of title 38,
U.S.C., so that a program that is not subject to approval under
section 3672 of title 38, U.S.C., may be approved by a state
approving agency or VA acting in the role of a state approving
agency when the criteria for approval of accredited programs at
for-profit institutions are met.
Section 206 would modify section 3676 of title 38, U.S.C.,
so that additional criteria for approval of a non-accredited
course may be required by a state approving agency only if the
Secretary of Veterans Affairs, in consultation with the state
approving agency and pursuant to regulations prescribed to
carry out this requirement, determines that the additional
criteria are necessary and treat public, private, and
proprietary for-profit educational institutions equitably.
Section 206 would modify section 3675 of title 38, U.S.C., so
that accredited courses must also meet those additional
criteria to be approved.
Section 207 of the bill would amend section 3693 of title
38, U.S.C., to modify the conditions under which VA generally
must conduct compliance surveys of educational institutions and
training establishments offering approved courses.
Section 208 would amend sections 3675(b) and 3676(c) of
title 38, U.S.C., to provide that, in order to be approved for
purposes of VA education benefits, a program designed to
prepare an individual for licensure or certification in a
state, or for employment pursuant to standards developed by a
board or agency of a state in an occupation that requires
approval or licensure, the program also must meet any
instructional curriculum licensure or certification
requirements of the state, or meet such standards developed by
a board or agency of a state. It would also require that any
course of education designed to prepare a student for licensure
to practice law be accredited by a recognized party and
authorize the VA Secretary to waive any of those requirements
in certain circumstances. It would add a subsection (d) to
section 3679 of title 38, U.S.C., providing that VA must
disapprove a course of education described above unless the
educational institution providing the course publicly discloses
any conditions or additional requirements to obtain the
license, certification, or approval for which the course is
designed to provide preparation. Finally, it would provide
that, if, after enrollment in a course that is subject to
disapproval by reason of these changes, an individual pursues
courses at the same educational institution while remaining
continuously enrolled, any course pursued by the individual at
that institution will not be subject to disapproval.
Section 209 would amend section 3317 of title 38, U.S.C.,
to allow Marine Gunnery Sergeant John David Fry Scholarship
(hereinafter, ``Fry Scholarship'') recipients to participate in
the Yellow Ribbon Program.
Section 210 would amend section 3301 of title 38, U.S.C.,
to count as active duty for purposes of the Post-9/11 GI Bill
reservists' service under section 12301(h) of title 10, U.S.C.,
under which the Secretary of a military department may order a
reservist to active duty ``to receive authorized medical
care''; ``to be medically evaluated for disability''; or ``to
complete a required Department of Defense health care study''.

TITLE III--HOMELESS VETERANS MATTERS

Section 301 would amend section 2002(1) of title 38,
U.S.C., so that the VA definition of homeless would include
those individuals described in section 11302(b) of title 42,
U.S.C., such as an individual fleeing domestic violence.
Section 302 would amend section 2012 of title 38, U.S.C.,
to provide that the per diem rate paid to certain entities that
provide services to homeless veterans may exceed the rate paid
to State homes in the case of services provided to a homeless
veteran who is placed in housing that will become permanent
housing upon termination of those services (transition-in-
place). In those cases, the maximum per diem would be 150
percent of the State home rate.
Section 303 would amend section 2062 of title 38, U.S.C.,
to provide that dental services may be provided to a veteran
who, for 60 consecutive days, has been housed using the Housing
and Urban Development-VA Supportive Housing program.
Section 304 would amend section 2021 of title 38, U.S.C.,
to expand the scope of the homeless veterans' reintegration
program to include veterans participating in VA's supported
housing program for which rental assistance is provided under
section 8(o)(19) of the United States Housing Act; Indians who
are veterans and receiving assistance under the Native American
Housing Assistance and Self Determination Act; and veterans who
are transitioning from being incarcerated.
Section 305 would add a new section 2013 to title 38,
U.S.C., to require VA to carry out a program under which VA
provides case management services to improve the retention of
housing by veterans who were previously homeless and are
transitioning to permanent housing and veterans who are at risk
of becoming homeless. VA would be required to provide a report
to Congress on the results of the program.
Section 306, in a freestanding provision, would require VA
to carry out a pilot program under which the VA Secretary will
provide intensive case management interventions to a veteran
who is enrolled in the VA homeless registry and the VA health
care system. VA would be required to provide a report to
Congress on the results of the pilot program.
Section 307 would add a new section 2067 to title 38,
U.S.C., to require VA to establish and operate a center known
as the National Center on Homelessness Among Veterans, thereby
codifying the already existing Center.
Section 308 would add a new section 2022A to title 38,
U.S.C., to authorize VA to enter into partnerships with public
or private entities to fund a portion of the general legal
services provided by those entities to homeless veterans and
veterans at risk of homelessness.
Section 309 would amend section 2012 of title 38, U.S.C.,
to require VA, each year, to review each grant recipient and
eligible entity that received a per diem payment under section
2012 of title 38, U.S.C., for a service furnished to a veteran
during the 1-year period preceding the review to evaluate the
performance of the grant recipient or eligible entity during
that period. For any grant recipient or eligible entity whose
performance was evaluated, VA may only provide per diem to that
grant recipient or eligible entity in the following year if VA
determines that such performance merits continued receipt of
per diem. Also, VA would be required to establish uniform
performance targets throughout the United States for all grant
recipients and eligible entities that receive per diem payments
for purposes of evaluating their performance.
Section 310 would repeal section 2065 of title 38, U.S.C.,
to remove a requirement that VA provide an annual report to
Congress on the activities of VA's programs for homeless
veterans.
Section 311 would require that, not later than 270 days
after enactment, GAO must complete a study of VA programs that
provide assistance to homeless veterans, including an
assessment of whether those programs are meeting the needs of
veterans and a review of recent efforts by VA to improve the
privacy, safety, and security of female veterans.
Section 312, in a freestanding provision, would require VA
to assess and measure the capacity of programs that receive
grants or per diem payments. VA would be required to develop
and use tools to examine the capacity of those programs at both
the national and local level.
Section 313, in a freestanding provision, would require VA
to submit a report to Congress describing and assessing
outreach conducted by VA to realtors, landlords, property
management companies, and developers to educate them about the
housing needs of veterans and the benefits of having veterans
as tenants.

TITLE IV--HEALTH CARE MATTERS

Section 401 provides a short title for Title IV of the
bill: Jason Simcakoski Memorial Act.

SUBTITLE A--EMPLOYMENT OF DIRECTORS AND HEALTH CARE PROVIDERS

Section 411 would amend Public Law 113-146 to require VA to
increase the number of graduate medical education residency
positions at VA medical facilities by up to 1,500 positions
over the next 10 years, rather than the current 5-year
requirement, and would extend an annual reporting requirement
through 2024.
Section 412 would amend section 7423(a) of title 38,
U.S.C., to provide an exception to the requirement that the
hours of employment for a full-time VA physician or physician
assistant must consist of not less than 80 hours in a biweekly
pay period, so that VA may modify the hours of employment for a
full-time physician or physician assistant to be more or less
than 80 hours in a biweekly pay period if the total hours for
the employee do not exceed 2,080 hours in a calendar year.
Section 413 would modify section 7451(a)(2) of title 38,
U.S.C., to allow VA to offer rates of pay that are competitive
with non-VA facilities within the same labor market areas when
hiring for physician assistant positions.
Section 414 would amend section 7306 of title 38, U.S.C.,
to require the Office of the Under Secretary for Health to
include such Directors of Veterans Integrated Service Networks
as may be appointed to suit VA's needs and would strike the
requirement that directors be either a qualified doctor of
medicine or a qualified doctor of dental surgery or dental
medicine.
Section 415 would add a new section 7481 to title 38,
U.S.C., providing that pay for a Medical Director or Director
of a Veterans Integrated Service Network will consist of basic
pay set forth under section 7404(a) of title 38, U.S.C.,
(setting grades and pay scales for VA health professionals) and
market pay determined under this new authority. The amount of
market pay would be determined by the Secretary on a case-by-
case basis and must consist of pay intended to reflect the
needs of VA with respect to the recruitment and retention of
the Director.
Section 416, in a freestanding provision, would require VA,
as part of the hiring process for each health care provider
after the date of enactment, to request from the medical board
of each state in which the health care provider has a medical
license information on any violation of the requirements of the
medical license of the health care provider and information on
whether the health care provider has entered into any
settlement agreement for a disciplinary charge relating to the
practice of medicine.
Section 417, in a freestanding provision, would provide
that, notwithstanding section 552a of title 5, U.S.C.,
(regarding disclosure of Federal records about an individual),
VA must, with respect to any VA health care provider that has
violated a requirement of his/her medical license, provide to
the medical board of each state in which the health care
provider is licensed or practices all relevant information
contained in the State Licensing Board Reporting File or any
successor file.
Section 418, in a freestanding provision, would provide
that, not later than 2 years after enactment, VA would be
required to submit to the Committee on Veterans' Affairs of the
Senate and House of Representatives a report on VA's compliance
with its policy to conduct a review of each VA health care
provider who transfers to another VA medical facility or leaves
VA to determine whether there are any concerns, complaints, or
allegations of violations relating to the provider and, if
there are, to take appropriate action.

SUBTITLE B--OPIOID THERAPY AND PAIN MANAGEMENT

Section 421, in a freestanding provision, would provide
that, not later than 1 year after enactment, VA and the
Department of Defense must jointly update the VA/DOD Clinical
Practice Guideline for Management of Opioid Therapy for Chronic
Pain.
Section 422, in a freestanding provision, would provide
that, not later than 180 days after enactment, VA would be
required to expand VA's Opioid Safety Initiative to include all
VA medical facilities; require all employees responsible for
prescribing opioids to receive increased education and
training; establish a pain management team at each medical
facility; require participation in the state prescription drug
monitoring programs (hereinafter, ``PDMP''); report on the
feasibility and advisability of advanced real-time tracking of
opioid use data in the Opioid Therapy Risk Report tool;
increase the availability of opioid receptor antagonists such
as naloxone and provide a report on compliance; include in the
Opioid Therapy Risk Report tool information on when health care
providers access the tool and the most recent urine drug test
for each veteran; and require notification of opioid abuse risk
in the computerized patient record system.
Section 423, in a freestanding provision, would require
that VA and DOD ensure that the Pain Management Working Group
(hereinafter, ``PMWG'') of the VA-DOD Health Executive
Committee includes a focus on the opioid prescribing practices
of health care providers of each Department; the ability of
each Department to manage acute and chronic pain, including
training health care providers with respect to pain management;
the use by each Department of complementary and integrative
health (hereinafter, ``CIH''); the concurrent use by health
care providers of each Department of opioids and prescription
drugs to treat mental health disorders, including
benzodiazepines; the practice by health care providers of each
Department of prescribing opioids to treat mental health
disorders; the coordination in coverage of and consistent
access to medications prescribed for patients transitioning
from receiving health care from DOD to VA; and the ability of
each Department to identify and treat substance use disorders.
Section 424 would add a new section 7309A to title 38,
U.S.C., to require VA to establish within each Veterans
Integrated Service Network a Pain Management Board.
Section 425, in a freestanding provision, would require VA,
not later than 2 years after enactment, to enter into a
contract with an independent entity to conduct an independent
review of the Opioid Safety Initiative and the opioid
prescribing practices of VA health care providers. The VA
Secretary must review annually the prescription rates of each
medical facility and conduct investigations, through the Office
of the Medical Inspector, on prescription rates that conflict
with or are otherwise inconsistent with the standards of
appropriate and safe care.

SUBTITLE C--PATIENT ADVOCACY

Section 431 would add a new section 7309B to title 38,
U.S.C., to establish in the Office of the Under Secretary for
Health an Office of Patient Advocacy to carry out VA's Patient
Advocacy Program. The Director would be appointed by the Under
Secretary for Health and would report directly to the Under
Secretary for Health.
Section 432, in a freestanding provision, would provide
that, not later than 90 days after enactment, and not less
frequently than once every 90 days thereafter, each VA medical
center must host a community meeting open to the public on
improving VA health care and that, not later than 1 year after
enactment, and not less frequently than annually thereafter,
each community based outpatient clinic must host a community
meeting open to the public on improving VA health care.
Section 433, in a freestanding provision, would provide
that, not later than 90 days after enactment, VA must, in as
many prominent locations as appropriate to be seen by the
largest percentage of patients and family members at each
medical facility, display the purposes of the Patient Advocacy
Program and the contact information for the patient advocate at
such medical facility and display the rights and
responsibilities of patients and family members of patients and
with respect to community living centers and other VA
residential facilities, residents and family members of
residents at such medical facility.
Section 434, in a freestanding provision, would provide
that, not later than 3 years after enactment, GAO must submit
to the Committee on Veterans' Affairs of the Senate and House
of Representatives a report on the Patient Advocacy Program.

SUBTITLE D--COMPLEMENTARY AND INTEGRATIVE HEALTH

Section 441, in a freestanding provision, would provide
that, not later than 180 days after enactment, VA must develop
a plan to expand materially and substantially the scope of the
effectiveness of research and education on, and delivery and
integration of, complementary and integrative health services
into the health care services provided to veterans.
Section 442, in a freestanding provision, would provide
that, not later than 180 days after completion of the plan to
expand research and education on, and delivery and integration
of, complementary and integrative health services, VA would be
required to carry out a pilot program to assess the feasibility
and advisability of integrating the delivery of complementary
and integrative health services with other health care services
provided by VA for veterans with mental health conditions,
chronic pain conditions, other chronic conditions, and such
other conditions as the VA Secretary determines appropriate.

SUBTITLE E--FAMILY CAREGIVERS

Section 451 would amend section 1720G of title 38, U.S.C.,
to expand eligibility for VA's Program of Comprehensive
Assistance for Family Caregivers to veterans with a serious
injury incurred or aggravated in the line of duty in the active
military, naval, or air service on or before May 7, 1975,
during the 2-year period following the date on which the VA
Secretary submits to Congress a certification that the
Department has fully implemented the information technology
system required by section 452(a) of the bill. After the date
that is 2 years after the date on which the certification is
submitted, eligibility would be expanded to also include
veterans with a serious injury incurred or aggravated in the
line of duty in the active military, naval, or air service
after May 7, 1975, and before September 11, 2001.
Section 452, in a freestanding provision, would require VA
to implement an information technology system that fully
supports the Family Caregiver Program and allows for data
assessment and comprehensive monitoring by not later than
December 31, 2016.
Section 453 would amend requirements in Public Law 111-163
for VA's annual evaluation report on the Program of
Comprehensive Assistance for Family Caregivers and the Program
of General Caregiver Support to include a description of any
barriers to accessing and receiving care and services. The
report on the Program of Comprehensive Assistance for Family
Caregivers would also include an evaluation of the sufficiency
and consistency of the training provided to family caregivers.
Section 454, in a freestanding provision, would establish a
VA advisory committee on caregiver policy.
Section 455, in a freestanding provision, would require VA
to contract with an independent entity to conduct a
comprehensive study on veterans who have incurred a serious
injury or illness and individuals acting as caregivers for
veterans.

SUBTITLE F--OTHER HEALTH CARE MATTERS

Section 461 would add a new section 1703A to title 38,
U.S.C., to provide that VA may enter into agreements to provide
nursing home care and those agreements may be entered into
without regard to any law that would require VA to use
competitive procedures in selecting the party with which to
enter into the agreement. Generally, a nursing home in carrying
out that agreement would not be subject to any law that
Medicare providers are not subject to.
Section 462 would amend section 1745 of title 38, U.S.C.,
to provide that VA may enter into agreements to provide nursing
home care and those agreements may be entered into without
regard to any law that would require VA to use competitive
procedures in selecting the party with which to enter into the
agreement. Generally, a State home in carrying out that
agreement would not be subject to any law that Medicare
providers are not subject to.

TITLE V--OTHER MATTERS

Section 501 would amend section 7253 of title 38, U.S.C.,
to temporarily expand the U.S. Court of Appeals for Veterans
Claims from 7 to 9 judges through 2020.
Section 502 would repeal section 604(b) of Public Law 113-
291 in order to realign the housing allowance provided to VA
beneficiaries using Post-9/11 GI Bill benefits so it is paid at
the same rate as the Basic Allowance for Housing provided to
active duty military personnel in pay grade E-5 at the ``with
dependents'' rate.
Section 503 would add a new section 527A to title 38,
U.S.C., to require VA to carry out a program of internal audits
and self-analysis to improve the furnishing of benefits and
health care to veterans and their families. VA would be
required to carry out the program through an office established
for that purpose within the Office of the Secretary that is
interdisciplinary and independent of the other offices within
the Office of the Secretary and the administrations, staff
organizations, and staff offices identified for audits.
Section 504, in a freestanding provision, would require the
VA Secretary to provide each VA employee who is in a managerial
position with periodic training on the rights of whistleblowers
and how to address a report by an employee of a hostile work
environment, reprisal, or harassment; how to effectively
motivate, manage, and reward the employees who report to the
manager; and how to effectively manage employees who are
performing at an unacceptable level and access assistance from
the VA human resources office and the Office of General Counsel
with respect to those employees.

Background and Discussion

TITLE I--BENEFITS

Sec. 101. Expedited payment of survivor benefits.

Section 101 of the Committee bill, which is derived from
S. 1451, would authorize VA to pay benefits to a survivor of a
veteran who has not filed a formal claim, if the record
contains sufficient evidence to establish the survivor's
entitlement to such benefits.
Background. Section 5101 of title 38, U.S.C., requires a
claimant to file a formal claim as a condition of receiving VA
benefits. When a survivor of a veteran files a claim for VA
benefits based upon the veteran's death, however, the
information and evidence necessary to decide the claim is often
already in the veteran's claims file. In its Fiscal Year 2016
Budget, VA included a legislative proposal that would authorize
VA to initiate and pay a survivor's claim without receipt of a
formal application whenever sufficient evidence is in the
veteran's record to begin processing such claim. Elimination of
the claim requirement would allow VA to automate the delivery
of uninterrupted benefits to qualifying survivors.
Committee Bill. Subsection (a) of section 101 of the
Committee bill would amend section 5101 of title 38, U.S.C., to
authorize VA to pay benefits under chapter 13 (dependency and
indemnity compensation) and chapter 15 (pension) and sections
2302 (funeral expenses), 2307 (burial benefits), and 5121
(accrued benefits) of title 38, U.S.C., to a survivor of a
veteran who has not filed a formal claim if VA determines that
the record contains sufficient evidence to establish the
survivor's entitlement to those benefits. For purposes of
establishing an effective date under section 5110 of title 38,
U.S.C., the date on which VA is notified of the death of the
veteran will be treated as the date of the receipt of the
survivor's application for benefits. These changes would apply
with respect to claims for benefits based on a death occurring
on or after the date of enactment.

Sec. 102. Increase in special pension for Medal of Honor recipients.

Section 102 of the Committee bill, which is derived from
S. 2022, would amend section 1562 of title 38, U.S.C., to
increase from $1,299.61 to $3,000 the monthly special pension
VA provides to Medal of Honor recipients.
Background. Under section 1562(a) of title 38, U.S.C., VA
provides a monthly special pension to individuals who have been
entered on the Medal of Honor roll of a military service. The
current monthly payment is $1,299.61. Under section 1562(e) of
title 38, U.S.C., VA is required to increase the monthly
stipend effective December 1 of each year by the same percent
increase as any cost-of-living adjustment provided to
recipients of Social Security benefits.
Committee Bill. Section 102 of the Committee bill would
amend section 1562(a) of title 38, U.S.C., to increase to
$3,000 the monthly special pension provided to Medal of Honor
recipients. That change would take effect 1 year after the date
of enactment, except that, if that date is not the first day of
a month, the change would take effect on the first day of the
first month beginning after that date. If the increase takes
effect before December 1, 2016, VA would not make a cost-of-
living adjustment to the special pension amount until December
1, 2017.
The Committee is of the view that an increase is warranted
to help to defray the out-of-pocket costs incurred by Medal of
Honor recipients in order to speak at or attend events around
the country.

TITLE II--EDUCATION MATTERS

Sec. 201. Restoration of entitlement to Post-9/11 educational
assistance for veterans affected by closures of educational
institutions.

Section 201 of the Committee bill, which is derived from
S. 2253, would require VA to provide a continued monthly
housing stipend and restore educational benefits to veterans
affected by the permanent closures of educational institutions
if a veteran is forced to discontinue a course and did not
receive credit, or lost training time, toward completion of the
educational program.
Background. Section 3680 of title 38, U.S.C., describes the
manner in which VA is to provide educational assistance
payments and subsistence allowances during the period of
veterans' or dependents' enrollment in an educational program.
At the 100 percent level of entitlement of the Post-9/11 GI
Bill, veterans are eligible for 36 months of tuition benefits
and a monthly stipend equivalent to the amount of basic
allowance for housing payable under section 403 of title 37,
U.S.C., for a member with dependents in pay grade E-5. This
stipend is intended to cover housing, food, utilities, and
other expenses while attending school.
Currently, section 3680, subsection (a)(3)(B), of title 38,
U.S.C., authorizes VA to continue to pay educational assistance
and subsistence allowances during certain temporary school
closures. These temporary closures are subject to regulations
the VA Secretary shall prescribe and include periods when
schools are temporarily closed due to an emergency, such as a
strike, or under established policy, such as the issuance of a
presidential Executive Order. However, this temporary
continuance of benefit payments may not exceed 4 weeks in any
12-month period and the VA Secretary is not granted similar
statutory authority to continue benefit payments in the event
of a permanent school closure.
VA pays benefits for the term, quarter, or semester up to
the time of the school's permanent closure, but the student
beneficiary is charged education entitlement for the period
prior to the closure for which benefits are received, even
though he/she does not earn credit toward his/her program due
to the unexpected closure. In some instances, this could result
in a beneficiary exhausting entitlement prior to completing an
educational program. There is no statutory authority that would
allow VA to restore Post-9/11 GI Bill entitlement for a term,
quarter, or semester for which a beneficiary fails to receive
credit toward program completion due to such a closure.
In April 2015, Corinthian Colleges, Inc., filed for
bankruptcy and abruptly closed 28 schools while students were
actively attending classes. Approximately 422 Post-9/11 GI Bill
beneficiaries were adversely impacted by these closures and
stopped receiving their housing allowances. In some instances,
this resulted in a beneficiary exhausting his or her Post-9/11
GI Bill entitlement prior to completing an educational program
with no additional VA benefits to complete their degree. This
may cause a significant financial burden for veterans and other
beneficiaries, as the monthly housing payments are often a
primary source of income, and may prevent veterans from
achieving their educational goals.
Committee Bill. Section 201(a) of the Committee bill would
add a new subsection (d) to section 3312 of title 38, U.S.C.,
to allow for the restoration of entitlement to educational
assistance and provide other relief for veterans affected by a
school closure. Specifically, if VA determines that a
beneficiary was forced to discontinue a course or courses as a
result of a permanent school closure and did not receive
credit, or lost training time, toward completion of the
educational program, no payment of educational assistance would
be charged against an individual's entitlement to educational
assistance under the Post-9/11 GI Bill, or counted against the
aggregate period for which an individual may receive
educational assistance under two or more programs. Pursuant to
subsection 201(a)(2) of the Committee bill, this provision
would apply to any beneficiary impacted by education
discontinuance in fiscal year 2015, so as to include those
impacted by the Corinthian closures, and would apply to any
beneficiaries impacted by future school closures.
Section 201(b) of the Committee bill would amend section
3680(a) of title 38, U.S.C., and grant the VA Secretary the
authority to continue payments of monthly housing stipends
until the date of the end of the term, quarter, or semester
during which the school closure occurred, or the date that is 4
months after the date of the school closure, whichever date is
soonest. The Committee intends for this time to allow veterans
and their dependents the ability to make alternative
arrangements for income or enroll in a different educational
institution to complete a course or program.

Sec. 202. Modification and improvement of transfer of unused Post-9/11
Educational Assistance to family members.

Section 202 of the Committee bill, which is an original
provision, would modify section 3319 of title 38, U.S.C., so
that a servicemember must serve 10 years and agree to serve an
additional 2 years in order to be eligible to transfer unused
Post-9/11 GI Bill benefits. Section 202 would also amend
section 3319 of title 38, U.S.C., to cap monthly housing
allowance payments at 50 percent of the housing allowance that
would otherwise be payable to a child using transferred Post-9/
11 GI Bill benefits.
Background. The National Defense Authorization Act of
Fiscal Year 2013 (Public Law 112-239) established the Military
Compensation and Retirement Modernization Commission
(hereinafter, ``MCRMC'') to conduct a review of the military
compensation and retirement systems and to make recommendations
to modernize such systems. The MCRMC issued its final report in
January 2015 that included 15 recommendations around Pay and
Benefits, Health Benefits, and Quality of Life for
Servicemembers and Retirees. Recommendations 11 and 12 focused
largely on education benefits and transition programs. In May
2015, the MCRMC issued an addendum to its report updating its
recommendations.
The Post-9/11 GI Bill allows the Secretary of Defense to
authorize transfer of unused education benefits to dependent
family members as a retention tool when a servicemember meets
basic eligibility criteria. In its final report, the MCRMC
noted a misalignment of Post-9/11 GI Bill benefits and certain
retention needs of the military services. Specifically, they
noted that the years of service required to transfer unused
education benefits to dependents was not aligned with the years
of service in which the continuation rate, or retention, was
lower. The MCRMC reported that continuation rates for
servicemembers at 6 years of service averaged 35.3 percent from
1980 to 2010, but the continuation rate of servicemembers with
10 years of service averaged only 19.3 percent from 1980 to
2010.\1\ The MCRMC recommended changing the current requirement
that a servicemember complete 6 years of service and agree to 4
more years in order to transfer his/her unused education
benefits to dependents, and require that servicemembers
complete 10 years of service and agree to serve 2 more years to
be eligible for transferring the benefits.
---------------------------------------------------------------------------
\1\Final Report of the Military Compensation and Retirement
Modernization Commission, at 166. www.mcrmc.gov/public/docs/report/
mcrmc-finalreport-29jan15-lo.pdf.
---------------------------------------------------------------------------
Another part of the MCRMC recommendation to improve
education benefits noted the disparity in housing allowances
paid to dependents using transferred education benefits when
compared to the actual on-campus costs of room and board.
Recommendation 11 of the Final Report cited two annual studies
from October 2013 in which the highest on-campus room and board
fees and the lowest on-campus room and board fees were
identified, and then compared those costs to the amount in
housing allowances paid to Post-9/11 GI Bill beneficiaries. The
amount of housing allowances paid for the least expensive and
most expensive room and board costs were 171 percent and 222
percent of the actual costs, respectively.\2\ Based on this
finding, the MCRMC recommended eliminating the monthly housing
allowance portion of Post-9/11 GI Bill benefits for spouses and
children using transferred education benefits.
---------------------------------------------------------------------------
\2\Final Report of the Military Compensation and Retirement
Modernization Commission, at 167-168. www.mcrmc.gov/public/docs/report/
mcrmc-finalreport-29jan15-lo.pdf.
---------------------------------------------------------------------------
Committee Bill. Section 202(a) of the Committee bill would
amend subsection 3319(b)(1) of title 38, U.S.C., to replace the
required completed 6 years of service with a requirement to
complete 10 years of service. It would also amend that
subsection to replace the required agreement to serve at least
4 more years as a member of the uniformed services with an
agreement to serve at least 2 more years. Section 202(b) of the
Committee bill would amend subsection 3319(g)(1)(A) of title
38, U.S.C., to require that a servicemember transferring
benefits to a spouse complete at least 10 years of service
instead of only 6 years of service, before the spouse to whom
benefits were transferred may commence using the benefits.
Section 202(c) of the Committee bill adds to subsection
3319(h)(3)(B) of title 38, U.S.C., an exception to the monthly
rate of educational assistance payable to a child using
transferred entitlement. The exception specifies that monthly
housing stipends under section 3313 of title 38, U.S.C., paid
to children using transferred benefits when they pursue degree
programs or non-college degree programs, shall be paid at 50
percent of the rate they would otherwise be paid if the veteran
was using the benefit.
Section 202 of the Committee bill also includes a technical
correction to change ``armed forces'' to ``Armed Forces'' each
place it appears in section 3319 of title 38, U.S.C., and
specifies that the changes made by subsections (a) through (c)
of the Committee bill will apply to the transfer of unused
education benefits initiated beginning 180 days after
enactment. Unused education benefits transferred to dependents
prior to 180 days after enactment would not be subject to the
new service requirements or to the exception for rate of
monthly stipend payments to children using transferred benefits
as implemented by the Committee bill.

Sec. 203. Codification and improvement of election process for Post-9/
11 Educational Assistance.

Section 203 of the Committee bill, which is an original
provision, would codify in a new section 3326 of title 38,
U.S.C., the provisions now found in section 5003(c) of Public
Law 110-252 and would add a provision to that new section
providing that, in the case of an individual who on or after
January 1, 2016, submits to VA an election of which program to
use that VA determines is clearly against the interests of the
individual or who fails to make an election, VA may make an
alternative election on behalf of the individual that VA
determines is in the best interests of the individual. This
section would also provide that VA must promptly notify the
veteran of such alternate election and allow the veteran 30
days to modify the election.
Background. Section 5003 of the Post-9/11 Veterans
Educational Assistance Act of 2008 (Public Law 110-252) created
the Post-9/11 GI Bill by adding chapter 33 to title 38, U.S.C.
Section 5003(c) of that law was added as a note to the newly
created section 3301 of title 38, U.S.C., specifying procedures
and rules for individuals with eligibility for the Montgomery
GI Bill to use the Post-9/11 GI Bill instead. Part of those
procedures for using the Post-9/11 GI Bill instead of another
education benefit included requiring the veteran to make an
irrevocable election to give up entitlement to a previous
benefit in order to use the Post-9/11 GI Bill instead.
VA staff have reported to Congressional staff that the
requirement for making an irrevocable election frequently
delays processing new claims for Post-9/11 GI Bill benefits.
This is due to veterans often electing to give up entitlement
to a benefit to which they are not entitled, or they may make
an election that goes against their best interests. When this
occurs, VA staff must send clarification to the veteran in
writing and request return of written confirmation of the
election or an election to give up a different benefit
entitlement to which the veteran is entitled.
Committee Bill. Section 203 of the Committee bill would
create a new section 3326 in title 38, U.S.C. This new section
would put into code the procedures and rules for an individual
to use the Post-9/11 GI Bill benefit instead of another
education benefit to which they are entitled. In addition to
the existing procedures and rules governing this process, the
Committee bill would authorize the VA Secretary to change the
individual's irrevocable election to give up entitlement to a
certain benefit when the original election is clearly against
the individual's interest or when no such election was made.
This section of the Committee bill would also repeal section
5003(c) of the Post-9/11 Veterans Educational Assistance Act of
2008 (Public Law 110-252; 38 U.S.C. 3301 note).

Sec. 204. Centralized reporting of veteran enrollment by certain
groups, districts, and consortiums of educational institutions.

Section 204 of the Committee bill, which is an original
provision, would modify section 3684 of title 38, U.S.C., so
that an ``educational institution'' for purposes of reporting
to VA enrollments in education programs would include a group,
district, or consortium of separately accredited educational
institutions located in the same state that are organized in a
manner that facilitates the centralized reporting of
enrollments in the group, district, or consortium of
institutions.
Background. Some educational institutions operate as part
of a district or consortium even though each school is
individually accredited. Consolidation of certain functions can
streamline administration and reporting. Under section 3684 of
title 38, U.S.C., each separate educational institution must
certify enrollment of students using VA educational benefits in
order for those benefits to be paid. This applies to each
institution even in cases where they otherwise operate as part
of a consortium for purposes of reporting enrollment and
student information.
Committee Bill. Section 204 of the Committee bill would
amend section 3684 of title 38, U.S.C., to add chapters 32 and
33 of title 38, U.S.C., to the list of benefits requiring
educational institutions to report enrollments of students to
VA. Section 204 of the Committee bill also defines the term
``educational institution'' for purposes of section 3684(a) of
title 38, U.S.C. This added definition specifies that an
educational institution includes a group, consortium, or
district composed of separately accredited schools in the same
state, so long as they are organized to facilitate central
reporting of enrollments from across the group of institutions.

Sec. 205. Improved role of state approving agencies in administration
of veterans educational benefits.

Section 205 of the Committee bill, which is an original
provision, would amend section 3672 of title 38, U.S.C., so
that an education program would be deemed approved for purposes
of VA education benefits only if a state approving agency
determines that the program meets the deemed-approved criteria.
It would also modify section 3675 of title 38, U.S.C., so that
a program that is not subject to approval under section 3672 of
title 38, U.S.C., may be approved by a state approving agency
or VA acting in the role of a state approving agency when the
criteria for approval of accredited programs at for-profit
institutions are met.
Background. The Post-9/11 Veterans Educational Assistance
Improvements Act of 2010 (Public Law 111-377) added section
3672(b)(2) to title 38, U.S.C., in order to streamline approval
of education programs at certain educational institutions. This
new provision made it easier for new programs at existing
institutions to be approved for educational assistance but it
also took the state approving agencies out of the approval
process and limited their ability to deny approval to programs.
Committee Bill. In order to strengthen the ability of state
approving agencies to oversee the approval of new courses of
education, section 205 of the Committee bill amends section
3672 of title 38, U.S.C., to require that a state approving
agency determine whether or not an educational institution is
within one of the five listed categories before it can be
deemed approved. The Committee bill also amends section 3675 of
title 38, U.S.C., to clarify that only state approving
agencies, or the VA Secretary when acting as the state
approving agency, has the authority to approve accredited
programs that are not covered under section 3672 of title 38,
U.S.C.

Sec. 206. Modification of criteria used to approve courses for purposes
of veterans educational benefits.

Section 206 of the Committee bill, which is an original
provision, would modify section 3676 of title 38, U.S.C., so
that additional criteria for approval of a non-accredited
course may be required by a state approving agency only if the
VA Secretary, in consultation with the state approving agency
and pursuant to regulations prescribed to carry out this
requirement, determines that the additional criteria are
necessary and treat public, private, and proprietary for-profit
educational institutions equitably. Section 206 would modify
section 3675 of title 38, U.S.C., so that accredited courses
must also meet those additional criteria to be approved.
Background. Section 3676 of title 38, U.S.C., specifies
criteria for state approving agencies to use in approving
nonaccredited courses for the use of VA education benefits. One
such criteria in paragraph (14) of subsection (c) of that
section authorizes the individual state approving agency to
establish additional criteria in addition to those listed in
section 3676(c) of title 38, U.S.C. Although intended to allow
for use of relatively minor additional criteria, in 2014 a
state passed a law requiring additional criteria that were not
applied equally to all institutions and created a significant
new criteria for certain schools to meet.
Committee Bill. Section 206 of the Committee bill would
amend section 3676(c)(14) of title 38, U.S.C., to require the
VA Secretary to approve any additional criteria deemed
necessary by a state approving agency. In making that
determination, the VA Secretary must ensure such additional
criteria treat all educational institutions equitably. This
change would apply to additional criteria developed after
January 1, 2013, or to investigations conducted on or after
October 1, 2015, pursuant to section 3674 of title 38, U.S.C.

Sec. 207. Surveys for compliance of educational institutions and
training establishments with requirements relating to
administration of veterans educational benefits.

Section 207 of the Committee bill, which is an original
provision, would amend section 3693 of title 38, U.S.C., to
modify the conditions under which VA generally must conduct
compliance surveys of educational institutions and training
establishments offering approved courses.
Background. Section 3693 of title 38, U.S.C., directs the
VA Secretary to conduct annual compliance surveys of
institutions that enroll veterans or eligible individuals using
educational assistance. These surveys are intended to ensure
educational institutions and their courses comply with the
relevant requirements under chapters 30 through 36 of title 38,
U.S.C. In testimony before the Committee on September 16, 2015,
Dr. Joseph W. Wescott II, of the National Association of State
Approving Agencies, noted that the current requirements for VA,
and state approving agencies that assist VA, to conduct
compliance surveys are onerous and do not allow VA the needed
flexibility to focus compliance surveys on the schools most in
need of oversight. The National Association of State Approving
Agencies submitted a legislative proposal to ensure more
institutions receive compliance surveys at least once every 2
years. Their proposal also directed VA to identify which
institutions would receive surveys in advance each year and
preserved the ability for the VA Secretary to waive the
compliance survey requirement for institutions with a record of
demonstrated compliance.
Committee Bill. Section 207 of the Committee bill would
amend section 3693 of title 38, U.S.C., to require VA to
perform a compliance survey at least once every 2 years for
each educational institution or training establishment which
enrolls 20 or more individuals eligible for VA educational
assistance. This section of the Committee bill also directs the
VA Secretary to design the compliance surveys to ensure all
applicable provisions of chapters 30 through 36 of title 38,
U.S.C., are followed by the institution, that each compliance
survey specialist not perform more than 40 surveys per year,
and that VA provide to the state approving agencies in advance
of each fiscal year a list of the institutions to be surveyed
for that year.

Sec. 208. Modification of requirements for approval for purposes of
educational assistance provided by Department of Veterans
Affairs of programs designed to prepare individuals for
licensure or certification.

Section 208 of the Committee bill, which is derived from
S. 1938, would improve the approval of certain programs of
education for purposes of VA educational assistance provided by
requiring that educational programs meet state instructional
curriculum licensure or certification requirements.
Background. State approving agencies were established by
each state after the passage of the original ``GI Bill,'' the
Veterans' Readjustment Act of 1944, to approve, disapprove, and
monitor education and training programs, specifically regarding
oversight and approval of quality educational programming in
which a veteran or dependent can enroll while using GI Bill
benefits. In addition to program approval, state approving
agencies conduct compliance, training, liaison, and outreach
efforts.
However, due to different requirements for certification or
licensure across states and differences in state approving
agency approval practices, some veterans may use GI Bill
benefits for educational programs that cannot count towards a
credentialing requirement. Although a school has institutional
accreditation, it may lack appropriate programmatic
accreditation or fail to meet state-specific criteria required
for certification or licensure. Examples of this have been
found in programs teaching law, education, criminal justice,
and health care, including nursing, psychology, medical
assisting, dental assisting, and surgical technology. Veterans
who graduate from programs that do not meet licensing or
credentialing requirements are unable to sit for a qualifying
examination to be hired in the field in which they studied.
According to testimony from the National Association of State
Approving Agencies in September 2015, ``while it is true that
all persons that attend career schools, such as law or nursing,
do not always seek or find satisfying employment in that
particular career field, it is certainly not an unfair
expectation for a veteran who graduates from such programs to
be qualified to sit for the license or certification exam.''
The issue of unlicensed or unapproved programs that do not
meet appropriate career qualifications is particularly evident
when veterans attend law schools in California that are not
approved by the American Bar Association. California allows
graduates of an unaccredited law school to take the bar
examination. Veterans who have used GI Bill benefits to attend
unaccredited California law schools would be prohibited from
taking the bar examination in other states or, in some cases,
would have to first practice law in California for a period of
time before being allowed to sit for the bar examination.
Educational assistance provided by the Department of
Defense is subject to requirements meant to ensure that
programs of education lead to employment. Section 541 of Public
Law 113-66, the Fiscal Year 2014 National Defense Authorization
Act, prohibits the use of Department of Defense educational
assistance programs and authorities for education programs that
do not meet the licensure or certification requirements of a
state, or are not approved or licensed by the appropriate state
board or agency. This policy change has not yet been applied to
all VA educational assistance.
Committee Bill. Subsection (a) of section 208 of the
Committee bill would amend subsection (c) of section 3676 of
title 38, U.S.C., by requiring the appropriate state approving
agency to approve the VA educational assistance application of
an unaccredited educational course, which is designed to
prepare a student for licensure or certification, only if the
course meets the instructional curriculum requirements of such
state. Section 208(a) of the Committee bill would further amend
subsection (c) of section 3676 of title 38, U.S.C., by
requiring that all courses designed to prepare an individual to
practice law be accredited by an accrediting agency or
association recognized by the Secretary of Education specified
in section 1099(b) of title 20, U.S.C., namely the American Bar
Association. This provision would require that Post-9/11 GI
Bill beneficiaries only attend accredited law schools and
ensure that beneficiaries attending law school in California
would be eligible to take the bar examination in any state.
Subsection (b) of section 208 of the Committee bill would
amend subsection (c) of section 3676 of title 38, U.S.C., by
adding a new subsection stipulating conditions under which the
VA Secretary could administer a waiver to override the
aforementioned approval requirements for unaccredited
educational courses. VA could waive approval requirements if
the course does not meet requirements at any time during the 2-
year period preceding the date of the waiver, but the waiver
would further the purposes of VA educational assistance
programs or further an individual's education interests, and
the educational institution does not provide any commission,
bonus, or incentive payment based on success in securing
enrollments or financial aid during student recruiting or
admission activities. The Committee intends this provision to
allow the VA Secretary flexibility in allowing the use of GI
Bill benefits at an educational institution that will further
serve the education or employment interests of a veteran or
dependent.
Subsection (c) of section 208 of the Committee bill would
amend section 3675(b)(3) of title 38, U.S.C., and would apply
the standards of approval for VA educational assistance
established in subsections (b) and (c) of the Committee bill to
already accredited courses, including non-degree accredited
programs offered by for-profit educational institutions.
Subsection (d) of section 208 of the Committee bill would amend
section 3672(b)(2) of title 38, U.S.C., to further apply these
standards of approval to accredited standard college degree
programs offered at public or not-for-profit educational
institutions. Both subsections (c) and (d) of the Committee
bill are intended to ensure that the new standards of approval
for VA educational assistance are applied equitably across all
sectors of education.
Subsection (e) of section 208 of the Committee bill would
amend section 3679 of title 38, U.S.C., by requiring the VA
Secretary or state approving agency to disapprove any course of
education unless the educational institution publicly discloses
any conditions or additional requirements, including training,
experience, or examinations, required to obtain the state
license or certification and discloses each condition or
requirement publicly. The Committee included this provision in
order to ensure that GI Bill beneficiaries are aware of state
requirements in order to gain employment in their field of
study before pursuing a course of education.
Subsection (f) of section 208 of the Committee bill would
ensure that, if a student is enrolled in a course of education
that is subject to disapproval for VA educational assistance,
but continuously enrolled at the institution for another course
of education that is not disapproved, this course would not be
subject to disapproval and the student could continue in the
approved course. This provision would ensure that VA education
benefits are only prohibited from unaccredited programs, rather
than entire institutions, if beneficiaries were to pursue more
than one course of education at the same educational
institution.

Sec. 209. Expansion of Yellow Ribbon G.I. Education Enhancement
Program.

Section 209 of the Committee bill, which was derived from
S. 1460, would extend the Yellow Ribbon Program to cover
recipients of the Marine Gunnery Sergeant John David Fry
Scholarship, a benefit available to surviving spouses and
dependents of a servicemember who died in the line of duty,
while serving on active duty, on or after September 11, 2001.
Background. The Fry Scholarship provides Post-9/11 GI Bill
benefits specifically to the surviving spouses and children of
servicemembers who died in the line of duty while on active
duty after September 10, 2001. Fry Scholarship beneficiaries
receive up to 36 months of benefits, including tuition and fees
paid directly to the school, a monthly housing allowance, and a
books and supplies stipend.
Tuition and fees at private schools may exceed the
statutory limit on Post-9/11 GI Bill benefits. Subsection
(e)(II) of section 3313 of title 38, U.S.C., stipulates that
the Post-9/11 GI Bill benefit is capped at $17,500 per academic
year at non-public or foreign institutions of higher education
beginning on August 1, 2011. This rate is adjusted each
subsequent academic year based on the yearly increase in the
average cost of undergraduate tuition due to inflation (section
3015(h), title 38, U.S.C.). From August 2015 to July 31, 2016,
Post-9/11 GI Bill payment rates to a private or foreign school
will be capped at up to $21,084.89 per academic year.
In order to assist with tuition and fees in excess of the
academic year cap, many institutions participate in the Yellow
Ribbon Program. This program is a voluntary agreement between
VA and the participating educational institution in which an
institution agrees to make additional funds available for an
eligible beneficiary and VA matches that amount and issues
payments directly to the institution. This program provides
additional funding for eligible Post-9/11 GI Bill beneficiaries
when tuition and fee costs exceed the annual cap provided for
under section 3313 of title 38, U.S.C.
The Yellow Ribbon Program is available to veterans and most
transferred entitlement recipients receiving Post-9/11 GI Bill
benefits at the 100 percent benefit level attending private
institutions. However, Fry Scholarship beneficiaries are
prohibited by law from receiving Yellow Ribbon Program funding.
This creates inequity in eligibility for supplemental funding,
as the children and spouses of a servicemember who died in
service may face educational costs that children and spouses of
a veteran who did not make the ultimate sacrifice do not.
Committee Bill. Section 209(a) of the Committee bill would
amend section 3317(a) of title 38, U.S.C., to include children
and spouses of a servicemember who died in service as ``covered
individuals'' under section 3311(b) for educational assistance,
thus making them eligible for the Yellow Ribbon Program. This
provision would ensure that all Post-9/11 GI Bill education
benefit recipients, including veterans, transferees, and Fry
scholars, are eligible to apply for supplemental Yellow Ribbon
Program funding if they meet the basic eligibility requirements
and their institution is a participating partner with VA. The
Committee intends to remedy the inequity between Post-9/11 GI
Bill recipients and ensure that surviving spouses and
dependents are eligible for supplemental funding when
applicable. Section 209(b) of the Committee bill would
implement this expanded eligibility for academic years
beginning after the date that is 1 year after enactment.

Sec. 210. Consideration of certain time spent receiving medical care
from Secretary of Defense as active duty for purposes of
eligibility for Post-9/11 Educational Assistance.

Section 210 of the Committee bill, which is derived from
S. 602, would count as active duty for purposes of the Post-9/
11 GI Bill reservists' service under section 12301(h) of title
10, U.S.C., under which the Secretary of a military department
may order a reservist to active duty to receive authorized
medical care, be medically evaluated for disability, or
complete a required Department of Defense health care study.
Background. Section 3301 of title 38, U.S.C., defines
active duty for purposes of determining eligibility for the
Post-9/11 GI Bill. Members of the reserve components are
considered to have served on active duty for purposes of
determining eligibility based on specific authorities in
sections from titles 10, 14, and 32, U.S.C. Not included on
this list of authorities is section 12301(h) of title 10,
U.S.C. Reserve component members are ordered to serve under
section 12301(h) when they are receiving medical care, being
evaluated for disability, or completing a health care study.
The Department of Defense, in its testimony before the
Committee on May 13, 2015, noted that reserve component members
wounded in combat or injured in the line of duty are moved from
service under an authority that qualifies for Post-9/11 GI Bill
eligibility to serve under section 12301(h) instead. The effect
of this administrative move results in less accrual of
eligibility for Post-9/11 GI Bill benefits than their
counterparts in the active components who are wounded or
injured.
Committee Bill. Section 210 of the Committee bill would
amend section 3301 of title 38, U.S.C., to add service under
section 12301(h) of title 10, U.S.C., to the list of orders
under which reserve component members can serve to earn active
duty service time that counts towards their eligibility for the
Post-9/11 GI Bill. This amendment would take effect 1 year
after the date of enactment in order to allow VA sufficient
time to implement changes to how it calculates eligibility for
affected individuals. Any payment of benefits under chapter 33
of title 38, U.S.C., after 1 year from enactment would reflect
eligibility based on the relevant service under section
12301(h) of title 38, U.S.C.

TITLE III--HOMELESS VETERANS MATTERS

Sec. 301. Expansion of definition of homeless veterans for purposes of
benefits under the laws administered by the Secretary of
Veterans Affairs.

Section 301 of the Committee bill, which is derived from
S. 1885, would expand the definition of homeless veteran for
purposes of eligibility for VA benefits, to include a veteran
or veteran's family member fleeing domestic or dating violence,
sexual assault, stalking, or other dangerous or life-
threatening conditions in their current housing situation.
Background. Congress has authorized several initiatives to
provide VA with the tools necessary to end veteran
homelessness. Those who meet the definition of homeless veteran
are eligible to participate in these initiatives. Section
2002(1) of title 38, U.S.C., defines ``homeless veteran,'' for
purposes of eligibility for VA homeless programs, as the term
is defined in section 11302(a) of title 42, U.S.C., which
stipulates that a homeless individual must meet the following
criteria: lacks a fixed, regular, and adequate place to sleep
at night; has a primary nighttime residence that is a public or
private place not designed for, or ordinarily used as, a
regular sleeping accommodation, including a car or park; lives
in a transitional housing setting; resides in a location not
meant for human habitation; will imminently lose his/her
housing; or has experienced persistent housing instability.
The definition that the Department of Housing and Urban
Development (hereinafter, ``HUD'') uses to describe a homeless
individual includes the aforementioned definition, but also
includes an additional class of individuals, as defined by
section 11302(b) of title 42, U.S.C. This class of individuals
is comprised of ``any individual or family who is fleeing, or
is attempting to flee, domestic violence, dating violence,
sexual assault, stalking, or other dangerous or life-
threatening conditions in the individual's or family's current
housing situation, including where the health and safety of
children are jeopardized, and who have no other residence and
lack the resources or support networks to obtain other
permanent housing.''
In July 2011, a team led by Dr. Melissa E. Dichter,
Research Health Scientist at VA's Center for Health Equity
Research and Promotion, published a study entitled ``Intimate
Partner Violence Victimization Among Women Veterans and
Associated Heart Health Risks.'' The study found almost one-
third of the veteran participants had experienced intimate
partner, domestic or dating violence, as compared with less
than one-quarter of civilian participants. Within that sample,
veterans experienced intimate partner violence at a higher rate
than civilians.
Committee Bill. Section 301 of the Committee bill would
expand the definition of homeless veteran by amending section
2002(1) of title 38, U.S.C., to include veterans and their
families who may be homeless based on the circumstances defined
in section 11302(b) of title 42, U.S.C. It is the intent of the
Committee to align VA's definition of ``homeless veteran'' with
HUD's, and expand the current VA definition to ensure that
veterans fleeing domestic or dating violence and other life-
threatening situations are eligible to participate in VA's
programs for homeless veterans.

Sec. 302. Increased per diem payments for transitional housing
assistance that becomes permanent housing for homeless
veterans.

Section 302 of the Committee bill, which is derived from
S. 684, would increase the maximum per diem rate VA is
authorized to pay to providers that offer homeless veterans
transitional housing units and allow the veterans to transition
into permanent housing in the same unit.
Background. The Homeless Providers Grant and Per Diem
(hereinafter, ``GPD'') program was first established as a pilot
program, known as the Comprehensive Service Programs, in 1992,
through the Homeless Veterans Comprehensive Service Programs
Act of 1992 (Public Law 102-590). Congress established it as
the Homeless Providers GPD program in the Homeless Veterans
Comprehensive Assistance Act of 2001 (Public Law 107-95).
Under current law, section 2012 of title 38, U.S.C., VA
awards grants and provides per diem payments to public and non-
profit private entities operating transitional housing
facilities and supportive services programs for veterans. The
per diem payment, which is set at a maximum of $43.32 per day,
per veteran housed, is calculated based on the daily cost of
care, but may not exceed the rate paid to State homes for
domiciliary care. The GPD program is VA's largest transitional
housing program.
In 2012, VA established the Transition in Place
(hereinafter, ``TIP'') program for GPD providers, and it
subsequently awarded grants to 31 GPD providers to carry out
TIP. Following this model, providers offer transitional housing
assistance in apartment-style housing and allow veterans to
assume responsibility for the lease upon the end of
participation in transitional housing. Implementation of this
model, however, may cause an increase in operational costs for
the providers.
Committee Bill. Section 302 of the Committee bill would
amend section 2012(a)(2) of title 38, U.S.C., to increase the
maximum per diem rate for homeless veteran service providers
participating in the TIP program to compensate for an increase
in operational costs. It would authorize the per diem rate VA
provides to certain entities that provide services to homeless
veterans to exceed the rate paid to State homes in the case of
services provided to a homeless veteran who is placed in
housing that will become permanent housing upon termination of
those services (transition-in-place). In those cases, the
maximum per diem would be 150 percent of the State home rate.
It is the Committee's intent to provide an incentive for
GPD providers to join the TIP program and increase permanent
housing opportunities for homeless veterans.

Sec. 303. Expansion of Department of Veterans Affairs authority to
provide dental care to homeless veterans.

Section 303 of the Committee bill, which is derived from
S. 684, would expand eligibility for the Homeless Veteran
Dental Program (hereinafter, ``HVDP'').
Background. The Homeless Veterans Comprehensive Assistance
Act of 2001 (Public Law 107-95) expanded VA's authority to
provide one-time outpatient dental services and treatment for
certain veterans who, for a minimum of 60 consecutive days, are
receiving care in a domiciliary, a therapeutic residence,
community residential care, or a setting for which VA provides
funds for a GPD provider. VA provides these dental services to
eligible homeless veterans through HVDP. Dental services
provided include those necessary for the veteran to gain or
regain employment, to alleviate pain, or to treat moderate,
severe, or complicated and severe gingival and periodontal
pathology.
Section 303 of the Committee bill would expand eligibility
to include veterans receiving assistance under section 8(o) of
the United States Housing Act, which includes veterans
receiving housing through the HUD-VASH program. Expanding
services to this group of veterans is aligned with VA's
implementation of the Housing First model. Historically, VA has
provided permanent housing to homeless veterans only after
compliance with treatment or other requirements while veterans
resided in other non-permanent housing. In January 2013, all VA
facilities implemented the Housing First model, which provides
access to permanent housing accompanied by access to supportive
services. With this transition in strategy, veterans may be
placed in permanent housing through HUD-VASH who could benefit
from certain services currently only available to those
considered homeless.
Committee Bill. Section 303 of the Committee bill would
amend subsection (b) of section 2062 of title 38, U.S.C., to
expand eligibility for HVDP to include veterans who, for 60
consecutive days, have been housed under section 8(o) of the
United States Housing Act, which would include those veterans
participating in the HUD-VASH program.

Sec. 304. Clarification of eligibility for services under homeless
veterans reintegration programs.

Section 304 of the Committee bill, which is derived from
S. 425, would expand eligibility for the Department of Labor's
Homeless Veterans' Reintegration Program (hereinafter,
``HVRP'').
Background. The Stewart B. McKinney Homeless Assistance Act
(Public Law 100-77) established HVRP. Through this program,
competitive grants are annually awarded to public and private
entities that provide employment and training services that
veterans need to re-enter the labor force.
Under current law, section 2021 of title 38, U.S.C., HVRP
is only open to homeless veterans. Section 304 would expand
eligibility to veterans participating in HUD-VASH, Indians who
are veterans and receiving assistance under NAHASDA, and
veterans who are transitioning from being incarcerated.
Under VA's Housing First model, veterans placed in the HUD-
VASH program are not required to meet any standards of
employment prior to entry in the program. As a result, there
are veterans, including those coming out of chronic
homelessness, in HUD-VASH who are in need of employment
assistance and could benefit from a program like HVRP, but are
not eligible. In addition, veterans transitioning from being
incarcerated and Indians who are veterans and receiving
assistance under NAHASDA, since the HUD-VASH program is not
widely available on reservations, could also benefit from the
availability of additional job training and assistance
resources.
Committee Bill. Section 304 of the Committee bill would
amend section 2021(a) of title 38, U.S.C., to include among
those eligible for HVRP veterans participating in VA's
supported housing program for which rental assistance is
provided under section 8(o)(19) of the United States Housing
Act of 1937; Indians who are veterans and receiving assistance
under NAHASDA; and veterans who are transitioning from being
incarcerated. The Committee recognizes that certain Federal
programs that require homelessness for eligibility were
established prior to the implementation of VA's Housing First
strategy, therefore, restricting access to those who may be
transitioning from homelessness to the HUD-VASH program.

Sec. 305. Program to improve retention of housing by formerly homeless
veterans and veterans at risk of becoming homeless.

Section 305 of the Committee bill, which is derived from
S. 1885, would require VA to award grants for the provision of
case management services for veterans who are transitioning to
permanent housing and those who are at risk for homelessness,
addressing a current gap in case management service delivery.
Background. The Administration set a goal in 2009 to end
nationwide veteran homelessness by 2015. The 2015 Annual
Homeless Assessment Report indicated that homelessness among
veterans has declined by 35 percent, or 25,642 veterans, since
2009. Despite this significant progress, 47,725 veterans
remained homeless on a single night in January 2015 according
to HUD's Point in Time count from January 2015.
As communities nationwide reach critical junctures in their
efforts to end veteran homelessness, occupancy in transitional
housing programs continues to decrease. In testimony before the
Committee in October 2015, Dr. Thomas Lynch, Assistant Deputy
Under Secretary for Health Clinical Operations at the Veterans
Health Administration (hereinafter, ``VHA''), stated: ``As the
number of homeless veterans decreases, the need for some of
this transitional housing will diminish, but there will be a
continued need for permanent housing interventions like rapid
re-housing and permanent supportive housing.'' Many homeless
veterans participating in transitional housing programs and
seeking to transition to permanent housing are eligible to
participate in HUD-VASH. Despite access to HUD-VASH vouchers,
many veterans are finding that insufficient availability of
affordable and safe permanent housing options is limiting the
ability to secure long-term permanent housing.
In communities that have made significant progress in
ending homelessness among veterans, the declining necessity of
transitional housing but continued need for permanent housing
interventions is especially challenging. Because there are
fewer veterans in need of transitional housing facilities,
facilities are receiving less funding based on the per diem
payment structure. Veterans at risk of homelessness in these
communities have less transitional housing opportunities and
these facilities risk insolvency. VA and community partners
must ensure there is sufficient availability of affordable
permanent housing for veterans seeking long-term housing
solutions. VA's GPD program should be restructured to include
an option for GPD grantees to focus efforts on shorter lengths
of stay in transitional housing, achieve quicker permanent
housing planning, and repurpose existing transitional housing
facilities into permanent housing units to ensure long-term
solutions for homeless veterans.
Committee Bill. Subsection (a) of section 305 of the
Committee bill would amend title 38, U.S.C., to redesignate
current section 2013 as 2014 and insert a new section 2013 to
require VA to carry out a program to increase housing stability
and retention by providing grants to community organizations
that provide case management to formerly homeless veterans.
This new section would require VA to implement a program to
provide case management services to improve housing retention
by formerly homeless veterans who are transitioning to
permanent housing, and veterans who are at risk of becoming
homeless. Subsection (b) of new section 2013 of title 38,
U.S.C., would provide for the VA Secretary's provision of
grants, in which the Secretary would be required to give
priority to organizations that demonstrate a capability to
provide such case management services previously described,
particularly organizations that have, or are currently,
providing transitional housing services and decide to convert
their transitional housing programs into permanent housing for
homeless veterans. These grants include the per diem payments
established in section 2012 of title 38, U.S.C., and the grant
program for homeless veterans stipulated in section 2061 of
title 38, U.S.C. This provision would allow communities that
are reaching critical junctures in the fight to end
homelessness to repurpose existing transitional housing
capacity for more pressing needs, such as permanent housing
opportunities for veterans.
Subsection (b) of new section 2013 of title 38, U.S.C.,
would additionally require the VA Secretary to give grant
provision priority to an organization that voluntarily stops
receiving GPD payments and converts an existing transitional
housing facility into a permanent housing facility that meets
housing quality standards established in section 1437f(o)(8)(B)
of title 42, U.S.C. This section would enable GPD grantees with
the expertise and capacity to provide for homeless veterans to
repurpose existing transitional housing facilities into
permanent housing units without losing current GPD funding.
Subsection (c) of section 305 of the Committee bill would
additionally require VA to submit a report to Congress within 1
year of enactment to assess the new program, which will include
the following reporting requirements: percentage of veterans
who received case management services who were able to retain
permanent housing; percentage of veterans who were not in
permanent housing at the end of the program; program use by
veterans who received case management services provided through
VA housing assistance; and an assessment of the employment
status of veterans who received case management services under
the program.

Sec. 306. Pilot program on provision of intensive case management
interventions to homeless veterans who receive the most health
care from the Department of Veterans Affairs.

Section 306 of the Committee bill, which is derived from
S. 1885, would require VA to implement a 3-year pilot program
in at least six locations to assess the feasibility and
advisability of providing intensive case management
interventions to homeless veterans who receive the most health
care from VA.
Background. Those who may be considered health care super-
utilizers often struggle with chronic conditions or behavioral
health needs, which lead them to make frequent trips to the
emergency room and have many hospital admissions. Treating
these most frequent health care users is challenging and
costly, particularly when they face difficult environmental
situations, such as unsanitary housing or homelessness.
Dr. Jeffrey Brenner, the executive director of the Camden
Coalition of Healthcare Providers in New Jersey determined that
treatment, particularly hospital admission and repeated use of
expensive diagnostic tests, provided to a small group of
individuals who were utilizing the most health care was
accounting for the bulk of health care costs in the local area.
Using this data, he established a program model that reduced
health care costs by targeting the population that was
utilizing the most health care and enrolling them in care
coordination services and providing case management through a
team of nurses, social workers, community health workers, and
health coaches. These interventions build relationships
necessary to facilitate the provision of health care services
to the most vulnerable individuals and empower patients with
skills and support to avoid hospital readmission, thus lowering
health care costs.
This model may have similar success when applied to
homeless veterans who use the most VA health care. On May 4,
2012, the VA Office of Inspector General (hereinafter, ``OIG'')
published a report, ``Homeless Incidence and Risk Factors for
Becoming Homeless in Veterans,'' which analyzed a study
conducted to estimate incidences and risk factors of veterans.
In the report, the OIG concluded that the presence of mental
health or substance abuse disorders or mental illness is the
strongest predictor of homelessness among veterans. Almost half
or more of the surveyed homeless veterans were diagnosed with
mental disorders, including 48 percent of male Operation
Enduring Freedom/Operation Iraqi Freedom veterans and 67
percent of women who were not Operation Enduring Freedom/
Operation Iraqi Freedom veterans. Additionally, homeless
veterans were more likely to receive VA disability benefits for
service-connected disabilities than their domiciliary
counterparts, and more than half of the homeless veterans
studied were receiving VA compensation for these disabilities.
When left untreated, these behavioral conditions pose
significant challenges to attaining and maintaining permanent
housing and gainful employment, and substandard living
conditions and homelessness often exacerbate existing health
conditions. Applying the management intervention model that
proved successful in New Jersey to veterans who use the most VA
health care could address the health care needs of the most
vulnerable veterans while simultaneously decreasing VA health
care costs.
Committee Bill. Section 306 of the Committee bill would, in
a freestanding provision, require VA to commence a pilot
program on the provision of case management interventions to
homeless veterans who receive the most health care from VA.
Subsection (a) of section 306 of the Committee bill would
require VA to commence a pilot program by September 1, 2016,
that would assess the feasibility and advisability of providing
intensive case management interventions to ``covered
veterans.'' Subsection 306(b) of the Committee bill would
define ``covered veterans'' as a veteran enrolled in the VA
homeless registry and the annual patient enrollment system,
section 1705(a) of title 38, U.S.C.
The pilot program would be carried out at not fewer than
six locations as selected by the VA Secretary, as established
in subsection (c) of section 306. The Committee intends that,
by requiring VA to implement the program in at least six
locations, VA will be able to determine the extent to which the
program is successful before considering expansion or
continuation of the program. The bill would direct the VA
Secretary to select at least three locations in cities with the
largest populations of homeless veterans in the United States
and at least three locations in suburban or rural settings.
Subsection 306(c) of the Committee bill additionally would
establish that the VA Secretary shall only select locations for
the pilot program in areas with an existing high degree of
interaction and coordination between VA and community
organizations that provide housing and social services for
homeless veterans, veterans at risk of homelessness, and low-
income veterans. The Committee intends this section to ensure
that the pilot program is carried out in areas where a
successful track record of coordination between VA and local
organizations will increase the likelihood of success for the
pilot and its ability to serve as a model to establish case
management interventions nationwide.
Subsection (d) of section 306 of the Committee bill would
require the VA Secretary to provide intensive case management
services to at least 20 covered veterans who receive the most
VA health care and related services at each location. These
individuals would receive intensive case management assistance
related to gaining and maintaining access to housing and
services in order to improve the stability of their housing and
the appropriateness of the health care that they receive.
Subsection (e) of section 306 of the Committee bill would
require that no later than December 1, 2018, the VA Secretary
submit to the Committee on Veterans' Affairs of the Senate and
House of Representatives a report on the pilot program. The
report must include assessments of: the types and frequencies
of intensive case management interventions provided under the
pilot program; the housing and employment status of each
veteran who received an intensive case management intervention,
including a comparison of employment status of each veteran
before and after the intervention; the VA health care and
related services used by veterans who received intensive case
management interventions, including the cost incurred by VA to
provide such care and services before and after receiving such
interventions; the number of veterans who received intensive
case management interventions based on urban versus suburban or
rural locations; a comparison of the cost incurred by VA based
on the pilot program carried out in urban versus rural or
suburban locations; and a comparison of the costs VA would have
incurred for the provision of health care and services without
the intensive case management interventions in urban versus
suburban or rural locations of the pilot program.
The Committee intends that VA deploy this pilot program in
different communities nationwide to determine the success of
the care model in the veteran population, as well as any
reduction in health care costs by improving the efficacy of
outreach teams providing intensive case management
interventions to homeless veterans.

Sec. 307. Establishment of National Center on Homelessness Among
Veterans.

Section 307 of the Committee bill, which is derived from
S. 1885, would codify the current role of the VA National
Center on Homelessness Among Veterans (hereinafter, ``NCHAV'')
as a center of research, evaluation, and dissemination of best
practices regarding services for homeless veterans.
Background. The NCHAV was established in 2009 to support
VA's Five Year Plan to End Homelessness Among Veterans, as
outlined in the Administration's ``Opening Doors: Federal
Strategic Plan to Prevent and End Homelessness.'' The
University of Pennsylvania serves as the NCHAV's primary
academic partner and, as such, the center is located in
Philadelphia, Pennsylvania. The center also has satellite
facilities in Tampa, Florida, in partnership with the
University of South Florida, and Bedford, Massachusetts, in
partnership with the University of Massachusetts Medical
School. The NCHAV has been an important contributor to the
Administration's goal of ending veteran homelessness and,
according to its Web site, ``works in collaboration with [the
Veterans Health Administration's] Homeless Programs Office,
network directors, network homeless coordinators, national
professional associations, and community partners as well as
with their academic partners.'' This independent center has
worked to ensure that VA is effectively collaborating with
community partners and applying the necessary tools to reshape
the housing and service delivery model in urban and rural
communities that experience veteran homelessness. By analyzing
VA homelessness programs and disseminating research and
homeless program models to the field, the NCHAV has played an
important role in ensuring continued progress in decreasing the
number of homeless veterans nationwide. The success of the
Housing First model is an example of how NCHAV research can be
translated into more informed policy for homeless veterans.
Committee Bill. Subsection (a) of section 307 of the
Committee bill would add a new section 2067 to title 38,
U.S.C., to codify the existing NCHAV. This would require the VA
Secretary to oversee a center that operates independently of
other VA homelessness programs. Subsection (a) of new section
2067 of title 38, U.S.C., would require that the NCHAV
implement the following functions: carry out and promote
research into the causes and contributing factors to veteran
homelessness; assess the effectiveness of VA programs to meet
the needs of homeless veterans; identify and disseminate best
practices with regard to housing stabilization, income support,
employment assistance, community partnerships, and other
matters as the VA Secretary deems appropriate; integrate
evidence-based best practices, policies, and programs into VA
programs for homeless veterans and ensure VA staff and
community partners are effectively able to implement them; and
serve as a resource center for all research and training
activities carried out by VA, Federal entities, and community
partners to promote the exchange of information with respect to
veteran homelessness.
As more communities have ended, or are close to ending,
veteran homelessness, VA will need to examine how to best
allocate funding between various programs aimed at ending
veteran homelessness. The Committee intends to codify the NCHAV
to make permanent the important research regarding the most
cost-effective approaches to ending veteran homelessness and
the continuation of support to VA homelessness programs in
order to fully eliminate veteran homelessness.

Sec. 308. Partnerships with public and private entities to provide
legal services to homeless veterans and veterans at risk of
homelessness.

Section 308 of the Committee bill, which is derived from
S. 684, would authorize VA to enter into partnerships with
public or private entities to fund a portion of the general
legal services provided by those entities to homeless veterans
and veterans at risk of homelessness.
Background. VA conducts an annual Community Homelessness
Assessment, Local Education and Networking Groups (hereinafter,
``CHALENG'') survey to identify the needs of homeless veterans.
The 2014 CHALENG survey results indicated that legal assistance
was among the top ten highest unmet needs among both male and
female veterans. Collectively, they indicated needing legal
assistance to prevent eviction and foreclosure, for child
support issues, to help restore a driver's license, and for
outstanding warrants and fines. Such issues can be a result of
homelessness, or can contribute to homelessness.
VA does not currently have statutory authority to fund any
portion of legal services, but a number of VA facilities host
non-VA legal service providers, such as law school clinics,
private pro bono lawyers, and Legal Aid clinics to assist
veterans who are homeless or at risk of homelessness.
In addition, the Supportive Services for Veteran Families
Program (hereinafter, ``SSVF'') provides grants to
organizations who will coordinate or provide supportive
services to very low-income veteran families who are homeless
or at risk of becoming homeless. Through this program, grantees
are authorized to partner with legal services providers to
address unmet legal needs that may be a barrier to stable
housing. Providing legal services is not a requirement,
however, and as a result, not all veterans who receive
assistance through SSVF have access to legal services.
Committee Bill. Section 308 of the Committee bill would
amend chapter 20 of title 38, U.S.C., by inserting a new
section, 2022A, after section 2022, to authorize VA to enter
into partnerships with public and private entities to fund a
portion of legal services provided to homeless veterans and
veterans at risk of homelessness. VA would also be required to
ensure that, to the extent practicable, the partnerships are
made with entities equitably distributed across the geographic
regions of the United States, including rural communities,
tribal lands of the United States, Native Americans, and tribal
organizations. It is the intent of the Committee to expand
legal services for homeless veterans and veterans at risk of
homelessness by authorizing VA to partner with public or
private entities to fund a portion of the cost of providing
legal services.

Sec. 309. Administrative improvements to grant and per diem programs of
Department of Veterans Affairs.

Section 309 of the Committee bill, which is derived from
S. 1885, would implement administrative improvements to the GPD
program of the Department.
Background. VA provides Federal funding to many
transitional housing grantees to support their efforts to
decrease veteran homelessness nationwide. These GPD program
grantees help veterans secure residential stability, increase
their skills and income, and achieve greater self-determination
to support their transition from transitional to permanent
housing.
There is currently no national standard among GPD grantees
that serve homeless veterans, and GPD grantees are not required
to demonstrate success in assisting veterans into permanent
housing or increasing their income level. In testimony before
the Committee on July 29, 2015, Lisa Tepper Bates, the
Executive Director of the Connecticut Coalition to End
Homelessness, recommended a policy change that would require
the GPD program to move ``away from the per diem payment
structure to a competitive grant program or performance-based
contract'' to ensure that programs are outcome-oriented. By
setting national performance targets for the housing placement
rates and the average income improvements of veterans served by
transitional housing grantees, VA will be equipped to assess
whether the performance of a GPD grantee merits continued
funding, ensure financial integrity among GPD grantees, and
increase the use of performance outcomes as an oversight tool
to reduce waste or abuse.
Committee Bill. Section 309 of the Committee bill would
amend section 2012 of title 38, U.S.C., by requiring the VA
Secretary to review, on a yearly basis, each eligible GPD
grantee to evaluate the performance of the grant recipient or
per diem entity. This evaluation would assess the success of
the grant recipient or eligible entity in assisting veterans to
obtain, transition into, and retain permanent housing and
increasing the income of veterans, whether by helping veterans
obtain employment or receive income-related benefits for which
the veteran may be eligible.
Section 309 of the Committee bill would require the VA
Secretary to utilize these performance evaluations to determine
whether the GPD grantee's performance merits continued receipt
of GPD payments, and require the VA Secretary to only authorize
continued funding if the aforementioned evaluation affirms the
efficacy of the GPD grantee in assisting veterans' transition
into permanent housing. This provision would additionally
require the VA Secretary to establish uniform, nationwide
performance targets for all grantees and eligible entities that
receive per diem payments for the purpose of conducting fair
and equitable performance evaluations. The Committee intends
this section to ensure that GPD grantees are best utilizing
these payments in a manner that will support homeless veterans.
If the performance evaluations of grant recipients or eligible
entities do not merit continued VA payments, this section
grants the VA Secretary the authority to discontinue such
payments to such grantees.

Sec. 310. Repeal of requirement for annual reports on assistance to
homeless veterans.

Section 310 of the Committee bill, which is derived from
S. 684, would repeal the requirement that VA annually submit to
Congress a report on assistance to homeless veterans.
Background. The Homeless Veterans Comprehensive Assistance
Act of 2001 (Public Law 107-95) established a requirement that
VA submit an annual report to the Committee on Veterans'
Affairs of the Senate and House of Representatives on its
homelessness programs. The reports detail VA services for
homeless veterans, including data from the previous year and an
overview of Veterans Health Administration and Veterans
Benefits Administration programs that serve homeless veterans.
Committee Bill. Section 310 of the Committee bill would
repeal section 2065 of title 38, U.S.C., which requires VA to
provide an annual report to Congress on the activities of VA's
programs for homeless veterans. The Committee does not believe
that this report continues to be necessary and believes VA
could more effectively utilize the time and resources spent on
the report to further support efforts to serve homeless
veterans. The Committee expects VA to be responsive and
transparent when requested to respond to questions about its
programs for homeless veterans and recognizes that VA collects
data and conducts analysis, regardless of a Congressional
reporting requirement.

Sec. 311. Comptroller General of the United States study on homeless
veterans programs of the Department of Veterans Affairs.

Section 311 of the Committee bill, which is derived from
S. 684, would require the Comptroller General to complete an
assessment of VA programs that provide assistance to homeless
veterans and a review of VA efforts to improve the safety and
security of female veterans participating in the programs.
Background. VA has six strategic pillars that include at
least 25 programs intended to assist homeless veterans. These
pillars include outreach and communication, treatment,
prevention, housing/supportive services, income/employment/
benefits, and community partnerships.
Nine percent of the 47,725 homeless veterans identified in
HUD's Point in Time count from January 2015 were women. A
September 2011 report by VA's OIG, entitled ``Safety, Security,
and Privacy for Female Veterans at a Chicago, IL Homeless Grant
Provider Facility,'' a December 2011 GAO report entitled
``Homeless Women Veterans: Actions Needed to Ensure Safe and
Appropriate Housing,'' and a March 2012 OIG report entitled
``Audit of the Homeless Providers Grant and Per Diem Program''
highlighted safety and security risks affecting women veterans
within the GPD program. GAO recommended that VA establish
gender-specific safety and security standards for GPD programs,
especially those serving both men and women. In its 2012
report, the OIG made a similar recommendation, in addition to
recommending that the GPD program application process include
provider commitment to veteran safety, security, and privacy.
According to GAO, in response to one of its
recommendations, in July 2013, VA revised and published its GPD
Handbook, which included a new section on services for female
veterans. GAO also indicated that VA changed its GPD
application process to require new applicants to include
information about the gender of the homeless population the
applicant plans to serve.
Committee Bill. Section 311 of the Committee bill would
require that, not later than 270 days after enactment, the
Comptroller General complete a study of VA programs that
provide assistance to homeless veterans, including an
assessment of whether those programs are meeting the needs of
veterans, any gaps or duplication in the provision of services,
and a review of recent efforts by VA to improve the privacy,
safety, and security of female veterans.
As the number of homeless veterans continues to decline, it
is important to ensure homeless programs are targeted to the
demographics in the geographic areas that need them. A full
assessment of VA's homelessness programs would also assist with
identifying gaps or duplication in services in order to more
effectively utilize resources and serve homeless veterans.
The OIG and GAO findings in regard to the safety and
security risks faced by female veterans within VA GPD programs
are alarming. It is important to ensure policies and procedures
are in place to protect female veterans in VA homeless
programs.

Sec. 312. Requirement for Department of Veterans Affairs to assess
comprehensive service programs for homeless veterans.

Section 312 of the Committee bill, which is derived from
S. 684, would require VA to assess and measure the capacity of
programs that receive grants or per diem payments in addition
to developing and using tools to examine the capacity of those
programs at both the national and local level.
Background. A March 2012 VA OIG report entitled ``Audit of
the Homeless Providers Grant and Per Diem Program'' found that
VA's GPD program did not assess bed capacity to inform funding
priorities and needs in underserved geographic areas and did
not accurately report program outcomes. The OIG determined that
the improvement of program evaluation would ensure program
funding is aligned with program goals. This report followed the
December 2011 GAO report entitled ``Homeless Women Veterans:
Actions Needed to Ensure Safe and Appropriate Housing,'' which
found that VA lacked data on the needs and characteristics of
homeless women veterans at the national, state, and local
levels. GAO indicated that, without this information, VA is
unable to effectively plan services, allocate grants, and
monitor progress in ending veteran homelessness.
Committee Bill. Section 312(a) of the Committee bill, in a
freestanding provision, would require VA to assess and measure
the capacity of GPD programs, including how well they achieve
their stated goals at the national level, placements in
permanent housing and employment, and increases in the regular
income of participants in the programs. Section 312(b) of the
Committee bill would require that, in conducting the required
assessment, VA develop and use tools to examine the capacity of
the programs at the national and local levels in order to
assess whether sufficient capacity exists to meet the needs of
homeless veterans in each geographic area; whether existing
capacity meets the needs of the subpopulations of homeless
veterans located in each geographic area; and the amount of
capacity that GPD providers have to provide TIP services. In
its assessment, VA would also be required to consider the
availability of resources to GPD programs. Section 312(d) of
the Committee bill would require VA to utilize information
collected under this section to set specific goals to ensure
the GPD programs are effectively serving homeless veterans, to
assess whether the programs are meeting the specific goals, to
inform funding allocations for the programs, and to improve the
referral of homeless veterans to GPD programs. Section 312(e)
of the Committee bill would require that not later than 180
days after the assessment is completed, VA submit a report to
the Committee on Veterans' Affairs of the Senate and House of
Representatives on the assessment and include recommendations
for legislative and administrative actions for improving the
programs.
As the number of homeless veterans continues to decrease,
it is important that VA assess the demographics and geographic
region of those who could benefit from transitional housing to
ensure appropriate allocation of resources. In addition, proper
assessment of the program will also help inform VA efforts to
establish specific goals to ensure the program is effectively
meeting the needs of homeless veterans.

Sec. 313. Report on outreach relating to increasing the amount of
housing available to veterans.

Section 313 of the Committee bill, which is derived from
S. 1885, would require a VA report on outreach related to the
amount of housing available to veterans.
Background. In order to combat veteran homelessness, VA is
conducting outreach to ensure that veterans are appropriately
connected with VA and community services. VA is currently
working to proactively seek out veterans in need of assistance
and connect veterans with housing solutions, health care, and
employment services. This outreach to identify and engage
veterans who have experienced chronic homelessness is necessary
to facilitate connections between homeless veterans and
community-based providers.
VA is additionally collaborating with Federal, state, and
local agencies to expand employment and affordable housing
options for veterans seeking transitional and permanent
housing. The Committee is aware of current VA efforts to
conduct outreach to realtors, landlords, property management
companies, and developers, particularly in communities with
competitive housing markets. Given the shortage of safe and
affordable permanent housing, these outreach efforts may help
to ensure that more housing opportunities are made available to
veterans who are currently homeless or at risk for
homelessness. Greater information is necessary to determine
whether VA's current outreach efforts are effectively
increasing availability of safe and affordable housing options
nationwide, particularly in communities with a high level of
veteran homelessness. With additional information about current
outreach, VA could explore additional measures that could be
implemented to encourage entities to rent to homeless or
formerly homeless veterans.
Committee Bill. Section 313 of the Committee bill, in a
freestanding provision, would require the VA Secretary to
submit to the Committee on Veterans' Affairs of the Senate and
House of Representatives a report describing and assessing VA
outreach to realtors, landlords, property management companies,
and developers to educate them about the housing needs of
veterans as well as the benefits of having veterans as tenants.
The Committee intends this report to serve as a resource to
assess the current outreach and determine its success in
decreasing homelessness among veterans.

TITLE IV--HEALTH CARE MATTERS

Sec. 401. Short title.

Section 401 of the Committee bill, which is derived from
S. 1641, would establish the short title of Title IV as the
Jason Simcakoski Memorial Act.
Background. On August 30, 2014, U.S. Marine veteran Jason
Simcakoski died at the Tomah Veterans Affairs Medical Center
(hereinafter, ``VAMC'') in Tomah, Wisconsin, as a result of
mixed drug toxicity. Jason was 35 when he died.
Since 2003, Jason was a patient at the Tomah VAMC,
primarily being treated for anxiety, post traumatic stress
disorder (hereinafter, ``PTSD'') and substance use disorder. At
the time of his death, he was prescribed numerous medications
including opioids, specifically buprenorphine along with
benzodiazepines. While he occasionally presented with
intermittent pain, not chronic pain, VA providers at the VAMC
prescribed a number of opioid pain medications in combination
with benzodiazepines. In addition to other prescribed
analgesics, commonly known as painkillers, at the time of his
death, Jason was given buprenorphine--an opioid intended to
treat addiction--at a higher than the U.S. Food and Drug
Administration recommended dose, although he was not diagnosed
with an opioid addiction. He was also prescribed several
benzodiazepines including diazepam, which, together with the
buprenorphine, produced a known dangerous interaction that
ultimately led to his death.\3\
---------------------------------------------------------------------------
\3\Office of Inspector General, Department of Veterans Affairs;
``Unexpected Death of a Patient During Treatment with Multiple
Medications Tomah VA Medical Center Tomah, Wisconsin.'' Report No: 15-
02131-471; August 6, 2015.
---------------------------------------------------------------------------
The growing use and abuse of prescription painkillers such
as opioids is a growing public health crisis in the United
Sates. More Americans now die every year from drug overdoses,
mostly from prescription painkillers, than they do in motor
vehicle crashes. In 2012, health care providers wrote 259
million prescriptions for opioid pain medications-- enough for
every American adult to have a bottle of pills.\4\
Inappropriate use of opioids is a particular problem in the
veteran community and at VA. Jason's tragic story illustrates a
larger, ongoing problem of dangerous use and over prescription
of opioids at the Tomah facility as well as throughout the VA.
---------------------------------------------------------------------------
\4\Centers for Disease Control and Prevention (CDC); CDC Vital
Signs, ``Opioid Painkiller Prescribing.'' July 2014; http://
www.cdc.gov/vitalsigns/opioid-prescribing/.
---------------------------------------------------------------------------
Committee Bill. Section 401 of the Committee bill would
name Title IV of the Committee bill in honor of Jason's memory.
The Committee believes the Jason Simcakoski Memorial Act would
aid VA in providing safer and more effective pain management
care to our nation's veterans.

SUBTITLE A--EMPLOYMENT OF DIRECTORS AND HEALTH CARE PROVIDERS

Sec. 411. Extension of period for increase in graduate medical
education residency positions at medical facilities of the
Department of Veterans Affairs.

Section 411 of the Committee bill, which is derived from
S. 1676, allows VA an additional 5 years to increase the number
of graduate medical education residency positions at medical
facilities of VA by 1,500 positions.
Background. The Veterans Access, Choice, and Accountability
Act of 2014 (P.L. 113-146; 38 U.S.C. 7302 note), requires the
VA Secretary to increase the number of GME residency positions
by 1,500 residency slots during the 5-year period that began 1
year after enactment of Public Law 113-146. In filling the
increased residency slots, the VA Secretary is required to
focus on residencies in the areas of primary care, mental
health, and any other specialty the Secretary determines
appropriate. Furthermore, P.L. 113-146 requires the Secretary
to give a priority to GME residency slots at medical facilities
that do not have existing medical residency programs and that
are located in communities that have a high concentration of
veterans. As of January 2016, only 372 new residency positions
have been filled. The Committee has learned that expanding
these residency slots requires VA employees to conduct many
hours of outreach to facilities and academic medical centers
that would potentially serve as partners for the residency
slots, particularly because of the requirement that VA focus on
facilities that do not have existing medical residency
programs. As a result, the full increase in residency slots is
not expected to be complete within the originally mandated
timeline.
Committee Bill. Section 411 of the Committee bill would
amend paragraph (2) of section 301(b) of P.L. 113-146 by
extending the timeline for completing the expansion of the
residency slots from 5 years to 10 years.

Sec. 412. Modification of hours of employment for physicians and
physician assistants employed by the Department of Veterans
Affairs.

Section 412 of the Committee bill, which is derived from
S. 1450, would modify the requirements for full-time employee
status for physicians and physician assistants employed by VA.
Background. Section 7423(a) of title 38, U.S.C.,
establishes the hours that are used to determine whether an
employee physician or physician assistant is a full-time
employee. A full-time employee is one who works eighty hours
over a 2-week period. The Committee has learned that these
strict hour requirements for physicians and physician
assistants, while similar to those of other VA employees, can
create complications, particularly when scheduling physicians
and physician assistants for emergency call schedules. The
Committee has heard from stakeholders that allowing more
flexible scheduling when determining whether a physician or
physician assistant employee is a full-time employee would
simplify staffing for VA medical facilities and make it easier
to ensure facilities are appropriately staffed.
Federal agencies, including VA, are able to implement
alternative work schedules including flexible work schedules
and compressed work schedules in order to help the employee
balance work and family or personal responsibilities.
Committee Bill. Section 412 of the Committee bill would
create an exception for determining full-time employee status
for physicians and physician assistants by amending section
7423(a) of title 38, U.S.C., as long as the total hours of
employment for a calendar year do not exceed 2,080 hours.
The Committee intends that this provision allow VA
flexibility in scheduling physicians and physician assistants
to better reflect the schedules that those providers typically
keep in health care systems outside of VA. The Committee does
not intend that this provision affect the current requirements
related to overtime pay or flexible work schedules.

Sec. 413. Requirement that physician assistants employed by the
Department of Veterans Affairs receive competitive pay.

Section 413 of the Committee bill, which is derived from
S. 1676, would include physician assistants in the types of
providers who are eligible for locality pay.
Background. Section 7451(a)(2) of title 38, U.S.C., allows
VA to ensure that rates of pay for health care personnel
positions within VA facilities are competitive with the rates
of pay in non-VA facilities in the same labor market area. This
allows VA to operate on fair footing with other potential
health care employers that would be competing to hire for the
same or similar positions. VA is explicitly authorized to use
locality pay for registered nurses and the positions listed in
section 7401(1) and (3) of title 38, U.S.C. Although the VA
Secretary is able to appoint other specialties to the list,
this authority has yet to be utilized. VA is affiliated with
more than 30 accredited physician assistant education programs
and offers continuing medical education programs, tuition
support programs, education debt reduction programs, and
employee incentive scholarship programs as incentives to help
grow the number of physician assistants within VA. However,
physician assistant positions can still be difficult for
facilities to fill. According to a September 2015 VA OIG review
entitled, ``Office of Inspector General Determination of
Veterans Health Administration's Occupational Staffing
Shortages,'' physician assistants were the occupation with the
fourth largest staffing shortages for 2014.
Committee Bill. Section 413 of the Committee bill would
amend section 7451(a)(2) of title 38, U.S.C., to allow VA to
offer rates of pay that are competitive with non-VA facilities
within the same labor market areas when hiring for physician
assistant positions.

Sec. 414. Establishment of positions of Directors of Veterans
Integrated Service Networks in Office of Under Secretary for
Health of Department of Veterans Affairs and modification of
qualifications for Medical Directors.

Section 414 of the Committee bill, which is derived from
S. 1676, would amend section 7306 of title 38, U.S.C., to
create positions of Directors of Veterans Integrated Service
Networks and change the qualifications for a Medical Director.
Background. Under section 7306(a)(4) of title 38, U.S.C.,
the Office of the Under Secretary for Health consists in part
of ``[s]uch Medical Directors as may be appointed to suit the
needs of the Department, who shall be either a qualified doctor
of medicine or a qualified doctor of dental surgery or dental
medicine.'' Under current law, a VISN Director or Medical
Director is not eligible to be hired under VA's hiring
authority provided by title 38, U.S.C., because VA is not able
to appoint non-physicians using its title 38 hiring authority.
Both Medical Directors and VISN Directors are hired under title
5, U.S.C., as part of the Senior Executive Service
(hereinafter, ``SES'') of the government. Even though
individuals hired to these positions are hired as an SES and
paid at a higher rate than the general schedule pay for title 5
employees, they are paid substantially less than their private
sector counterparts as well as the VA medical providers
reporting to them. This pay disparity makes it difficult for VA
to recruit non-VA employees and current VA providers to fill
positions of VISN Directors and Medical Directors.
Committee Bill. Section 414 of the Committee bill would
amend section 7306(a)(4) of title 38, U.S.C., by inserting
``and Directors of Veterans Integrated Service Networks'' after
``such Medical Directors'' and further amend the section by
deleting the requirement that Medical Directors appointed under
this section shall be a qualified physician or dentist.

Sec. 415. Pay for Medical Directors and Directors of Veterans
Integrated Service Networks.

Section 415 of the Committee bill, which is derived from
S. 1676, would add a new section 7481 to title 38, U.S.C.,
providing that pay for a Medical Director or Director of a
Veterans Integrated Service Network will consist of basic pay
set forth under section 7404(a) of title 38, U.S.C., (setting
grades and pay scales for VA health professionals) and market
pay determined under this new authority.
Background. Under current law, a VISN Director or Medical
Director is not eligible to be hired under VA's hiring
authority provided by title 38, U.S.C., because VA is not able
to appoint non-physicians using its title 38 hiring authority.
Both Medical Directors and VISN Directors are hired under title
5, U.S.C., as part of the SES. Even though people appointed to
these positions are hired as an SES and paid at a higher rate
than the general schedule pay for title 5 employees, they are
paid substantially less than their private sector counterparts
as well as the VA medical providers reporting to them. This pay
disparity makes it difficult for VA to recruit non-VA employees
and current VA providers to fill positions of VISN Directors
and Medical Directors.
Committee Bill. Section 415 of the Committee bill would
change how the pay for VISN Directors and Medical Directors is
calculated.
Section 415(a) of the Committee bill would create a new
subchapter VII in chapter 74 of title 38, U.S.C., to create a
new section 7481 entitled ``Pay for Medical Directors and
Directors of Veterans Integrated Service Networks.'' Section
7481(a), as added, would direct that the basic pay for a
Medical Director or VISN Director will be set under section
7404(a) of title 38, U.S.C. Section 7481(b) would allow for
market pay through an adjustment of such pay dependent on the
experience of the Directors, the complexity of the facility,
the labor market in the geographic area, and other
considerations as deemed appropriate by the VA Secretary. Under
section 7481(c), the VA Secretary would be directed to
determine every 2 years a maximum and minimum level of pay for
Medical Directors and VISN Directors and publish those amounts
in the Federal Register. Section 7481(d) would clarify that pay
received under this section would be considered pay for the
purposes of receiving retirement benefits under chapters 83 and
84 of title 5, U.S.C. Subsection 7481(e) would clarify that a
decrease in pay due to an adjustment by the Secretary to the
market pay for Medical Directors and VISN Directors will not be
treated as an adverse action.
Section 415(b) of the Committee bill would make a clerical
change to add the new subchapter VII to the table of contents
in title 38, U.S.C.
Section 415(c) of the Committee bill would provide for an
effective date that is 1 year after the date of enactment.

Sec. 416. Additional requirements for hiring of health care providers
by the Department of Veterans Affairs.

Section 416 of the Committee bill, which is derived from
S. 1641, would require the VA Secretary to consider information
from the medical boards of each state in which a health care
provider holds or has held a medical license during the hiring
process at VA.
Background. When hiring health care providers, VA's policy
is to conduct license verification of all active and currently
held licenses as part of credentialing, which must be completed
before any provider delivers health care at a VA facility. This
is typically accomplished by querying the respective state
licensure board's (hereinafter, ``SLB'' or ``board'') public
facing Web site in the state where the provider holds a
license. If the licensure board has taken an action on the
license, that information will be available. This practice is
outlined in VHA Handbook 1100.19 and VHA Directive 2012-030.
However, recent media reports regarding practicing VA providers
whose credentials have not been verified, who have been
misrepresented, and who have previously entered into
settlements or completed disciplinary actions in other states
where they may hold a medical license have highlighted the need
to ensure protocols are being followed.\5\ VA must do more to
guarantee its providers are of the highest quality and are, at
the very least, in good standing with each SLB in which they
hold a license to protect our nation's veterans.
---------------------------------------------------------------------------
\5\http://www.desmoinesregister.com/story/opinion/editorials/2016/
01/04/editorial-va-doctors-should-licensed-where-they-practice/
78127258/ and http://www.kare11.com/story/news/investigations/2015/11/
20/va-doctor-certification-scandal-grows/76130672/
---------------------------------------------------------------------------
Committee Bill. Section 416 of the Committee bill would, in
a freestanding provision, require the Department to issue
regulations that require, as part of the hiring process, VA to
obtain information on medical license violations from each SLB
where a provider holds or has held a license during the
provider's career as well as information on whether the
provider has entered into any settlement agreements with the
board for disciplinary charges relating to medical practice.

Sec. 417. Provision of information on health care providers for
Department of Veterans Affairs to state medical boards.

Section 417 of the Committee bill, which is derived from
S. 1641, would require VA to send to each state licensing
board, where a provider holds a license, and the board in the
state where the provider practices, information concerning a
report of a violation during the provider's practice at VA
without the board making a request for such information.
Background. Under the current policy outlined in VHA
Handbook 1100.18, medical facilities must report each licensed
health care professional whose behavior or clinical practice so
substantially fails to meet generally accepted standards of
clinical practice as to raise reasonable concern for the safety
of patients. In each instance, the medical facility Director
must prepare a Reporting File to submit to each SLB where the
professional holds a license.\6\ However, the report statement
sent to the SLB is typically limited to a generic description
of the clinical shortcomings involved, unless the SLB responds
to the Director with a formal request for more information.
SLBs and the Federation of State Medical Boards have indicated
that it is quite difficult for boards to receive up-front,
timely, and comprehensive information on violations or
assistance with investigations from VA. SLBs also highlighted
that they find it extremely difficult to gain any information
even if the SLBs follow VA's exact procedure to gain such
information. Material received is so heavily redacted it is of
little use. It is critical VA improve communication with SLBs
and improve transparency surrounding medical practice
violations to remain accountable for high-quality and safe
care.
---------------------------------------------------------------------------
\6\VA Views for S. 1641, Testimony submitted before the Senate
Veterans' Affairs Committee, ``Legislative Hearing'' on June 24, 2015.
---------------------------------------------------------------------------
Committee Bill. Section 417 of the Committee bill would, in
a freestanding provision, require the Department to send each
SLB where a provider holds a license, and the SLB in the state
where the provider practices, the full information concerning a
report of a violation during the provider's practice at VA
without the board making a request for such information. While
VA providers are not required to hold a license in the same
state where the medical facility resides, the Committee
believes that such state's board should, nonetheless, have
access to information about a clinical violation committed at a
facility in their state to ensure the board can fulfill its
obligation to uphold safe medical practice.

Sec. 418. Report on compliance by Department of Veterans Affairs with
reviews of health care providers leaving the Department or
transferring to other facilities.

Section 418 of the Committee bill, which is derived from
S. 1641, would require VA to submit a report to Congress on
compliance with the VA policy to conduct a review of every VA
clinician leaving or transferring to another facility to
uncover any concerns, complaints, or allegations of violations
of medical practice and to take appropriate action.
Background. There are approximately 1400 points of care
across VA's health care system. Transfers of health care
providers to different VA facilities can occur as a positive
job opportunity for providers,\7\ as a result of need for
providers in specific facilities, or as a major adverse
employment action.\8\ Because a provider transferring to a new
facility can occur for a variety of reasons, it can be
difficult to determine whether a provider has left a facility
with outstanding allegations of violations related to their
medical practice without an active review of their employment
records being conducted. This is also true when a provider
moves to a non-VA medical facility.
---------------------------------------------------------------------------
\7\http://www.vacareers.va.gov/students-trainees/physicians.asp.
\8\VA Handbook 5021/10 Transmittal Sheet, Employee/Management
Relations, updated November 8, 2012.
---------------------------------------------------------------------------
VHA has the authority under section 501 of title 38,
U.S.C., to report medical professionals employed at VA whose
behavior or clinical practice failed to meet the generally
accepted standards of clinical practice as to raise reasonable
concerns for patient safety. VHA Handbook 1100.18 requires VA
to cooperate with SLBs by initiating reports regarding concerns
about patient safety and in terms of cooperating with inquiries
from an SLB. VA's quality assurance program authorized under
Public Law 99-660, the Public Health Service Act, requires the
Department to report to the relevant SLBs any licensed health
care professional who was fired or who resigned following the
completion of a disciplinary action relating to such
professional's clinical competence, resigned after having had
his or her clinical privileges restricted or revoked, or
resigned after serious concerns about such professional's
clinical competence had been raised but not resolved. The
Committee has heard from stakeholders that compliance with the
reporting requirements in VHA Handbook 1100.18 to SLBs varies
from facility to facility.
Committee Bill. Section 418 of the Committee bill would, in
a freestanding provision, require VA to report to the Committee
on Veterans' Affairs of the Senate and House of Representatives
its compliance with the VA policy of review and credentialing
to ensure it is carried out consistently across facilities to
maintain accountability for safe, high-quality care within 2
years of enactment of the Committee bill. This report would
include a review of whether VA took appropriate action on
concerns, complaints, or allegations of violations that relate
to the medical practice of health care providers. The report
would be due not later than 2 years from the enactment of the
Committee bill.

SUBTITLE B--OPIOID THERAPY AND PAIN MANAGEMENT

Sec. 421. Guidelines on management of opioid therapy by Department of
Veterans Affairs and Department of Defense and implementation
of such guidelines by Department of Veterans Affairs.

Section 421 of the Committee bill, which is derived from
S. 1641, would require the Secretaries of Veterans Affairs and
Defense to update the joint VA/DOD Clinical Practice Guideline
for Management of Opioid Therapy for Chronic Pain.
Background. In 2010, VA and DOD updated the joint VA/DOD
CPG for Management of Opioid Therapy for Chronic Pain. However,
despite the growing number of opioid prescriptions and changes
in best practices and treatments, the CPG, which guides
clinicians in making treatment decisions regarding prescription
of opioids for patients suffering from chronic pain, has not
been updated for more than 5 years. Additionally, a 2014 OIG
report found that not all of VA's practices concerning opioid
prescribing align with recommendations in the CPG.\9\
---------------------------------------------------------------------------
\9\Office of Inspector General, Department of Veterans Affairs;
``Healthcare Inspection--VA Patterns of Dispensing Take-Home Opioids
and Monitoring Patients on Opioid Therapy.'' Report No. 14-00895-163;
May 14, 2014.
---------------------------------------------------------------------------
Committee Bill. Section 421 of the Committee bill would, in
a freestanding provision, outline requirements for updating the
joint VA/DOD CPG for Management of Opioid Therapy for Chronic
Pain. Subsection (a) of section 421 of the Committee bill would
require VA and DOD to update and enhance the joint VA/DOD CPG
for Management of Opioid Therapy for Chronic Pain. It would
further require the updated CPG to incorporate the Centers for
Disease Control and Prevention's (hereinafter, ``CDC'') safe
opioid prescribing guidelines for the treatment of chronic,
non-cancer pain in outpatient settings where practical. The
Committee believes it is critical for opioid prescribing
guidance to be up-to-date and consistent across Federal
agencies to ensure that all providers have access to the same
tools to make the best treatment decisions for their patients.
The Committee expects VA and DOD to incorporate CDC guidelines
where applicable and acknowledges that some CDC recommendations
may not be appropriate for the veteran community. The Committee
also expects that CDC guidelines alone, which only address
chronic pain in outpatient settings, would not be sufficient to
serve as an update to the CPG and directs VA and DOD to
consider all relevant evidence to ensure that the final CPG is
robust and relevant to the patient population of both
departments.
This subsection would also require the updated CPG to
enhance guidance concerning absolute contraindications for
opioid therapy, including prescribing opioids and
benzodiazepines concurrently, and prescribing opioids to treat
mental health conditions and patients without any pain.
Stronger guidance is needed because the OIG found that VA's
practice of prescribing and dispensing benzodiazepines
concurrently with opioids was not fully in alignment with
acceptable standards.\10\ This is despite the fact that the
current CPG advises clinicians against this practice and notes
it as an absolute contraindication.\11\ Updated recommendations
against prescribing opioid therapy for patients with severe
mental health conditions, including PTSD and substance use
disorder, as well as to treat mental health conditions are also
needed due to the inappropriate practices at the Tomah VAMC
where a psychiatrist was among the top opioid prescribers--
providing large amounts of narcotics to patients with mental
health issues.\12\
---------------------------------------------------------------------------
\10\OIG report; VA Patterns of Dispensing Opioids, May 2014.
\11\VA/DOD Clinical Practice Guideline for the Management of Opioid
Therapy for Chronic Pain; May, 2010, at 25.
\12\OIG; Administrative Closure, Tomah VA Medical Center.
---------------------------------------------------------------------------
Moreover, section 421 would require the CPG to include
stronger recommendations regarding consistent urine drug
screenings--including that such screenings should be done at
least once a year--for patients on long term opioid therapy and
guidance that clinicians must appropriately interpret and act
on the results. At the Tomah VAMC and throughout VHA, reports
show that clinicians have not been consistently conducting or
taking appropriate action based on urine drug screenings to
determine if a patient on opioid therapy is misusing
opioids.\13\
---------------------------------------------------------------------------
\13\OIG; Administrative Closure, Tomah VA Medical Center and OIG
report; VA Patterns of Dispensing Opioids, May 2014.
---------------------------------------------------------------------------
The Committee recognizes the CPG contains non-binding
recommendations aimed to inform and help clinicians in
decisionmaking, and that providers' practices will vary when
they appropriately take into account the needs of their
individual patients. However, the Committee is concerned that,
despite the recommendations in the 2010 CPG, overprescribing
and abuse of opioids within VA has risen dramatically. Further,
evidence indicates VA's opioid prescribing practices are not
always consistent with acceptable standards as recommended in
the CPG. As such, the Committee expects the updated CPG to
include stronger and more robust recommendations to help
guarantee clinicians deliver the safest and most effective
care.
Finally, subsection (a) of section 421 would direct the
updated CPG to include a requirement that all VA providers
utilize the VA Opioid Therapy Risk Report tool prior to
starting a patient on opioid therapy. Comprehensive use of this
electronic tool, which helps providers manage their entire
panel of patients' prescribed pharmacotherapy for acute or
chronic pain, for all VA patients on opioid therapy, is
absolutely essential to ensuring providers deliver and are held
accountable for high quality and safe care.
Subsection (b) of section 421 would require the VA
Secretary and the Secretary of Defense to jointly consult with
the Pain Management Working Group of the Health Executive
Committee of the Department of Veterans Affairs-Department of
Defense Joint Executive Committee before updating the CPG.
Subsection (c) of section 421 would define the term
``controlled substance'' as having the same meaning as in
section 802 of title 21, U.S.C. The Committee intends to ensure
consistency in defining ``controlled substance'' for the
purpose of this bill.

Sec. 422. Improvement of opioid safety measures by Department of
Veterans Affairs.

Section 422 of the Committee bill, which is derived from
S. 1641, would require VA to expand the Opioid Safety
Initiative across all medical facilities; enhance pain
management education and training for VA providers; identify
and designate pain management teams at each VA medical
facility; augment tracking and monitoring of opioid use at the
Department; increase the availability of opioid receptor
antagonists; include certain information and capabilities on
the Opioid Risk Report tool; and incorporate notification of
risk in the computerized health record.
Background. Started in August 2012 as a pilot program in
Minneapolis, Minnesota, to reduce dependency on opioid use, the
OSI was implemented nationwide a year later. In written
testimony to the Committee on March 26, 2015, the then Interim
Under Secretary for Health at VHA, Dr. Carolyn Clancy, noted
key clinical metrics measured by the OSI from quarter 4, fiscal
year 2012 to quarter 1, fiscal year 2015 indicated a 13 percent
reduction in the number of patients receiving opioids. It
should be noted VA saw a 2 percent increase in the number of
patients utilizing its outpatient pharmacy services during that
same period. Given the relative success of OSI to date, it is
critical VHA expand and fully implement the initiative in all
of its facilities as soon as possible to improve safe pain
management.
The OSI and VHA's National Pain Management Strategy offers
providers education and training to enhance competencies and to
promote the CPG for Management of Opioid Therapy for Chronic
Pain, including through such efforts as the dissemination of
the OSI toolkit.\14\ To enhance this effort and ensure
consistency across the whole system, VHA should leverage the
existing Interdisciplinary Chronic Pain Management Training
Team Program to provide education on the CPG, additional
training on screening, and improve identification and referral
of patients with substance use disorder.
---------------------------------------------------------------------------
\14\VHA National Pain Management Strategy, Implementation of the
Stepped Care Model; October 2012. Power Point Presentation. http://
www.va.gov/PAINMANAGEMENT/docs/VHA_Natl_
Pain_Mgmt_Strategy_Kerns_Oct2012.pptx
---------------------------------------------------------------------------
Limiting the provision of opioids, as appropriate, to
providers with expertise in analgesics or pain care is critical
in holding providers accountable for safe care and to prevent
patient abuse and diversion. For example, at the Tomah VAMC,
one of the most prolific prescribers of opioids was a
psychiatrist without expertise in pain management. The use of
interdisciplinary pain medicine specialty teams at VA
facilities should serve as a valuable resource in combating
such abuse and be implemented system-wide. As of 2014, 40
facilities (28 percent) have fully implemented
interdisciplinary pain medicine specialty teams while another
56 (40 percent) have partially implemented these teams.
A critical aspect of the OSI is the Opioid Therapy Risk
Report tool, an electronic tool that helps providers manage
their entire panel of patients prescribed pharmacotherapy for
acute or chronic pain. Not all VA providers currently use this
tool, as VA does not mandate its use. VA providers who
prescribe opioids should use this tool consistently to ensure
safe prescribing and to help prevent diversion, abuse, and
double-prescribing.
The Opioid Therapy Risk Report tool should also be enhanced
to provide real-time data updates on patient information,
rather than once in a 24 hour period, and by better interacting
with providers in the community. Many veterans who access care
at VA also obtain care in the community who may also prescribe
them medication. The lack of access to a state's prescription
drug monitoring program presents VA providers a challenge in
safely prescribing opioids to their patients. Therefore, the
Opioid Therapy Risk Report tool could be further enhanced by
allowing VA providers to access the state PDMPs in an effort to
see a patient's opioid therapy history from outside providers.
Moreover, VHA should seek to fully implement its clinicians'
ability to transmit VA prescription information to state PDMPs
to guarantee that private clinicians have comprehensive
information about their patients' history of prescribed
controlled substances. Currently, 83 of the 130 VAMCs are
transmitting prescription drug information to their respective
state PDMPs.
Finally, while all VA facilities have naloxone on emergency
crash carts, only 77 percent of VA facilities are currently
dispensing naloxone rescue kits for patient take home use. Not
all facility pharmacies have such kits immediately on hand for
dispensing and must order it or have it mailed to a patient who
is prescribed a rescue kit. In an effort to improve VA's
Overdose Education and Naloxone Distribution Program, the
Department should expand access to naloxone and other opioid
receptor antagonists by requiring every medical facility
pharmacy to have opioid receptor antagonists on hand for
dispensing and to expand the naloxone take home program.
Committee Bill. Section 422 of the Committee bill would, in
a freestanding provision, outline requirements for improving
VA's opioid safety measures. Subsection (a) of section 422 of
the Committee bill would require an expansion of the OSI to all
medical facilities within 180 days of enactment of the
Committee bill. The Committee believes it is critical the OSI
be expanded and fully implemented in all VA facilities as soon
as possible to improve safe pain management. Subsection (b)
would require all prescribers of opioid medications to receive
pain management and safe opioid prescribing education and
training to safely and effectively manage patients with chronic
pain, and to appropriately comply with the updated CPG.
Subsection (c) would require each medical facility to identify
and designate a pain management team of clinicians. Each VISN
would establish protocols for the designation of such teams
that specify that providers without expertise in prescribing
analgesics or who have not completed the education and training
may not prescribe opioids unless done in consultation with a
provider with pain management expertise or who is on the pain
management team, and refers such patient to the team for any
subsequent prescriptions and related therapy.
Subsection (d) would require VA to improve the Opioid
Therapy Risk Report tool by enabling access to information from
state PDMPs to help clinicians identify opioid use by veterans
outside VA and must also submit information to the state PDMP.
It would also require VA to conduct a feasibility study on
further enhancements to the real-time tracking of, and access
to data on, opioid use by veterans, concurrent prescribing of
opioids in different health care settings, and mail-order
prescriptions of opioids to veterans.
To help reduce overdose deaths, subsection (e) would
require the Department to increase the availability of opioid
receptor antagonists, such as naloxone, for veterans. Every
medical facility pharmacy would be required to have opioid
receptor antagonists on hand for dispensing. All veterans at
risk of opioid overdose would have greater access to an opioid
receptor antagonist kit and receive training on the proper
administration of such drugs. VA would be required to report to
Congress regarding implementation of this requirement.
Subsection (f) would require the VA Secretary to include
information on the most recent time a health care provider
accessed the tool and information on the results of the most
recent urine drug test for each veteran. The VA Secretary would
also be required to ensure the Opioid Therapy Risk Report tool
could determine whether a VA health care provider prescribed
opioids without accessing the information in the tool.
Subsection (g) would require VA to update its Computerized
Patient Record System with an alert that a patient is at high
risk of being an opioid abuser, or has a history of opioid
abuse to help all clinicians prevent abuse and diversion, and
to help improve identification and treatment of substance use
disorders.
Subsection (h) would define the term ``controlled
substance'' as having the same meaning as in section 802 of
title 21, U.S.C. The Committee intends to ensure consistency in
defining ``controlled substance'' for the purpose of this bill.

Sec. 423. Enhancement of joint working group on pain management of the
Department of Veterans Affairs and the Department of Defense.

Section 423 of the Committee bill, which is derived from
S. 1641, would enhance the existing Health Executive Committee
working group on pain management, established through the VA/
DOD Joint Executive Committee, by incorporating opioid therapy
issues. It would also require the HEC working group to work
with other relevant working groups to address opioid
prescribing practices, the management of chronic pain and
substance use disorders, the use of complementary and
integrative health services, and continuum of care issues
related to the military to civilian transition. The VA and DOD
Secretaries would also be required to consult with the HEC
working group prior to release of any updates to the CPG on
opioid therapy.
Background. As part of the VHA National Pain Management
Strategy, the HEC Pain Management Working Group, established
through the JEC, is working to consider the current clinical
practice guidelines for opioid therapy and the opioid risk
strategy.\15\ The HEC PMWG focuses on efforts to improve pain
management for VA and DOD beneficiaries that are complementary
to the Institute of Medicine (hereinafter, ``IOM'') report on
pain and the forthcoming National Pain Action Plan being
developed by the Interagency Pain Research Coordinating
Committee through the National Institutes of Health
(hereinafter, ``NIH''). Recent HEC activities include
developing a standardized pain screening and assessment
protocol, clinical pain policy support for VA and DOD
providers, the creation of a new VA/DOD pain management
curriculum, and integration of nonpharmacologic treatment
options or integrative medicine into practice. As part of this
work, the HEC PMWG addresses some issues surrounding the use of
opioid therapy, such as developing a coordinated program for
long-term opioid therapy principles of practice to include
prescribing practices and provider/patient agreement
standards.\16\
---------------------------------------------------------------------------
\15\http://www.va.gov/PAINMANAGEMENT/docs/
VHA_Natl_Pain_Mgmt_Strategy_Kerns_ Oct2012.pptx
\16\VA/DOD Joint Executive Committee Annual Report, Fiscal Year
2014, at 37.
---------------------------------------------------------------------------
Opioid therapy has become a primary component of pain
management and treatment within VA/DOD, so it is critical that
the HEC PMWG officially incorporate issues surrounding opioid
therapy as a key, consistent focus of its work. Due to the
comprehensive expertise of the HEC, the group should be
required to consult and review any updates to the CPG on opioid
therapy before release. Further, issues surrounding opioid
therapy fundamentally overlay with the wide-range of pain
related issues considered by the HEC and other relevant
committees, such as the HEC on mental health.
Committee Bill. Section 423 of the Committee bill would, in
a freestanding provision, outline requirements for the HEC
PMWG. Subsection (a) of section 423 of the Committee bill would
require the HEC PMWG to include issues related to opioid
prescribing practices, the management of chronic pain, as well
as substance use disorders, the use of CIH services and
continuum of care issues surrounding servicemembers'
transitioning from the Armed Services to the civilian sector in
its areas of focus. Subsection (b) of section 423 of the
Committee bill would further require the HEC PMWG to coordinate
and consult with other relevant Federal agencies, including the
CDC, to review and comment on the VA/DOD CPG for Management of
Opioid Therapy for Chronic Pain, or any successor guideline,
before any update is released. During this process, the
Committee expects that the working group closely coordinate
with related HEC working groups on related issues, including
the concurrent use of opioids and prescription drugs such as
benzodiazepines, and the use of opioids to treat mental health
disorders. Subsection (c) of section 423 of the Committee bill
would require the HEC working group to report, within a year of
enactment of the Committee bill, on VA/DOD efforts to update
their joint CPG for Management of Opioid Therapy for Chronic
Pain as required in subsection (a) of section 421 of the
Committee bill.

Sec. 424. Establishment of pain management boards of the Department of
Veterans Affairs.

Section 424 of the Committee bill, which is derived from
S. 1641, would create a pain management board in each VISN to
serve as an expert resource for patients, families, providers,
and other employees of VA on the treatment of veterans with
pain.
Background. VA currently offers multidisciplinary chronic
pain management services through pain medicine, neurology,
anesthesia, physical medicine and rehabilitation, psychology,
psychiatry, nursing, and integrated medical teams. These
services can include comprehensive pain assessment, pain
psychology, acupuncture, interventional procedures, physical
therapy, medication management, yoga, psychoeducation, aquatic
therapy, and biofeedback. VA also provides training and
resources for providers through the Opioid Safety Initiative
toolkit that was developed through a national task force
convened by the National Pain Management Program.
The March 2014 OIG Administrative Closure on opioid
prescribing at the Tomah VAMC recommended that the facility
should consider some variant of the tumor board model as one
avenue by which to foster interdisciplinary management when
presented with very complex cases requesting early opioid
refills.\17\ Tumor board reviews are interdisciplinary
treatment plans in which doctors from different specialties
discuss the care plan for a specific patient.
---------------------------------------------------------------------------
\17\Office of Inspector General, ``Administrative Closure, Alleged
Inappropriate Prescribing of Controlled Substances and Alleged Abuse of
Authority, Tomah VA Medical Center.'' Tomah, Wisconsin. March 2014 at
11.
---------------------------------------------------------------------------
On March 30, 2015, the Senate Homeland Security and
Governmental Affairs Committee and House Committee on Veterans'
Affairs held a joint oversight hearing on the Tomah VAMC. At
that hearing, Dr. Carolyn Clancy testified on behalf of VA and
supported the inclusion of pain management boards at VA. Dr.
Clancy expressly supported the inclusion of veterans and family
members on pain management boards.\18\
---------------------------------------------------------------------------
\18\Response to Representative Kind from Dr. Carolyn Clancy, M.D.,
Interim Under Secretary for Health, Veterans Health Administration
before the U.S. Senate Homeland Security and Governmental Affairs
hearing on Tomah VAMC Oversight; March 30, 2014. http://www.cq.com/doc/
congressionaltranscripts-4656019?4
---------------------------------------------------------------------------
Committee Bill. Subsection (a) of section 424 of the
Committee bill would add a new section 7309A to title 38,
U.S.C., to establish pain management boards in each VISN. These
pain management boards would supplement the Department's
ability to provide recommendations for treatment of patients
with complex pain; provide consultations with health care
professionals, patients, and family members about pain
management resources and best practices of the Department;
oversee compliance with and provide recommendations to improve
compliance with the best pain management practices of
providers, including the prescribing guidelines; oversee the
pain management practices of the pain management teams of each
medical facility of the Department in the VISN covered by the
pain management board; host education events on pain management
and treatment; and hold public events on best practices on pain
management and CIH.
The VA Secretary would be required to appoint individuals
to each pain management board. Membership would include a board
certified pain medicine specialist, a trained and qualified
member of the primary care team of a VA medical facility with
experience in pain care, a pain psychologist, a pain social
worker, a clinical pharmacist, a pain point of contact for the
VISN, a physician with addiction and psychopharmacology
experience and expertise, an allied health care professional, a
clinician with expertise in CIH, a clinical behavioral
therapist, a patient advocate, a representative of the labor
interests of employees of the Department who are responsible
for prescribing drugs, two current or former clinical patients
who are representative of the demographic of patients covered
by the VISN, and a family member of a current or former
clinical patient who is representative of the demographic of
patients served by the VISN. The Committee intends that one
individual be able to meet the criteria for multiple required
categories.
The VA Secretary would be required to take into
consideration the clinical duties of Department employees in
determining their terms of service. Members of the pain
management board would not be paid for their service on the
pain management board except to receive travel expenses,
including per diem, in lieu of subsistence for travel that
relates to their duties as pain management board members.
Members of the pain management board may be temporarily excused
from their clinical duties as an officer or employee of the
Department when they are needed to carry out their duties as
members of the pain management board. However, should the
Department determine that such employees are needed for
clinical care duties at a given time in order to maintain
patient access to quality health services, their clinical
duties would supersede their duties for the pain management
board. In order to protect patient privacy and confidentiality,
certain pain management board members, including patient
advocates, labor union representatives as described above, and
current or former clinical patients or their family members
would not have access to identifying information of a patient
or other confidential information to a patient unless that
individual is the patient advocate and has been granted
permission by the patient to be present in order to represent
the interest of the patient. The Committee intends membership
on the pain management board to be non-disruptive to VA
employees' other duties. An employee of the Department may not
have an adverse personnel action taken against them as a result
of communicating with a member of a pain management board.
Each pain management board may provide treatment
recommendations for patients with complex clinical pain cases.
Each pain management board may only provide specific clinical
recommendations concerning a patient's complex pain management
case if the patient or other qualifying individual has already
requested and received a recommendation from the pain
management team at their respective facility and is not
satisfied with the team's recommendation. Members of the board
who are not clinical professionals would not be permitted to
participate in treatment recommendations and would not be
permitted to access patient information. However, at the
request and consent of the patient, a patient advocate may be
present to ensure that the patient's interests are represented
and that the veteran has a stronger voice in his or her care
decisions. An individual may request a clinical recommendation
if that individual is a patient, the spouse of a patient, an
individual who has been designated by the patient to make
health care decisions for the patient or to receive health care
information for the patient, a physician of the patient or an
employee of a Department medical facility. It is not the
Committee's intent that treatment recommendations dictate the
treatment plan to be used by the health care provider, but
rather would be used to assist the patient and health care
provider in determining the best treatment plan. Based on the
board activities and treatment recommendations, each pain
management board may provide recommendations on best practices
regarding pain management in cases of complex clinical pain to
VISN-level health care professionals.
Not later than January 31 of each year, each pain
management board must submit a report to the Committee on
Veterans' Affairs of the Senate and House of Representatives on
the pain management practices carried out in the VISN including
a summary and explanation of the treatment recommendations made
throughout the previous year and recommendations for best
practices that were provided to health care professionals in
the previous year.
Subsection (b) of section 424 of the Committee bill would
modify the table of sections at the beginning of chapter 73 of
title 38, U.S.C., to include pain management boards. Subsection
(c) of section 424 of the Committee bill would make the
amendments in this section effective 1 year from enactment of
the Committee bill.

Sec. 425. Review, investigation, and report on use of opioids in
treatment by Department of Veterans Affairs.

Section 425 of the Committee bill, which is derived from
S. 1641, would direct VA, within 2 years of the enactment of
this bill, to enter into a contract with an independent expert
on clinical prescribing practices to conduct a review of the
VA's OSI and VA providers' opioid prescribing practices. In
addition, this section would require VA to conduct an internal
annual review, investigate certain opioid prescribing patterns,
and report on its use of opioid therapy.
Background. According to the March 2014 OIG Administrative
Closure concerning opioid prescribing at the Tomah VAMC,
providers at Tomah were among the highest opioid prescribers in
the region and their prescribing practices varied considerably
among their peers.\19\ At the request of this Committee, the
OIG recently conducted a general investigation on VA opioid
prescribing patterns and submitted a report to Congress, which
found that not all of VA's practices concerning opioid
prescribing aligned with recommendations in the VA/DOD Clinical
Practice Guideline for Management of Opioid Therapy for Chronic
Pain.\20\
---------------------------------------------------------------------------
\19\Office of Inspector General, ``Administrative Closure, Alleged
Inappropriate Prescribing of Controlled Substances and Alleged Abuse of
Authority, Tomah VA Medical Center.'' Tomah, Wisconsin, March 2014.
\20\Office of Inspector General, Department of Veterans Affairs;
``Healthcare Inspection--VA Patterns of Dispensing Take-Home Opioids
and Monitoring Patients on Opioid Therapy.'' Report No. 14-00895-163;
May 14, 2014.
---------------------------------------------------------------------------
Currently, VA does not have a process in place for a
systematic and regular review, investigation, and reporting of
its opioid prescription practices and trends by medical
facility and by provider. Such information would allow Congress
to conduct more effective oversight of VA and would allow VA to
more effectively manage this important aspect of patient care.
Similarly, ensuring that the Committee and members of Congress
from the areas where VA's opioid use requires investigation are
informed of this scenario in a timely way allows for better
oversight and any intervention that may be helpful in
supporting patients in these facilities.
Committee Bill. Section 425 of the Committee bill would, in
a freestanding provision, outline the requirements for a review
of VA's use of opioids in treatment. Subsection (a) of section
425 of the Committee bill would require VA to contract, within
2 years of the enactment of this bill, with an independent
party experienced with assessing clinical prescribing practices
to conduct a review of VA's OSI and VA health care providers'
opioid prescribing practices. The Committee intends for VA to
identify a credible expert or organization such as an
appropriate component of the National Academies of Science,
Engineering, and Medicine to carry out this review. This
subsection would require the independent entity conducting the
review to provide a report on its findings and recommendations
within 30 days after completing the review. The report would be
submitted to the VA Secretary and the Committee on Veterans'
Affairs of the Senate and House of Representatives.
This subsection further details the specific elements that
would be required in the report, including: recommendations for
improvements to the OSI; information on veteran deaths as a
result of sentinel events related to opioids prescribed by a VA
provider; VA prescription rates and indications for opioid
prescriptions at all VA medical facilities where opioids are
used to treat non-cancer, non-palliative, and non-hospice care
patients; prescription rates and indications by provider for
benzodiazepines and opioids prescribed concurrently; an
assessment of the extent to which VA prescription rates are
aligned with standards for appropriate care; an assessment of
the practice and effectiveness of VA providers treating
patients without any pain, including patients with mental
health conditions, with opioids; and an assessment of the
extent to which VA is in compliance with the VA/DOD Clinical
Practice Guideline for Management of Opioid Therapy for Chronic
Pain. In addition, this subsection would provide additional
topics that could be covered in the review, such as policy
recommendations for VA employee performance management
practices to address VA providers who are not practicing
according to VA standards or are not following the VA/DOD
clinical guidelines for contraindications for opioid use. The
Committee intends to use this report as a means of holding the
Department accountable for safe opioid prescribing practices.
Subsection (b) of section 425 of the Committee bill would
require VA to conduct an internal annual review, investigation,
and report on its use of opioid therapy. Within 1 year of
enactment of this bill and at least annually thereafter, VA
would be required to collect and review data on opioid
prescriptions at each VA medical facility for non-cancer, non-
palliative, and non-hospice care patients. The review would
include rates, by health care provider, of (1) concurrent
prescriptions for benzodiazepines and opioids, (2) prescribed
or dispensed mail-order opioids to patients who were
simultaneously being treated with opioids as in-patients, and
(3) prescribed opioids for patients who were concurrently
prescribed opioids by a non-VA provider. The Committee intends
for this review to provide a baseline of information about the
opioid prescribing practices and patterns of specific
facilities and providers which may help in identifying trends
and outliers in this area of clinical practice.
This section would also require VA to investigate opioid
prescription rates when the Secretary determines that they are
inconsistent with the standards of appropriate and safe use.
Such investigations would include information on the specific
facility and provider rates of opioid prescription and must be
conducted through the VHA Office of the Medical Inspector. The
bill would require that VA immediately notify the Committee on
Veterans' Affairs of the Senate and House of Representatives
and each member of the Senate and House who represent the area
in which the investigation is being conducted. The Committee
intends to ensure that information on relevant opioid use is
shared in a timely manner with appropriate members of Congress,
including Committee members and local delegations. In addition,
within 1 year of the enactment of this bill and at least
annually thereafter, VA would be required to submit a report to
the Committee on Veterans' Affairs of the Senate and House of
Representatives that includes the previous year's number of
patients and percentage of VA patients who were prescribed
opioids absent any pain or were prescribed benzodiazepines and
opioids concurrently by VA providers. The report must also
include the number and percentage of non-cancer, non-
palliative, and non-hospice care patients treated with opioids,
both as an in-patient and by mail-order prescription or who
received opioid prescriptions from VA and non-VA providers
concurrently. In addition, VA must report, by medical facility,
the number of times a pharmacist overrode a critical drug
interaction involving opioids, the full results of the review
and investigation referenced above, and an assessment of VA's
compliance with the VA/DOD CPG for Management of Opioid Therapy
for Chronic Pain. In general, the Committee intends for these
reviewing, reporting, and investigating measures to reveal the
opioid prescribing practices of VA providers, including
compliance with the updated guidelines, deaths from opioids,
prescribing rates, and concurrent use of opioids and
benzodiazepines and to add a measure of accountability for VA's
opioid use.
Subsection (c) of section 425 of the Committee bill would
define the term ``prescription rate'' as the number of patients
treated with opioids divided by the total number of pharmacy
users of a particular facility or provider, the average number
of morphine equivalents per day prescribed for patients being
treated with opioids, and the average number of opioid
prescriptions per patient of the patients being treated with
opioids at a particular facility by a particular provider.

SUBTITLE C--PATIENT ADVOCACY

Sec. 431. Establishment of Office of Patient Advocacy of the Department
of Veterans Affairs.

Section 431 of the Committee bill, which is derived from
S. 1641, would create an Office of Patient Advocacy that
reports to the Under Secretary for Health to manage the
responsibilities of patient advocates, and to ensure that the
mission of the program is focused on advocating on behalf of
patients. The Office of Patient Advocacy would ensure that
patient advocates receive appropriate training in patient
advocacy that is consistent throughout VA. In addition, VA
would be required to submit an annual report to Congress on the
activities of the Office of Patient Advocacy.
Background. In 2010, when the Office of Patient Centered
Care and Cultural Transformation (hereinafter, ``OPCC&CT'') was
initially stood up, VA's Office of Patient Advocacy functions
were moved to this office. As a result, VA does not currently
have a stand-alone Office of Patient Advocacy. The Associate
Director for Veteran Experience within VA coordinates a Patient
Advocacy Program, which VA plans to update to ensure that the
functions are clearly meeting the needs of veterans and
prioritizing veteran experience with VA services.
A number of veterans and veterans service organizations
have noted that VA's patient advocates are often ineffective or
experience barriers to effectively advocating for veterans due
to a conflict of interest inherent in the current structure of
the program. Specifically, the written testimony that the
Veterans of Foreign Wars provided for the legislative hearing
on June 24, 2015, raised concerns that patient advocates cannot
effectively meet their obligations to veterans when their chain
of command includes VA medical facility staff who are
responsible for the actions and policies they are required to
address. These concerns about a conflict of interest based on
the organization of the program have been echoed by other
stakeholders.
Committee Bill. Subsection (a) of section 431 of the
Committee bill would amend subchapter I of chapter 73 of title
38, U.S.C., to establish an Office of Patient Advocacy
(hereinafter, ``Office'') within the Office of the Under
Secretary for Health. The bill would require the VA Secretary
to appoint a Director of the Office of Patient Advocacy to lead
the Office and report to the Under Secretary for Health.
Creating a dedicated Office is central to achieving this
goal. Establishing the Office within the Office of the Under
Secretary for Health and having the Director report to the
Under Secretary would signal the Committee's commitment to
elevating the responsibility for patient advocacy to top
leadership within VA. In addition, a dedicated office reporting
to the Under Secretary for Health would ensure that the program
remains accountable to the needs of veterans and their
families, would help prevent any undue pressure on advocates
from the local medical facility leadership and would help to
ensure that patient advocates perform their duties with an
emphasis on addressing the patients' concerns rather than
protecting the medical facility's leadership.
Further, this section would establish that the function of
the Office is to carry out VA's Patient Advocacy Program. While
VA is working to re-focus the Patient Advocacy Program on
veteran experience, the Committee believes that this essential
program needs to be strengthened and intends that the Patient
Advocacy Program would guarantee that the veteran is at the
center of patient advocacy efforts. This section would also
delineate that patient advocacy responsibilities include:
resolving complaints by veterans, presenting issues experienced
by veterans to a variety of audiences, apprising veterans of
their rights and responsibilities as patients in the VA system,
tracking and compiling data on veteran complaints, establishing
a process for sharing that data, identifying--at least
quarterly--opportunities to improve health care services based
on veteran complaints, elevating significant complaints to
appropriate staff for further review, supporting any VA patient
advocacy programs, ensuring that all appeals and final
decisions regarding veteran health care issues handled through
patient advocacy programs are tracked, understanding all
relevant laws and directives related to veterans' rights in
receiving health care, ensuring veterans receiving mental
health care services are aware of their rights established
under the Protection and Advocacy for Mentally Ill Individuals
Act of 1986, fulfilling requirements for the inspection of
controlled substances, and documenting and reporting any
potentially threatening behavior to appropriate authorities.
The Committee intends that establishing these responsibilities
in statute would further advance the effort to keep the patient
as the top priority in its advocacy efforts.
In addition, this section would require the Director of the
Office to provide training to patient advocates and ensure that
the training is consistent throughout VA. The Committee intends
that the Director establish a uniform means of training patient
advocates to ensure that a consistent message and instruction
would be conveyed across all VA locations. Lastly, the section
would define the term ``controlled substance'' as having the
same meaning as in section 802 of title 21, U.S.C. The
Committee intends to ensure consistency in defining
``controlled substance'' for the purpose of this bill.
Subsection (b) of section 431 of the Committee bill would
add ``7309B. Office of Patient Advocacy'' to the table of
sections at the beginning of chapter 73 as amended by section
424(b). Subsection (c) of section 431 of the Committee bill
would direct VA to establish the Office referenced in section
(a) and would ensure that it is fully operational by 1 year
after enactment. The Committee intends to allow VA the
necessary time to stand up the new Office, but also to ensure
VA does so in a timely way so that veterans receive the benefit
of the work of the Office quickly.

Sec. 432. Community meetings on improving care from Department of
Veterans Affairs.

Section 432 of the Committee bill, which is derived from
S. 1641, would require each medical facility to host public,
community meetings on improving VA's health care services.
Background. In October 2014, following a series of town
hall meetings held at each VA medical facility and regional
benefits office in August and September 2014, the VA Secretary
directed all medical and benefits facilities to hold similar
town hall meetings on a quarterly basis to improve
communication with and to hear feedback directly from veterans
across the country on their experiences with VA benefits and
services. The Secretary noted that, at that time, VA was taking
a hard look at all of its practices and functions in order to
reorganize the Department around the needs of veterans. The
Secretary emphasized that direct feedback from veterans,
employees, and stakeholders was an important component of that
reorganization, and key to improving VA's services and
operations.
Committee Bill. Section 432 of the Committee bill would, in
a freestanding provision, outline requirements for community
meetings. Subsection (a) of section 432 of the Committee bill
would require each VA medical center to host a community
meeting--open to the public--on improving VA health care. The
Committee believes that formalizing these meetings would help
to ensure that veterans, families, staff, and other
stakeholders have a stronger voice as VA plans and implements
its strategy for transforming the Department to make it more
veteran-centric.
The Committee bill would require that the first meeting
take place not later than 90 days after enactment and that
subsequent meetings take place at least every 90 days
thereafter. In addition, this section would require Community
Based Outpatient Clinics to hold, at least annually, publicly
open community meetings on improving VA health care, the first
of which to be convened no later than 1 year after the
enactment of this bill.
Subsection (b) of section 432 of the Committee bill would
require the VISN Director to attend at least one community
meeting per year at each medical center in the VISN. The VISN
Director may send a designee to attend at least one community
meeting per year at each of the Community Based Outpatient
Clinics in the VISN. Subsection (c) of section 432 of the
Committee bill would require each VA medical center and
Community Based Outpatient Clinic to announce its schedule of
community meetings to the Committee on Veterans' Affairs of the
Senate and House of Representatives and to each member of
Congress who represents the region where the meetings are being
held.
The Committee believes that this section of the bill is
consistent with Secretary McDonald's earlier efforts to solicit
feedback from veterans by hosting town hall meetings to hear
the concerns of veterans, families, staff, and other
stakeholders.\21\
---------------------------------------------------------------------------
\21\VA Views for S. 1641, Testimony submitted before the Senate
Veterans' Affairs Committee, ``Legislative Hearing'' on June 24, 2015.
---------------------------------------------------------------------------

Sec. 433. Improvement of awareness of patient advocacy program and
patient bill of rights of Department of Veterans Affairs.

Section 433 of the Committee bill, which is derived from
S. 1641, would require VA to prominently display information on
the Patient Advocacy Program in each medical facility,
including contact information for that facility's patient
advocate. VA would also be required to display the VA patients'
bill of rights in a well-traveled area of each medical
facility.
Background. VA currently posts information in medical
facilities concerning the contact information for the patient
advocate and the rights and responsibilities of patients and
family members. This bill would require VA to also post the
Patient Advocacy Program's purpose and to enhance the
visibility of all of this information in medical facilities
nationwide, thus giving it greater prominence and creating
better visibility on this information for patients and family
members who may need support from a patient advocate.
Committee Bill. Section 433 of the Committee bill would, in
a freestanding provision, require the VA Secretary to display,
at each VA medical facility, the purpose of the Patient
Advocacy Program with the contact information for the
facility's patient advocate. It would also require the VA
Secretary to post the rights and responsibilities of patients,
residents, and family members at VA medical facilities,
community living centers, and other VA residential facilities.
The section would also require that this information be
displayed within 90 days of the enactment of the Committee bill
and would require that the VA Secretary ensure that it is
displayed in prominent locations where the greatest possible
number of patients and family members can see it.
The Committee intends that VA place a high importance on
disseminating this key information and that VA seek additional
ways to improve awareness of the Patient Advocacy Program and
the services it can provide to veterans and family members. The
Committee further intends that the VA Secretary ensure that
this critical information would be easily visible in as many
locations in the facility as possible.

Sec. 434. Comptroller General report on Patient Advocacy Program of
Department of Veterans Affairs.

Section 434 of the Committee bill, which is derived from
S. 1641, would require GAO to conduct a study and issue
recommendations to Congress on improving VA's Patient Advocacy
Program as carried out and managed by the new Office of Patient
Advocacy established by this bill.
Background. The Patient Advocacy Program is for all
veterans who receive care at VHA facilities and clinics and
their families to have someone to go to with concerns about
patient care. The Patient Advocacy Program establishes a
Patient Advocate at every VA medical center. The VHA Patient
Advocacy Program Handbook provides the requirements for the
Patient Advocacy Program including what is required from the
service-level advocates up to what is required at the facility
and VISN level. The Handbook establishes minimum expectations
for the Patient Advocacy Program including that patients must
have easy access to someone who will hear their complaint,
patients must have their complaints addressed in a timely
manner, advocates must utilize the Patient Advocate Tracking
System, and the Patient Advocacy Program must be integrated
with the Facility Veteran Customer Service and Service Recovery
Activities. The Handbook was last updated in 2005.
Committee Bill. Subsection (a) of section 434 of the
Committee bill would, in a freestanding provision, require GAO
to deliver a report on VA's Patient Advocacy Program within 3
years of the enactment of this bill. Subsection (b) of section
434 of the Committee bill would establish that the elements to
be included in the report are: recommendations for improving
the program and any other information about the program as GAO
deems appropriate. The bill would further provide options for
additional elements that may be included in the report: a
description of the Patient Advocacy Program, including its
purpose and activities; the extent to which the program is
achieving its purpose at the time of the review; an assessment
of the staffing of the program; an assessment of the adequacy
of training for program staff; and a review of veteran and
family member awareness and use of the program.
The Committee intends for the report to provide a general
sense of the working of the program at the time of the review
and an assessment of its general effectiveness. The Committee
included several potential topics that might be included, but
intends for GAO to have the flexibility to determine the key
elements included in the report based on what their research
and investigation of the program uncovers. The Committee
intends that, in addition to providing critical information
about the current state of the program, the review and
culminating report would serve as a baseline for future
evaluations of the patient advocacy services provided by VA.

SUBTITLE D--COMPLEMENTARY AND INTEGRATIVE HEALTH

Sec. 441. Expansion of research and education on and delivery of
complementary and integrative health to veterans.

Section 441 of the Committee bill, which is derived from
S. 1641, would direct VA to develop a plan to expand research
and education on and delivery of CIH to veterans.
Background. In recent years, VA has worked to transform the
traditional practice of medicine to one that is patient-
centered and optimizes overall health while minimizing risk of
harm to the patient. The approach is focused on the overall
well-being of individuals, rather than solely disease
management. To better meet the goals of providing patient-
centered care to veterans, VA created the OPCC&CT. The OPCC&CT
plays a role in identifying best practices for VA care, such as
the movement toward patient-centered care or the utilization of
CIH services and therapies. However, further research and
education on, and the delivery and integration of, CIH into the
health care services provided to veterans is necessary. VA
needs to understand the comparative effectiveness of various
CIH therapies as well as the various approaches for integrating
such therapies into traditional health services. Finally,
identifying barriers to receiving or providing CIH to veterans
will allow VA to overcome such barriers and improve delivery of
these therapies to veterans. A variety of terms are used to
describe therapies such as acupuncture, massage therapy, and
guided imagery. Particular organizations and individuals have
strong preferences and rationales for the utilization of one
particular terminology over another. For the purposes of this
legislation, the utilization of the term ``complementary and
integrative health services'' to describe these therapies
should not be construed to interject a position of this
Committee in this debate. Rather, this terminology is utilized
to conform to the terminology currently utilized by NIH. NIH
currently defines complementary and integrative health services
as ``practices and products of non-mainstream origin'' and the
practice of incorporating complementary approaches into
mainstream health care.
Committee Bill. Section 441 of the Committee bill would, in
a freestanding provision, outline requirements for VA to
develop a plan to expand research and education on CIH.
Subsection (a) of section 441 of the Committee bill would
require VA, within 6 months of the effective date of that
section, to develop a detailed plan to expand research and
education on and the delivery and integration of CIH services
for veterans. Subsection (b) of this section would specify that
the plan shall outline research on the comparative
effectiveness of various CIH services and strategies to
integrate CIH services into other health care services provided
by the Department. Additionally, the plan would outline
education and training of health care professionals in the
Department on CIH services, the appropriate uses of those
services, and how such services would be integrated into
existing health care services for veterans. Furthermore, the
plan would require centers of innovation at Department medical
centers to carry out research, education, and clinical
activities on CIH. Finally, the plan would outline an approach
for the identification or development of metrics and outcome
measures to evaluate the delivery of CIH services as well as an
approach to integrate and deliver CIH services with other
health care services provided by the Department.
Subsection (c) of section 441 of the Committee bill would
require VA, in creating the plan, to consult with the Director
of the National Center on CIH of the NIH; the Commissioner of
Food and Drugs; institutions of higher education, private
research institutes, and individual researchers who have
extensive experience in CIH; nationally recognized CIH
providers; and other officials, entities, and individuals who
have experience in CIH as VA deems appropriate. VA would
consult with these parties in developing the plan; identify
specific CIH services that are promising or supported by
research for veterans; identify barriers to the effective
implementation and integration of CIH services; and offer
solutions to overcome such barriers. Subsection (d) of section
441 of the Committee bill would define the term ``complementary
and integrative health'' to have the meaning given that term by
the NIH. As the Committee seeks to align VA's terminology used
to describe CIH services, VA should follow any recommendations
and actions by NIH and the Department of Health and Human
Services to revise said terminology.

Sec. 442. Pilot program on integration of complementary and integrative
health within Department of Veterans Affairs medical centers.

Section 442 of the Committee bill, which is derived from
S. 1641, would require VA to carry out a 3-year program to
assess the feasibility and advisability of integrating the
delivery of CIH services with other health care services
provided by the Department for veterans' mental health
diagnoses, pain management, and chronic illness.
Background. Currently, CIH is used in VA facilities
primarily for the purpose of pain management. Additionally,
according to VA/DOD Clinical Practice Guidelines for Management
of post traumatic stress, CIH therapies may be more acceptable
to patients ``reluctant to accept mental health labels or
interventions'' and have ``the added benefit of increasing
socialization'' because many of these therapies are practiced
in a group setting. CIH is also used to help individuals manage
stress and to promote general wellness. According to the April
2011 edition of ``VA Research Currents,'' a 2011 study
conducted by VA's Health Care Analysis and Information Group
showed the use of CIH has grown substantially within VA over
the last 10 years. VA's survey noted that, out of 125 VA
facilities nationwide that responded, only 12 percent have an
integrated medicine clinic where CIH is provided. Integration
of CIH services within VA's Patient Aligned Care Teams
(hereinafter, ``PACT'') is necessary to ensuring its
utilization in collaboration with other primary care services.
The integration of mental health services as part of PACT is
vital for the improved utilization of these services and the
reduction of stigma associated with their use. CIH services may
also benefit from such integration.
While CIH services are not currently available at every VA
facility, there is interest in expanding access to such
services for veterans. Of the remaining facilities that
participated in the 2011 survey that did not provide CIH
services at the time, half either indicated a desire to provide
CIH or were in the process of establishing a program. CIH
therapies provide an alternative to veterans who do not respond
to more conventional therapies as well as for those interested
in avoiding the use of prescription medications. Such therapies
could also be used in conjunction with more conventional
therapies to maximize veterans' health and well-being.
Additionally, CIH therapies may be utilized in the treatment of
seriously injured veterans--such as those receiving care at
VA's polytrauma centers--as well as veterans receiving new,
less acute diagnoses.
Committee Bill. Section 442 of the Committee bill would, in
a freestanding provision, outline requirements for the pilot
program. Subsection (a) of section 442 would require VA to
carry out a program, through the OPCC&CT, to assess the
feasibility and advisability of integrating CIH services with
other health care services provided by the Department. Under
the program, CIH services would be provided to veterans with
mental health, chronic pain, or other chronic conditions. This
subsection would specify that, during the development of the
program, potential barriers to the integration of CIH services
into VA medical centers must be identified and resolved.
Subsections (b) and (c) of section 442 of the Committee
bill would require the program to be carried out during a 3-
year period at no fewer than 15 separate VA medical centers.
Subsection (c) of section 442 of the Committee bill also would
require that at least two VA medical centers designated by VA
as polytrauma centers be included as program sites. The medical
centers chosen must include locations in rural areas, areas
that are not in close proximity to an active duty military
installation, and different geographic locations. Furthermore,
consideration of medical centers with prescription rates of
opioids that are in conflict with or are inconsistent with the
standards of appropriate and safe care would be given priority.
Subsection (d) of section 442 of the Committee bill would
require VA to, as part of the program, provide covered CIH
services to covered veterans. Subsection (e) of section 442 of
the Committee bill would specify that covered veterans shall
include any veteran who has a mental health condition diagnosed
by a VA clinician, experiences chronic pain, or has a chronic
illness being treated in a VA facility. Additionally, veterans
who do not meet any of the above criteria can request to
participate or be referred by a VA clinician.
Subsection (f) of section 442 of the Committee bill would
define covered services as those CIH services selected by the
VA Secretary. Under the program, those covered CIH services
would be administered by clinicians hired by VA who, to the
extent possible, solely provide such services. Covered services
must be included in the PACT initiative of the Office of
Patient Care Services, Primary Care Program Office in
coordination with the OPCC&CT. Covered services would be
available to veterans for the treatment of mental health
disorders, chronic pain, or other chronic conditions who have
or have not received traditional treatments from VA for such
conditions. Subsection (g) of section 442 of the Committee bill
would specify that, in order to participate in the program,
veterans must voluntarily elect to participate in consultation
with a VA clinician. Subsection (h) of this section would
require VA to report to Congress not later than 3 years after
commencing the pilot. The reports must include the findings,
conclusions, and recommendations with respect to the
utilization and efficacy of CIH centers established under the
program, an assessment of the benefits of the program, and the
comparative effectiveness of various CIH therapies, barriers
identified, and recommendations for continuation or expansion.

SUBTITLE E--FAMILY CAREGIVERS

Sec. 451(a)(1). Expansion of family caregiver program of Department of
Veterans Affairs.

Section 451(a)(1) of the Committee bill, which is derived
from S. 1085, would expand eligibility for VA's Program of
Comprehensive Assistance for Family Caregivers.
Background. The Caregivers and Veterans Omnibus Health
Services Act of 2010 was signed into law on May 5, 2010. It
established the Program of General Caregiver Support Services
and the Program of Comprehensive Assistance for Family
Caregivers. The Program of Comprehensive Assistance for Family
Caregivers (hereinafter, ``the Program'') provides additional
support services to caregivers beyond what is provided through
the Program of General Caregiver Support Services, including a
monthly financial stipend, health care coverage through the
Civilian Health and Medical Program of the Department of
Veterans Affairs (hereinafter, ``CHAMPVA''), counseling and
mental health services, respite care, and technical assistance.
The Program is only available to veterans who have serious
injuries (including traumatic brain injury, psychological
trauma, or other mental disorder) incurred or aggravated in the
line of duty in the active military, naval, or air service on
or after September 11, 2001.
In September 2014, GAO released a report on the Program
entitled ``Actions Needed to Address Higher-Than-Expected
Demand for the Family Caregiver Program.'' The report noted,
``Caregivers enable those for whom they are caring to live
better quality lives and can contribute to faster
rehabilitation and recovery.'' Supporting caregiving activities
not only ensures equity of services and benefits available to
the caregivers of our most seriously injured veterans, it may
further enable veterans to remain at home rather than admitting
them to a potentially more expensive institutional setting,
such as a nursing home.
Prior to the Program's implementation, VA initially
estimated that 4,000 caregivers would be approved for the
program; however, as of December 14, 2015, 22,616 caregivers
had been approved. GAO's 2014 report on the Program made
specific recommendations for improvement. Among its
recommendations, GAO recommended that VA ``expedite the process
for identifying and implementing an [information technology
(hereinafter, ``IT'')] system that fully supports the program
and will enable [the Veterans Health Administration] program
officials to comprehensively monitor the program's workload,
including data on the status of applications, appeals, home
visits, and the use of other support services, such as respite
care.'' GAO also recommended that the VA Secretary direct the
Under Secretary for Health ``to use data from the IT system,
once implemented, as well as other relevant data to formally
reassess how key aspects of the program are structured and to
identify and implement modifications as needed to ensure that
the program is functioning as envisioned so that caregivers can
receive the services they need in a timely manner.''
Committee Bill. Section 451(a)(1) of the Committee bill
would amend section 1720G of title 38, U.S.C., to require VA to
expand eligibility for the Program to all eras of veterans in
two phases. The first phase of expanded eligibility would begin
during the 2-year period beginning on the date on which the VA
Secretary submits to Congress a certification that VA has fully
implemented an IT system to support the Program. Section
451(a)(1)(B) of the Committee bill would require VA to submit
the certification date in the Federal Register within 30 days
to ensure public notification. The first phase includes
veterans with a serious injury incurred or aggravated in the
line of duty in the active military, naval, or air service on
or before May 7, 1975. The second phase of eligibility would
begin 2 years after the first phase. This includes those
injured in the line of duty after May 7, 1975, and before
September 11, 2001.
The eligibility criteria created an inequity between post-
9/11 veterans and pre-9/11 veterans. However, VA has
encountered numerous challenges in implementing the program,
and it is clear improvements are needed to ensure the program
is meeting the needs of those currently enrolled and can
sustain an increase in eligible veterans.
The Program's expansion in two phases, as required by this
section, is intended to ensure the Program does not get
overwhelmed and continues to operate as intended, providing
services in a timely manner, while enrolling those who have
become newly eligible. The publication of the VA Secretary's
certification date in the Federal Register is intended to
ensure veterans are notified of the Program's impending
expansion.

Sec. 451(a)(2). Expansion of needed services in eligibility criteria.

Section 451(a)(2) of the Committee bill, which is derived
from S. 1085, would expand the Program's eligibility criteria
for needed services.
Background. Current law, section 1720G of title 38, U.S.C.,
provides that veterans eligible for the Program must be in need
of personal care services because of an inability to perform
one or more activities of daily living, a need for supervision
or protection based on symptoms or residuals of neurological or
other impairment or injury, or such other matters as the VA
Secretary considers appropriate.
Committee Bill. Section 451(a)(2) of the Committee bill
would amend subsection (a)(2)(C) of section 1720G of title 38,
U.S.C., to include a need for regular or extensive instruction
or supervision without which the ability of the veteran to
function in daily life would be seriously impaired among the
criteria considered for needed personal care services. It is
the intent of the Committee to ensure the Program is
consistently inclusive of the caregiving needs required by
mental health conditions, traumatic brain injuries or other
conditions with which eligible veterans may be diagnosed.

Sec. 451(a)(3). Expansion of services provided.

Section 451(a)(3) of the Committee bill, which is derived
from S. 1085, would expand the services provided to caregivers
under the Program of Comprehensive Assistance for Family
Caregivers to include legal and financial planning services.
Background. In 2014, the RAND Corporation released a
report, ``Hidden Heroes: America's Military Caregivers,'' which
examined characteristics of military caregivers and services
available to them. The report indicates that, of the military
caregiver-specific programs identified by RAND, few provide
long-term planning assistance, including legal and financial
planning, for military caregivers.
Committee Bill. Section 451(a)(3) of the Committee bill
would amend subsection (a)(3)(A)(ii) of section 1720G of title
38, U.S.C., to require VA to include financial planning
services and legal services related to the needs of injured
veterans and their caregivers as among the services provided to
caregivers. The section makes clear that VA should provide
these services through the use of contracts with or the
provision of grants to public or private entities.
While section 451(a)(3) requires that financial planning
and legal services be offered to caregivers in the Program, it
is the Committee's intent that VA not provide these services
themselves, but instead partner with public or private
entities. It is also the Committee's intent that, to the
maximum extent practicable, VA should utilize partnerships that
will provide the services pro bono.

Sec. 451(a)(4). Modification of stipend calculation.

Section 451(a)(4) of the Committee bill, which is derived
from S. 1085, would expand the number of factors VA should
consider when determining the amount and degree of personal
care services provided for certain veterans.
Background. Currently, there are three levels of caregiver
stipends based on the amount and degree of personal care
services provided. This was established pursuant to section
1720G of title 38, U.S.C. According to current regulations, the
stipend payment is based on the number of hours of caregiving
required by the veteran. The maximum stipend is based on the
requirement of 40 hours of caregiving each week, the median
stipend is based on the requirement of 25 hours of caregiving
each week, and the lowest stipend is based on the requirement
of 10 hours of caregiving each week. In order to determine the
degree of personal care services required by the veteran, VA
evaluates the veteran and establishes a clinical rating based
on specific criteria regarding the ability to perform
activities of daily living and the need for supervision or
protection based on symptoms or residuals of neurological or
other impairment or injury.
Committee Bill. Section 451(a)(4) of the Committee bill
would amend subsection (a)(3)(C) of section 1720G of title 38,
U.S.C., to ensure VA is considering the assessment by the
family caregiver of the needs and limitations of the veteran;
the extent to which the veteran can function safely and
independently in the absence of such supervision, protection,
or instruction; and the amount of time required for the family
caregiver to provide such supervision, protection, or
instruction to the veteran when determining the amount and
degree of personal care services provided for a veteran whose
need for personal care services is based on a need for
supervision or protection or regular instruction or supervision
under subsection (a)(2)(C) of section 1720G of title 38, U.S.C.
The Committee understands that these determinations are
made at the VA Medical Center level and the intent is to ensure
consistency by VA in determining the amount of hours of
caregiving required by the veteran.

Sec. 451(a)(5). Periodic evaluation of need for certain services.

Section 451(a)(5) of the Committee bill, which is derived
from S. 1085, would require VA to periodically evaluate the
needs of the veteran and the skills of the family caregiver to
determine if additional instruction, preparation, training, or
technical support is needed.
Background. Under section 1720G of title 38, U.S.C., VA is
required to provide instruction, preparation, and training for
family caregivers to provide care to veterans, in addition to
ongoing technical support to address routine, emergency, and
specialized caregiving needs of the family caregiver.
Committee Bill. Section 451(a)(5) of the Committee bill
would amend subsection (a)(3) of section 1720G of title 38,
U.S.C., to require that, in providing instruction, preparation,
and training under subparagraph (A)(i)(I) of that section and
technical support under subparagraph (A)(i)(II) of that section
to each approved family caregiver, the VA Secretary
periodically evaluate the needs of the veteran and the skills
of the family caregiver to determine if additional instruction,
preparation, training, or technical support is necessary.
The requirement for periodic evaluation of this support
will ensure that caregivers have ongoing access to resources
and support for their unique needs as they care for veterans,
especially given that a veteran's needs may change over time as
well as caregiving techniques and best practices.

Sec. 451(a)(6). Use of primary care teams.

Section 451(a)(6) of the Committee bill, which is derived
from S. 1085, would require the VA Secretary to collaborate
with the veteran's primary care team when evaluating
applications for the Program, to the extent practicable.
Background. Under subsection (a)(5) of section 1720G of
title 38, U.S.C., when reviewing applications submitted jointly
by the veteran and family caregiver, VA is required to evaluate
the veteran to identify the personal care services required and
to determine whether the requirements could be significantly or
substantially satisfied through personal care services from a
family member. The determination for a veteran's approval for
the Program is a clinical decision; however, there is no
statutory requirement that VA include the veteran's primary
care team in the evaluation.
Committee Bill. Section 451(a)(6) of the Committee bill
would amend subsection (a)(5) of section 1720G of title 38,
U.S.C., to require that the VA Secretary evaluate each
application submitted jointly by an eligible veteran and family
member in collaboration with the veteran's primary care team to
the maximum extent practicable.
Though the veteran's primary care team maintains the
veteran's treatment once in the Program, it is the intent of
the Committee to ensure multidisciplinary input in the initial
evaluation process, when possible.

Sec. 451(a)(7). Assistance for family caregivers.

Section 451(a)(7) of the Committee bill, which is derived
from S. 1085, would authorize VA, in providing caregiver
services required under current law, to partner with Federal
agencies, States, and private, non-profit, and other entities
to provide the assistance.
Background. There are numerous public and private entities
that provide caregiver services. According to VA's fiscal year
2013 annual report to Congress on assistance and support
services for caregivers, among the services VA provides under
the Program, it contracts with a non-profit organization to
provide the family caregivers' core curriculum training and
with respite care providers in communities.
Committee Bill. Section 451(a)(7) of the Committee bill
would amend subsection (a) of section 1720G of title 38,
U.S.C., to authorize VA to enter into contracts, provider
agreements, and memoranda of understanding with Federal
agencies, States, and private, non-profit, and other entities
to provide family caregiver services required by section 1720G
of title 38, U.S.C. The VA Secretary may provide assistance
under this authority only if it is reasonably accessible to the
family caregiver and is substantially equivalent or better in
quality to similar services provided by VA. In addition, the VA
Secretary could provide fair compensation to entities that
provide assistance under this authority.
The Committee recognizes that other entities provide
services the Program is required to provide, including respite
care, and that VA in some cases is already partnering with
these other entities to provide services. It is the Committee's
intent that, if appropriate in order to provide the services
and they are equivalent or better in quality to similar
services provided by VA, VA continues to utilize its authority
to partner with entities. This could ensure availability of
services and could reduce any duplication.

Sec. 451(b). Modification of definition of personal care services.

Section 451(b) of the Committee bill, which is derived from
S. 1085, would modify the definition of personal care services.
Background. Subsection (d)(4) of section 1720G of title 38,
U.S.C., defines ``personal care services'' as services that
provide the veteran assistance with one or more independent
activities of daily living (subsection (d)(4)(A) of section
1720G of title 38, U.S.C.) and any other non-institutional
extended care (subsection (d)(4)(B) of section 1720G of title
38, U.S.C.).
Committee Bill. Section 451(b) of the Committee bill would
strike ``independent'' in subsection (d)(4)(A) of section 1720G
of title 38, U.S.C., and amend subsection (d)(4) to include
supervision or protection based on symptoms or residuals of
neurological or other impairment or injury and regular or
extensive instruction or supervision without which the ability
of the veteran to function in daily life would be seriously
impaired.
This section is consistent with changes made by sections
451(a)(2) and 451(a)(4) of the Committee bill, which recognize
the need for regular or extensive instruction or supervision
within the definition of personal care services and ensure the
consideration of these personal care needs when determining the
caregiver stipend.

Sec. 452. Implementation of information technology system of Department
of Veterans Affairs to assess and improve the family caregiver
program.

Section 452 of the Committee bill, which is derived from
S. 1085, would require VA to implement a new IT system and
conduct ongoing monitoring and modifications after the system
is implemented.
Background. The requirement that VA implement a new IT
system that can easily retrieve data that will allow all
aspects of the Program to be assessed and comprehensively
monitored, that can manage data, and that has the ability to
integrate with other relevant VHA IT systems, is consistent
with recommendations made by GAO in its September 2014 report.
The report indicated that the IT system currently utilized, the
Caregiver Application Tracker, was developed quickly due to
time constraints on implementing the Program. VA initially
expected the Program to be much smaller, and the Caregiver
Application Tracker was not designed to manage a high volume of
information. As a result, VA is not able to effectively monitor
and assess the Program.
Committee Bill. Section 452 of the Committee bill would, in
a freestanding provision, outline requirements for implementing
an IT system. Section 452(a) of the Committee bill would
require VA to implement an IT system that fully supports the
Program and allows for data assessment and comprehensive
monitoring of the Program not later than December 31, 2016. The
IT system would also be required to include the ability to
easily retrieve data that will allow for comprehensive
monitoring of all aspects of the Program and workload trends,
in addition to the ability to manage data with respect to a
number of caregivers that is greater than the number of
caregivers expected to apply for the Program, and the ability
to integrate the system with other relevant Veterans Health
Administration IT systems. These requirements are consistent
with the GAO recommendations, and it is the Committee's
understanding that the process for developing the new IT system
to support the Program is already underway.
Section 452(b) of the Committee bill would require VA to
use the IT system to assess key aspects of the Program within
180 days of implementation. Section 452(c) of the Committee
bill would require VA to also use the IT system for ongoing
monitoring and assessment, including data on the status of
applications and the use by caregivers of support services such
as respite care. In addition, VA would be required to identify
and implement necessary modifications to ensure the Program is
functioning as intended and providing veterans and caregivers
with services in a timely manner. These requirements are also
consistent with the recommendations made by GAO. In order for
expansion of the Program to begin, the VA Secretary must
certify to the Committee on Veterans' Affairs of the Senate and
House of Representatives and the Comptroller General that the
IT system has been implemented. Section 452(d)(3) of the
Committee bill would require VA to submit the certification,
along with a description of its implementation and utilization
for program monitoring not later than December 31, 2017.
Section 452(d)(1) of the Committee bill would require VA,
within 90 days of enactment, to submit a report to the
Committee on Veterans' Affairs of the Senate and House of
Representatives and the Comptroller General, providing an
update on the status of the planning, development, and
deployment of the IT system. The section would also require
that the report include an assessment of the needs of family
caregivers and veterans who would be eligible for the Program,
as expanded, as well as resources needed for their inclusion.
The intent of this requirement is to ensure proper
preparation for the expansion. The Committee expects to be kept
up to date on the progress of the IT system implementation and
deployment and be informed of any changes to the timeline. By
including GAO as a recipient of the report, GAO will have the
opportunity to review VA's progress in implementing its
recommendations, as required by section 452(d)(2) of the
Committee bill. While GAO's audit quality control processes
require GAO to at least annually follow up on, track, and
record the extent to which GAO's recommendations have been
implemented, the Committee expects GAO to follow up on its
recommendations for the Program more often than annually and
periodically inform the Committees on VA's implementation
status until VA has taken the appropriate corrective actions to
address GAO's findings and recommendations. The Committee also
directs the Comptroller General to notify the Committee on
Veterans' Affairs of the Senate and the House of
Representatives once it has verified that the recommended
actions have been implemented and, to the extent possible, that
the desired outcomes are being achieved, within 45 days of that
determination.

Sec. 453. Modifications to annual evaluation report on caregiver
program of Department of Veterans Affairs.

Section 453 of the Committee bill, which is derived from
S. 1085, would amend requirements for VA's annual evaluation
report on VA's caregiver programs.
Background. Pursuant to the Caregivers and Veterans Omnibus
Health Services Act of 2010 (section 1720G note of title 38,
U.S.C.), VA submits an annual report to the Committee on
Veterans' Affairs of the Senate and House of Representatives.
Currently, VA is required to report on both the Program of
Comprehensive Assistance for Family Caregivers and the Program
of General Caregiver Support and include information regarding
the number of caregivers receiving assistance, the cost to VA
to provide such assistance, a description of outcomes achieved
by the program, an assessment of their effectiveness and
efficiency, and recommendations for legislative or
administrative action. For the Program of Comprehensive
Assistance for Family Caregivers, VA is also required to report
on outreach activities carried out, in addition to an
assessment of the manner in which resources are expended.
Committee Bill. Section 453 of the Committee bill would
amend subparagraph (A)(iv) of section 101(c)(2) of the
Caregivers and Veterans Omnibus Health Services Act of 2010 to
require that VA's annual evaluation report on the Program of
Comprehensive Assistance for Family Caregivers and the Program
of General Caregiver Support include a description of any
barriers to accessing and receiving care and services. It would
also amend subparagraph (B) of such section to require that the
report on the Program of Comprehensive Assistance for Family
Caregivers also include an evaluation of the sufficiency and
consistency of the training provided to family caregivers. The
additional information on barriers to care and services and the
sufficiency and consistency of training will help further
inform the Committee on the effectiveness of the Program and
potential issues that may need to be addressed.

Sec. 454. Advisory committee on caregiver policy.

Section 454 of the Committee bill, which is derived from
S. 1085, would establish a VA advisory committee on caregiver
policy.
Background. VA has 25 advisory committees, including 15
that were established by statute. Advisory committees provide
VA with the opportunity to gain insight from experts and those
impacted by programs and policies. The recommendations and
reports from advisory committees can be a beneficial resource
as VA develops new programs and policies and strengthens its
current programs and policies.
Committee Bill. Section 454 of the Committee bill, in a
freestanding provision, would direct VA to establish an
advisory committee on caregiver policy to regularly review and
recommend veteran caregiver policies to VA, to examine and
advise the implementation of the policies, to evaluate their
effectiveness, to recommend standards of care for caregiver
services and respite care services provided to veterans or
caregivers by private entities, to develop recommendations for
legislative or administrative action to enhance and eliminate
gaps in the provision of services to caregivers and veterans,
and to make recommendations on coordination with state and
local agencies and relevant non-profit organizations on
maximizing the use and effectiveness of resources for veteran
caregivers. The advisory committee would be required to submit
to VA and Congress annual reports on its assessments,
recommendations, and evaluations. The advisory committee would
be authorized through December 31, 2021.
The intent of the advisory committee is to not only review
and evaluate VA policies relating to caregivers of veterans,
but also to identify gaps and duplication in services and
opportunities for coordination with state and local agencies
and relevant non-profit organizations. Federal and state
agencies, in addition to other private entities, provide
services to caregivers, and the Committee believes there is
potential for increased coordination to reduce duplication and
maximize opportunities. If legislation establishing a similar
committee that may have duplicative responsibilities is enacted
through separate legislation, the Committee recognizes that
this specific committee may no longer be necessary.

Sec. 455. Comprehensive study on seriously injured veterans and their
caregivers.

Section 455 of the Committee bill, which is derived from
S. 1085, would require VA to provide for the conduct of a
comprehensive study on veterans and caregivers by an
independent entity.
Background. VA conducts numerous studies, through
collaboration with public and private entities, on health care
related issues impacting veterans. While VA is currently
engaged in research on such issues as traumatic brain injury,
post traumatic stress disorder, and certain aspects of
caregiving, it is not engaged in a comprehensive study on
veterans and caregivers.
Committee Bill. Section 455 of the Committee bill, in a
freestanding provision, would require VA to partner with an
independent entity through a grant or contract to conduct a
comprehensive study on veterans who have incurred a serious
injury or illness, including a mental health injury or illness,
and individuals who are acting as caregivers for veterans.
Section 455(d) of the Committee bill would require that the
study would begin 4 years after the expansion of the Program,
though specific requirements for veteran or caregiver
participation in the Program in order to be included in the
study are not specified and left up to the independent entity.
Section 455(b) of the Committee bill would require the study to
include the health of the veteran, and if applicable, the
impact of the caregiver on the health of the veteran; the
employment status of the veteran, and if applicable, the impact
of the caregiver on the employment status of the veteran; the
financial status and needs of the veteran; and the veteran's
use of benefits available through VA. Section 455(e) of the
Committee bill would require VA to submit a report on the
results of the study to the Committee on Veterans' Affairs of
the Senate and House of Representatives. Additional insight
into the impact of caregivers on veterans' health and well-
being and the needs of caregivers and the veterans for whom
they care will help inform VA and Congress on any improvements
or modifications that could be made.

SUBTITLE F--HEALTH CARE AGREEMENTS

Sec. 461. Authorization of agreements between the Department of
Veterans Affairs and non-Department extended care providers.

Section 461 of the Committee bill, which is derived from
S. 2000, would add a new section 1703A to title 38, U.S.C., to
provide that VA may enter into agreements to provide nursing
home care and those agreements may be entered into without
regard to any law that would require VA to use competitive
procedures in selecting the party with which to enter into the
agreement. Generally, a nursing home in carrying out that
agreement would not be subject to any law that Medicare
providers are not subject to.
Background. Currently, if VA cannot provide extended care
services to veterans at a VA nursing home or community living
center, VA may contract to provide those services in the
community. However, the contract VA would enter into with a
community extended care provider would be required to be
Federal Acquisition Regulation (hereinafter, ``FAR'') based
agreements. FAR-based agreements require reporting of employee
and applicant data and demographics that would be burdensome to
extended care providers, and has served as a deterrent for
extended care providers to care for veterans. As Fred Benjamin,
Vice President and Chief Operating Officer of Medicalodges,
Inc., testified before the Committee on June 3, 2015, ``[f]or
our company, and many extended care providers, FAR-based
agreements are simply not workable, and a streamlined approach
that still protects Veterans, taxpayers, and preserves
oversight is desperately needed.'' Medicare and Medicaid
providers are not considered to be Federal contractors by
regulations developed by the Department of Labor; however, if
those same extended care providers care for a veteran they will
be required to enter into a FAR-based agreement.
Committee Bill. Section 461 of the Committee bill would
authorize VA to enter into agreements that are exempt from
certain provisions of law to provide extended care services to
veterans.
Section 461(a) of the Committee bill would create a new
section 1703A in title 38, U.S.C., which would provide VA the
authority to enter into provider agreements to provide extended
care services to veterans. Section 1703A(a) of title 38,
U.S.C., would allow VA to provide extended care services to
veterans through the use of agreements if that care cannot be
provided at a VA facility. Section 1703A(b) defines which
veterans would be eligible for care under a Veterans Extended
Care Agreement and directs that VA may not direct veterans to a
particular provider. Section 1703A(c) would define the eligible
providers to be participants of the United States Medicare and
Medicaid programs or other providers the VA Secretary deems
appropriate. Section 1703A(d) would require VA to promulgate
regulations to establish a certification process for providers.
Section 1703A(e) would establish the terms of the Veterans
Extended Care Agreements to specify the rates VA would
reimburse, ensure the return of medical records to VA, ensure
that the provider does not attempt to collect compensation from
a third party or health care plan for extended care services
provided under the agreements, ensure that only care authorized
by VA would be provided under the agreement, and would
establish a methodology for providers to submit bills to VA.
Section 1703A(f) would establish the circumstances under which
an agreement could be terminated.
Section 1703A(g) would direct VA to conduct periodic
reviews of agreements over $1,000,000 annually to determine if
the extended care services should be provided at VA, through a
contract, or through a sharing agreement. Section 1703A(h)
would exclude the Veterans Extended Care Agreements from any
law that would require VA to use competitive contracting
procedures; however, the providers would be required to follow
certain laws relating to ethics, fraud, integrity, or those
laws that subject a person to civil or criminal penalties as if
they were incorporated in the agreements. The language in
section 1703A(h) was overwhelmingly agreed upon on a bipartisan
basis by members of the Committee as a result of an amendment
offered in Committee and reflects a compromise suggested by a
Democratic Senator.
Section 1703A(i) would direct VA to establish a procedure
to monitor the quality of care provided through the agreements.
Section 1703A(j) would direct VA to establish procedures for
providers to present disputes related to the agreements.
Section 1703A(k) would provide that this section would
sunset 2 years after enactment of the Jason Simcakoski Memorial
Act.
Section 461(b) of the Committee bill would direct VA to
promulgate an interim final rule to carry out this section no
later than 1 year after the date of enactment.
Section 461(c) of the Committee bill would make a clerical
change to add section 1703A to the table of contents for
chapter 17 of title 38, U.S.C.
It is the Committee's intent that a Veterans Extended Care
Agreement will not be considered a ``contract'' or ``contract-
like instrument'' as those terms are defined in Executive Order
13658 and its implementing regulations (29 C.F.R. Part 10). Any
Veterans Extended Care Agreement will not be treated as a
Federal contract or subcontract for the acquisition of goods or
services and will not be subject to any provision of law
governing Federal contracts or subcontracts for the acquisition
of goods or services. This section intends to ensure veterans'
access to high-quality extended care if that care is not
available directly from VA while ensuring providers are subject
to robust terms and conditions that address the quality of care
for veterans, oversight of the provision of such care, and
protections for taxpayers.

Sec. 462. Modification of authority to enter into agreements with State
homes to provide nursing home care.

Section 462 of the Committee bill, which is derived from
S. 2000, would amend section 1745 of title 38, U.S.C., to
provide that VA may enter into agreements to provide nursing
home care and those agreements may be entered into without
regard to any law that would require VA to use competitive
procedures in selecting the party with which to enter into the
agreement. Generally, a State home in carrying out that
agreement would not be subject to any law that Medicare
providers are not subject to.
Background. Currently, VA may enter into contracts or
agreements with State Veterans Homes to provide extended care
services to certain veterans; however, those contracts or
agreements would need to be FAR-based contracts. FAR-based
agreements require reporting of employee and applicant data and
demographics that would be burdensome to State Veterans Homes.
Medicare and Medicaid providers are not considered to be
Federal contractors by regulations developed by the Department
of Labor; however, a State Veterans Home agreement or contract
with VA would be a FAR-based agreement.
Committee Bill. Section 462 of the Committee bill would
amend section 1745 of title 38, U.S.C., to modify how VA enters
into agreements exempt from certain provisions of law with
State Veterans Homes. Section 462(a) of the Committee bill
would amend section 1745(a) of title 38, U.S.C., by replacing
language to provide VA the authority to enter into agreements
with State Veterans Homes. Section 462(b) of the Committee bill
would further amend such section to exempt the agreements from
any law that would require competitive contracting procedures.
Section 462(c) of the Committee bill would direct that section
1745, as amended, would apply to agreements entered into 30
days after the date of enactment.
It is the Committee's intent that an agreement made under
this section will not be considered a ``contract'' or
``contract-like instrument'' as those terms are defined in
Executive Order 13658 and its implementing regulations (29
C.F.R. Part 10). Any agreement entered into will not be treated
as a Federal contract or subcontract for the acquisition of
goods or services and will not be subject to any provision of
law governing Federal contracts or subcontracts for the
acquisition of goods or services. This section intends to
ensure veterans' access to high-quality extended care services
if that care is not available directly from VA while ensuring
providers are subject to robust terms and conditions that
address the quality of care for veterans, oversight of the
provision of such care, and protections for taxpayers.

TITLE V--OTHER MATTERS

Sec. 501. Extension of temporary increase in number of judges on United
States Court of Appeals for Veterans Claims.

Section 501 of the Committee bill, which is derived from
S. 1754, continues the expansion of the United States Court of
Appeals for Veterans Claims from seven to nine authorized
judges through January 1, 2021.
Background. The Veterans Court is a national court of
record established under Article I of the Constitution that
reviews appeals from decisions rendered by VA's Board of
Veterans' Appeals. Under section 7253(a) of title 38, U.S.C.,
the Veterans Court was originally authorized to be composed of
not more than seven judges. In 2001, the Veterans Court was
temporarily expanded from seven to nine authorized judges for
the period spanning January 2002 through August 2005 by Public
Law 107-103. In 2008, the Veterans Court was again expanded
from seven to nine authorized judges until January 2013 by
Public Law 110-389. By December 2012, a full complement of nine
judges had been confirmed by the U.S. Senate. Since then, two
judges have retired, leaving the total number of confirmed
judges at the time of the writing of this report at seven.
Because the most recent temporary expansion of the court has
expired, the eighth and ninth judges cannot be replaced. In
recent years, the Board of Veterans' Appeals has increased the
volume of decisions it is rendering annually, suggesting there
may be a larger volume of incoming appeals ripe for Veterans
Court review in the coming years.
Committee Bill. Subsection (a) of section 501 of the
Committee bill would amend section 7253 to expand the number of
authorized judges at the Veterans Court to nine through January
1, 2021. Subsection (b) of section 501 of the Committee bill
would require the chief judge of the Veterans Court to report
to Congress not later than June 30, 2020, on the temporary
expansion, including an assessment on the effect of the
expansion to ensure appeals are handled in a timely manner, a
description of the types of ways in which the complexity levels
of appeals may vary based on appellants' eras of service, and a
recommendation on whether the number of judges should be
adjusted at the end of the expansion time.
It is the view of the Committee that allowing the temporary
expansion of the court to continue until 2021 will help allow
the Veterans Court to address the anticipated surge in incoming
appeals. Because the workload of the Veterans Court has varied
over the years based on a number of factors, the temporary
expansion coupled with the reporting requirement will allow
Congress to again assess the appropriate size of the court
prior to the expiration of this expansion.

Sec. 502. Repeal inapplicability of modification of basic allowance for
housing to benefits under laws administered by Secretary of
Veterans Affairs.

Section 502 of the Committee bill, which is an original
provision, would repeal section 604(b) of Public Law 113-291 in
order to realign the housing allowance provided to VA
beneficiaries using Post-9/11 GI Bill benefits so it is paid at
the same rate as the Basic Allowance for Housing provided to
active duty military personnel in pay grade E-5 at the ``with
dependents'' rate.
Background. Section 604 of the Carl Levin and Howard P.
``Buck'' McKeon National Defense Authorization Act for Fiscal
Year 2015 (Public Law 113-291) allowed the Secretary of Defense
to change how basic allowance for housing is computed under
section 403 of title 37, U.S.C. Specifically, it authorized the
Secretary of Defense to reduce the monthly allowance rate by 1
percent of the average national housing costs for each pay
grade and dependent status. This provision is similar to
section 603 of the legislative proposals for fiscal year 2015
that the Department of Defense transmitted to Congress.
As part of the final language agreed to by the Senate and
the House of Representatives, subsection 604(b) of Public Law
113-291 specified that any authorized reductions to the monthly
rate under section 403 of title 37, U.S.C., would not apply to
benefits paid by the VA Secretary. Instead, that subsection
specified that benefits paid by the VA Secretary would be paid
according to section 403 of title 37, U.S.C., as that section
was written prior to enactment of Public Law 113-291.
Committee Bill. Section 502 of the Committee bill repeals
section 604(b) of the Carl Levin and Howard P. ``Buck'' McKeon
National Defense Authorization Act for Fiscal Year 2015 (Public
Law 113-291), removing the exception of benefits paid by the
Secretary of Veterans Affairs from the new calculation of basic
allowance for housing under section 403 of title 37, U.S.C. The
repeal of section 604(b) in the Carl Levin and Howard P.
``Buck'' McKeon National Defense Authorization Act for Fiscal
Year 2015 (Public Law 113-291) is made effective January 1,
2016, with the intent that housing allowance rates for benefits
under chapters 31 and 33 of title 38, U.S.C., will match those
prescribed according to section 403 of title 37, U.S.C., when
those rates are adjusted on August 1, 2016.

Sec. 503. Department of Veterans Affairs program of internal audits.

Section 503 of the Committee bill, which is derived from
S. 1641, would establish an independent and interdisciplinary
office in the Office of the Secretary to regularly conduct
internal audits to improve the delivery of benefits and health
care to veterans and their families.
Background. In fiscal year 2016, Congress provided VA $71.2
billion in discretionary funding, which is in addition to the
$94.5 billion in the Department's mandatory accounts. This
funding is vitally important for providing health care and
benefits to our nation's veterans. However, the Department does
not currently undertake a regular, formal audit process to
determine whether its funds are being used for the maximum
benefit of veterans and their families, despite the fact that
VHA is the largest integrated health system in the country.
Many of the nation's largest health systems, such as Emory
Health care, have an established internal audit process to
identify and evaluate risks to the system as well as to drive
efforts at improving the system and protecting institutional
resources. The ability to conduct internal audits allows large
health care systems to monitor systemic adherence to policies
and procedures and to address any pressing concerns within the
organization.
In January 2015, GAO added VHA to the GAO High Risk List, a
designation that GAO assigns to government operations and
programs it has identified as high risk due to vulnerability to
fraud, waste, abuse, and mismanagement or the need to transform
in order to address economic, efficiency, or effectiveness
challenges. GAO concluded it was necessary to place VA on this
list because of ambiguous policies and inconsistent processes,
inadequate oversight and accountability, information technology
challenges, inadequate training for staff, and unclear resource
needs and allocation priorities within VHA. If VA is to comply
with the recommendations GAO made in order to be removed from
the High Risk List, then it will need to prove a sustained
ability to allocate resources appropriately in areas of the
highest need and to consistently implement policies across the
health care system. In order to understand where resources are
most needed, VA must have a better understanding of where the
biggest problems are and an ability to determine how to address
those problems. The ability to self-assess issues through an
internal review process would assist VA in addressing any new
issues before they rise to the level of threatening VA's
ability to deliver health care or benefits.
Section 201 of the Veterans Access, Choice, and
Accountability Act of 2014 (Public Law 113-146) required the
commissioning of an Independent Assessment of the Health Care
Delivery Systems and Management Processes of the Department of
Veterans Affairs (hereinafter, ``Independent Assessment''). The
Independent Assessment was reported to the Committee on
September 1, 2015, and cost approximately $68 million to
complete. This assessment provided an important review of VHA
programs, including those that the Committee has held hearings
on during the past year, such as construction, the non-VA care
program, and the addition of VA to GAO's High Risk List. One of
the key findings from the Independent Assessment was the need
to take a systemic approach to addressing the challenges at VA
that were identified in the Independent Assessment.
Enhanced internal assessment is an important tool for
identifying opportunities early--before material weaknesses
develop--for improvement of conditions within the Department
that can result in financial loss or can affect care. On
January 12, 2016, an OIG Audit of Non-VA Medical Care
Obligations found VA facilities returned $1.9 billion to the
Department of Treasury in fiscal year 2013 because the
facilities did not manage their obligations appropriately. OIG
found a reduction in the over-obligation of Non-VA Care funds
from approximately 29 percent to 10 percent would have allowed
an increase in approximately $358 million in direct Non-VA Care
services to veterans. A September 28, 2015, OIG Administrative
Investigation revealed Senior Executive Service employees were
utilizing the relocation program and employee incentives in the
Veterans Benefits Administration, including spending $1.8
million for 23 reassignments from fiscal year 2013 to fiscal
year 2015. The OIG identified an inadequate approval process
and a lack of standardization regarding practices regarding
annual salary increases as contributing factors to this
excessive spending by VA. The findings in these two reports
illustrate systematic failures within VA that might have been
prevented before costing the agency millions of dollars in lost
or inappropriately used resources. A more robust internal
auditing system could uncover problems at an early stage and
serve as an alert that intervention is needed in order to
preserve resources and avoid fraud, waste, and abuse.
In addition to the work done at GAO and OIG, the Committee
plays a vital role in the ongoing oversight of VA. VA's lack of
a consistent process and protocol regarding internal auditing
and self-assessment impacts many of the topics the Committee's
work covers. In fact in 2015, Committee oversight addressed
several budget shortfalls, including cost overruns associated
with building a new medical center in Denver and the poor
financial forecasting that led to a $3.2 billion gap in VHA's
non-VA care budget.
Despite the success of the above-mentioned audits,
investigations and Congressional inquiries, these alone cannot
achieve the type of insight into risks, effectiveness, and
planning that is necessary to ensure the Department's smooth
provision of benefits and health care to veterans and their
families. In order to demonstrate the Department's ability to
consistently manage the funding that is provided to it for the
care and benefits of veterans and their families, the Committee
believes the VA Secretary must engage in regular, independent
review across the Department's offices to better monitor the
delivery of health care and benefits to veterans and their
families.
Committee Bill. Subsection (a) of section 503 of the
Committee bill would establish a program of internal audits and
self-analysis at VA. The Committee believes this program will
improve the delivery of benefits and health care to veterans
and their families. The newly-established program would be an
independent, interdisciplinary office within the Office of the
Secretary tasked with conducting periodic risk assessments.
These risk assessments would then be utilized to develop a plan
to conduct internal audits.
The VA Secretary would be required to audit no fewer than
five covered administrations or their functions, staff
organizations, or staff offices each year. In determining which
risk assessments to undertake, the VA Secretary would be
required to prioritize administrations, such as VHA or the
Veterans Benefits Administration and their functions, such as
mental health and compensation and pension. Audits of staff
organizations, including the Office of Acquisition, Logistics,
and Construction, the Board of Veterans' Appeals, and the
Office of Regulation Policy and Management, and staff offices,
including the Office of the Assistant Secretary for
Congressional and Legislative Affairs, the Office of the
Assistant Secretary for Information and Technology, and the
Office of Management would also be authorized.
Subsection (b) of section 503 of the Committee bill would
require the VA Secretary to complete the first required risk
assessment within 180 days of enactment. When the VA Secretary
completes an audit under the program, the VA Secretary would be
required to submit a report on the audit to the Senate and
House Committees on Veterans' Affairs, the Senate and House
Committees on Appropriations, the Senate Committee on Homeland
Security and Governmental Affairs, and the House Committee on
Oversight and Government Reform within 90 days of completion of
the audit. The submitted report would include a summary of the
audit, the findings in the report, the recommendations for
legislative or administrative action to improve the furnishing
of benefits and health care to veterans and their families and
the plans, including timelines, to carry out the
recommendations that the VA Secretary can complete without
legislative action.
Finally, the VA Secretary would be required to submit to
the Senate and House Committees on Veterans' Affairs, the
Senate and House Committees on Appropriations, the Senate
Committee on Homeland Security and Governmental Affairs, and
the House Committee on Oversight and Government Reform by
September 1 of each year a plan for risk assessments and audits
to be conducted in the next fiscal year.

Sec. 504. Improvement of training for managers.

Section 504 of the Committee bill, which is derived from
S. 1856, would require VA to provide periodic training to its
managers.
Background. On June 24, 2015, the Committee held a
legislative hearing to consider certain benefits and health
care legislation pending before the Committee. The Partnership
for Public Service (hereinafter, ``Partnership'')--a
nonpartisan, non-profit organization dedicated to revitalizing
the Federal civil service and transforming the way government
works--testified at the hearing. In its testimony, the
Partnership mentioned that ``the biggest contributor to the
performance problems at the VA is the quality of the
management, rather than the quality of the system.''\22\ The
Partnership also mentioned that ``the process for removing or
disciplining a Federal employee is daunting in terms of the
time and effort required, and this discourages some managers
from taking appropriate action.''\23\ According to the
Partnership, often managers are not trained in handling
disciplinary actions and administrative support to take
action.\24\ The importance of training was also stressed during
the Committee's legislative hearing on September 16, 2015, by
Donald F. Kettl, a professor at the School of Public Policy at
the University of Maryland. In his testimony in support of
S. 1856, Professor Kettl discussed how S. 1856 would
significantly advance the nation's efforts to care for its
veterans for it places training at the center of the
Department's career development network.\25\ In his testimony,
Professor Kettl mentioned that training is the most essential
component, for the Committee is not only trying to solve the
serious problems that plague the Department today, but the
Committee is also building the foundation on which its future
service to veterans depends. According to Professor Kettl,
``[t]he only effective way to avoid future crises is to build--
now--the capacity the Department will need tomorrow.''\26\ To
bring greater accountability to the Department, and to build
the capacity the Department will need in the future, the
Department must invest in providing regular training to its
managers.
---------------------------------------------------------------------------
\22\Testimony of Max Stier, President and CEO of the Partnership
for Public Service, during a hearing entitled, ``Pending Health and
Benefits Legislation,'' before the Senate Committee on Veterans'
Affairs, June 24, 2015, available at http://www.veterans.senate.gov/
imo/media/doc/PPS%20Stier%20Testimony%206.24.15.pdf.
\23\Id.
\24\Id.
\25\Testimony of Donald F. Kettl, Professor, School of Public
Policy University of Maryland, during a hearing entitled, ``Pending
Health and Benefits Legislation,'' before the Senate Committee on
Veterans' Affairs, September 16, 2015, available at http://
www.veterans.senate.gov/imo/media/doc/
D%20Kettl%20Testimony%2009.16.2015.pdf.
\26\Id.
---------------------------------------------------------------------------
Committee Bill. Section 504 would require VA to provide
each employee who is in a managerial position with periodic
training on the following: (1) the rights of whistleblowers and
how to address a report by an employee of a hostile work
environment, reprisal, or harassment; (2) how to effectively
motivate, manage, and reward the employees who report to the
manager; and (3) how to effectively manage employees who are
performing at an unacceptable level and access assistance from
the VA Office of Human Resources Management and the Office of
General Counsel with respect to those employees.

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 Congressional Budget Office
(hereinafter, ``CBO''), estimates that enactment of the
Committee bill would, relative to current law, decrease direct
spending by $4.1 billion over 10 years and increase
discretionary spending by $3.5 billion over 5 years. Enactment
of the Committee bill 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, September 9, 2016.
Hon. Johnny Isakson,
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. 425, the Veterans
Homeless Programs, Caregiver Services, and Other Improvements
Act of 2015.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann Futrell.
Sincerely,
Keith Hall,
Director.

Enclosure.

S. 425--Veterans Homeless Programs, Caregiver Services, and Other
Improvements Act of 2015

Summary: Enacting S. 425 would reduce benefits provided
under certain education programs administered by the Department
of Veterans Affairs (VA) while expanding eligibility under
those programs for some beneficiaries. The bill also would
increase the amount of the pension paid to Medal of Honor
recipients. On net, those changes would decrease direct
spending by $4.1 billion over the 2017-2026 period.
In addition, S. 425 would make a number of changes to VA's
health care programs, including expanding the caregivers
program, improving benefits for homeless veterans, and
increasing pay for medical staff. In total, CBO estimates that
implementing those provisions would cost $3.5 billion over the
2017-2021 period, subject to appropriation of the necessary
amounts.
Pay-as-you-go procedures apply because enacting the
legislation would affect direct spending. Enacting the bill
would not affect revenues. CBO estimates that enacting S. 425
would not increase net direct spending or on-budget deficits in
any of the four consecutive 10-year periods beginning in 2027.
S. 425 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would benefit public entities, including educational
institutions and health care providers, that provide services
to veterans. Any costs those entities might incur would be
incurred as conditions of participating in a voluntary federal
program.
Estimated cost to the Federal Government: The estimated
budgetary effect of S. 425 is shown in Table 1. The costs of
this legislation fall within budget function 700 (veterans
benefits and services).

Table 1.--Estimated Budgetary Effects of S.425, The Veterans Homeless Programs, Caregiver Services, and Other
Improvements Act of 2015
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
---------------------------------------------------------
2017 2018 2019 2020 2021 2017-2021
----------------------------------------------------------------------------------------------------------------
DECREASES IN DIRECT SPENDINGa

Estimated Budget Authority............................ -13 -151 -300 -426 -453 -1,345
Estimated Outlays..................................... -13 -151 -300 -426 -453 -1,345

INCREASES IN SPENDING SUBJECT TO APPROPRIATION

Estimated Authorization Level......................... 40 162 518 1,105 1,902 3,728
Estimated Outlays..................................... 33 143 482 1,040 1,808 3,507
----------------------------------------------------------------------------------------------------------------
Note: Details do not add to totals because of rounding.
aEnacting S.425 would have effects beyond 2020. CBO estimates that under the bill, direct spending would
decrease by $4.1 billion over the 2017-2026 period.

Basis of estimate: For this estimate, CBO assumes that
S. 425 will be enacted at the start of fiscal 2017, that the
estimated amounts will be appropriated each year, and that
outlays will follow historical spending patterns for affected
programs.

Direct spending

S. 425 would reduce the amounts paid for certain education
and rehabilitation benefits provided by VA and expand
eligibility for those programs. It also would increase the
amount of the pension the department pays to Medal of Honor
recipients. On net, those changes would decrease direct
spending by $4.1 billion over the 2017-2026 period (see Table
2).
Reduced Housing Allowances. Under the Post-9/11 GI Bill
(Chapter 33), VA provides monthly housing allowances to certain
beneficiaries while they are in school. Those allowances are
set at the amount of the housing allowance paid by the
Department of Defense (DOD) to enlisted servicemembers with
dependents and a rank of E-5. Additionally, VA provides some
disabled veterans enrolled in education and training for
rehabilitation with a monthly stipend at that same rate.
Section 502 would reduce those payments.

Table 2.--Estimate of the Effects of S.425 on Direct Spending
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
------------------------------------------------------------------------------------------
2017 2018 2019 2020 2021 2022 2023 2024 2025 2016 2017-2021 2017-2026
--------------------------------------------------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Reduced Housing Allowances
Estimated Budget Authority................................. -8 -137 -269 -373 -387 -408 -429 -450 -468 -481 -1,174 -3,410
Estimated Outlays.......................................... -8 -137 -269 -373 -387 -408 -429 -450 -468 -481 -1,174 -3,410
Transferred Education Benefits
Estimated Budget Authority................................. -10 -24 -42 -64 -80 -91 -102 -117 -131 -151 -220 -812
Estimated Outlays.......................................... -10 -24 -42 -64 -80 -91 -102 -117 -131 -151 -220 -812
Restoration of Education Benefits
Estimated Budget Authority................................. 3 3 4 4 5 5 5 5 6 6 19 46
Estimated Outlays.......................................... 3 3 4 4 5 5 5 5 6 6 19 46
Credit for Time in Medical Care
Estimated Budget Authority................................. 0 3 3 3 4 4 4 4 4 5 13 34
Estimated Outlays.......................................... 0 3 3 3 4 4 4 4 4 5 13 34
Fry Scholarships
Estimated Budget Authority................................. 2 2 2 2 3 3 3 3 3 3 11 26
Estimated Outlays.......................................... 2 2 2 2 3 3 3 3 3 3 11 26
Medal of Honor Pensions
Estimated Budget Authority................................. 0 2 2 2 2 2 2 1 1 1 6 14
Estimated Outlays.......................................... 0 2 2 2 2 2 2 1 1 1 6 14
------------------------------------------------------------------------------------------
Total Changes in Direct Spending
Estimated Budget Authority............................... -13 -151 -300 -426 -453 -485 -517 -554 -585 -617 -1,345 -4,102
Estimated Outlays........................................ -13 -151 -300 -426 -453 -485 -517 -554 -585 -617 -1,345 -4,102
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Details do not add to totals because of rounding.

The Department of Defense sets its housing allowances on
the basis of average housing costs for each locality. The
Congress, in the National Defense Authorization Act for Fiscal
Year 2016 (Public Law 114-92), authorized the department to
reduce those allowances by up to 5 percent below the average.
DOD has cut that allowance by 2 percentage points to 98 percent
of the average for 2016. CBO expects that DOD will phase in the
rest of the reduction by 1 percentage point a year through
2019. Under current law, VA's housing allowances are exempt
from those reductions. Section 502 would strike VA's exemption,
resulting in a decrease in the allowances provided by VA.
Based on current enrollment data, CBO estimates that about
800,000 people will use Chapter 33 benefits in 2017, and that
the housing allowance per beneficiary will average about $7,800
in that year. (Many beneficiaries are not eligible to receive a
housing allowance from VA, and most of those who do only
receive the allowance during the 9-month academic year; thus,
the average payment is significantly less than the
approximately $19,500 in housing allowance that an E-5 with
dependents would receive in 2017.) On that basis, and
accounting for growth in the eligible population and
incorporating annual inflation, CBO estimates that enacting
section 502 would reduce direct spending for Chapter 33
benefits by about $3.2 billion over the 2017-2026 period.
About 27,000 disabled veterans enrolled in college,
apprenticeship programs, or on-the-job training through VA's
rehabilitation services receive the same housing stipend as
that provided to Chapter 33 beneficiaries. Those stipends would
be similarly affected by section 502. CBO estimates that
cutting the stipends as described above would reduce direct
spending for rehabilitative benefits by about $170 million over
the 2017-2026 period.
In total, enacting section 502 would reduce direct spending
by $3.4 billion over the 2017-2026 period.
Transferred Education Benefits. Servicemembers who earn
benefits under the Post-9/11 GI Bill can use those benefits
themselves or transfer them to their dependents. Section 202
would modify the authorities under which servicemembers may
make such transfers. On net, those changes would reduce direct
spending by about $800 million over the 2017-2026 period, CBO
estimates.
Housing Allowance. Section 202 would reduce by half the
monthly housing allowance paid to children who use transferred
benefits. That reduction would apply to benefits that are
transferred to children180 days or more after the bill is
enacted. Based on current payment levels and adjusting for the
effect of section 502 as discussed above and for expected
inflation, CBO estimates that the annual payment for the
housing allowance under the Post-9/11 GI Bill will average
about $7,600 in 2017 and $8,500 over the 2017-2026 period.
(That annual payment may represent an academic years' worth of
benefits for one student or portions of an academic year for
two or more students.)
Based on data from DOD, CBO estimates that about 38,000
servicemembers will transfer their education benefits to their
children each year. Less than 10 percent of children who
receive transferred benefits will be college-aged at the time
of the transfer and only half will reach college age during the
subsequent 10-year period. Thus, the reduction in the housing
allowance would affect a small number of annual payments
initially--about 1,700 in 2017. The number of reduced payments
would increase over time to about 40,000 annual payments in
2026. CBO estimates that the number of annual payments that
would be cut in half under section 202 would total roughly
210,000 over the 2017-2026 period, reducing direct spending by
$940 million.
Conditions for Transferring Benefits. Section 202 also
would change the terms under which servicemembers may transfer
Chapter 33 benefits to their spouses and children. Under
current law, members must serve at least 6 years and agree to
serve another 4 years to be eligible to transfer their
benefits. Spouses are able to begin using those transferred
benefits immediately, while children must wait until the member
has completed 10 years of service. Under section 202, members
would have to serve at least 10 years, and agree to serve an
additional 2 years in order to transfer benefits. Spouses and
children could begin using benefits as soon as they are
transferred by the member.
CBO expects that those changes would cause some
servicemembers who, under current law, would choose to transfer
benefits, to instead leave the military and use their benefits
themselves. Because servicemembers would have to wait four more
years before committing to additional military service, they
would have more opportunities to leave the armed forces. Also,
spouses would have to wait an additional 4 years to use
transferred benefits, somewhat reducing their value to the
spouse. Finally, the length of service required from the member
would increase from 10 years to 12 years.
Based on the rate at which personnel leave the military
between their 6th and 10th years of service, CBO estimates that
each year about 1,800 members who would have committed to
additional service in order to transfer benefits under current
law would, under this provision, leave the military and retain
those benefits for their own use. That change would have
several offsetting effects that would, on net, increase direct
spending by $125 million over the 2017-2026 period, CBO
estimates. Those effects include:

Increased costs of $520 million for an additional
17,000 servicemembers who would separate and use additional
benefits;
Increased costs of $40 million for the roughly
1,400 additional recruits who would replace some of those
separating servicemembers and then later separate and use
education benefits near the end of the budget window;
Decreased costs of $245 million because spouses
who do receive transferred benefits would have to wait an
additional 4 years to use them, reducing the total number of
spouses who attend school over the next 10 years by about
5,500;
Decreased costs of $90 million because about 3,700
fewer spouses would receive transferred benefits; and
Decreased costs of $100 million because about
14,000 fewer children would receive transferred benefits, about
1,700 of whom would have reached college age during the next 10
years.

Restoration of Education Benefits. Section 201 would
increase the education benefits that VA provides under the
Post-9/11 GI Bill by restoring some of those benefits to
students who attend institutions that permanently close during
an academic term.
Under current law, VA pays educational institutions at the
start of the academic term for beneficiaries' tuition and fees.
It then reduces the months of education benefits available to
those students by the duration of that term. If a school
permanently closes during the term, students will have been
charged for use of the benefit, but may not have received
academic credit. Additionally, VA discontinues payment of the
monthly housing allowance to students at the time the school
closes. Military personnel earn 36 months of Chapter 33
benefits if they serve on active duty after September 11, 2001;
however, beneficiaries may have fewer than 36 months available
if servicemembers transfer a portion of the benefit to
dependents or use education benefits under a different VA
education program. The bill would direct VA to restore lost
months of education benefits to students who do not receive
credit for a term as a result of school closures occurring in
2015 or thereafter.
Restoring benefit months would increase VA's payments only
for those students who would otherwise use every month of
education benefit currently available to them. In addition,
those new costs would not begin to accrue for a beneficiary
until that individual had used each month of eligibility
available to them under current law and continued on to use
months newly available under this provision. Thus, CBO expects
that additional costs resulting from closures in a particular
year would occur over several subsequent years.
On the basis of data from VA regarding usage rates for its
education programs, CBO expects that roughly 900 students using
the Post-9/11 GI Bill will be affected by school closures each
year and that about half of those beneficiaries will use every
month of education benefit available to them under the current
program. Thus, CBO estimates that under section 201, about 450
beneficiaries a year would receive about 5 months of restored
eligibility that they would use over the succeeding years. CBO
further estimates that the average cost of that additional
usage would be $6,300 in 2017 and would increase with inflation
in subsequent years. On that basis, restoring benefits under
section 201 would increase direct spending by $28 million over
the budget window, CBO estimates.
Section 201 also would require VA to continue to pay the
monthly housing allowance to beneficiaries affected by school
closures for the lesser of 4 months or the remainder of the
cancelled term. Under that requirement, CBO estimates that 900
students a year would receive an average of three additional
months of housing allowance at a cost of $1,900 per person in
2017. After incorporating annual inflation, those additional
payments would increase direct spending by a total of $18
million over the 2017-2026 period, CBO estimates.
In total, enacting section 201 would increase direct
spending by $46 million over the 2017-2026 period.
Credit for Time in Medical Care. Section 210 would allow
the time a reservist serves on active duty while receiving
medical care or undergoing a medical evaluation to count as
qualifying service for accruing education benefits under the
Post-9/11 GI Bill. To qualify for full benefits under Chapter
33, veterans must serve 36 months on active duty or receive a
disability retirement. Reduced benefits, between 40 percent and
90 percent of the full benefit, are available to veterans who
serve less than 36 months but at least 90 days.
On the basis of historical data from the Department of
Defense regarding activations for medical evaluations or care,
CBO estimates that about 1,000 reservists will be called to
active duty for those reasons annually, and spend an average of
7 months in that status. That additional qualifying service
would increase benefit payments for those reservists who would
not qualify for full Chapter 33 benefits under current law.
That change would apply to benefits used after 2017. On the
basis of average benefits, CBO estimates that those reservists
who would receive an additional $2,600 in benefits in 2018.
That amount would increase annually to reflect the increased
cost of higher education.
Based on personnel data from DOD, CBO estimates that under
section 210, about 25 percent of the reservists who are
activated for medical care would receive and use additional
benefits as a result of that service. Because beneficiaries
typically attend school over several years, approximately 1,000
people would receive a larger benefit each year. In total, the
additional payments from VA for those benefits would increase
direct spending by $34 million over the 2017-2026 period, CBO
estimates.
Fry Scholarships. The Marine Gunnery Sergeant John David
Fry Scholarship provides 36 months of education benefits under
the Post-9/11 GI Bill to spouses and children of servicemembers
who died on active duty at any time after September 11, 2001.
Section 209 would allow recipients of the Fry scholarship to
receive additional benefits under the Yellow Ribbon GI
Education Enhancement Program (YRP). As part of the Post-9/11
GI Bill, that program provides additional payments for some
students--such as those at certain private schools and out-of-
state students attending public schools--who face tuition and
fees above what VA will typically cover. Institutions
participating in the YRP agree to cover a portion of the
difference between the tuition charged and the amount that VA
would otherwise pay. VA then matches that financial assistance,
thereby reducing or eliminating students' out-of-pocket
expenses.
In 2014, VA made payments averaging $5,700 for 4 percent of
the students who were eligible for the Yellow Ribbon Program.
About 5,600 people with Fry Scholarships will attend school
each year, CBO estimates. Assuming the same percentage of
students with Fry Scholarships get similar YRP benefits
(incorporating annual inflation), those additional payments
would increase direct spending by $26 million over the 2017-
2026 period, CBO estimates.
Medal of Honor Pensions. Effective 1 year from the date of
enactment, section 102 would increase the special monthly
pension rate paid to Congressional Medal of Honor recipients
from $1,299 per month to $3,000 per month, and adjust it
annually thereafter for inflation. As of 2015, there were 79
individuals receiving a special monthly pension for the Medal
of Honor. While CBO estimates that, on average, one new living
recipient will receive a Metal of Honor and thus a special
monthly pension each year, expected mortality rates for the
existing population will cause the total number of recipients
to decline gradually over the coming years. After accounting
for projected mortality, new recipients, and inflation, CBO
estimates that section 102 would increase direct spending for
those pensions by $14 million over the 2018-2026 period.

Spending subject to appropriation

S. 425 contains a number of provisions that would enhance
the support services provided to homeless veterans. Other
provisions would modify VA's administration of its health care
programs and expand eligibility and benefits for caregivers. In
total, CBO estimates that implementing the bill would cost $3.5
billion over the 2017-2021 period, assuming appropriation of
the necessary amounts (see Table 3).
Health Care Administration. Title IV would modify certain
aspects of VA's health care program. In total CBO estimates
implementing the provisions under title IV would cost $3.4
billion over the 2017-2021 period.
Expansion of Caregivers Program. The Family Caregivers
program provides stipends, health insurance, respite care,
training, and other forms of support to caregivers of eligible
veterans who are enrolled in the program. Eligible veterans are
those who require assistance in daily activities such as
bathing, eating, or grooming as a result of injuries incurred
during military service on or after September 11, 2001. Section
451 would open that program, in two stages, to eligible
veterans of any era, and would expand the benefits offered
under the program to include legal and financial planning
services. In total, CBO estimates that implementing this
section would cost $2.9 billion over the 2017-2021 period.

Table 3.--Estimated Effects of S.425 on Spending Subject to Appropriation
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
------------------------------------------------------
2017 2018 2019 2020 2021 2017-2021
----------------------------------------------------------------------------------------------------------------
Health Care Administration
Expansion of Caregivers Program
Estimated Authorization Level.......................... 10 12 310 969 1,768 3,069
Estimated Outlays...................................... 9 12 278 895 1,673 2,867
Overtime for Medical Staff
Estimated Authorization Level.......................... 1 1 1 1 1 5
Estimated Outlays...................................... 1 1 1 1 1 5
Competitive Pay for Physician Assistants
Estimated Authorization Level.......................... 0 16 16 17 17 66
Estimated Outlays...................................... 0 14 16 17 17 64
Competitive Pay for Directors
Estimated Authorization Level.......................... 0 19 22 26 27 94
Estimated Outlays...................................... 0 17 21 25 27 90
Guidelines for Opioid Therapy
Estimated Authorization Level.......................... 1 7 14 16 17 55
Estimated Outlays...................................... 1 6 13 16 17 53
Opioid Safety Measures
Estimated Authorization Level.......................... 18 20 20 21 22 101
Estimated Outlays...................................... 16 20 20 21 22 99
Pain Management Boards
Estimated Authorization Level.......................... 0 9 9 9 10 37
Estimated Outlays...................................... 0 8 9 9 10 36
Assessment of Opioid Therapy
Estimated Authorization Level.......................... 0 1 3 3 3 10
Estimated Outlays...................................... 0 1 3 3 3 10
Office of Patient Advocacy
Estimated Authorization Level.......................... * * 1 1 1 3
Estimated Outlays...................................... * * 1 1 1 3
Community Meetings
Estimated Authorization Level.......................... * 1 1 1 1 4
Estimated Outlays...................................... * 1 1 1 1 4
Complementary and Integrative Health
Estimated Authorization Level.......................... 0 6 7 7 0 20
Estimated Outlays...................................... 0 5 7 7 1 20
IT System
Estimated Authorization Level.......................... 1 1 * * * 2
Estimated Outlays...................................... 1 1 * * * 2
Agreements for Extended Care
Estimated Authorization Level.......................... 0 4 10 0 0 14
Estimated Outlays...................................... 0 4 9 1 0 14
State Veterans Homes
Estimated Authorization Level.......................... 0 50 80 0 0 130
Estimated Outlays...................................... 0 40 80 10 0 130
------------------------------------------------------
Subtotal, Health Care Administration
Estimated Authorization Level........................ 31 147 494 1,071 1,867 3,610
Estimated Outlays.................................... 28 130 459 1,007 1,773 3,397

Homeless Veterans
Dental Care
Estimated Authorization Level.......................... * 8 15 24 25 72
Estimated Outlays...................................... * 7 14 23 25 69
Homeless Veterans Reintegration Program
Estimated Authorization Level.......................... 4 4 4 4 4 20
Estimated Outlays...................................... * 3 4 4 4 15
Case Management
Estimated Authorization Level.......................... * 1 1 1 1 4
Estimated Outlays...................................... * 1 1 1 1 4
Legal Services for Homeless Veterans
Estimated Authorization Level.......................... * 1 1 2 2 6
Estimated Outlays...................................... * 1 1 2 2 6
------------------------------------------------------
Subtotal, Homeless Veterans
Estimated Authorization Level........................ 4 14 21 31 32 102
Estimated Outlays.................................... * 12 20 30 32 94

Other Matters
Court of Appeals for Veterans Claims
Estimated Authorization Level.......................... 0 * 1 1 1 3
Estimated Outlays...................................... 0 * 1 1 1 3
Internal Audits
Estimated Authorization Level.......................... * 1 2 2 2 7
Estimated Outlays...................................... * 1 2 2 2 7
Training for Managers
Estimated Authorization Level.......................... * * * * * 1
Estimated Outlays...................................... * * * * * 1
------------------------------------------------------
Subtotal, Other Matters
Estimated Authorization Level........................ * 1 3 3 3 11
Estimated Outlays.................................... * 1 3 3 3 11
Reports, Studies, and Evaluations

Estimated Authorization Level............................ 5 * * * * 5
Estimated Outlays........................................ 5 * * * * 5
------------------------------------------------------
Total Spending Subject to Appropriation
Estimated Authorization Level........................ 40 162 518 1,105 1,902 3,728
Estimated Outlays.................................... 33 143 182 1,040 1,808 3,507
----------------------------------------------------------------------------------------------------------------
Note:IT = Information Technology; details do not add to totals because of rounding; * = less than $500,000.

Stage one of this provision would open eligibility for the
Family Caregivers program to eligible veterans who were injured
during service on or before May 7, 1975. That stage would begin
within 2 years of the date of enactment (after VA develops and
certifies a new IT system to track benefits, as required under
section 452). The second stage would begin 2 years after stage
one, and would open the program to the remaining eligible
veterans--those injured during service after May 7, 1975, and
before September 11, 2001. For the purposes of this estimate,
CBO assumes that S. 425 will be enacted by October 2016, that
stage one of the proposal will begin in October 2018, and that
stage two will begin in October 2020.
In 2015, costs for the Family Caregivers Program totaled
$454 million, about $18,300 per participating veteran. Most of
that cost resulted from stipends paid to caregivers. To qualify
as a caregiver, individuals must be at least 18 years of age
and either a member of a veteran's extended family or live with
the veteran full time. Stipends are paid monthly and are based
on the hours of daily care the veteran requires and the
prevailing wage for home health aides. In 2015, stipends paid
under the program ranged from $7,700 to $29,000 on an annual
basis, and averaged roughly $15,600. Caregivers also are
eligible to participate in CHAMPVA, a program run by VA that
provides health insurance for dependents and survivors of
certain disabled veterans. In addition, the Family Caregiver
Program provides up to 30 days a year of respite care, as well
as training and other support services. In 2015, costs under
the Family Caregivers Program for CHAMPVA and the remaining
services averaged about $2,700 per veteran.
CBO's estimate of the cost of expanding the Caregivers
program is based on the usage and average costs of the existing
program, and the number of veterans with significant, service-
connected disabilities in the cohorts that would be newly
eligible. However, to account for the advanced age of the newly
eligible veterans, our estimate reflects the following findings
from a recent RAND study:\1\
---------------------------------------------------------------------------
\1\Ramchand, Rajeev, Terri Tanielian, Michael P. Fisher, Christine
Anne Vaughan, Thomas E. Trail, Caroline Batka, Phoenix Voorhies,
Michael Robbins, Eric Robinson and Bonnie Ghosh-Dastidar. Hidden
Heroes: America's Military Caregivers. Santa Monica, CA: RAND
Corporation, 2014.

Disabled veterans rely more heavily on assistance
for daily activities as they age,
Older veterans tend to rely on older caregivers,
and
Health care costs for caregivers increase with
age.

For stage one, CBO estimates that about 20,000 additional
veterans would benefit from the program in 2019, growing to
roughly 44,000 by 2021. CBO expects that the youngest members
of this cohort will be in their late 60s. After factoring in a
heavier reliance on caregiver assistance for activities of
daily living and higher health care costs for caregivers
because of advanced age we estimate that the average cost per
participant would be about $30,000 in 2019. However, through
the General Caregiver Program--which provides limited support
services to caregivers of eligible veterans from all eras--VA
already provides respite care to assist some caregivers.
Accounting for those current benefits in our estimate reduces
the average added cost per participant to $29,400. After
accounting for gradual implementation and incorporating annual
inflation, CBO estimates that stage one of this proposal would
cost $2.5 billion over the 2019-2021 period.
In the second stage of expansion we estimate that about
29,000 additional veterans would use the Family Caregivers
program in 2021. Because veterans in this group would be
younger than those under the initial expansion we expect they
would have less reliance on caregiver assistance (lower stipend
amount) and the caregivers would be younger (lower CHAMPVA
costs). On average, in 2021, we estimate the incremental cost
per participant would be $28,000, after accounting for existing
benefits under the General Caregiver Program. After factoring
in a gradual implementation for the second stage of expansion
and incorporating annual inflation, CBO estimates additional
costs for the Family Caregivers Program of $367 million in
2021. Those costs would grow to be in the tens of billions of
dollars over the 10-year window, CBO estimates.
In addition, under this section CBO estimates that roughly
34,000 caregivers in the current Family Caregivers Program (for
veterans injured during service after September 11, 2001) would
receive legal and financial support services. On the basis of
the resources necessary to provide counseling under the
existing program, we estimate an average annual cost of $130
per beneficiary for legal and financial services. CBO estimates
it would cost $23 million over the 2017-2021 period to provide
those benefits to individuals eligible for the Family
Caregivers Program under current law. The costs of providing
that additional benefit for individuals newly eligible for the
Family Caregivers Program under this provision are included in
the above estimates of adding those individuals to the program.
Furthermore, in anticipation of the surge of new
applications upon expansion of the Family Caregivers Program,
VA would need to hire and train additional staff to manage the
program (caregiver support line, outreach activities, and
monitoring). On the basis of the overhead costs to manage the
existing program of $7 million in 2014 for 19,000 participants
and incorporating annual inflation, CBO estimates staffing
costs of $400 per participant. To handle roughly 20,000 new
beneficiaries starting in 2018, CBO estimates additional
overhead costs of $16 million in 2017 and 2018.
Overtime for Medical Staff. Section 412 would allow VA to
offer flexible work hours (above or below 80 hours on a
biweekly basis) to physicians or physician assistants (PAs) who
work for VA on a full-time basis, provided the total work hours
in a calendar year did not exceed 2,080. VA reports that the
department does not compensate physicians for overtime;
however, it does offer overtime pay to PAs at a premium rate of
25 percent of the employee's basic hourly rate.
VA employs roughly 1,800 PAs on a full-time basis. Using
the average weekly hours for PAs in the private sector (where
overtime pay is offered) of 40.63 hours, we estimate that PAs
will work an average of 33 hours over the calendar year at the
overtime pay rate (about $14 above their basic hourly rate of
$55, which includes the pay increase under section 413). After
factoring in the time to prepare regulations, we estimate that
implementing the section would cost $5 million over the 2017-
2021 period.
Competitive Pay for Physician Assistants. Beginning 1 year
after enactment, section 413 would require VA to compensate PAs
at rates that are competitive with those paid by health care
providers in the private sector. Currently, VA employs about
1,850 physician assistants. On the basis of wages paid by
private-sector providers, we estimate that the pay rate for
those employees would increase by about 6 percent in 2018 (from
$112,000 to $120,000) if VA paid competitive rates.
In addition, we expect that the higher pay level would help
ameliorate VA's current difficulties in recruiting and
retaining physicians' assistants, and would thus increase the
total number of PAs employed by VA. On the basis of data from
VA on hiring and retaining nurses, who are paid at competitive
rates, CBO estimates that under section 413 VA would employ
roughly 2,000 physicians' assistants by 2021 (or an 8 percent
increase above the current staffing level). On that basis, CBO
estimates that implementing this section would cost $64 million
over the 2018-2021 period.
Competitive Pay for Directors. One year after enactment,
section 415 would allow VA to offer competitive pay (based on
compensation in the private market) to directors of regional
and medical facilities at the department. VA employs about 130
directors at an average compensation amount of $220,000 in
2015. On average, compensation for medical directors in the
private sector is about $320,000. As a result of the increase
in salary, CBO estimates that VA would be able to fully staff
the 140 Medical Director positions by 2021. After factoring in
a 1-year delay and additional hiring, CBO estimates that
implementing this provision would cost $90 million over the
2018-2021 period.
Guidelines for Opioid Therapy. Within 1 year of enactment
of this bill, section 421 would require VA and DOD to jointly
update their guidelines for managing opioid therapy for chronic
pain. The updated guidelines would require VA to expand
participation in the state-run Prescription Drug Monitoring
Program (PDMPs) to include all VA medical facilities and to
conduct both routine and random urine drug tests for patients
receiving opioid therapy.
On the basis of information from VA and DOD, we estimate
minimal costs to update the VA/DOD Clinical Practice Guideline
for Management of Opioid Therapy for Chronic Pain.
In 2015, the PDMPs cost about $4 million to operate at 64
percent of the VA medical facilities. CBO estimates that
increasing the program nationwide would cost an additional $2
million each year. After factoring in a 1-year period to update
the guidelines, we estimate expanding the PDMPs would cost $9
million over the 2017-2021 period.
According to VA, about 255,000 (or 77 percent) of the
333,000 patients being treated for pain had at least one urine
drug screening in 2015. After accounting for the growth in the
number of such patients, we estimate about 100,000 additional
urine tests would need to be completed each year at an average
cost of about $110 per test to meet the updated requirements.
After factoring in the necessary time to update the guidelines,
we estimate that conducting urine tests would cost $44 million
over the 2017-2021 period.
In total, CBO estimates that implementing this section
would cost $53 million over the 2017-2021 period.
Opioid Safety Measures. Section 422 would require VA to
expand its safety measures by improving training on providing
pain management and prescribing opioids, establishing pain
management teams at each medical facility, and improving
patient tracking through electronic reports.
This provision would create pain management teams
throughout the VA health care system. According to VA, each
medical facility currently has its own methods to manage and
oversee pain therapy; however, they do not always have
designated pain management teams. Under this provision, VA
would be required to implement a protocol for such teams. Based
on information from VA, we expect that establishing and
implementing such protocols at roughly 1,000 medical facilities
would require very little additional work and would have an
annual cost of roughly $6,500 per facility. On that basis, CBO
estimates that establishing the pain management teams
nationwide would cost $33 million over the 2017-2021 period.
Section 422 also would require VA to expand the nationwide
availability of certain treatments such as Naloxone kits for
opioid overdose. According to VA, it currently has roughly
55,000 patients with opioid-use disorder and roughly 28,000
Naloxone kits in its inventory. CBO estimates that it would
cost roughly $14 million each year to ensure the availability
of kits (at a cost of about $400 per kit) for those 55,000
patients who have the greatest potential risk of overdose. On
that basis, CBO estimates it would cost $66 million over the
2017-2021 period to expand the availability of such treatments.
This section also would require VA to enhance the ability
of the electronic Opioid Therapy Risk Report (OTRR) to access
information on prescribed drugs through the Prescription Drug
Monitoring Programs. According to VA, such modifications to the
OTRR would require minimal analyst and programming support. CBO
estimates that implementing that requirement would cost less
than $500,000 over the 2017-2021 period.
In total, CBO estimates that implementing section 422 would
cost $99 million over the 2017-2021 period.
Pain Management Boards. One year after enactment of this
bill, section 424 would require VA to establish Pain Management
Boards in each of the 21 VA health care regions to do the
following:

Consult with patients and family members,
Oversee use of best practices in managing pain and
issue recommendations for treating difficult cases, and
Host educational and public events.

Under this provision, CBO expects that the regional
boards--whose members might be spread across multiple states--
would usually hold regular board meetings via phone or virtual
conferencing. However, face-to-face meetings may be needed on
occasion; thus, CBO estimates annual per diem and travel costs
of $250 for 315 individuals (based on 15 board members in each
of the 21 VA health care regions). CBO also expects VA would
hire roughly 60 support staff (or 3 support staff per board)
with an average compensation of $120,000. After factoring in a
1-year delay, CBO estimates that implementing this section
would cost $36 million over the 2017-2021 period.
Assessment of Opioid Therapy. Under section 425, within 2
years of enactment of the bill, VA would be required to enter
into a contract with an independent entity to assess and report
on opioid prescribing practices at VA medical facilities.
Beginning no later than 1 year after enactment, this section
also would require VA to collect and analyze data on
prescription rates of opioids and usage of opioid therapy at
all VA medical facilities and to provide annual reports to the
Congress on those matters. CBO estimates that implementing
those requirements would cost about $1 million each year for
data collection and coordination at all medical facilities.
On the basis of information from VA and independent
entities who worked on similar studies, CBO estimates an
independent review would take 3 years and cost $2 million each
year, beginning in 2019. In total, CBO estimates it would cost
$10 million over the 2017-2021 period to implement section 425.
Office of Patient Advocacy. Within a year of enactment,
section 431 would establish a new Office of Patient Advocacy
under the Undersecretary of Health at VA. According to VA, the
department has already established a Client Services Response
Team (CSRT) that reports directly to the Undersecretary of
Health's office. We expect this provision would mostly codify
existing practice; however, we think VA would hire two
additional support staff and a director (with an average
compensation level of $200,000 for each new employee) to assist
the CSRT's efforts. After factoring in the time to hire the new
staff, we estimate it would cost $3 million over the 2017-2021
period to implement this section.
Community Meetings. Section 432 would require VA Medical
Centers and Community Based Outpatient Clinics to host
community meetings on an annual and quarterly basis,
respectively. Those meetings would be open to the public. VA
currently hosts town hall meetings to get feedback from
veterans, their family members and other community
stakeholders. On the basis of information from VA, CBO
estimates that VA would need to hold an additional 500 such
meetings a year to meet the requirements of this provision.
Based on costs in the private sector, we estimate VA would
spend roughly $1,500 per meeting for audio visual equipment,
staff time, and supplies. In total, CBO estimates implementing
this provision would cost $4 million over the 2017-2021 period.
Complementary and Integrative Health. Section 442 would
require VA to operate a 3-year program at 15 VA Medical Centers
to assess the feasibility of integrating complementary and
alternative medicine with traditional care. On the basis of
VA's implementation of other pilot programs of similar scope
(such as using meditation for veterans with Post Traumatic
Stress Disorder), CBO expects that developing and operating the
program would require two additional medical practitioners at
each of the 15 facilities to provide nontraditional care, as
well as two additional employees at each facility to engage in
research, training, and assessment of the program.
The use of complementary and alternative medicine also
would partially displace the use of traditional care (emergency
care, primary care, and physical therapy) but would lead to
greater use of medical services on balance, than under current
law. Specifically, CBO estimates that the net cost to deliver
medical services, after adjusting for the expected reduction in
usage of traditional health care services would be roughly
$66,000 per medical provider, resulting in costs of roughly $2
million annually during the 3-year pilot program.
On the basis of information from VA, CBO further estimates
that the annual cost per person for the research and training
personnel was $127,000 in 2015. Thus, in total, implementing
section 442 would cost $20 million over the 2018-2021 period,
CBO estimates.
IT System. By December 31, 2016, section 452 would require
VA to develop and implement an IT system to track and assess
data of the Family Caregiver Program. VA reports that it is
currently working on enhancing its existing IT system, the
Caregivers Application Tracker system, to allow for an easier
application process, as well as tracking stipend awards and
other benefits. As a result, we estimate this requirement would
mostly codify existing practice and would have no budgetary
effect. However, the provision also includes assessment and
reporting requirements that CBO estimates would cost $2 million
over the 2017-2021 period.
Agreements for Extended Care. Section 461 would
temporarily--through 2019--exempt VA from the requirements of
the Federal Acquisition Regulation (FAR) for the purposes of
entering into agreements to provide long-term care to veterans
in private facilities. The FAR is a set of rules that governs
the conditions under which most federal agencies may purchase
goods and services. VA has faced continuing challenges securing
access to certain long-term care facilities because of the high
cost of the contractual requirements (mostly related to
reporting, compensation, and fringe benefits) under the FAR.
Under this provision, CBO expects that VA will be able to
contract for long-term care for more veterans than is possible
under current law. This section also would require VA to
develop a system, similar to that used by Medicare, to monitor
the care provided to veterans in such extended care facilities.
According to VA, there are a total of 150 extended care
facilities that have terminated their contracts with VA due to
the strict requirements of the FAR. After factoring in the time
for VA to place veterans, CBO estimates that by 2018 VA would
enter into non FAR agreements with about 30 of those
facilities. Based on information from VA, we estimate that, on
average, veterans would occupy three beds at each of those
facilities at a per diem rate of $280--with an average length
of stay of 113 days. Based on information from the department,
we expect that after the authority provided under this section
expires in 2019, VA would lose access to the extended stay
facilities under non FAR agreements, and would therefore have
to place veterans in facilities with existing contracts. Thus,
we estimate no additional costs after 2019.
CBO also estimates that VA would incur administrative costs
of $1 million each year to increase its monitoring of care
provided to veterans in extended care facilities by expanding
its use of existing data gathered by the states and the Centers
for Medicare and Medicaid on extended care facilities. In total
we estimate discretionary costs of $14 million over the 2017-
2021 period.
State Veterans' Homes. Section 462 would temporarily--
through 2019--waive the requirements of the FAR for contracts
and agreements that VA enters into with state-run nursing homes
for veterans. Under current law, the state veterans' homes
(SVHs) are required to fill 75 percent of their beds with
veterans. VA is required to pay SVHs the full cost of care for
veterans with a service-connected disability (SCD) rating of 70
percent or more, under a contract or agreement. For all other
veterans, VA pays SVHs a grant based on a fixed daily
allowance.
According to VA, in 2015 the Department used such
agreements to reimburse state-run nursing homes at a daily rate
of $380 for each veteran with a SCD of 70 percent or more--at
an annual cost of roughly $350 million (or 37 percent of the
total reimbursements to SVHs). However, those agreements do not
comply with the FAR, and VA does not expect to be able to enter
into FAR agreements with any of the SVHs. In the absence of
this legislation, CBO expects that VA will gradually phase out
the use of such agreements as those veterans who are currently
under that payment structure die or leave the SVHs. We expect
those veterans would be replaced by veterans under the lower
daily allowance rate of roughly $100 per patient. By allowing
VA to enter into non FAR agreements, CBO estimates that this
proposal would nearly triple VA's reimbursements to SVHs for
veterans with severe SCDs.
As a result, after factoring in a gradual phase out of
using non FAR agreements, CBO estimates that enacting this
provision would cost $130 million over the 2018-2021 period.
The additional costs from waiving the FAR requirements would
begin in 2017. However, appropriations have already been
provided for such agreements in 2017, so we estimate no
additional funding would be necessary in that year.
Homeless Veterans. Title III would authorize VA to expand
benefits provided to homeless veterans, such as dental care,
employment assistance, and legal services. In total, CBO
estimates implementing those requirements would cost $94
million over the 2017-2021 period.
Dental Care. One year after enactment of the bill, section
303 would expand eligibility for dental care to veterans
receiving certain forms of housing assistance. Under current
law, veterans who receive short-term housing assistance through
VA may receive limited dental care to alleviate pain, as part
of treatment for a more severe periodontal disease, or to aid
in getting a job. This section would provide that same out-
patient dental care to certain veterans receiving longer-term
housing assistance through the Department of Housing and Urban
Development-VA Supportive Housing (HUD-VASH) program and
transitional housing through a non-VA entity.
Based on an analysis of information from VA, CBO estimates
about 3,700 veterans would take advantage of this benefit in
2018, growing to about 10,000 by 2020. At an average cost of
about $2,000 per veteran in 2018, and incorporating the effects
of medical inflation and a 1-year delay in implementation, CBO
estimates that providing dental care to those additional
homeless veterans would cost $69 million over the 2018-2021
period.
Homeless Veterans Reintegration Program. Section 304 would
expand the eligibility for the Homeless Veterans Reintegration
Program (HVRP). HVRP provides grants to agencies and
organizations that provide job placement, training, and
vocational counseling to homeless veterans.
This section would extend the benefits to veterans
receiving longer-term housing assistance through HUD-VASH,
newly released veterans who were incarcerated, and certain
veterans who are Native Americans. According to VA, roughly
17,000 veterans would become eligible for the HVRP program
under this proposal. Based on the current participation levels
for HVRP, we estimate that under section 304 about 1,800 new
beneficiaries would seek job placement annually at an average
cost of $2,000 in 2017. CBO estimates that implementing this
provision would cost $15 million over the 2017-2021 period.
Case Management. Within 1 year of enactment of the bill,
section 306 would require VA to conduct a pilot program to
assess the feasibility of using intensive case management
practices for certain homeless veterans who are enrolled in the
VA health care system. The pilot program would operate in at
least six locations in the VA health care system and would
include no fewer than 20 veterans at each location.
Based on the size of the pilot program and information from
VA, CBO expects that implementing this provision would require
the department to hire six full-time case managers at an
average salary of $100,000. After adjusting for projected
salary increases for federal workers, CBO estimates a total
cost of $4 million over the 2017-2021 period.
Legal Services for Homeless Veterans. Section 308 would
allow VA to collaborate with public and private entities to
provide legal assistance (in areas such as housing, family law,
and criminal defense) to veterans at risk of homelessness. On
the basis of existing rates of participation in the Supportive
Service Low Income Vets and Families program, which currently
provides limited legal services to veterans at risk of
homelessness, CBO estimates that roughly 15,000 veterans would
take advantage of the proposed legal assistance.
Further, given the number and dollar amount of stipends
provided to the health professional trainees (which includes
fellows, residents, and students) rotating through VA, CBO
estimates that VA would award stipends of $20,000
(incorporating annual inflation) to about 90 legal fellows to
provide services to veterans. Because of the time necessary to
write regulations and to develop partnerships, CBO expects that
this program would not be fully implemented for several years.
As a result, CBO estimates that implementing section 308 would
cost $6 million over the 2017-2021 period.
Other Matters. Title V would extend the temporary increase
in the number of judges for the Court of Appeals for Veterans
Claims, establish a program of internal audits within VA, and
provide training to managers throughout VA. CBO estimates that
implementing title V would cost $11 million over the 2017-2021
period.
Court of Appeals for Veterans Claims. Section 501 would
extend, through January 1, 2021, the authority for the Court of
Appeals for Veterans Claims (CAVC) to appoint a new judge to
the court should a position become vacant. Previous legislation
allowed for the court to expand from seven judges to nine in
order to address the workload of the court. The authority to
appoint a new judge to maintain nine judges expired on January
1, 2013.
According to the CAVC, the cost of a judge and his or her
chamber is about $1 million per year. CBO expects that one
judge will leave or retire over the next several years; thus,
under section 501 one new judge would be appointed. Therefore,
CBO estimates that implementing section 201 would cost $3
million over the 2017-2021 period.
Internal Audits. Section 503 would establish an office and
program of internal audits--independent of other offices within
VA--to do periodic risk assessments and analysis of various
organizations and staff offices within the department. Based on
information from VA, CBO expects that VA would hire 10
additional support staff and a director (with an average
compensation level of $200,000 per staff member) to carry out
the internal audits. After factoring in the time to hire the
new staff, we estimate that implementing this provision would
cost $7 million over the 2017-2021 period.
Training for Managers. Section 504 would require VA to
provide training to managers in several areas. Such training
would cover: ensuring rights of whistleblowers, effectively
managing and motivating employees, and managing employees who
are performing at an unacceptable level. According to VA, while
managers are currently required to undergo training similar to
that required by section 504, the agency would need to add new
and updated content to meet all the requirements of the bill.
On the basis of VA's current practices, CBO expects that VA
would enter into a contract with a private entity to implement
those changes at a cost of $1 million over the 2017-2021
period.
Reports, Studies, and Evaluations. The bill would require
VA to produce a total of 13 reports on matters such as opioid
therapy, patient advocacy, and benefits to caregivers of
injured veterans. It also would require a study by the
Government Accountability Office of programs offered to
homeless veterans. Based on the costs of similar studies and
reports, CBO estimates that meeting those requirements would
cost a total of $5 million over the 2017-2021 period.
Pay-As-You-Go Considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget-reporting and enforcement
procedures for legislation affecting direct spending or
revenues. The net changes in outlays that are subject to those
pay-as-you-go procedures are shown in the following table.

Table 4.--CBO Estimate of Pay-As-You-Go Effects for S.425 as ordered reported by the Senate Committee on Veterans' Affairs on December 9, 2015
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
------------------------------------------------------------------------------------------------
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2016-2021 2016-2026
--------------------------------------------------------------------------------------------------------------------------------------------------------

NET INCREASE OR DECREASE (-) IN THE DEFICIT
Statutory Pay-As-You-Go Impact......................... 0 -13 -151 -300 -426 -453 -485 -517 -554 -585 -617 -1,345 -4,102
--------------------------------------------------------------------------------------------------------------------------------------------------------

Increase in Long-Term Direct Spending and Deficits: CBO
estimates that enacting S. 425 would not increase net direct
spending or on-budget deficits in any of the four consecutive
10-year periods beginning in 2026.
Intergovernmental and private-sector impact: S. 425
contains no intergovernmental or private-sector mandates as
defined in UMRA and would benefit public entities, including
educational institutions and health care providers, that
provide services to veterans. Any costs those entities might
incur would be incurred as conditions of participating in a
voluntary federal program.
Previous cost estimates: On June 3, 2015, CBO transmitted a
cost estimate for S. 1376, the National Defense Authorization
Act for Fiscal Year 2016, as ordered reported by the Senate
Committee on Armed Services on May 19, 2015. Section 605 of
that bill is similar to section 502 of S. 425. The estimates
differ because other legislation has been enacted in the
interim that changed costs under current law and because VA
provided additional information on how it would implement the
provision.
On November 19, 2015, CBO transmitted a cost estimate for
H.R. 3016, the Veterans Employment, Education, and Healthcare
Improvement Act, as ordered reported by the House Committee on
Veterans' Affairs on September 17, 2015. Section 301 of that
bill is similar to section 202 of S. 425. The costs of section
202 are higher because of interactive effects with other
provisions of the bill. Section 302 of that earlier bill also
would increase benefits under the Fry Scholarships in a more
expansive manner than would section 209 of S. 425, thus, the
costs in this estimate are lower. Section 210 of S. 425 is
similar to section 307 of H.R. 3016 and section 103 of H.R. 475
the GI Bill Processing Improvement and Quality Enhancement Act
of 2015, as ordered reported by the House Committee on
Veterans' Affairs on May 21, 2015. Section 210 would credit
military service before the date of enactment of the bill; the
previous bills would not. However, the estimate for the
proposal has been updated for new information. Thus, on net,
the cost of section 210 is less than the previous estimates.
On May 4, 2016, CBO transmitted a cost estimate for
H.R. 4063, the Promoting Responsible Opioid Management and
Incorporating Scientific Expertise Act, as ordered reported by
the House Committee on Veterans' Affairs on February 25, 2016.
Sections 102 and 201 of that bill are similar to sections 422
and 432 respectively of S. 425, and the estimated costs for
those provisions are the same. Section 302 of H.R. 4063 is
similar to section 442 of S. 425, but would be effective 1 year
later. The estimated costs for those provisions differ only
because of that timing effect.
Estimate prepared by: Federal Costs: Ann E. Futrell, David
Newman, and Dwayne M. Wright; Impact on State, Local, and
Tribal Governments: Jon Sperl; Impact on the Private Sector:
Paige Piper/Bach.
Estimate approved by: H. Samuel Papenfuss, 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(b) 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 December 9, 2015, meeting. One
amendment by Senator Isakson was adopted by voice vote; Senator
Brown and Senator Hirono requested to be recorded as voting no
on the amendment. S. 425 as amended, and as subsequently
amended during the Committee meeting, was agreed to by voice
vote, without dissent, and ordered favorably reported to the
Senate.

Agency Report

On May 13, 2015, David R. McLenachen, Acting Deputy Under
Secretary for Disability Assistance, Veterans Benefits
Administration; on June 3, 2015, Dr. Thomas Lynch, Assistant
Deputy Under Secretary for Health Clinical Operations, Veterans
Health Administration; on June 24, 2015, Dr. Rajiv Jain,
Assistant Deputy Under Secretary for Health for Patient Care
Services, Veterans Health Administration; on September 16,
2015, Thomas Lynch, Assistant Deputy Under Secretary for Health
Clinical Operations, Veterans Health Administration; on October
6, 2015, Thomas Lynch, Assistant Deputy Under Secretary for
Health Clinical Operations, Veterans Health Administration; and
on November 18, 2015, Curtis L. Coy, Deputy Under Secretary for
Economic Opportunity, Veterans Benefits Administration, from
the Department of Veterans Affairs appeared before the
Committee on Veterans' Affairs and submitted testimony on
various bills incorporated into the Committee bill. In
addition, on July 15, 2015; September 4, 2015; and December 8,
2015, VA provided views on various bills incorporated into the
Committee bill. Excerpts from these statements are reprinted
below:

STATEMENT OF DAVID R. MCLENACHEN, ACTING DEPUTY UNDER SECRETARY FOR
DISABILITY ASSISTANCE, VETERANS BENEFITS ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS

Good afternoon, Mr. Chairman and Members of the Committee.
I am pleased to be here today to provide the views of the
Department of Veterans Affairs (VA) on pending legislation
affecting VA's programs, including the following: S. 270,
S. 602, S. 627, the ``21st Century Veterans Benefits Delivery
Act,'' the ``Veterans' Compensation Cost-of-Living Adjustment
Act of 2015,'' and a draft bill concerning VA small business
contracting, Veterans benefits, and burial matters. We will
separately provide views on the following bills: S. 681;
sections 202, 203 and 206 of the ``21st Century Veterans
Benefits Delivery Act;'' the bill associated with legislative
proposals from the Report of the Military Compensation and
Retirement Modernization Commission; the bill associated with
legislative proposals from the Department of Defense (DOD); and
sections 201 and 206 of the consolidated bill related to bills
from the 113th Congress. Accompanying me this afternoon is
Renee Szybala, Assistant General Counsel.

* * * * * * *

S. 602

S. 602, the ``GI Bill Fairness Act of 2015,'' would amend
the term ``active duty'' under chapter 33 of title 38, to
include certain time spent receiving medical care from DOD as
qualifying active duty service performed by members of the
Reserve and National Guard. Under this bill, individuals
ordered to active duty under section 12301(h) of title 10,
United States Code, to receive authorized medical care; to be
medically evaluated for disability or other purposes; or to
complete a required DOD health care study, would receive credit
for this service under the Post-9/11 GI Bill.
S. 602 would apply as if it were enacted immediately after
the enactment of the Post-9/11 Veterans Educational Assistance
Act of 2008, Public Law 110-252.
VA defers to DOD regarding the change to qualifying active
duty service under the Post-9/11 GI Bill, with the observation
that a similar proposal was submitted by the Administration for
inclusion with the 2016 NDAA, with an exception that this bill
would be retroactive. Currently, individuals with qualifying
active duty service of at least 30 continuous days who are
honorably discharged due to a service-connected disability
become eligible for 100 percent of the Post-9/11 GI Bill
benefit. Because service under 10 U.S.C. Sec. 12301(h) does not
meet the current definition of active duty, Guard and Reserve
members with such service who are discharged under these
circumstances do not automatically qualify for 100 percent of
the benefit. If enacted, this change would allow for an
increase in benefits from the 40-90 percent benefit tier up to
the 100 percent level, and the change would be retroactive to
as early as August 1, 2009.
The proposed change to the eligibility criteria under the
Post-
9/11 GI Bill would require VA to make changes to the type of
data that are exchanged between DOD and VA through the VA/DOD
Identity Repository (VADIR) and displayed in the Veteran
Information System (VIS). In addition, new rules would need to
be programmed into the Post-9/11 GI Bill Long Term Solution
(LTS) in order to calculate eligibility based on service under
section 12301(h) and to allow for benefit payments retroactive
to 2009. VA estimates that it would need 1 year from enactment
of S. 602 to complete these changes.
VA estimates that administrative cost requirements
associated with the enactment of S. 602 would be insignificant.
The Department is still evaluating benefit and resource costs
related to this legislation.
------

STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR
HEALTH CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS

Good morning Chairman Isakson, Ranking Member Blumenthal,
and Members of the Committee. Thank you for inviting us here
today to present our views on several bills that would affect
VA benefits programs and services. Joining us today is Maureen
McCarthy, M.D., VHA's Deputy Chief Patient Care Services
Officer and Susan Blauert, Deputy Assistant General Counsel in
VA's Office of General Counsel.
We do not yet have cleared views on sections 2 and 4 of
S. 297, S. 471, the draft bill on Joint VA-DOD formulary for
pain and psychiatric medications, and the draft bill Veterans
Health Act of 2015. We will forward the views to the Committee
as soon as they are available.

* * * * * * *

S. 425, HOMELESS VETERANS' REINTEGRATION PROGRAMS REAUTHORIZATION ACT
OF 2015

S. 425 would extend the authorization of appropriations for
the Department of Labor's Homeless Veteran Reintegration
Programs (HVRP) and the Homeless Women Veterans and Homeless
Veterans with Children Reintegration Grant Program from 2015 to
2020. The bill would further expand the population eligible to
receive services under HVRP to include not only homeless
Veterans but also Veterans who are participating in the
Department of Housing and Urban Development-VA Supportive
Housing (HUD-VASH) program, receiving assistance under the
Native American Housing Assistance and Self-Determination Act
of 1996, or transitioning from incarceration.
VA defers to the Department of Labor for views and costs on
S. 425; however, we offer that this bill would provide
additional services for homeless and at-risk Veterans in the
critical area of employment, which is a key factor in achieving
and maintaining stability in permanent housing. Veterans
transitioning from incarceration often face multiple barriers
to successful reentry, and expanding HVRP eligibility to this
population would help address the employment-related needs of a
population of Veterans who are often at high risk of becoming
homeless. It would also be especially helpful for Veterans
transitioning from incarceration who may not be eligible for VA
services.

S. 684, HOMELESS VETERANS PREVENTION ACT OF 2015

Section 2 of S. 684 would amend 38 U.S.C. Sec. 2012(a)(2)
to increase the per diem payments for Veterans who are
participating in the VA's Homeless Provider Grant and Per Diem
(GPD) Program through a ``transition in place'' (TIP) grant.
The per diem payments under GPD TIP would be increased to 150
percent of the VA State Home rate for domiciliary care,
compared to the current payment which is the lesser of 100
percent of the VA State Home rate for domiciliary care or the
daily cost of care minus other sources of payments to the per
diem recipient for furnishing services to homeless veterans.
VA supports section 2. This new provision would facilitate
and provide support for Veterans moving from transitional to
permanent housing. Supporting Veterans' transition from
homelessness to permanent housing is a strategy VA believes
will be effective in our efforts to end homelessness among
Veterans. By allowing Veterans to ``transition in place'' to
permanent housing, the Department would provide a valuable
alternative for Veterans who may not need or be interested in
participating in the HUD-VASH program.
Section 3 would amend 38 U.S.C. Sec. 2012(a) to permit a
grantee receiving per diem payments under the GPD Program to
use part of these payments for the care of a dependent of a
homeless Veteran who is receiving services covered by the GPD
grant. This authority would be limited to the time period
during which the Veteran is receiving services under the grant.
VA supports the intent of section 3, conditioned on the
availability of additional resources to implement this
provision. We feel that this authority is needed to fully reach
the entire homeless population. However, full implementation of
the legislation would require additional funding to avoid
diminished services in VA's full complement of programs for
homeless Veterans.
Section 4 would authorize the Secretary to enter into
partnerships with public or private entities to provide general
legal services to Veterans who are homeless or at risk of
homelessness. The language further specifies that VA is only
authorized to fund a portion of the cost of legal services.
VA supports section 4 as legal services remain a crucial
but largely unmet need for homeless and at-risk Veterans, but
respectfully recommends technical amendments to the bill
language. The Supportive Services for Veteran Families Program
currently allows for grantees to enter into partnerships with
legal service providers to address legal needs that pose
barriers to housing stability. However, this is not a required
service under the SSVF regulations and, therefore, is not
provided to Veterans through all SSVF programs. Rather than
authorizing VA to enter into ``partnerships,'' section 4 should
authorize VA to provide grants to ensure the language reflects
a funding mechanism that VA could use to execute it.
Furthermore, VA recommends removing the phrase ``a portion of''
from the proposed section 2022A(a). This change would allow VA
to fund a portion or the entirety of the legal services
provided under the partnership, thereby providing VA greater
flexibility to support these efforts. Finally, VA would like to
work with the Committee to make additional minor improvements
to section 4.
Section 5 would extend dental benefits under 38 U.S.C.
Sec. 2062 to a Veteran enrolled in the VA health care system
who is also receiving for a period of 60 consecutive days
assistance under the HUD-VASH program, or care under title 38
authority in one of the following settings: a domiciliary,
therapeutic residence, community residential care, or a GPD
program. For purposes of the 60-day requirement, it would
permit breaks in the continuity of assistance or care for which
the Veteran is not responsible.
VA appreciates the intent of section 5 to expand
eligibility for VA dental care, but cannot support it under a
realistic assumption of future funding availability. VA
believes these services would be especially valuable for this
group of Veterans, and we welcome further discussion with the
Committee.
VA supports section 6, which would provide permanent
authority for VA's Veterans Justice Outreach (VJO) and Health
care for Reentry Veterans (HCRV) Programs. VJO's goal is to
avoid the unnecessary criminalization of mental illness and
extended incarceration among Veterans by ensuring that eligible
Veterans involved with the criminal justice system have timely
access to VA's mental health and substance use services when
clinically indicated, and other VA services and benefits as
appropriate. Similarly, designed to address the community
reentry needs of incarcerated Veterans, HCRV's goals are to
prevent homelessness, reduce the impact of medical,
psychiatric, and substance abuse problems upon community
readjustment, and decrease the likelihood of re-incarceration
for those leaving prison. This permanent authority would
recognize the crucial role these programs play in preventing
and ending Veteran homelessness.
Section 7 would amend 38 U.S.C. Sec. 2044(e) to authorize
the use of $500 million from VA's FY 2016 Medical Services
appropriation for the Supportive Services for Veteran Families
(SSVF) Program, and to extend the existing $1 million
appropriation authority for training and technical assistance
to SSVF grantees through FY 2015.
While the $500 million level of this authorization is above
the level proposed in VA's budget, we nevertheless support an
authorization level that provides flexibility should VA
determine that additional funding is necessary and the
Department is in a position to dedicate higher amounts to the
program. VA thus supports the intent of section 7, but believes
that in order to ensure the provision of quality services to
Veteran families and the efficient execution of such additional
funds; this increased flexibility should be accompanied by an
increased proportional authorization in technical assistance
for SSVF providers.
Section 8 would require the Secretary to assess and measure
the capacity of programs receiving grants under 38 U.S.C.
Sec. 2011, or per diem payments under 38 U.S.C. Sec. 2012 or
2061.
VA believes the intent of section 8 is satisfied by
existing VA's Homeless Providers Grant and Per Diem Program
monitoring practices. VA's GPD Program regularly monitors
capacity and performance in grantees' programs, so section 8
would impose a new and potentially duplicative reporting
requirement. Although VA expects that compliance with section 8
would require time and effort from VA employees, the reporting
requirements are not unduly burdensome and would result in
minimal costs to VA. Therefore, VA does not object to section
8.
Section 9 would require the U.S. Comptroller General to
conduct an assessment of VA programs serving homeless Veterans
to determine whether these programs are meeting Veterans'
needs, and recent efforts to improve the privacy, safety, and
security of female Veterans receiving assistance under these
programs. VA supports the intent of section 9, but believes its
goals have been accomplished by recent reviews of VA homeless
programs conducted by the Government Accountability Office and
by VA's annual assessment of homeless Veterans' service needs
and the availability of responsive VA and community services.
Since its inception in 1994, VA's Project CHALENG (Community
Homelessness Assessment, Local Education and Networking Groups)
has surveyed participants (homeless and formerly homeless
Veterans, as well as VA and community service providers) on the
needs of homeless Veterans in their local communities, and the
extent to which these are addressed by existing VA and
community services. The results not only drive the development
of new local partnerships, but also generate a national picture
of male and female homeless Veterans' met and unmet service
needs, as identified by homeless Veterans themselves and the
service providers who work with them directly.
Section 10 would remove the requirement that VA report to
the Senate and House of Representatives Committees on Veterans'
Affairs on the activities of the Department during the calendar
year preceding the report under programs of the Department for
the provision of assistance to homeless veterans.
VA supports section 10. Removing this time consuming
reporting function would free up VA resources that could be
better used to internally asses the programs and implement
changes to enhance the benefits and services provided to
homeless Veterans. Furthermore, VA remains committed to
providing timely data reporting to the Committees upon request.
Removing this annual reporting requirement would recognize that
VA, on its own initiative, conducts ongoing data analysis of VA
homeless programs.

DRAFT BILL--DEPARTMENT OF VETERAN AFFAIRS PURCHASED HEALTH CARE
STREAMLINING AND MODERNIZATION ACT

This draft bill is similar to legislation requested by the
Administration to reform the authorities VA uses to purchase
hospital care, medical services, and extended care when that
care is not feasibly available at a VA facility, or through
contracts or sharing agreements entered into under other
authorities. We sincerely appreciate the Committee placing it
on the agenda today, and look forward to working with you on
this critical aspect of ensuring Veterans' timely access to
health care.
Section 2 would amend chapter 17 of title 38, U.S.C., by
adding a new section, ``1703A. Veterans Care Agreements with
certain health care providers.''
Subsection (a) of 1703A would provide that if VA is not
feasibly able to furnish hospital care, medical services, or
extended care within the Department or through the exercise of
other authority to enter into contracts or sharing agreements,
VA may enter into ``Veterans Care Agreements'' (VCA) with
eligible providers who are certified under subsection (c) of
the new 1703A. Eligibility for care would be determined in the
same manner as if the care or services were furnished directly
by a VA facility.
Subsection (b) would define eligible providers to include
Medicare and Medicaid providers; an Aging or Disability
Resource Center, an area agency on aging, or a State agency as
defined in section 102 of the Older Americans Act; a center for
independent living as defined in section 702 of the
Rehabilitation Act; and other providers the Secretary
determines to be appropriate.
Subsection (c) would require the Secretary to establish a
process for the certification and re-certification of eligible
providers. This process must include procedures for screening
providers according the risk of fraud, waste, and abuse and
must require the denial of applications from providers excluded
from certain Federal programs. VA notes that this provision
would require VA to certify all eligible providers, including
those participating in Medicare or Medicaid. In VA's
legislative proposal, VA would establish a separate
certification process for those eligible providers that are not
under the certification regimes of Medicare and Medicaid. VA
suggests this approach to avoid subjecting providers to
duplicative certification processes, which could dissuade
providers from entering VCAs.
Subsection (d) would require the inclusion of specific
terms in VCAs, including payment rates that are, to the extent
practicable, in accordance with the rates paid by the United
States in the Medicare program. Other requirements of VCAs
would include restricting care to that authorized by VA,
prohibiting third-party billing by providers, and submitting
medical records to the Department.
Subsection (e) would specify the terms and conditions under
which VA or the provider may terminate a VCA.
Subsection (f) would require the Secretary to review VCAs
of material size every 2 years to determine whether it is
feasible or advisable to provide the necessary care at
facilities of the Department or through contract or sharing
agreements entered into under other authorities.
Subsection (g) would specify that VCAs under section 1703A
are exempt from certain provisions of law governing Federal
contracting. Specifically, VCAs would be awarded without regard
to competitive procedures and would not subject an eligible
provider to certain laws that providers and suppliers of health
care services through the Medicare program are not subject to.
Providers entering into VCAs would be subject to all laws
regarding integrity, ethics, fraud, or that subject a person to
civil or criminal penalties, as well as all laws prohibiting
employment discrimination on the basis of race, color, national
origin, religion, gender, sexual orientation, gender identity,
disability, or status as a Veteran.
Subsection (h) would require the Secretary to establish a
system or systems to monitor the quality of care and services
provided to Veterans under section 1703A and to assess the
quality of care and services for purposes determining whether
to renew a VCA.
Subsection (i) would require the Secretary to establish
administrative procedures for providers to present disputes
arising under or related to VCAs. It would further require that
providers exhaust these administrative procedures before
seeking judicial review under the Contract Disputes Act.
Subsection (j) would direct the Secretary to prescribe
regulations to carry out section 1703A.
Section 3 of the draft bill would amend 38 U.S.C. Sec. 1745
to permit VA to enter into agreements with State Veterans Homes
that are exempt from certain provisions of law governing
Federal contracting. Specifically, an agreement could be
awarded without regard to competitive procedures and would not
subject a State Home to certain laws that providers and
suppliers of health care services through the Medicare program
are not subject to. An agreement would be subject to all laws
regarding integrity, ethics, fraud, or that subject a person to
civil or criminal penalties, as well as all laws prohibiting
employment discrimination on the basis of race, color, national
origin, religion, gender, sexual orientation, gender identity,
disability, or status as a Veteran. In addition, subsection (c)
would establish a separate effective date for the amendments
made by section 3 based on the effective date of implementing
VA regulations.
Although section 3 would eliminate the word ``contract'' in
section 1745, it would authorize VA to enter into
``agreements'' which VA believes would include contracts based
on the Federal Acquisition Regulation (FAR) contracts. VA thus
does not interpret this amendment to prohibit VA from using
FAR-based contracts if a State home requests it.
Similar to the legislation proposed by the Administration,
the draft bill would not result in additional costs and thus
would be budget neutral.
This bill is a critical reform that will address
deficiencies in current law, as well as provide a comprehensive
framework and foundation for the purchase of non-VA care in
those circumstances where it is not feasibly available from VA
or through contracts or sharing agreements. We strongly support
its enactment, which we believe is essential to maintaining
Veterans' access to care in every part of the country.

Mr. Chairman, thank for the opportunity to present the
Department's views on these bills and we will be glad to
respond to the Committee's questions.
------

STATEMENT OF DR. RAJIV JAIN, ASSISTANT DEPUTY UNDER SECRETARY FOR
HEALTH FOR PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS

Good morning Chairman Isakson, Ranking Member Blumenthal,
and Members of the Committee. Thank you for inviting us here
today to present our views on several bills that would affect
VA benefits programs and services. Joining us today is
Catherine Mitrano, Deputy Assistant Secretary for Resolution
Management, and Jennifer Gray, Staff Attorney in VA's Office of
General Counsel.
We do not yet have cleared views on the Draft Biological
Implant Tracking and Veteran Safety Act of 2015 or on S. 1117,
the Ensuring Veteran Safety Through Accountability Act of 2015.
Additionally, we do not have cleared views on sections 203,
205, 208, and 209(b) of S. 469, sections 3 through 8 of
S. 1085, section 2 of the draft bill referred to on the agenda
as ``Discussion Draft'' or sections 101-106, 204, 205, 403 and
501 of The Jason Simcakoski Memorial Opioid Safety Act. We will
be glad to work with the Committee on prioritization of those
views and cost estimates not included in our statement.

* * * * * * *

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF
2015

The Caregivers and Veterans Omnibus Health Services Act of
2010, Public Law 111-163, signed into law on May 5, 2010,
provided expanded support and benefits for caregivers of
eligible and covered Veterans. While the law authorized certain
support services for caregivers of covered Veterans of all
eras, other benefits were authorized only for qualified family
caregivers of eligible Veterans who incurred or aggravated a
serious injury in the line of duty on or after September 11,
2001. These new benefits for approved family caregivers,
provided under the Program of Comprehensive Assistance for
Family Caregivers, include a monthly stipend paid directly to
designated primary family caregivers and medical care under
CHAMPVA for designated primary family caregivers who are not
eligible for TRICARE and not entitled to care or services under
a health-plan contract.
Section 2 of S. 1085, the Military and Veteran Caregiver
Services Improvement Act of 2015, would remove ``on or after
September 11, 2001'' from the statutory eligibility criteria
for the Program of Comprehensive Assistance for Family
Caregivers, and thereby expand eligibility under the program to
Veterans of all eras who otherwise meet the applicable
eligibility criteria. Family caregivers could not receive
assistance under this expanded eligibility until Fiscal Years
2016, 2018, or 2020 depending on the monthly stipend tier for
which their eligible Veteran qualifies. Section 2 would also
add ``or illness'' to the statutory eligibility criteria, and
thereby expand eligibility to include those Veterans who
require a caregiver because of an illness incurred or
aggravated in the line of duty. In addition, the bill would
expand the bases upon which a Veteran could be deemed to be in
need of personal care services, to include ``a need for regular
or extensive instruction or supervision without which the
ability of the Veteran to function in daily life would be
seriously impaired.''
The bill would also expand the assistance available to
primary family caregivers under the Program of Comprehensive
Assistance for Family Caregivers to include child care
services, financial planning and legal services ``relating to
the needs of injured and ill veterans and their caregivers,''
and respite care that includes peer-oriented group activities.
The bill would ensure that in certain circumstances VA accounts
for the family caregiver's assessment and other specified
factors in determining the primary family caregiver's monthly
stipend amount. In addition, the bill would require VA to
periodically evaluate the needs of the eligible Veteran and the
skills of the family caregiver to determine if additional
instruction, preparation, training, or technical support is
needed, and it would require certain evaluation be done in
collaboration with the Veteran's primary care team to the
maximum extent practicable.
Section 2 of S. 1085 would also authorize VA, in providing
assistance under the Program of Comprehensive Assistance for
Family Caregivers, to ``enter into contracts, provider
agreements, and memoranda of understanding with Federal
agencies, States, and private, nonprofit, and other entities''
in certain circumstances. It would expand the definition of
family member to include a non-family member who does not
provide care to the Veteran on a professional basis, and it
would amend the definition of ``personal care services.'' The
bill would also end the Program of General Caregiver Support
Services on October 1, 2020, but would ensure that all of its
activities are carried out under the Program of Comprehensive
Assistance for Family Caregivers. Finally, the bill would amend
the annual reporting requirements for the Program of
Comprehensive Assistance for Family Caregivers.
In September 2013, VA sent a report to the Committees on
Veterans' Affairs of the Senate and House of Representatives
(as required by Section 101(d) of the Public Law 111-163) on
the feasibility and advisability of expanding the Program of
Comprehensive Assistance for Family Caregivers to family
caregivers of Veterans who incurred or aggravated a serious
injury in the line of duty before September 11, 2001. In that
report, VA noted that expanding the Program of Comprehensive
Assistance for Family Caregivers would allow equitable access
to seriously injured Veterans from all eras (who otherwise meet
the program's eligibility criteria) and their approved family
caregivers.
In the report, however, VA noted difficulties with making
reliable projections of the cost effect of opening the Program
of Comprehensive Assistance for Family Caregivers to eligible
Veterans of all eras, but estimated a population range of
32,000 to 88,000 additional Veterans in the first year
(estimated for FY 2014), at a cost of $1.8 billion to $3.8
billion in the first year (estimated for FY 2014). After VA
provided this report to Congress, the RAND Corporation
published a report titled, ``Hidden Heroes: America's Military
Caregivers,'' which estimates a significantly larger eligible
population (1.5 million) that may be eligible if the program
were expanded to caregivers of pre-9/11 Veterans. VA's
estimates in the 2013 report did not account for expansion to
eligible Veterans with an illness incurred or aggravated in the
line of duty, other Veterans who would become eligible for the
program based on the amendments in section 2 of S. 1085, or the
additional assistance that would become available to primary
family caregivers under the bill.
VA cannot responsibly provide a position in support of
expanding the Program of Comprehensive Assistance for Family
Caregivers without a realistic consideration of the resources
necessary to carry out such an expansion, including an analysis
of the future resources that must be available to fund other
core direct-to-Veteran health care services. That consideration
includes the budget levels included in the fiscal year 2016
budget resolution adopted by Congress, S. Con. Res 11, as well
as the fiscal year 2016 Military Construction/VA appropriations
measures passed in the House and awaiting action in the Senate
(H.R. 2029). This is especially true as VA presses to
strengthen mental health services and ensure the fullest
possible access to care across the system.
While VA has not provided views on section 7 of S. 1085,
the Department of Justice advises that it has constitutional
concerns with that provision, which it will provide to the
Committee under separate cover.
We wish to make it very clear that VA believes an expansion
of those benefits that are currently limited by era of service
would result in equitable access to the Program of
Comprehensive Assistance for Family Caregivers for long-
deserving caregivers of those who have sacrificed greatly for
our Nation. However, VA cannot endorse this measure before
further engaging with Congress on these fiscal constraints,
within the context of all of VA health care programs. VA
welcomes further discussion of these issues with the Committee.

* * * * * * *

DRAFT LEGISLATION--JASON SIMCAKOSKI MEMORIAL
OPIOID SAFETY ACT

Section 201 would establish within the Office of the Under
Secretary for Health an office to be known as the ``Office of
Patient Advocacy.'' The Office would carry out the Patient
Advocacy Program of VA. This section would also establish the
responsibilities of patient advocates at VA medical facilities.
VHA currently has a Patient Advocacy program established to
ensure that all Veterans and their families served in VHA
facilities and clinics have their complaints addressed in a
convenient and timely manner. The program operates under a
philosophy of Service Recovery, whereby patient complaints are
identified, resolved, classified, and utilized to improve
overall services to Veterans.
As health care continues to evolve, so does the role of the
Patient Advocate. The role of the advocate in VHA has
traditionally been more reactive, i.e. responding to issues as
they arise, hearing and reacting to patient complaints as they
bring them forward. With a heightened awareness of the
importance of a positive, patient experience, VHA is on the
pathway to transform the program including the role of the
Patient Advocate to focus on a more proactive approach by all
staff that would result in a more positive patient experience.
Earlier this month, to maintain the highest standard for
responding to patient issues while continually improving the
advocacy program, VHA established the Client Services Response
Team (CSRT), reporting directly to the Office of the Under
Secretary for Health. The CSRT is charged to centralize and
streamline internal processes to improve VHA's overall
responsiveness to the concerns of Veterans, employees and other
key stakeholders.
The proposed bill reflects the existing Patient Advocacy
program but does not account for the strategy to transform the
Patient Advocate role to keep pace with private sector advances
in patient experience. The model has been successfully
demonstrated in VHA pilots and private sector health care
systems\27\ and is consistent with VA's vision of providing
world-class customer service. This vision will engage staff
from across the organization as well as Veterans to be actively
involved in the transformation process. VA is thus very
supportive of the concept in section 201, but has concerns that
detailed statutory directives could restrict the evolution and
breadth of the Patient Advocacy program.
---------------------------------------------------------------------------
\27\Merlino, J (2015). Service fanatics: how to build a superior
patient experience the Cleveland Clinic way. New York, NY: McGraw-Hill
Education.
---------------------------------------------------------------------------
VA supports section 202 which would require VA Medical
Centers and Community Based Outpatient Clinics to host
community meetings, open to the public, on improving health
care from the Department. This section is consistent with
current practices of hosting Town Hall meetings to hear from
Veterans, families, and other stakeholders.
Section 203 would require VA display at each VA medical
facility the purposes of the Patient Advocacy Program, contact
information for the patient advocate, and the rights and
responsibilities of patients and family members. VA supports
increasing the awareness of the Patient Advocacy Program and
the Rights and Responsibilities of Veterans and family members.
This section is consistent with current practices of posting
this information in medical facilities and would only require
the addition of posting the Patient Advocacy Program's purpose.
VA supports the intent of title III which seeks to expand
research, education and delivery of complementary and
integrative health (CIH) to Veterans. VA is committed to
expanding the research, education and delivery of complementary
and integrative health services to Veterans. Aligning with VA's
Blueprint for Excellence VHA leadership identified as its
number one strategic goal ``to provide Veterans personalized,
proactive, patient-driven health care.'' This approach to
health care prioritizes the Veteran and their values, and
partners with them to create a personalized strategy to
optimize their health, healing, and well-being. Many of the
strategies that may be of benefit extend beyond what is
conventionally addressed or provided by the health system and
includes CIH. To this end, VA is establishing the Integrative
Health Coordinating Center within the Office of Patient
Centered Care and Cultural Transformation (OPCC&CT).
OPCC&CT, along with Patient Care Services, deployed a
national survey on CIH to better understand the evolution of
how these services are being provided across the system and to
advance further implementation. The survey was deployed to all
VA parent medical facilities with a 100 percent completion
rate. This report is being finalized this month for review by
VHA and VA leadership.
VA is preparing the current workforce through a focus on
education of the clinical staff. OPCC&CT developed the Whole
Health Clinical Education Program which is designed to educate
clinicians in providing a proactive, whole person approach.
This includes learning how to effectively integrate CIH
approaches. This inter-professional training includes VA
physicians, nurses, dietitians, chaplains and other clinical
staff. The core curriculum was designed and launched in 2014
and targets traditional health care providers across VHA.
The evaluation demonstrated that clinicians had improved
attitudes towards Integrative Health, as well as changes in
intentions to integrate mindful awareness in interactions with
Veterans, encourage the use of self-care strategies, encourage
the use of integrative health strategies during clinical
encounters, and to co-manage patients with practitioners
outside their own medical paradigm.
To implement safe and effective management of pain, VHA's
National Pain Program office oversees several work groups and a
National Pain Management Strategy Coordinating Committee
representing the VHA offices of nursing, pharmacy, mental
health, primary care, anesthesia, education, integrative
health, and physical medicine and rehabilitation. Working with
the field, these groups develop, review and communicate strong
pain management practices to VHA clinicians and clinical teams.
VHA has multiple projects, coordinated under the National
Pain Program office, to support and educate clinicians and
Veterans about safe and effective stepped pain management,
including use of opioids. Programs such as the Opioid Safety
Initiative (OSI), the Joint Pain Education and Training Project
(JPEP) with Department of Defense (DOD), the Tiered Acupuncture
Training Across Clinical Settings (ATACS) with DOD, the Pain
Mini-residency, Pain Specialty Care Access Network (SCAN ECHO),
asynchronous Web-based training, and Community of Practice
calls all reach across the VHA to train primary care providers
in all settings in the assessment and treatment of pain and in
the use of patient education in self-management, the use of
multiple modalities such as behavioral, integrative medicine
(Complementary and Alternative Medicine, or CAM), and physical
therapies and the use of consultant specialists in pain, mental
health, and CAM.
For example, on the topic of opioids safety, all the
education programs listed above, except ATACS which is focused
on acupuncture skill training, have presentations on universal
precautions and risk management in opioid therapy for pain,
including clinical evaluation, written informed consent,
screening such as urine drug monitoring, use of state
monitoring programs, and safe tapering. Related specifically to
safe opioid prescribing, the VHA has implemented the Opioid
Safety Initiative, a mandatory academic detailing program that
identifies targets of risky practices (e.g., high opioid doses,
co-prescribed benzodiazepines, use of urine drug screens) and
universally monitors these practices in VHA at the provider and
facility/VISN level through appointed VISN and facility OSI and
Pain Management Point of Contact, or POCs. A POC is a clinician
appointed and supported at the VISN level who is an
appropriately trained, experienced and credentialed in pain
medicine, pain management, or another credential appropriate to
the clinical discipline. These individuals identify targets of
risky practices through regular monthly and `on-demand'
progress reports, and provide education and counseling for
facilities and prescribers whose patterns of prescribing and
pain management practices require remediation.
To provide clinical education and resource support to
providers and facilities for successful OSI implementation, the
National Pain Program office established the interdisciplinary
OSI Toolkit Task Force to systematically peer-review and
standardize clinical education and patient education materials
for distribution throughout VHA. The OSI Toolkit Task force has
completed peer-review, revision and approval of the below
trainings and materials and meets regularly to peer-review,
revise, and publish new ``strong practices'' that are
identified in VHA.
Most recently, in March 2015, the National Pain Management
launched the new Opioid Therapy Risk Report tool which provides
detailed information on the risk status of Veterans taking
opioids to assist VA primary care clinicians with pain
management treatment plans. This tool is a core component of a
reinvigorated focus on patient safety and effectiveness.
In 2014, VA's Office of Academic Affiliations in
conjunction with Physical Medicine and Rehabilitation Services
launched a national VA Chiropractic residency program. The VA
Chiropractic program has been engaged in chiropractic education
and training for a decade. Since 2004 over 1,500 chiropractic
students have completed clinical rotations at 24 VA facilities.
The VA chiropractic residency program focuses on Integrated
Clinical Practice, with training emphasizing the provision of
chiropractic care in an integrated health care system,
collaborating with primary care Patient Aligned Care Teams
(PACTs), specialty care, and other medical and associated
health providers and trainees. Individual residencies are
administered by the respective local VA facilities. Each VA
facility partners with its affiliated Council on Chiropractic
Education accredited chiropractic school in conducting the
program.
VA Research is actively engaged with the community of
scientists in establishing the evidence base for complementary
and integrative health treatments for physical and mental
conditions, the latter including examining the benefit of CIH
therapy for PTSD, suicide prevention, and mood disorders. As
these studies are completed, results will be evaluated to
determine potential impact on Clinical Practice Guidelines. The
VA Evidence-based Synthesis Program in conjunction with OPCC&CT
and Patient Care Services has examined the scientific
literature on various CAM services and have presented the
findings in the form of ``evidence maps.'' An evidence review
and map in acupuncture, yoga, Tai Chi and mindfulness has been
completed. The findings from these reviews are helping to
inform decisions on how to best use CAM within VA and identify
areas for further research.
Section 401 would require that as part of the hiring
process VA reach out to state medical boards to ascertain
whether a prospective employee has any violations over the past
twenty years, or has entered into a settlement agreement
related to the employee's practice of medicine. VA does not
feel that additional legislation is needed to accomplish this.
VHA policy, already in place, requires the verification of all
current and previously held licenses for all licensed health
care providers. At the time of initial appointment all current
and previously held licenses are verified with the state
licensing board issuing the license. Verification requires
querying the state licensing board for not only the issue date
and expiration date, but also any pending or previous adverse
actions. If an adverse action is identified, the verification
requires obtaining all documentation available associated with
such action, including but not limited to copies of any
agreements. At the time of expiration of a license as well as
at the time of reappraisal, VHA policy requires querying the
state licensing board to confirm renewal of the license as all
as whether or not there have been any new pending or previous
adverse actions. If the license is not renewed, VHA policy
requires confirmation that the license expired in good standing
and if not, what was not in good standing.
At the time of initial appointment, all health care
providers are queried through the National Practitioner Data
Bank (NPDB). The NPDB is a national flagging system that serves
as a resource for hospitals and other health care entities
during the provider credentialing process. The NPDB provides
information about past adverse actions of health care
providers. VHA also enrolls all independent, privileged
providers in the NPDB's Continuous Query program for ongoing
monitoring of not only adverse actions taken against a
credential, but also paid malpractice. VHA receives
notification of a new report within 24 hours of the report
being filed with the NPDB.
Additionally, at the time of initial appointment, all
physicians are queried through the Federation of State Medical
Boards (FSMB) Federation Physician Data Center, a nationally
recognized system for collecting, recording and distributing to
state medical boards and other appropriate agencies data on
disciplinary actions taken against licensees by the boards and
other governmental authorities. The report returned from the
FSMB Physician Data Center not only identifies if there are any
adverse actions recorded against a physician's license but also
lists all of the physician's known licenses, current or
previously held, serving as double-check that the physician
reported all licenses during the credentialing process. In
addition, the licenses of all physicians are monitored through
a contract with the FSMB's Disciplinary Alert Service (DAS).
Through this contract, all physicians are enrolled in the DAS
which offers ongoing monitoring of physician licensure. If a
new action against a physician's license is reported to the
FSMB DAS, VHA receives a notification of the report within 24
hours. The staff at the physician's facility then contacts the
reporting state licensing board to obtain the details of the
action.
If the facility learns of an adverse action taken against a
provider license, the staff at the facility must obtain
information from the provider against whom the action was taken
and consider it as well as the information obtained from the
state licensing board. This review is documented to include the
reasons for the review, the rationale for the conclusions
reached, and the recommended action for consideration and
appropriate action by the facility.
Section 402 would require VA to provide the relevant state
medical board detailed information about any health care
provider of VA that has violated a requirement of their medical
license. We also believe in this case additional legislation is
not required. VA has broad authority to report to state
licensing boards those employed or separated health care
professionals whose behavior or clinical practice so
substantially failed to meet generally-accepted standards of
clinical practice as to raise reasonable concern for the safety
of patients. The authority to report those professionals is
derived from VA's long-standing statutory authority, contained
in 38 U.S.C. 7401-7405, which authorizes the Under Secretary
for Health, as head of VHA, to set the terms and conditions of
initial appointment and continued employment of health care
personnel, as may be necessary, for VHA to operate medical
facilities. This authority includes requiring health care
professionals to obtain and maintain a current license,
registration, or certification in their health care field.
The Veterans Administration Health-Care Amendments of 1985,
Public Law 99-166, and Part B of Title IV of Public Law 99-660,
the Health Care Quality Improvement Act of 1986, are Acts
require VHA to strengthen quality assurance and reporting
systems to promote better health care. Pursuant to section 204
of Public Law 99-166, VA established a comprehensive quality
assurance program for reporting any licensed health care
professional to state licensing boards who:

(1) Was fired or who resigned following the
completion of a disciplinary action relating to such
professional's clinical competence;
(2) Resigned after having had such professional's
clinical privileges restricted or revoked; or
(3) Resigned after serious concerns about such
professional's clinical competence had been raised, but
not resolved.

The statutory provisions of 38 U.S.C. 7401-7405, augmented
by Public Laws 99-166 and 99-660, provide VHA ample authority
to make reports to state licensing boards when exercised
consistent with Privacy Act requirements for release of
information. VHA policy requires the VA medical facility
Director to ensure that within seven calendar days of the date
a licensed health care professional leaves VA employment, or,
information is received suggesting that a current employee's
clinical practice has met the reporting standard, an initial
review of the individual's clinical practice is conducted to
determine if there may be substantial evidence that the
individual so substantially failed to meet generally-accepted
standards of clinical practice as to raise reasonable concern
for the safety of patients.
Usually this review is conducted and documented by first
and second level supervisory officials. When the initial review
suggests that there may be substantial evidence that the
licensed health care professional so failed to meet generally-
accepted standards of clinical practice as to raise reasonable
concern for the safety of patients, the medical facility
Director is responsible for immediately initiating a
comprehensive review to determine whether there is, in fact,
substantial evidence that this reporting standard has been met.
This review involves the preparation of a state licensing board
Reporting File. VHA policy defines the process for collecting
evidence; notifying the provider of the intent to report which
affords the provider the opportunity to respond in writing to
the allegations; and then the review process to assure that VHA
has complied with the Privacy Act prior to reporting.
It is VA's policy to cooperate whenever possible with an
inquiry by a state licensing board. VA medical facilities must
provide reasonably complete, accurate, timely, and relevant
information to a state licensing board in response to
appropriate inquiries.
Mr. Chairman, thank you for the opportunity to present our
views on the legislation today and we will be glad to answer
any questions you or other Members of the Committee may have.
------

STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR
HEALTH CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS

Good afternoon Chairman Isakson, Ranking Member Blumenthal,
and Members of the Committee. Thank you for inviting us here
today to present our views on several bills that would affect
VA benefits programs and services. Joining me today are Robert
Worley, Director of the Education Service in the Veterans
Benefits Administration, Catherine Mitrano, Deputy Assistant
Secretary for Resolution Management, and Susan Blauert and Kim
McLeod, who are both Deputy Assistant Counsels in VA's Office
of General Counsel

* * * * * * *

S. 1450, DEPARTMENT OF VETERANS AFFAIRS EMERGENCY MEDICAL STAFFING
RECRUITMENT AND RETENTION ACT

S. 1450 would allow VA to arrange flexible physician and
physician assistant work schedules to allow for the hiring and
full implementation of a hospitalist physician system and to
accommodate the unusual work schedule requirements for
Emergency Medicine (EM) Physicians.
VA supports increased flexibility for critical medical
personnel. Hospitalist physicians and EM physicians specialize
in the care of patients in the hospital, often working
irregular work schedules to accommodate the need for continuity
of efficient hospital care. VA believes that increased
scheduling flexibility would align VA practice with the private
sector, facilitating the recruitment, retention of emergency
physicians and the recruitment, retention and operation of a
hospitalist physician system at VA medical centers (VAMC). We
note concerns that the Office of Personnel Management will
provide in its statement for the record with respect to certain
of the bill's provisions. The Administration looks forward to
working with the Congress and our agency partners to finalize
language on these provisions.
VA believes S. 1450 would be cost neutral in terms of
impact on salaries as it merely authorizes flexibility in
physician and physician assistant work schedules to allow for
the hiring and full implementation of a hospitalist physician
system and improvements in EM physician coverage and enhanced
ability to recruit EM trained and experienced physicians.

S. 1451, VETERANS' SURVIVORS CLAIMS PROCESSING
AUTOMATION ACT OF 2015

S. 1451, the ``Veterans' Survivors Claims Processing
Automation Act of 2015,'' would authorize VA to pay benefits to
a survivor of a Veteran who has not filed a formal claim if the
record contains sufficient evidence to establish the survivor's
entitlement to such benefits. The bill would specify that the
date on which a survivor notifies VA of the Veteran's death
would be treated as the date of receipt of the survivor's
application for benefits. S. 1451 would be applicable to claims
based on a death occurring on or after the date of enactment of
this legislation.
VA supports S. 1451. The Department submitted a similar
legislative proposal for the Fiscal Year (FY) 2016 Budget.
Under 38 U.S.C. 5101(a), a claimant must file a formal claim as
a condition of receiving benefits. However, when a survivor of
a Veteran files a claim for VA benefits based upon the
Veteran's death, the information and evidence necessary to
decide the claim is often contained in the Veteran's claims
file. As a result, it is not necessary from a practical
standpoint for a claimant to file a formal claim in such
circumstances. Elimination of the formal-claim requirement
would automate the delivery of uninterrupted benefits to
qualifying survivors.
VA has one technical comment. VA would prefer to change the
language from ``the date on which a survivor of a Veteran
notifies the Secretary of the death of the Veteran,'' to ``the
date on which the Secretary is notified of the Veteran's
death.'' The modified language would allow VA to be more
liberal when providing benefits in instances where the survivor
is not the individual notifying VA of the Veteran's death.
VA estimates that there would be no benefit or general
operating expenses (GOE) associated with S. 1451.

S. 1460, FRY SCHOLARSHIP ENHANCEMENT ACT OF 2015

S. 1460 would allow recipients of the Marine Gunnery
Sergeant John David Fry Scholarship to be eligible for the
Yellow Ribbon program under the Post-9/11 GI Bill. The Yellow
Ribbon program is currently available to Veterans and most
transfer-of-entitlement recipients receiving Post-9/11 GI Bill
benefits at the 100 percent benefit level attending
institutions of higher learning. The program provides payment
for up to half of the tuition-and-fee-charges that are not
covered by the Post-9/11 GI Bill, such as charges that exceed
an academic year cap or out-of-state charges, if the
institution enters into an agreement with VA to pay or waive an
equal amount of the charges that exceed Post-9/11 GI Bill
coverage. This bill would take effect for the academic year
(August 1) beginning after the date of enactment.
VA does not object to S. 1460, subject to Congress
identifying acceptable offsets for the additional benefit
costs. VA would need to make modifications to its existing
information technology (IT) systems to implement this
legislation. Specifically, VA would need to modify the Benefits
Delivery Network (BDN), the VA-Online Certification of
Enrollment (VA-ONCE), and the Post-9/11 GI Bill Long-Term
Solution (LTS), to calculate eligibility and award Yellow
Ribbon program payments for Fry Scholarship beneficiaries. VA
estimates that it would require 1 year from the date of
enactment to make the IT system changes necessary to implement
the proposed legislation.
VA estimates the benefit costs associated with enactment of
the bill to be $492,000 in FY 2016, $2.7 million over 5 years,
and $6.2 million over 10 years. Although VBA administrative
costs are estimated to be insignificant, IT costs are estimated
to be $5 million. This IT estimate consists of the design,
development, testing, and deployment of the new functionality
that would be needed to meet the requirements of this
legislation.

S. 1856, VA EQUITABLE EMPLOYEE ACCOUNTABILITY ACT OF 2015

* * * * * * *

Section 6 of S. 1856 would require VA to provide all
managers with periodic training on whistleblower rights and
managing and motivating employees. VA already offers managers
the training discussed in section 6. Moreover, some training,
such as whistleblower rights and protections, is already
required for all managers. Nevertheless, VA is committed to the
principles of section 6 of S. 1856 and supports this section.

* * * * * * *

S. 1938, CAREER READY STUDENT VETERANS ACT OF 2015

S. 1938, the ``Career-Ready Student Veterans Act of 2015,''
would amend title 38, United States Code, to improve the
approval of certain VA programs of education for purposes of
educational assistance.
This bill would amend 38 U.S.C. 3676(c), pertaining to the
approval of non-accredited courses, by adding new requirements
to the criteria that must be met for State approving agencies
to approve institutions' written applications for approval of
non-accredited courses. First, in the case of a program
designed to prepare an individual for licensure or
certification in a State, the program would need to meet any
instructional curriculum licensure or certification
requirements of that State. Second, in the case of a program
designed to prepare an individual for employment pursuant to
standards developed by a board or agency of a State in an
occupation that would require approval or licensure, the
program would need to be approved or licensed by such board or
agency of the State.
The bill also would add subsection (f) to section 3676 to
permit VA to waive the aforementioned requirements in the case
of a program of education offered by an educational institution
if VA determined:

The educational institution was accredited by an
agency or association recognized by the Department of
Education;
The program did not meet the requirements at any
time during the 2-year period preceding the date of the waiver;
The waiver furthers the purposes of the
educational assistance programs administered by VA or would
further the education interests of individuals eligible for
assistance under such programs;
The educational institution does not provide any
commission, bonus, or other incentive payment based directly or
indirectly on success in securing enrollments or financial aid
to any persons or entities engaged in any student recruiting or
admission activities or in making decisions regarding the award
of student financial assistance, except for the recruitment of
foreign students residing in foreign countries who are not
eligible to receive Federal student assistance.

Subsection (d) of the proposed legislation would add a new
subsection to section 3679 of title 38 to require VA to
disapprove a non-accredited course of education designed to
prepare an individual for licensure or certification in a State
or for employment pursuant to standards developed by a board or
agency of a State in an occupation that requires approval or
licensure, if the educational institution providing the course
of education does not publicly disclose any conditions or
additional requirements, including training, experience, or
exams, required to obtain the license, certification, or
approval for which the course of education is designed to
provide preparation.
Subsection (e) of this bill would amend section
3672(b)(2)(A)(i) to include the new approval requirements for
non-accredited courses in the approval requirements for
``deemed approved'' accredited programs.
The bill would also amend 38 U.S.C. 3675, to apply the new
requirements in section 3676(c), to the approval conditions for
accredited courses offered by private for-profit institutions.
VA supports the intent behind this bill. However, we do not
support the bill as currently drafted for a number of reasons.
If enacted, the bill would ensure that non-accredited
courses pursued by GI Bill beneficiaries meet all of the State
requirements for licensure or certification in a given
occupation or career field and would be approved by the State
board or agency that developed the standards. VA does not
oppose the concept of additional criteria for the approval of
non-accredited courses. However, we note that, as written, the
bill would not allow the Secretary to waive the requirement for
non-accredited courses, as the institution must be accredited
in order to meet the criteria for a waiver. VA is unclear as to
the reason why an accreditation requirement would be inserted
in the approval criteria for non-accredited programs. In
general, an institution's accreditation applies to all of the
courses offered by the institution, and accredited courses have
different approval requirements.
Additionally, the bill would ensure that accredited courses
at private, for-profit institutions meet all State requirements
for certification and licensure. VA supports efforts to ensure
that Veterans and other GI Bill beneficiaries are well-trained
and adequately equipped to obtain employment and achieve
economic success. However, we note that the proposed licensure
and certification requirements would not be applied to similar
programs at public and private, not-for-profit institutions.
Consequently, the bill does not ensure that all Veterans and
beneficiaries would receive all of the training required for
licensure or certification in their chosen occupational fields.
VA also has concerns about the language in the new section
3679(d), which would require the disapproval of waived programs
if the educational institution does not publicly disclose the
additional conditions or requirements needed in order to meet
licensing or certification requirements. VA believes ``the
Secretary or the appropriate State approving agency'' should be
substituted for ``the Secretary,'' as the State approving
agencies are responsible for the approval of non-accredited
courses. As State employees, they have subject matter expertise
with regard to the specific State requirements for licensure or
certification and, consequently, are better-positioned to
determine the gaps in training or conditions that must be
publicized. In addition, to be consistent with approval
authorities in other sections of chapter 36, VA believes that
both the Secretary and the SAA should have this authority.
VA is unclear as to the intent underlying the proposed
amendment to 3672(b)(2)(A)(i). As written, it could be
interpreted to include non-accredited programs in a ``deemed
approved'' category. However, if the intent is to make the
proposed paragraphs (14) and (15) of section 3676(c) apply to
accredited programs at public and proprietary not-for-profit
institutions of higher learning as well, then it should be
reworded to read, ``Subject to paragraphs (14) and (15) of
section 3676(c) of this title, an accredited.'' In addition, we
note that, as currently drafted, the licensure and
certification requirements could not be waived for these
programs. VA believes that the waiver authority should apply to
accredited programs at public and proprietary not-for-profit
institutions of higher learning as well as to accredited
courses at private, for-profit institutions and non-accredited
programs.
VA estimates that there would be no additional mandatory or
discretionary cost requirements associated with the enactment
of this bill.

DRAFT BILL REGARDING IMPROVEMENTS IN EDUCATIONAL ASSISTANCE

Section 1 of the proposed legislation would add a new
section (3326) under subchapter III of chapter 33, title 38
U.S.C. Specifically, this section proposes to recodify the
provisions of Public Law (Pub. L.) 110-252, section 5003(c), to
bring those requirements into title 38, and it proposes a few
amendments to those requirements.
The Post-9/11 GI Bill (or chapter 33) requires individuals
to relinquish eligibility to some other VA education benefit,
as applicable, in order to receive the chapter 33 benefits.
Subsection (a) of the proposed 38 U.S.C. 3326 would define
the eligibility requirements for individuals to elect chapter
33 educational benefits. Individuals would be able to elect to
receive chapter 33 benefits if, as of August 1, 2009, they were
entitled to the MGIB-AD, MGIB-Selected Reserve (SR), or the
Reserve Educational Assistance Program, and had some or all of
their entitlement remaining under those programs. Individuals
would be able also to elect chapter 33 if they are making
contributions to receive MGIB-AD, or previously declined
participation in the MGIB-AD program.
Subsection (b) of the proposed 38 U.S.C. 3326 would call
for the cessation of contributions toward MGIB-AD if an
individual elects to receive chapter 33 while still making
contributions to MGIB-AD. The obligation to make contributions
would cease the first month after the individual elects chapter
33 benefits.
Subsection (c) of the proposed 38 U.S.C. 3326 would address
the revocation of remaining entitlement transferred to a
dependent under MGIB-AD, if the individual who transferred the
benefit elects to receive chapter 33 benefits instead. The
proposed legislation would allow the transferor to revoke any
unused benefits that have been transferred to a dependent. If
the transferor revoked the transferred benefits from his or her
dependent, then the remaining entitlement would be available
for the transferor to use under chapter 33. If the transferor
did not elect to revoke the transferred MGIB-AD benefits, then
those benefits would remain available to the dependent under
MGIB-AD.
Subsection (d) of the proposed 38 U.S.C. 3326 would state
that individuals who make an election would be eligible for
benefits under chapter 33, rather than under the relinquished
benefit. It also would state that if individuals elected to
receive chapter 33 in lieu of MGIB-AD, and had previously used
entitlement under MGIB-AD, they would have eligibility under
chapter 33 for the number of months of entitlement that were
remaining under MGIB-AD, plus any entitlement that was revoked
from a dependent in accordance subsection (c).
Subsection (e) of the proposed 38 U.S.C. 3326 would allow
individuals who elect to receive educational assistance under
chapter 33 to receive payments at the rate available under the
relinquished benefit if their educational pursuit is authorized
under the relinquished benefit, but not under chapter 33. Any
entitlement used would be charged against chapter 33 in the
same manner as it would be charged against the relinquished
benefit.
Subsection (f) of the proposed 38 U.S.C. 3326 would outline
additional chapter 33 assistance for members who made
contributions toward the MGIB-AD program. A refund of MGIB-AD
contributions would be issued to a qualifying Veteran as an
increase to the last monthly housing stipend when benefit
entitlement is exhausted. The amount of the refund would be
calculated by taking the remaining months of entitlement under
MGIB-AD, at the time of the chapter 33 election, plus the
number of months, if any, of entitlement under chapter 30 that
were revoked by the individual and dividing that number by 36.
The result would be multiplied by the dollar amount that the
Veteran contributed toward the MGIB-AD, and the resulting
amount would be issued in conjunction with the final monthly
housing stipend. This proposed legislation would also change
the corresponding language currently contained in section
5003(c) of Pub. L. 110-252 by also authorizing refunds to
individuals pursuing programs at non-degree granting
institutions.
Subsection (g) of the proposed 38 U.S.C. 3326 would provide
for continued entitlement to additional assistance for critical
skills, specialty, and/or service (i.e., a college fund or
kicker) to which an individual was entitled under MGIB-AD or
MGIB-SR prior to relinquishing one of those benefits and
establishing eligibility under chapter 33. The additional
assistance would be paid in conjunction with the individual's
monthly housing stipend.
Subsection (h) of the proposed 38 U.S.C. 3326 would provide
VA with the authority to make an alternative election for an
individual if the election submitted by the applicant is not in
his or her best interest. If an individual elected to receive a
benefit that would be clearly not in his or her best interest
on or after January 1, 2016, VA would be able to change the
election and would be required to notify the individual of the
change within 7 days. The individual would be allowed 30 days
from the date he or she received the VA notification to modify
or revoke the election made by VA. In addition, VA would notify
the individual of the change of election by electronic means
whenever possible. These provisions are not included in section
5003(c) of Pub. L. 110-252; therefore, they would constitute a
new authority.
Subsection (i) of the proposed 38 U.S.C. 3326 would provide
that any election made under section 3326 would be irrevocable.
Finally, this section would repeal subsection (c) of
section 5003 of the Post-9/11 Veterans Educational Assistance
Act of 2008 (Pub. L. 110-252; 38 U.S.C. 3301 note).
VA does not object to (a) through (g) of the proposed 38
U.S.C. 3326 because these provisions are, generally, identical
to those that were enacted in section 5003(c) of Pub. L. 110-
252, with the exception of one minor change in the proposed
section 3326(f), which would also authorize refunds of MGIB-AD
contributions to individuals receiving monthly stipend payments
for pursuit of non-degree programs under 38 U.S.C. 3313(g).
However, VA has concerns with subsection (h) of the
proposed 38 U.S.C. 3326, which would allow VA to make an
alternative election on behalf of the Veteran that VA
determines is in his or her best interests. As individuals'
situations are different, elections made in the best interest
of a Veteran would be highly subjective. While one claims
examiner might view an election option as being the best,
another might disagree. Therefore, VA recommends specific
criteria for an election be added to the legislation that would
eliminate subjectivity. For example, in some instances, a
Veteran elects to relinquish MGIB-AD to receive chapter 33
benefits when he or she has only a few months of MGIB-AD
entitlement remaining. If the individual has more than one
qualifying period of service, it may be in that individual's
best interest to finish 36 months of entitlement under MGIB-AD
before beginning to receive chapter 33 benefits--the individual
could then receive up to 12 months of entitlement under chapter
33. If this situation met the criteria in the legislation as
enacted, the Veteran's claim would be processed under the
chapter 30 program until his or her entitlement under that
program ends.
VA also recommends that the proposed legislation include
language to allow VA to make an election in cases where a
Veteran or Servicemember applies for chapter 33 benefits and
does not elect to relinquish any benefit. This would allow VA
to maximize automation, improve processing times, and obviate
the need to contact the Veteran for an election.
Further, VA has concerns with the impact this subsection
would have on the automation of original claims using LTS. If
VA has to make an alternative election under chapter 33 when a
Veteran is eligible for more than one benefit, claims'
examiners would have to review the majority of chapter 33
original claims. The need for this review would limit the
number of original claims that could be automated through LTS
without human intervention, increasing the length of time that
Veterans would be waiting to receive their benefits.
VA estimates the cost of this section would be
insignificant because subsections (a) through (g) of the
proposed 38 U.S.C. 3326 are provisions that are already in
place under section 5003(c) of Pub. L. 110-252 and, therefore,
would result in no additional cost. In some cases, subsection
(h) may result in a Veteran receiving a better benefit that
would increase costs to VA. However, due to VA's current
outreach efforts, such as the GI Bill Comparison Tool, and the
amount of information available to assist Veterans in making
informed decisions on education benefits, VA does not
anticipate making a significant number of alternative
elections. Therefore, anticipated costs to the readjustment
benefits account are insignificant.
Section 2 would amend 38 U.S.C. 3684(a) to define the term
``educational institution'' to include a group, district, or
consortium of separately accredited educational institutions
located in the same State, and which are organized in a manner
that facilitates the centralized reporting of their
enrollments. This legislation would also amend section 3684(a)
to include individuals enrolled under chapters 32 and 33.
The proposed legislation would apply to any reports of
enrollment submitted on or after the date of enactment.
VA supports section 2. This legislation would allow each
institution in a district/consortium to certify a student's
enrollment regardless of where the student is matriculated.
Furthermore, since school certifying officials at ``District''
institutions have access to student records and all courses
have universal numbering, VA compliance visits could be done at
any institution and records would be available for students who
attend any of the institutions included in the group, district,
or consortium.
There would be no additional cost for implementing this
provision because the reporting fees would be paid to the
school that is certifying the enrollment, regardless of the
location of the institution.
Section 3 would amend subsection 38 U.S.C. 3313(c)(1)(A) to
limit the benefits paid for pursuit of certain degree programs
at a public institution of higher learning (IHL). It would
limit the amount of tuition and fees payable for certain
programs at IHLs, specifically those that involve a contract or
agreement with an entity (other than another public IHL) to
provide a program of education or a portion of a program of
education, to the same amount per academic year that applies to
programs at private or foreign IHLs. This section would be
effective the first day of a quarter, semester, or term
(whatever is applicable) after the legislation's enactment.
VA supports legislation that would limit the amount of
tuition and fee payments at public IHLs that involve contracted
training. VA is concerned about high tuition and fee payments
for enrollment in degree programs involving flight training at
public IHLs. Education benefit payments for these types of
programs have increased tremendously with the implementation of
P.L. 111-377, and in some cases, public institutions seem to be
targeting Veterans for their flight-related training programs.
There has been a significant increase in flight training
centers, specifically those that offer helicopter training,
that have contracted with public IHLs to offer flight-related
degrees. Sometimes these programs charge higher prices than
those that would be charged if the student had chosen to attend
the vocational flight school for the same training.
Additionally, VA has also noticed a growing number of VA
beneficiaries are taking flight courses as electives. VA allows
for ``rounding out,'' whereby non-required courses may be taken
to bring a student's course load up to full-time status in the
student's last term. Based on anecdotal evidence, some schools
are enrolling students in these very expensive flight courses
when ``rounding out'' is applicable. In most cases, these
courses are not specifically required for the Veteran's degree.
VA is still determining the costs associated with this
provision.
Section 4 would add a new section 3699 to title 38, U.S.C.,
requiring VA to make available to educational institutions
information about the amount of educational assistance to which
a Veteran or other individual is entitled under chapter 30, 32,
33, or 35. This information would be provided to the
educational institution through a secure information technology
system accessible by the educational institution and updated
regularly to reflect any amounts used by the Veteran or other
individual.
VA supports the intent behind providing educational
institutions with the number of months of educational
assistance to which a Veteran is entitled. Currently, VA
provides the amount of a Veteran's entitlement (original and
remaining) and other information (i.e., the delimiting date) to
the educational institution through the VA Online Certification
of Enrollment (VA-ONCE) system. The educational institution in
which the student is enrolled can view this information for
individuals training under chapters 30, 1606, and 1607 after VA
processes an award for education benefits. This functionality
is not currently available for Veterans or other individuals
training under chapters 32, 33, or 35; therefore, VA would need
to make programming changes to VA-ONCE in order to make this
information available as well.
VA recommends removing the requirement to provide
information for individuals training under chapter 32 from the
proposed legislation. Chapter 32 usage has decreased from 560
beneficiaries in FY 2008 to 2 beneficiaries for fiscal year
2015 through June 30, 2015. Because eligibility for chapter 32
ends 10 years after an individual's release from active duty,
the majority of those with remaining entitlement are likely
also eligible for benefits under chapter 33.
VA estimates the administrative costs for developing the
functional requirements of this section to be $500,000, and the
information technology (IT) costs associated with this section
to be $5 million to make enhancements to VA-ONCE to provide
newly required information to educational institutions.
Section 5 would amend 38 U.S.C. 3672(b)(2)(A) to authorize
State Approving Agencies (SAA) to determine if a program of
education is deemed to be approved for purposes of this chapter
if the program is one of the following:

An accredited standard college degree program
offered at a public or not-for-profit proprietary educational
institution that is accredited by an agency or association
recognized for that purpose by the Secretary of Education.
A flight training course approved by the Federal
Aviation Administration (FAA) that is offered by a certified
pilot school that possesses a valid FAA pilot school
certificate.
An apprenticeship program registered with the
Office of Apprenticeship, Employment Training Administration,
Department of Labor; or a State apprenticeship agency
recognized by the Office of Apprenticeship pursuant to the Act
of August 16, 1937 (popularly known as the ``National
Apprenticeship Act;'' 29 U.S.C. 50, et seq.).
A program leading to a secondary school diploma
offered by a secondary school approved in the state in which it
is operating.
A licensure test offered by a Federal, state, or
local government.

This legislation also would amend 38 U.S.C. 3675(a)(1) to
substitute ``A State approving agency, or the Secretary when
acting in the role of a State approving agency'' for ``the
Secretary or a State approving agency.'' Further, this
legislation proposes to amend section 3675 to expand the
approval of other courses by authorizing an SAA, or the
Secretary when acting in the role of a SAA, to approve
accredited programs (including non-degree accredited programs)
not covered by section 3672 of title 38.
VA supports the clarification of the approval requirements
codified in 38 U.S.C. 3672(b)(2)(A), as detailed in section
2(a) of the proposed legislation. To be ``deemed approved,''
accredited programs must meet the requirements of a number of
provisions in chapter 36 of title 38. Consequently, compliance
with those provisions must be verified, which the proposed
change will make more explicit. However, to be consistent with
approval authorities in other sections of chapter 36, VA
believes that both the Secretary and the SAA should have
approval authority.
VA also supports the proposed change to 38 U.S.C. 3675 in
section 5(b) of the bill, to make those approval provisions
apply to accredited non-degree programs at public and private
non-profit IHLs that are not covered by section 3672 or by any
of the approval requirements currently contained in chapter 36
of title 38. However, VA does not support modifying the current
language that grants approval authority to both the Secretary
and the SAA. The Secretary was granted authority under P.L.
111-377 to approve those programs, if necessary. While VA has
no plans to take over approvals of all educational programs, it
does appreciate this flexibility of authority.
VA estimates there are no costs associated with this
section.
Section 6 would amend 38 U.S.C. 3676(c)(14) as it pertains
to the criteria used to approve non-accredited courses. Under
the proposed legislation, VA, in consultation with the SAA and
pursuant to regulations, would determine if additional criteria
may be deemed necessary for the SAA to approve an institution's
written application for a course of education. VA and the SAA
must treat public, private, and private for-profit educational
institutions equitably.
The legislation would also amend 38 U.S.C. 3675(b)(3) to
include this requirement as part of the approval conditions for
accredited courses offered by private for-profit institutions.
This change would apply with respect to criteria developed
pursuant to 38 U.S.C. 3676(c)(14) on or after January 1, 2013,
and an investigation conducted under 38 U.S.C. 3676(c) that is
covered by a reimbursement of expense paid by VA to a state,
pursuant to 38 U.S.C. 3674, on or after October 1, 2015.
While VA agrees with the intent underlining section 6, that
the approval requirements for non-accredited courses should be
applied equitably regardless of the type of institution
providing the training, VA does not believe that it should be
interjected into the SAA approval requirements applicable to
educational institutions located in the state over which the
SAA has jurisdiction. VA is not aware of any widespread
concerns regarding unfair practices or unequal treatment with
respect to additional SAA approval requirements. VA is
concerned about the amount of resources that could potentially
be involved in regulating the process, reviewing the SAA
requirements, and making determinations regarding necessity and
equity. In this instance, VA would have to coordinate with all
50 States, territories, and institutions of higher learning
regarding policy and procedure changes. At this time, VA cannot
quantify the level of effort required for coordination of this
scope. Consequently, VA recommends adding the requirement that
any additional criteria treat public, private, and proprietary
for-profit educational institutions equitably, without
requiring a formal process and a VA decision on each additional
requirement. This would ensure the consistent application of
additional SAA approval requirements, allow states to
promulgate additional requirements for educational institutions
located within their borders, and avoid the potentially
burdensome administrative process proposed in this section.
At this time, VA cannot quantify the costs and level of
effort required for coordination of this scope.
Section 7 would amend 38 U.S.C. 3693 by inserting a new
subsection (a) that would require VA to conduct an annual
compliance survey of educational institutions and training
establishments offering one or more courses approved for
enrollment of eligible Veterans or individuals, if at least 20
such Veterans or individuals are enrolled. VA would be
responsible for:

Designing the compliance surveys to ensure that
such institutions or establishments, as the case may be, and
approved courses are in compliance with all applicable
provisions of chapters 30 through 36 of title 38;
Surveying each of these educational institutions
and training establishments not less than once during every 2-
year period; and
Assigning not fewer than one education compliance
specialist to work on compliance surveys in any year for each
40 compliance surveys required to be made under this section
for such year.

Additionally, VA, in consultation with the SAAs, would
annually determine the parameters of the surveys, and not later
than September 1 of each year, make available to the SAAs a
list of the educational and training establishments that would
be surveyed during the fiscal year following the date of making
such list available.
VA supports this section as it would improve the compliance
survey process. VA recognizes the importance of compliance work
in ensuring timely and accurate payments to Veterans and their
families. As such, VA and the National Association of State
Approving Agencies formed a joint committee, the Compliance
Survey Redesign Working Group, to streamline and enhance the
compliance survey process.
Currently, there are approximately 16,000 approved domestic
and international IHLs and non-college degree institutions. Of
the 16,000 institutions, there were 11,260 active institutions
in calendar year 2013. During FY 2013 and FY 2014, VA and SAAs
completed well over 10,000 surveys, with just over 5,000
surveys completed in FY 2014. VA anticipates completing a
similar number of reviews in 2015. This work will be split
roughly in half between VA and SAAs, as it has been for the
last few years.
The statute requires VA to conduct annual surveys at 100
percent of schools with greater than 300 beneficiaries and non-
college degree programs. Schools with high numbers of
beneficiaries are more likely to have one or more full-time
school certifying officials and may not need a visit annually.
Institutions with a smaller number of beneficiaries are more
likely to have school certifying officials who have other
duties, and these institutions may not be as well-versed in
school certifying official requirements, especially as they
relate to the Post-9/11 GI Bill program.
This section would also create a new provision that would
require the Secretary to consult with SAAs when determining the
parameters of which institutions would receive a compliance
survey each year. VA believes this provision is unnecessary as
VA already consults with SAAs when determining where surveys
will be conducted. With the implementation of section 203 of
P.L. 111-377 (Post-9/11 Veterans Educational Assistance
Improvements Act of 2010), VA was granted the authority to
utilize SAAs to assist VA in conducting compliance surveys at
GI Bill-approved institutions. Although VA can use the services
of SAAs, VA continues to be ultimately responsible for
conducting compliance surveys.
There are no mandatory costs associated with section 7, and
there would be only minimal administrative costs associated
with this provision.

Mr. Chairman, thank you for the opportunity to present our
views on the legislation today and we will be glad to answer
any questions you or other members of the Committee may have.
------

STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR
HEALTH CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS

Good afternoon Chairman Isakson, Ranking Member Blumenthal,
and Members of the Committee. Thank you for inviting us here
today to present our views on several bills that would affect
VA benefits programs and services. Joining me today are Vince
Kane, Special Assistant to the Secretary and Jennifer Gray,
Staff Attorney in VA's Office of General Counsel
We do not have cleared views on sections 5 and 8 of
S. 1885. We also do not have cleared views on S. 1676, a bill
to increase the number of graduate medical education positions
treating veterans, to improve the compensation of health care
providers, medical directors, and directors of Veterans
Integrated Service Networks, and for other purposes. We will be
glad to work with the Committee on prioritization of those
views and cost estimates not included in our statement.

* * * * * * *

S. 1754, VETERANS COURT OF APPEALS SUPPORT ACT OF 2015

S. 1754 would amend section 7253(a) of title 38, United
States Code, by permanently increasing the maximum number of
judges presiding over the United States Court of Appeals for
Veterans Claims (Veterans Court) from seven to nine. Because
the bill would primarily affect the Veterans Court and would
not affect the operation of VA, we defer to the Veterans Court
as to whether S. 1754 should be enacted.

S. 1885, VETERAN HOUSING STABILITY ACT OF 2015

Section 2 of S. 1885 would expand the definition of
``homeless Veteran'' to include those Veterans fleeing domestic
violence and interpersonal violence (DV/IPV), aligning VA's
definition with that of the Department of Housing and Urban
Development (HUD). VA supports section 2. Since Veterans
fleeing from DV/IPV are considered at high risk for
homelessness, they are already served in VA's homeless programs
when it is clinically appropriate.
Section 3 would require VA to create a new program to
provide intensive case management interventions to homeless
Veterans in at least six locations selected by VA based on
criteria which is described in the bill. VA would also be
required to prepare a report for Congress on the outcomes of
the program. VA does not believe section 3 is necessary, as VA
is already authorized to provide intensive case management
through the HUD-VASH program. HUD-VASH is similarly already
authorized to provide flexible team-based care management and
thus does not require the proposed program to provide such
services.
Section 4 would require VA to award grants for the
provision of case management services for Veterans who are
transitioning to permanent housing and those who are at risk
for homelessness. This would help address a current gap in case
management service delivery. The Homeless Providers Grant and
Per Diem (GPD) program, for example, lacks the authority to
provide funding for case management services once a Veteran
exits a GPD-funded transitional housing program. However, such
services may be currently provided by grantees in VA's
Supportive Services for Veteran Families (SSVF) program.
Section 4 would also require the Secretary to prioritize
for grant funding those organizations that would voluntarily
stop receiving per diem payments under the GPD program (38
U.S.C. Section 2012) or Special Need awards (38 U.S.C. Section
2061), and be willing to use their transitional housing
facility for permanent housing. VA supports this section of the
bill. Currently there are nearly 9,000 transitional housing
beds developed through VA investment of capital in partnership
with community organizations. As the number of homeless
Veterans decreases, the need for some of this transitional
housing will diminish, but there will be a continued need for
permanent housing interventions like rapid re-housing and
permanent supportive housing. This grant funding could enable
VA to help fill this need for permanent housing interventions,
consistent with the VA's Housing First approach to assisting
homeless Veterans.
VA supports section 6, which would require VA and HUD to
collaboratively provide outreach to public housing authorities,
tribally designated housing entities, realtors, landlords,
property management companies, developers, and other relevant
audiences to educate them about the housing needs of Veterans
and encourage them to rent to Veterans. VA and HUD currently
collaborate on such efforts.
VA supports section 7, which would codify the role of the
VA National Center on Homelessness Among Veterans as a center
of research, evaluation, and dissemination of best practices
regarding services for homeless Veterans.

* * * * * * *

S. 2022, SPECIAL PENSION OF MEDAL OF HONOR RECIPIENTS

S. 2022 would amend section 1562(a) of title 38, United
States Code, by increasing the monthly rate for the Medal of
Honor Pension to $3,000. VA administers the Medal of Honor
Pension, a special pension benefit that is not based on income
level, need, or disability, to recipients of the Medal of
Honor. For reference, the monthly Medal of Honor Pension rate
established pursuant to 38 U.S.C. Sec. 1562 is currently
$1,299.61.
The bill would be effective either (1) 180 days after the
date of enactment, or (2) if the date 180 days after the date
of enactment does not fall on the first day of a month, the
first day of the first month beginning after the date that is
180 days after the date of enactment. If the increased rate for
the Medal of Honor Pension is effective prior to December 1,
2016, the monthly rate would not be increased by a cost of
living adjustment (COLA) for FY 2017. Annual COLA increases
would resume beginning on December 1, 2017.
VA supports S. 2022, subject to Congress identifying
acceptable offsets for the additional benefit costs. This
legislation would be consistent with Congress' original intent
for the Medal of Honor Pension, which was to serve as a
``recognition of superior claims on the gratitude of the
country'' and to ``reward * * * in a modest way startling deeds
of individual daring and audacious heroism in the face of
mortal danger when war is on.''
VA estimates that benefit costs to the appropriation for
compensation and pension would be $788,000 in FY 2016, $7.2
million over 5 years, and $16.1 million over 10 years.
------

STATEMENT OF CURTIS L. COY, DEPUTY UNDER SECRETARY FOR ECONOMIC
OPPORTUNITY, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS

Good morning, Mr. Chairman and Members of the Committee. I
am pleased to be here today to provide the views of the
Department of Veterans Affairs (VA) on pending legislation
affecting VA's programs, including the following: S. 2106,
S. 2134, S. 2170, S. 2253, and a draft bill regarding
whistleblower complaints. At this time, VA is unable to develop
cost estimates for the ``Department of Veterans Affairs
Veterans Education Relief and Restoration Act of 2015;''
however, we will provide these to you as soon as they are
available. Accompanying me this morning are Maureen McCarthy,
Acting Assistant Deputy Under Secretary for Health for Patient
Care Services, Veterans Health Administration and Meghan Flanz,
Deputy General Counsel, Legal Operations & Accountability.

* * * * * * *

S. 2134

S. 2134, the ``Grow Our Own Directive: Physician Assistant
Employment and Education Act of 2015,'' would establish a pilot
program to provide educational assistance to certain former
members of the Armed Forces for education and training as
physician assistants within the VA. While VA supports the
concept, the cost associated with the legislation would cause
concern within our available resources.
S. 2134 would require the Secretary to provide information
on the pilot program to eligible individuals. An eligible
individual would be defined as an individual who: (1) has
medical or military health experience while serving as a member
of the Armed Forces; (2) has received a certificate, associate
degree, baccalaureate degree, master's degree, or post-
baccalaureate training in a science related to health care; (3)
has participated in the delivery of health care services or
related medical services; and (4) does not have a degree of
doctor of medicine, doctor of osteopathy, or doctor of
dentistry.
S. 2134 would also require the Secretary to select no less
than 250 eligible individuals to participate in the program
with a minimum of 35 scholarship participants per year.
Priority would be given to: individuals who participated in the
Intermediate Care Technician Pilot Program of the Department
that was carried out by the Secretary between January 2011 and
February 2015, and individuals who agree to be employed as a
physician assistant for VHA in a community designated as a
medically underserved population and in a State with a per
capita Veteran population of more than 9 percent. Although VA
supports the minimum requirement of scholarship participants,
VA is concerned that the applicant pool of eligible individuals
may be insufficient to meet the required number.
S. 2134 would also require the Secretary, in carrying out
the pilot program, to provide educational assistance to
individuals participating in the program to cover the costs to
the individuals of obtaining a master's degree in physician
assistant studies or a similar master's degree. The legislation
would call for the use of the Health Professionals Educational
Assistance Program (HPEAP) and other educational assistance
programs the Secretary considers appropriate, to administer a
5-year pilot program.
S. 2134 would also require each individual participating in
the pilot program to enter into an obligated service agreement
with the Secretary to be employed as a physician assistant with
VHA for a period of time that is either specified in the HPEAP
or other educational assistance program or, if the individual
is participating through a program where an obligated service
period is not specified, a period of at least 3 years or such
other period as the Secretary considers appropriate.
The bill would also provide that where an individual who
participates in the pilot program fails to satisfy the period
of obligated service, he or she shall be liable to the United
States, in lieu of the obligated service, for the amount that
has been paid or is payable to or on behalf of the individual
under the pilot program, reduced by the proportion that the
number of days the individual served for completion of the
period of obligated service years to the total number of days
in the period of obligated service of such individual.
The bill would also require the Secretary to ensure that a
physician assistant mentor or mentors are available for
individuals participating in the pilot program at each facility
of VHA at which a participant in the pilot program is employed.
The bill would require the Secretary to seek to partner
with not less than
15 institutions of higher education that offer a master's
degree program in physician assistant studies or a similar area
of study accredited by the Accreditation Review Commission on
Education for the Physician Assistant. These institutions would
also agree to guarantee seats in such master's degree program
for pilot program participants, and to provide pilot program
participants with information on admissions criteria and
process. VA recommends that it be granted flexibility with the
final number of partnerships/affiliates as less than 15
institutions may be sufficient to meet these requirements.
The bill would also require four new employees to
administer the pilot program: a Deputy Director of Education
and Career Development of Physician Assistants; a Deputy
Director of Recruitment and Retention; a recruiter; and an
administrative assistant. All positions would be aligned with
VHA's Office of Physician Assistant Services.
This pilot program would require scholarship recipients to
complete a service obligation at a VA health care facility
after graduation and licensure/certification. VHA has had
difficulty recruiting and retaining physician assistants for
several years. Additionally, VHA Workforce Succession Strategic
Plan and Reports have listed physician assistants in the top
ten critical occupations, and VA's Office of Inspector
General's Critical Occupation Staffing Shortage Report has
listed physician assistants in the top five most critical
occupations shortages.
The total cost of the Health Professional Scholarship
Program for 450 awards over 5 years would be $56,573,810.
The total cost associated with administering the pilot
program over 5 years would be $2,764,667.
The total cost associated with establishment of pay grades
for physician assistants and the requirement of providing
competitive pay would be $374,921,436 over 10 years

* * * * * * *

S. 2253--DEPARTMENT OF VETERANS AFFAIRS VETERANS EDUCATION RELIEF AND
RESTORATION ACT OF 2015

This bill would amend title 38, U.S.C., to provide Veterans
affected by school closures with certain relief and restoration
of education benefits. The bill would add a new subsection (d)
to section 3312 of title 38, U.S.C., to allow for the
restoration of entitlement to educational assistance and
provide other relief for Veterans affected by a school closure.
More specifically, no payment of educational assistance would
be charged against an individual's entitlement to educational
assistance under the Post-9/11 GI Bill, or counted against the
aggregate period for which an individual may receive
educational assistance under two or more programs, if VA finds
that the individual was forced to discontinue a course or
courses as a result of a permanent school closure and did not
receive credit, or lost training time, toward completion of the
program of education being pursued at the time the school
closed.
S. 2253 also would amend section 3680(a) of title 38,
U.S.C., authorizing VA to prescribe regulations allowing VA to
continue a monthly housing allowance stipend under the Post-9/
11 GI Bill during a temporary school closure or for a limited
period following a permanent school closure. The housing
allowance would be payable until the end of the term, quarter,
or semester during which the school closure occurred, or 4
months after the date of the school closure, whichever is
sooner.
VA supports S. 2253, as it would allow VA to restore
entitlement and continue monthly housing allowance stipend
payments to Post-9/11 GI Bill beneficiaries impacted by school
closures. While VA currently has authority to continue payments
to beneficiaries when schools are temporarily closed due to an
emergency or under an established policy based on an Executive
Order of the President, there is no similar statutory authority
upon which to continue benefit payments in the event of a
permanent school closure. Furthermore, regardless of whether a
school closure is temporary or permanent, there is no statutory
authority that allows VA to restore entitlement for a term,
quarter, or semester for which a beneficiary fails to receive
credit toward program completion due to such a closure. VA
would interpret the bill to apply only to a course or courses
in which an individual was enrolled in FY 2015, and all current
or future enrollments. VA would also interpret the bill as
currently written to provide that the portion of a course or
courses that a beneficiary has participated in through the time
of the school's closure (e.g., the portion of an incomplete
college semester that has already passed at the time of a
school closure) is not charged against the beneficiary's
entitlement. We note that there appears to be a discrepancy
between the new subsection (d)(2), which applies to an
individual who meets the criteria of both (A) and (B) of that
subsection, and the applicability provision in section 2(a)(2)
of the bill, which describes new subsection (d) as applying if
the criteria of either paragraph (A) or paragraph (B) of
subsection (d)(2) are met.
The closure of educational institutions while GI Bill
beneficiaries are actively pursuing approved programs of
education or training negatively impacts Veterans and eligible
dependents in a number of ways. First, their monthly housing
benefits are suddenly and unexpectedly discontinued in the
middle of the term. In many cases, these payments are the
primary (or sole) source of funds for paying for housing, food,
utilities, and other basic necessities while attending school.
Second, while VA can pay benefits for the term, quarter, or
semester up to the time of the school's closure, the student is
still charged entitlement for that period, even though he/she
does not earn any credit toward program completion. In some
instances, this could result in a beneficiary exhausting his/
her entitlement before being able to complete his/her program
at another institution.
We will be pleased to provide for the record an estimate of
the cost of enactment of this bill.
------

Department of Veterans Affairs,
Washington, DC, July 15, 2015.
Hon. Johnny Isakson,
Chairman,
Senate Committee on Veterans' Affairs
U.S. Senate, Washington, DC.

Dear Mr. Chairman: The agenda for the Senate Committee on
Veterans' Affairs' June 3, 2015, and June 24, 2015, legislative
hearings included a number of bills that the Department of
Veterans Affairs (VA) was unable to address in our testimony.
We are aware of the Committee's interest in receiving our views
and cost estimates for those bills.
By this letter, we are providing the following remaining
views and cost estimates for the following bills from the
June 3, 2015, legislative hearing: S. 471, the Women Veterans
Access to Quality Care Act of 2015; and sections 4(b)-(c) and 5
of the draft Veterans Health Act of 2015.
We are also providing views and costs on the following
bills from the June 24, 2015, legislative hearing: the Draft
Biological Implant Tracking and Veteran Safety Act of 2015; on
S. 1117, the Ensuring Veteran Safety Through Accountability Act
of 2015; sections 203, 205, 208, and 209(b) of S. 469, the
Women Veterans and Families Health Services Act of 2015;
sections 3 through 8 of S. 1085, the Military and Veteran
Caregiver Services Improvement Act of 2015; section 2 of the
draft bill referred to on the agenda as ``Discussion Draft;''
and sections 101-106, 204, 205, 403 and 501 of the draft Jason
Simcakoski Memorial Opioid Safety Act.
In the time requested for transmittal of follow up views,
VA was not able to include in this letter the following views:
sections 2 and 4 of S. 297, the Frontlines to Lifelines Act of
2015; the draft bill on establishing a joint VA-Department of
Defense (DOD) formulary for systemic pain and psychiatric
medications; sections 2, 3, and 5 of the draft Veterans Health
Act of 2015, sections 203, 208, and 209(b) of S. 469, the Women
Veterans and Families Health Services Act of 2015; sections
4(b) and 8 of S. 1085, the Military and Veteran Caregiver
Services Improvement Act of 2015; and sections 105, 205, 403,
and 501 of the Jason Simcakoski Memorial Opioid Safety Act. The
remaining views can be forwarded in a separate and final
follow-up views letter.
We appreciate this opportunity to comment on this
legislation and look forward to working with you and the other
Committee Members on these important legislative issues.
Sincerely,
Robert A. McDonald,
Secretary.

Enclosure.

* * * * * * *

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES
IMPROVEMENT ACT OF 2015

Section 3 of this bill proposes to add a new section 3319A
to title 38 to authorize individuals who are eligible for and
participating in a program of comprehensive assistance for
family caregivers under 38 U.S.C. 1720G(a) the opportunity to
transfer their unused Post-9/11 GI Bill education benefits to
their dependents. Veterans may complete the transfer of
entitlement any time during the 15-year period beginning on the
date of their last discharge or release from active duty.
Transferees would be subject to the same rules in place for
individuals who receive transferred benefits under 38 U.S.C.
3319. However, there is no length of service requirement, and
the monthly rate of educational assistance would be the same
rate payable to the individual making the transfer. The
Secretary would be authorized to prescribe regulations to carry
out this section.
Currently, DOD determines eligibility for transfer of
entitlement. If enacted, the proposed legislation would require
VA to develop procedures to receive requests to transfer
entitlement for certain individuals, determine eligibility, and
award benefits for the transfer of entitlement program. Because
the transfer of entitlement provisions of the Post-9/11 GI Bill
were established as a recruitment and retention tool for the
uniformed services, VA defers to DOD on this section of the
bill. However, VA notes that Congress would need to identify
appropriate offsets for the cost of this legislation, which we
are unable to estimate at this time.
Section 4(a) would amend 37 U.S.C. 439, providing for
special compensation for members of the uniformed services with
catastrophic injuries or illnesses requiring assistance in
everyday living, by amending the definition of covered members
to include those Servicemembers who have a serious injury or
illness that was incurred or aggravated in the line of duty,
are in need of personal care services as a result of the
injury, and who would require hospitalization, nursing home
care, or other residential care in the absence of such personal
care services. Section 4(b) would further amend section 439 by
requiring VA to provide family caregivers of a Servicemember in
receipt of monthly special compensation assistance available to
family caregivers of eligible veterans under 38 U.S.C.
1720G(a)(3)(A), other than the monthly caregiver stipend. VA
would provide assistance under this subsection in accordance
with a memorandum of understanding (MOU) between VA and DOD,
and an MOU between VA and the Secretary of Homeland Security.
Section 4(c) would define the term ``serious injury or
illness,'' which would replace the term ``catastrophic injury
or illness,'' to mean an injury, disorder, or illness that (1)
renders the afflicted person unable to carry out one or more
activities of daily living; (2) renders the afflicted person in
need of supervision or protection due to the manifestation by
such person of symptoms or residuals of neurological or other
impairment or injury; (3) renders the afflicted person in need
of regular or extensive instruction or supervision in
completing two or more instrumental activities of daily living;
or (4) otherwise impairs the afflicted person in such manner as
the Secretary of Defense or Homeland Security prescribes.
VA defers to DOD and the Department of Homeland Security
regarding amendments sections 4(a) and 4(c).
VA is still analyzing section 4(b) and would be glad to
provide views at a later time.
Section 5 would authorize the Office of Personnel
Management (OPM) to promulgate regulations under which a
covered employee, which would include a caregiver defined in 38
U.S.C. 1720G or a caregiver of an individual receiving
compensation under 37 U.S.C. 439, to use a flexible schedule or
compressed schedule or to telework.
VA defers to OPM on this section.
Section 6 would amend the Public Health Service Act (42
U.S.C. 300ii), which governs lifespan respite care, to amend
the definition of ``adult with special need'' to include a
veteran participating in the family caregiver program under 38
U.S.C. 1720G. It would also amend the definition of ``family
caregiver'' to include family caregivers under 38 U.S.C. 1720G.
Furthermore, in awarding grants or cooperative agreements to
eligible State agencies to furnish lifespan respite care, the
HHS would be required to work in cooperation with the
interagency working group on policies relating to caregivers of
Veterans established under section 7 of this bill. Section 6
would also authorize appropriations of $15 million for fiscal
years 2016 through 2020 for these grants.
VA defers to HHS on this section.
Section 7 would establish an interagency working group on
policies relating to caregivers of Veterans and Servicemembers.
The working group would be composed of a chair selected by the
President, and representatives from VA, DOD, HHS (including the
Centers for Medicare & Medicaid Service), and the Department of
Labor. The working group would be authorized to consult with
other advisors as well. The working group's duties would
include regularly reviewing policies relating to caregivers of
Veterans and Servicemembers, coordinating and overseeing the
implementation of policies relating to these caregivers,
evaluating the effectiveness of such policies, developing
standards of care for caregiver and respite services, and
others. Not later than December 31, 2015, and annually
thereafter, the working group would be required to submit to
Congress a report on policies and services relating to
caregivers of Veterans and Servicemembers.
VA generally supports a working group that would provide a
forum for analyzing and evaluating different issues that family
caregivers of Veterans and Servicemembers face. Such a working
group would be ideally suited to considering in depth the types
of issues other provisions of this bill are intended to
address, and would also be able to evaluate emerging issues.
The Department of Justice advises, however, that it
believes the method for selecting members of the working group
raises Appointment Clause concerns, which DOJ will convey in
greater detail under separate cover.
Section 8(a) would require VA to conduct a longitudinal
study on Servicemembers who began their service after September
11, 2001. VA would be required to award a grant to or enter
into a contract with an appropriate entity unaffiliated with VA
to conduct the study. Within 1 year of the date of the
enactment of the Act, VA would be required to submit to the
Committees on Veterans' Affairs a plan for the conduct of the
study. Not later than October 1, 2019, and not less frequently
than once every 4 years thereafter, VA would be required to
submit to the Committees on Veterans' Affairs a report on the
results of the study. Section 8(b) would require VA to provide
for the conduct of a comprehensive study on Veterans who have
incurred a serious injury or illness and individuals who are
acting as caregivers for Veterans. VA would be required to
award a grant to or enter into a contract with an appropriate
entity unaffiliated with VA to conduct the study. The study
would be required to include the health of the Veteran and the
impact of the caregiver on the health of the Veteran, the
employment status of the Veteran and the impact of the
caregiver on that status, the financial status and needs of the
Veteran, the use by the Veteran of VA benefits, and any other
information VA considers appropriate. Not later than 2 years
after the date of the enactment of this Act, VA would be
required to submit to the Committees on Veterans' Affairs a
report on the results of this study.
VA is still analyzing this section and would be glad to
provide views at a later time.

* * * * * * *

DRAFT BILL, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

Section 101 would require, within 1 year of the date of the
enactment of the Act, VA and DOD to jointly update the VA/DOD
Clinical Practice Guideline for Management of Opioid Therapy
for Chronic Pain. The guidelines would have to include
guidelines for safely prescribing opioids for the treatment of
chronic, non-cancer pain in outpatient settings; enhanced
guidance with respect to absolute contraindications for opioid
therapy; enhanced guidance with respect to the treatment of
patients with behaviors or comorbidities, or a history of
substance abuse or addiction, that require consultation or co-
management of opioid therapy with one or more specialists;
enhanced guidance with respect to the conduct by health care
providers of an effectiveness assessment for patients receiving
opioid therapy; requirements that each VA and DOD provider,
before initiating opioid therapy, use VA's Opioid Therapy Risk
Report tool to assess the risk for adverse outcomes; guidelines
to govern the methodologies used by VA and DOD providers to
taper opioid therapy when adjusting or discontinuing opioid
therapy; guidelines with respect to appropriate case management
for patients receiving opioid therapy who transition between
inpatient and outpatient settings; enhanced recommendations on
the use of routine and random urine drug tests for all patients
before and during opioid therapy; and guidance that health care
providers discuss with patients before initiating opioid
therapy other options for pain management therapies. Before
updating these guidelines, VA and DOD would be required to
jointly consult with the working group on pain management and
opioid therapy established under section 3 of this bill. Within
1 year of the date of enactment of this Act, GAO would be
required to submit to the Committees on Veterans' Affairs a
report on the implementation of the updated guidelines by each
VA medical facility and the compliance of each medical facility
with these guidelines.
VA appreciates the intent of this thoughtful and
comprehensive bill, and agrees that more needs to be done to
support clinicians with clearer guidance and training on
prescribing medications for pain management. VA, because of its
central role in training physicians across the country, can
provide leadership by training clinicians in pain management
and supporting a team approach to care. There are cases where
the use of opioids is clinically indicated, albeit closely
controlled and monitored, to control pain when nothing else
does. We have a number of recommendations to improve the bill,
and would be glad to meet with the Committee to discuss these
further. For example, the requirement in section 101(b) that VA
and DOD jointly consult the working group on pain management
and opioid therapy established in section 103 of the bill would
be redundant, as the VA/DOD Health Executive Council (HEC)
already has a Pain Management Work Group whose focus is on
improving pain management practices in the two Departments.
Section 102(a) would require VA, within 180 days of
enactment, to expand the Opioid Safety Initiative to include
all VA medical facilities.
Section 102(b) would require VA to ensure all providers
responsible for prescribing opioids to receive education and
training on pain management and safe opioid prescribing
practices. The education and training would have to cover a
number of identified areas, and in providing the training, VA
would be required to use the Interdisciplinary Chronic Pain
Management Training Team Program.
Section 102(c) would require each VA medical facility to
identify and designate a pain management team of health care
professionals responsible for coordinating and overseeing
therapy at the facility for patients experiencing acute and
chronic pain that is not related to cancer. Each VISN Director
would be responsible for establishing protocols for the
designation of a pain management team at each VA medical
facility in the VISN, and the protocols would need to ensure
that any health care provider without expertise in prescribing
analgesics or who has not completed required training not
prescribe opioids, with limited exceptions. Within 1 year of
enactment of this Act, each VA medical facility would be
required to submit to the VISN Director a report identifying
the health care professionals that have been designated as
members of the pain management team at the facility.
Section 102(d) would require, within 18 months of the date
of the enactment of the Act, that VA provide for real time
tracking and access to data on the use of opioids and
prescribing practices. VA also would be required to ensure
access by VA health care providers to information on controlled
substances prescribed by community providers through State
prescription drug monitoring programs. Within 180 days of the
enactment of this Act, VA would be required to submit to
Congress a report on the implementation of these improvements.
Section 102(e) would require VA to increase the
availability of opioid receptor antagonists, such as naloxone,
to veterans and for use by VA health care providers treating
Veterans. Within 90 days of enactment of this Act, VA would be
required to equip each VA medical facility with opioid receptor
antagonists approved by FDA. VA notes that other opioid
receptor antagonists approved by FDA exist, but only one type
(naloxone) is approved for overdose reversal. This section also
directs VA to enhance training of providers on distributing
such antagonists, and to expand the Overdose Education and
Naloxone Distribution program to ensure all Veterans in receipt
of health care who are at risk of opioid overdose (as defined
by the bill) have access to opioid receptor antagonists and
training on their proper administration. Within 120 days of the
date of the enactment of this Act, VA would be required to
submit to the Committees on Veterans' Affairs a report on
compliance with this requirement.
Section 102(f) would require that VA include in the Opioid
Therapy Risk Report tool information on the most recent time
the tool was accessed by a VA health care provider with respect
to each Veteran and information on the results of the most
recent urine drug test for each Veteran. VA would also be
required to determine if a provider prescribed opioids without
checking the information in this tool first.
Section 102(g) would require VA to modify VA's Computerized
Patient Record System (CPRS) to ensure that any health care
provider that accesses the record of a Veteran will be
immediately notified whether the Veteran is receiving opioid
therapy and has a history of substance use disorder or prior
instances of overdose, has a history of opioid abuse, or is at
risk of becoming an opioid abuser.
VA agrees that additional training for providers is
necessary. Clinicians want to help Veterans and Servicemembers,
but often do not have the skills and resources to do so. A
well-trained physician and clinical team will know how to
evaluate comprehensively a patient with pain, including making
clinical diagnoses and how to develop a goal oriented
management plan for pain, as well as how to engage the
particular resource needs of each patient. Regarding other
parts of section 102, VA is currently taking steps to fulfill
the intent of many of these provisions. For example, section
102(e) would require VA to increase the availability of opioid
receptor antagonists approved by the FDA, and VA is currently
exploring ways to increase the availability of these life-
saving medications. Similarly, section 102(g) would require VA
to modify the Computerized Patient Record System to ensure
providers will be immediately notified about opioid risks for
each patient. VA's electronic health record already has real-
time mechanisms in place to alert VA health care providers of
existing opioid prescriptions to prevent prescribing of
additional opioids to Veterans who receive all their healthcare
and prescriptions through the VA system. These mechanisms
include real-time order checks that alert providers of
prescriptions with potential problems with duplication, drug
interactions, and doses in excess of the maximum recommended
amount. In some facilities, VA health care providers also can
check the State Prescription Drug Monitoring program databases
to determine if a Veteran has an opioid prescription outside of
VA.
Section 103 would establish within the VA-DOD Joint
Executive Committee (JEC) a working group on pain management
and opioid therapy for individuals receiving health care from
either VA or DOD. The working group would cover the prescribing
practices of health care providers in both Departments, the
ability of each Department to manage acute and chronic pain,
the use of complementary and integrative health in treating
such individuals, the concurrent use of opioids and
prescription drugs to treat mental health disorders, the
practice of prescribing opioids, the coordination in coverage
and consistent access to medications for patients receiving
care from VA and DOD, and the ability of each Department to
identify and treat substance use disorders. The working group
would be required to coordinate with other working groups
established under 38 U.S.C. 320, consult with other Federal
agencies, and review and comment on the VA/DOD Clinical
Practice Guideline for Management of Opioid Therapy for Chronic
Pain. The Secretaries of VA and DOD would be required to
jointly ensure that the working group is able to consult
meaningfully with respect to the updated guideline required by
section 101 of this bill within 1 year of the date of the
enactment of this Act.
As noted previously, the VA-DOD HEC already has a pain
management work group, so to that extent, we think VA and DOD
are already meeting the intent of section 103.
Section 104 would add a new section 7309A to title 38,
which would require VA to establish in each VISN a Pain
Management Board. These Boards would have a series of defined
duties, including consulting with health care professionals and
other VA employees in the VISN about resources and best
practices for pain management, overseeing compliance and
providing oversight of professionals using pain management
practices, and carrying out educational forums and public
hearings on best practices on pain management. The Boards would
be able to provide treatment recommendations for patients in
some situations. Each Board would be required to submit an
annual report to the Under Secretary for Health on pain
management practices within the VISN and recommended best
practices. VA would be required to submit an annual report to
Congress that contains comprehensive information from the
reports submitted by the Boards.
VA appreciates the intent of this provision, but is
concerned that the time it would take to participate in this
admittedly very important activity would be time these
professionals are not able to furnish direct clinical care and
treat patients. In particular, the clinicians who would be best
qualified to serve on such boards are also those likely to be
treating the most complex patients. If additional resources
were available to ensure that patient care would not suffer as
a result of implementing these Boards, this concern would be
alleviated. We note that the bill is unclear in terms of the
appointment of non-Federal employees to the Pain Management
Boards and the implications of such appointments under other
laws.
Section 105 would require VA to conduct a study on the
feasibility and advisability of carrying out a pharmacy lock-in
program under which veterans at risk for abuse of prescription
drugs would be permitted to receive prescription drugs only
from certain specified VA pharmacies. VA would be required to
report to the Committees on Veterans' Affairs within 1 year on
this study.
VA is still analyzing this section and would be glad to
provide views at a later time.
Section 106 would require the Comptroller General, within 2
years of the date of the enactment of this Act, to submit to
the Committees on Veterans' Affairs, a report on the Opioid
Safety Initiative and the opioid prescribing practices of VA
health care professionals. The report would include
recommendations for improvement, and VA would be required to
report to the Committees on Veterans' Affairs on a quarterly
basis on the actions taken by VA to address any outstanding
findings and recommendations from the Comptroller General.
We defer to GAO on this provision.
Section 106 would also require VA to conduct an annual
report and investigation on opioid therapy, and to submit this
report to the Committees on Veterans' Affairs. This report
would include information on patient populations and
prescribing patterns for opioids. Facilities that are among the
top 10 percent in prescription rates would be subject to a full
investigation by the Office of the Medical Inspector, and VA
would be required to notify the Committees on Veterans' Affairs
and the senators and representatives from the area in which the
facility is located.
Section 204 would require the Comptroller General to submit
to the Committees on Veterans' Affairs a report on VA's Patient
Advocacy Program, including recommendations and proposals for
modifying the program and other information the Comptroller
General considers appropriate.
We defer to GAO on this provision.
Section 205 would require VA, within 180 days of the date
of the enactment of this Act, to submit to the Committees on
Veterans' Affairs a report on the transitions undergone by
Veterans in receiving health care in different health care
settings. The report would have to include an evaluation of
VA's standards for facilitating and managing the transitions
undergone by veterans in receiving health care in different
settings, an assessment of the case management services that
are available, an assessments of the coordination in coverage
of and consistent access to medications, and such
recommendations to improve transitions, including coordination
of drug formularies between VA and DOD.
VA is still analyzing this section and would be glad to
provide views at a later time.
Section 403 would require, within 2 years of the date of
the enactment of this Act, VA to submit a report on its
compliance with VA's policy to conduct a review of each health
care provider who transfers to another VA medical facility or
leaves VA to determine whether there are any concerns,
complaints, or allegations of violations relating to the
medical practice of the health care provider, and to take
appropriate action with respect to any such concern, complaint,
or allegation.
VA is still analyzing this section and would be glad to
provide views at a later time.
Section 501 would add a new section 527A to title 38
requiring VA to carry out a program of internal audits and
self-analysis to improve the furnishing of benefits and health
care to veterans and their families. The Secretary would be
required to establish an office within the Office of the
Secretary to carry out these audits. The office would conduct
periodic risk assessments, develop plans in response to these
assessments, and conduct internal audits. At least five covered
administrations, staff organizations, or staff offices would
have to be audited each year. Within 90 days of completing an
audit, the Secretary would be required to submit to Committees
on Veterans' Affairs, the House Committee on Oversight and
Government Reform, and the Senate Committee on Homeland
Security and Government Affairs a report on the audit. The
first audit would have to be completed within 180 days of the
date of the enactment of this Act.
VA is still analyzing this section and would be glad to
provide views at a later time.
Overall, VA understands the bill is a well-intentioned
effort to combat a national public health problem, as outlined
in a 2011 study by the Institute of Medicine (IOM).
------

Department of Veterans Affairs,
Washington, DC, September 4, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

Dear Mr. Chairman: The agenda for the Senate Committee on
Veterans' Affairs' June 3, 2015, and June 24, 2015, legislative
hearings included a number of bills that the Department of
Veterans Affairs (VA) was unable to address in our testimony or
in our prior correspondence with you on July 15, 2015. By this
letter, we are providing the final remaining views and cost
estimates on the following bills from the June 3, 2015,
legislative hearing: sections 2 and 4 of S. 297, the Frontlines
to Lifelines Act of 2015; the draft bill on establishing a
joint VA-Department of Defense (DOD) formulary for systemic
pain and psychiatric medications; and sections 2, 3, and 5 of
the draft bill, Veterans Health Act of 2015.
We are also providing the final remaining views and cost
estimates on the following bills from the June 24, 2015,
legislative hearing: sections 203, 208, and 209(b) of S. 469,
Women Veterans and Families Health Services Act of 2015;
sections 4(b) and 8 of S. 1085, Military and Veteran Caregiver
Services Improvement Act of 2015; and sections 105, 205, 403,
and 501 of the Jason Simcakoski Memorial Opioid Safety Act.
We appreciate this opportunity to comment on this
legislation and look forward to working with you and the other
Committee Members on these important legislative issues.
Sincerely,
Robert A. McDonald,
Secretary.

Enclosure.

* * * * * * *

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES
IMPROVEMENT ACT OF 2015

Section 4(b) of S. 1085 would amend 37 U.S.C. 439 by
requiring VA to provide family caregivers of a Servicemember in
receipt of monthly special compensation assistance under 37
U.S.C. 439(a) the assistance that is currently provided to
family caregivers of eligible Veterans under 38 U.S.C.
1720G(a)(3)(A), other than the monthly caregiver stipend. VA
would provide assistance under this subsection in accordance
with a memorandum of understanding (MOU) between VA and DOD and
an MOU between VA and the Secretary of Homeland Security.
VA does not support section 4(b). DOD already provides many
of the services and supports available under VA's Program of
Comprehensive Assistance for Family Caregivers including health
care coverage, mental health services, and respite care.
Requiring VA to furnish these services as well would result in
a duplication of benefits.
Section 8(a) would require VA to conduct a longitudinal
study on Servicemembers who began their service after September
11, 2001. VA would be required to award a grant to or enter
into a contract with an appropriate entity unaffiliated with VA
to conduct the study. Within 1 year of the date of the
enactment of the Act, VA would be required to submit to the
Committees on Veterans' Affairs a plan for the conduct of the
study. Not later than October 1, 2019, and not less frequently
than once every 4 years thereafter, VA would be required to
submit to the Committees on Veterans' Affairs a report on the
results of the study. Section 8(b) would require VA to provide
for the conduct of a comprehensive study on Veterans who have
incurred a serious injury or illness and individuals who are
acting as caregivers for Veterans. VA would be required to
award a grant to or enter into a contract with an appropriate
entity unaffiliated with VA to conduct the study. The study
would be required to include the health of the Veteran and the
impact of the caregiver on the health of the Veteran; the
employment status of the Veteran and the impact of the
caregiver on that status; the financial status and needs of the
Veteran; the use by the Veteran of VA benefits; and any other
information VA considers appropriate. Not later than 2 years
after the date of the enactment of this Act, VA would be
required to submit to the Committees on Veterans' Affairs a
report on the results of this study.
We do not believe this section is necessary. Currently, VA
researchers are seeking new ways to address the mental health
issues of Iraq and Afghanistan Veterans, including PTSD. They
are also researching Traumatic Brain Injury (TBI) and its
treatment and are developing and testing prostheses that will
allow Veterans with amputations or other issues to live as
independently as possible. One major effort is the Marine
Resiliency Study (MRS), involving some 2,600 Marines who
deployed to Iraq and Afghanistan. Beginning in 2008, the
research team conducted clinical interviews on Marine bases and
collected psychological, social, and biological data before
deployment and then multiple times after deployment.
Researchers are analyzing the data to identify risk and
resilience factors for combat-related PTSD. The team recently
published two articles in JAMA Psychiatry. One shows
deployment-related brain injury to be a significant risk factor
for PTSD. Another implicates high levels of inflammation in the
body as a PTSD risk factor. VA is also conducting a
longitudinal study of the neuropsychological and mental
outcomes of Veterans of the Iraq war (CSP #566). VA will soon
have large datasets to characterize health status and changes
over time for Vietnam, Iraq, and Afghanistan Veterans, which
will be a rich resource for researchers.
In addition, VA researchers are already studying the impact
of caregivers on the health of Veterans. For example, one
recently initiated randomized study is examining the
effectiveness of an innovative caregiver skills training
program and whether it can help Veterans to have increased days
at home, reduced total health care costs, and higher
satisfaction with VHA health care compared to Veterans in usual
care; it will also examine if caregivers in the program have
lower depressive symptoms than caregivers who do not receive
the training. Another ongoing project is studying an
intervention aimed at dementia patients with pain, assessing
whether it decreases incidence of aggression, pain, caregiver
burden, injuries, use of antipsychotic medication, and nursing
home use. Another study is seeking to understand better how
war-related psychiatric symptoms of Operation Enduring Freedom/
Operation Iraqi Freedom Veterans may interfere with family
reintegration and negatively affect family functioning; this
study is testing whether difficulties with family reintegration
account for the impact of psychiatric symptoms on overall
family functioning over time. Another current study is
examining whether a brief, inexpensive intervention to foster
end-of-life preparation and completion improves quality of life
and health utilization for Veterans with serious illness and
improves outcomes for caregivers of these Veterans at the end
of life.
Additionally, VA works closely with other Federal research
agencies to ensure effective use of scarce taxpayer resources
in executing its research mission. We carry out joint
programmatic reviews with DOD and NIH to ensure that our
research efforts are complementary and not duplicative. Under
the auspices of the President's National Research Action Plan,
VA has worked with DOD to create two research consortia for TBI
and PTSD, at a combined investment of $107 million over 5
years. This tight coordination has become routine for all three
agencies, with benefits that accrue to Veterans and the
American public at large.

DRAFT BILL, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

Section 105 would require VA to conduct a study on the
feasibility and advisability of carrying out a pharmacy lock-in
program under which Veterans at risk for abuse of prescription
drugs would be permitted to receive prescription drugs only
from certain specified VA pharmacies. VA would be required to
report to the Committees on Veterans' Affairs within 1 year on
this study.
VA has numerous concerns with section 105. We believe a
pharmacy lock-in program, under which Veterans at risk for
abuse of prescription drugs are permitted to receive
prescription drugs only from certain specified VA pharmacies,
will lead to negative patient outcomes. For example, Veterans
who are traveling or require emergent/urgent medical care from
a VA facility may need to receive a prescription from another
VA facility's pharmacy to treat the Veteran's emergent/urgent
condition. The pharmacy lock-in program would prevent
medically-necessary drugs from being dispensed to Veterans. VA
health care providers receive duplicate order checks from other
VA facilities at the point of prescribing. These duplicate
order checks would notify the provider and pharmacist in real-
time that the Veteran is receiving similar medications at
another VA facility. Therefore we do not believe a study on a
pharmacy lock-in program would yield useful information.
Section 205 would require VA, within 180 days of the date
of the enactment of this Act, to submit to the Committees on
Veterans' Affairs a report on the transitions undergone by
Veterans in receiving health care in different health care
settings. The report would have to include an evaluation of
VA's standards for facilitating and managing the transitions
undergone by Veterans in receiving health care in different
settings, an assessment of the case management services that
are available, an assessments of the coordination in coverage
of and consistent access to medications, and such
recommendations to improve transitions, including coordination
of drug formularies between VA and DOD.
VA does not support Section 205 because its requirements
would duplicate multiple GAO investigations regarding the
health care transition of Servicemembers and Veterans, most
notably a November 2012 report, Recovering Servicemembers and
Veterans: Sustained Leadership Attention and Systematic
Oversight Needed to Resolve Persistent Problems Affecting Care
and Benefits. In response, DOD and VA are enhancing care
coordination and case management to improve transitions across
health care settings, including the development of an
Interagency Comprehensive Plan for Servicemembers and Veterans
requiring complex care coordination as well as a Lead
Coordinator to align and standardize care coordination
processes, roles, and responsibilities and to reduce confusion,
duplication, and frustration.
In addition, GAO is currently conducting a study,
Engagement on Care Transitions and Medication Management for
Post-Traumatic Stress Disorder and Traumatic Brain Injury (GAO
code 291282). GAO is interviewing DOD and VA officials, as well
as staff in the field. Thus far, GAO has conducted interviews
at the Washington, DC VA Medical Center, at Fort Hood, Texas,
and at Fort Carson, Colorado. VA looks forward to their
objective, third-party assessment.
Section 403 would require VA, within 2 years of the date of
the enactment of this Act, to submit a report on its compliance
with VA's policy to conduct a review of each health care
provider who transfers to another VA medical facility or leaves
VA to determine whether there are any concerns, complaints, or
allegations of violations relating to the medical practice of
the health care provider and to take appropriate action with
respect to any such concern, complaint, or allegation.
VA does not support section 403 because reporting systems
are already in place. VA has broad authority to report employed
or separated health care professionals to state licensing
boards when their behavior or clinical practice so
substantially failed to meet generally accepted standards of
clinical practice as to raise reasonable concern for the safety
of patients. VA medical facility Directors are required to
ensure that a review is conducted of the clinical practice of a
licensed health care professional who leaves VA employment or
when information is received suggesting that a current
employee's clinical practice has met the reporting standard. VA
has established a comprehensive quality assurance program for
reporting any licensed health care professional to state
licensing boards who was fired or resigned following the
completion of a disciplinary action relating to such
professional's clinical competence, resigned after having had
such professional's clinical privileges restricted or revoked,
or resigned after serious concerns about such professional's
clinical competence had been raised but not resolved. When a
report is made to a state licensing board, a copy of that
letter is also forwarded to VA Central Office. VA would be
happy to provide this information upon request, but we do not
believe a statutory requirement to submit this information is
warranted.
Section 501 would add a new section 527A to title 38
requiring VA to carry out a program of internal audits and
self-analysis to improve the furnishing of benefits and health
care to Veterans and their families. The Secretary would be
required to establish an office within the Office of the
Secretary to carry out these audits. The office would conduct
periodic risk assessments, develop plans in response to these
assessments, and conduct internal audits. At least five covered
administrations, staff organizations, or staff offices would
have to be audited each year. Within 90 days of completing an
audit, the Secretary would be required to submit to the
Committees on Veterans' Affairs, the House Committee on
Oversight and Government Reform, and the Senate Committee on
Homeland Security and Governmental Affairs a report on the
audit. The first audit would have to be completed within 180
days of the date of the enactment of this Act.
VA understands the intent of this section, but is concerned
about creating an entirely new structure that would in essence
duplicate efforts of other organizations, such as the Inspector
General or the Office of the Medical Inspector. We are also
concerned that legislation directing VA to create certain
offices or functions could produce conflict with the
Department-wide restructuring effort underway through the MyVA
initiative. VA recommends against further consideration of this
section until VA's MyVA restructuring plans are more advanced
so we can ensure that any new offices and functions are
properly aligned and do not overlap with the missions of other
organizations.
------

The Secretary of Veterans Affairs,
Washington, DC, December 8, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

Dear Mr. Chairman: By this letter, we are providing the
remaining views and cost estimates for the following bills from
the Committee's October 6, 2015, legislative hearing: S. 1676
and sections 5 and 8 of S. 1885.
We appreciate this opportunity to comment on this
legislation and look forward to working with you and the other
Committee Members on these important legislative issues.
Sincerely,
Robert A. McDonald.

Enclosure.

S. 1676, DELIVERING OPPORTUNITIES FOR CARE AND SERVICES FOR VETERANS
ACT OF 2015

Section 101 of S. 1676 would amend the Social Security Act
to direct the Secretary of Health and Human Services to not
take into account any resident within the field of allopathic
or osteopathic medicine who counts towards the obligation of
the Secretary of Veterans Affairs under section 301 (b)(2) of
the Veterans Access, Choice, and Accountability Act of 2014
(Public Law 113-146; 38 United States Code (U.S.C.) 7302 note)
(VACAA) when applying the limitations regarding the total
number of full-time equivalent residents in a hospital's
approved medical residency training program. The Secretary
would disregard such residents for cost reporting periods
beginning on or after July 1, 2016.
VA appreciates this effort to increase VA's ability to
expand graduate medical education (GME), including expanding
into underserved communities by allowing other community
partners to assist in GME development. Since VA does not
sponsor its own physician residency programs, it relies on its
academic affiliates to select and sponsor residents who then
receive a portion (typically around a quarter of their time) of
their clinical training in a VA facility. This arrangement can
help ensure that residents receive a well-rounded educational
experience. The current cap on residency positions funded by
the Centers for Medicare & Medicaid Services (CMS) limits the
ability of potential partners to sponsor new VACAA residency
positions in collaboration with VA.
This provision, however, would have a budget impact on CMS
and VA that could be significant, which makes support for this
provision contingent on the availability of resources for both
CMS and VA for its implementation. Still, however, VA believes
that a partnership with CMS on the VA GME Expansion could
assist with addressing known inequities in physician workforce,
including the increasing specialization of physicians and the
geographic maldistribution. VA's GME Expansion specifically
targets Primary Care and Mental Health, and focuses on GME
development in smaller and rural communities. A partnership
with CMS on this initiative could create significant and
beneficial change in the physician workforce for the nation.
Section 102 would amend section 301 (b) of the VACAA to
extend from 5 years to 10 years the time period provided for
the Secretary of Veterans Affairs to increase the number of GME
residency positions to 1,500; and extend by 5 years the time
period during which the Secretary must file annual reports to
Congress on residency positions at VA medical facilities. VA
supports section 102. This legislation would provide additional
time for VA to build the infrastructure needed to successfully
create the required new residency positions. VA estimates that
enactment of section 102 would be cost neutral.
Section 103(a) would require the Secretary of Veterans
Affairs and the Secretary of Health and Human Services to
jointly conduct a 6-year pilot program to establish not less
than three GME residency programs in behavioral medicine in
underserved areas in the United States. Section 103(b) would
require each residency program to provide participating
residents the opportunity to work with diverse patient
populations through rotations between medical facilities of VA,
the Indian Health Service, and facilities participating under
the Medicare program; provide education in the field of
behavioral medicine; be carried out in a manner consistent with
other residency programs supported and funded by VA and the
Department of Health and Human Services; and be located in a
community that is designated as a medically under-served area
under 42 U.S.C. 254b(b)(3)(A), in a state with a per capita
population of Veterans of more than 9 percent according to the
National Center for Veterans Analysis and Statistics and the
United States Census Bureau, and be within 100 miles of a
Reservation as defined in 25 U.S.C. 1452.
Section 103(c) would require the Secretary of Veterans
Affairs and Secretary of Human Health and Services to provide
to Congress at least annually a joint report containing certain
specified elements regarding implementation of the pilot
program.
VA appreciates the goals behind section 103 but does not
support these provisions. The extremely narrow criteria for the
location of the three pilot sites would make the pilot program
difficult to implement. For example, large states such as
California and New York would be disqualified from
consideration because of the per capita Veteran population
requirement. Also, the requirement that each pilot site be
located within 100 miles of a reservation would exclude many VA
facilities from participation. In addition, the extremely
limited residency training opportunities within the Indian
Health Service would create a challenge when seeking to provide
residents rotations through the Indian Health Service. Finally,
the requirement for detailed annual joint reports from the
Secretary of Veterans Affairs and the Secretary of Health and
Human Services would be unduly burdensome given the relatively
small portion of the GME workload these pilot sites would
represent. VA estimates that the reporting requirement in
section 103(c) would cost $260,000 annually and $1.56 million
over the course of the pilot program.
Section 104(a) would require the Secretary of Veterans
Affairs to include in the education and training program
required under section 7302(a)(1) of title 38 U.S.C., education
and training of marriage and family therapists (MFT) and
licensed professional mental health counselors (LPMHC). VA
supports the goal behind section 104(a) but does not believe
that section 104(a) is necessary as VA is presently providing
this training and will continue to do so.
Section 104(b) would require the Secretary to apportion
funding equally among the professions included in the education
and training program. VA does not support section 104 and has a
technical concern. It is unclear to which professions the
requirement for equal apportionment of funding would apply. If
the intent is to require equal funding among all professions,
VA does not support such a requirement. Presently, trainee
funding is allocated in accordance with future hiring needs and
capacity to support training programs at VA facilities. If the
intent is to provide equal funding for LPMHC and MFT training
programs, this would be problematic as well. VA has attempted
to provide equal funding for these two professions.
Nonetheless, internships are conducted in partnership with
academic affiliate programs and under principles ensuring a
quality educational experience and in the context of state
licensing laws governing the credentials of supervisors. We
have been able to rapidly expand LPMHC internships, but for the
MFT internships, the supervisory requirements do not allow
equally rapid expansion. A legislative requirement for equal
funding might actually result in curtailing training for one
profession, so that training for one profession does not exceed
funding for another.
Section 105 would amend section 7402(b)(11)(A) of title 38
to expand eligibility for appointment within VA as a LPMHC to
specifically include persons who hold a doctoral degree. VA
supports section 105. VA estimates that there would be no cost
associated with implementation of section 105.
Section 201 would amend section 7451(a)(2) of title 38 to
include physician assistants as ``covered positions'' to which
the competitive pay provisions of that section apply.
Presently, only registered nurses and certain positions as the
Secretary may determine upon recommendation of the Under
Secretary for Health are covered positions under section 7451.
While VA supports the intent of Section 201, VA's support
is conditioned on Congress providing the additional funding
necessary to support these costs. VA also believes that the
following health care professionals should also be added as
``covered positions'' to this section of the law to apply these
same competitive pay provisions to physical therapists,
occupational therapists, physical therapy assistants, and
occupational therapy assistants.
Recruitment and retention of physical and occupational
therapy professionals has been a longstanding challenge for VA.
A major recruitment and retention barrier for these disciplines
is the significant pay disparity between private sector market
pay and VA pay schedules for these therapies. Although special
pay rate authority exists at the local medical center level to
address these disparities, such authority is not consistently
utilized and is ineffective in many cases because special
salary rates are below the full performance level salary.
VA estimates that the cost of enactment of section 201 for
PAs would be $33.2 million in FY 2016, $129 million over 5
years, and $241 million over 10 years. In addition, VA
estimates that expansion of the cost of applying the
competitive pay provisions of section 7511 to physical
therapists, occupational therapists, physical therapy
assistants, and occupational therapy assistants would be $42.8
million in FY 2016, $220 million over 5 years, and $458 million
over 10 years.
Section 202 would amend section 7681 of title 38 to require
that not less than 30 percent of the amount of debt reduction
payments paid under the Education Debt Reduction Program (EDRP)
each year be paid to individuals who practice medicine in a
rural area or highly rural area or demonstrate a commitment to
practice medicine in such an area. Section 202 would define
``highly rural area'' to mean an area located in a county or
similar community that has less than seven individuals residing
in that county or community per square mile, ``rural area'' to
mean an area that is not an urbanized area or a highly rural
area, and ``urbanized area'' to have the meaning given that
term by the Director of the Bureau of the Census. VA does not
support section 202. VA recognizes the intent of the
legislation is to ensure use of EDRP for recruitment and
retention in rural and highly rural areas. However, the
proposed legislation would negatively impact the ability of
local facilities to effectively use EDRP by restricting the
flexibility that exists in the current process and seriously
misaligning funding with respect to relative representation of
clinical staff and vacancies.
EDRP is designed for recruitment and retention of health
care providers who are in difficult to recruit/retain health
care positions and who are providing direct patient care
services or services incident to direct patient care. Local
facilities prioritize hard-to-recruit-and-retain occupations
based on facility needs. Each VA medical facility receives EDRP
funding allocation to recruit and retain health care providers.
Many VA facilities, including both urban and rural facilities,
are in fierce competition with the private sector. In fact,
some of the hardest to recruit/retain facilities are in urban
areas where the cost of living is extremely high and where VA
has a harder time competing with the salaries offered by the
private sector.
Currently, the percentage of EDRP funding is on par with
the percentage of rural and highly rural facilities and
providers at those facilities. Rural and highly rural
facilities make up 12.6 percent of VA facilities, and employ
only 6 percent of VA's clinical providers and support staff. In
FY 2015, 11 percent of facilities receiving EDRP were rural or
highly rural, and employees at those facilities received 8
percent of the total EDRP funds distributed, commensurate with
their representation in the workforce. Furthermore, a review of
current recruitment activity rates indicates that only 5.4
percent of clinical vacancies are in rural and highly rural
facilities.
Requiring 30 percent of all EDRP funding be awarded to
rural facilities would create a significant disparity in
overall program funding for other sites, preventing facilities
with critical provider shortages from filling EDRP-eligible
positions. Restricting usage of nearly one-third of all EDRP
funding for rural areas would negatively impact the flexibility
afforded to local facilities to determine their specific health
care provider needs. Finally, past efforts to set aside EDRP
funds for various hiring initiatives have indicated that funds
set aside for special uses, such as this, are frequently under-
used because the employees hired at those sites or for those
positions simply do not have eligible student loan debt. It is
imperative that flexibility not be restricted for use of these
funds in a way that has unintended consequences, and
potentially limits the use of the funding all together. VA
estimates that there would be no cost associated with
implementation of section 202.
Section 203(a) would require the Secretary of Veterans
Affairs to submit to Congress a report on the medical workforce
of the Department not later than 120 days after the date of
enactment of the Act. Section 203(b) would require the report
to include specific elements. Specifically, section 203(b)(1)
would require the report to include how many LPMHCs and MFTs
are enrolled in the mental health professionals trainee program
of the Department; how many are expected to enroll in the
mental health professionals trainee program of the Department
during the 180-day period beginning on the date of submittal of
the report; a description of the eligibility criteria for such
counselors and therapists compared to other behavioral health
professions in the Department; a description of the objectives,
goals, and timing of the Department regarding increasing the
representation of such counselors and therapists in the
behavioral health workforce of the Department; and a
description of the actions taken by the Secretary, in
consultation with the Director of the Office of Personnel
Management (OPM), to create an occupational series for such
counselors and therapists and a timeline for the creation of
such an occupational series.
Section 203(b)(2) would require the report to include a
specific breakdown of spending by the Department in connection
with EDRP, as well as descriptions of how the Department
prioritizes such spending and the actions taken by the
Secretary to increase the effectiveness of such spending for
the purposes of recruitment of health care providers. Section
203(b)(3) would require the report to include a description of
any impediments to the delivery of telemedicine services to
Veterans and any actions taken by the Department to address
such impediments, including with respect to certain specified
issues.
Section 203(b)(4) would require the report to include an
update on the efforts of the Secretary to offer training
opportunities in telemedicine to medical residents in medical
facilities of the Department that use telemedicine, consistent
with medical residency program requirements established by the
Accreditation Council for Graduate Medical Education, as
required by the Honoring America's Veterans and Caring for Camp
Lejeune Families Act of 2012 (Public Law 112-154; 38 U.S.C.
7406 note). Section 203(b)(5) would require the report to
include an assessment of the development and implementation by
the Secretary of succession planning policies to address the
prevalence of vacancies in the Veterans Health Administration
(VHA) of more than 180 days, including development of an
enterprise position management system to more effectively
identify, track, and resolve such vacancies.
Section 203(b)(6) would require the report to include a
description of the actions taken by the Secretary, in
consultation with the Director of OPM, to address any
impediments to the timely appointment and determination of
qualifications for Directors of Veterans Integrated Service
Networks (VISN) and Medical Directors of the Department.
VA does not believe that the reporting requirements in
section 203 are necessary and the actions and initiatives
addressed by section 203 are already deployed or being pursued
within VHA. VA estimates that the costs associated with
enactment of section 203 would not be significant.
Section 301 would amend section 7306(a)(4) of title 38 to
add VISN Directors to the list of personnel who comprise the VA
Office of the Under Secretary for Health and remove the
requirement that Medical Directors be doctors of medicine,
dental surgery, or dental medicine.
Section 302 would amend chapter 74 of title 38 to add a new
subchapter VII and section 7481 regarding compensation for
Medical Directors and VISN Directors. Section 302 would
establish the elements of pay for Directors appointed under
section 7306(a)(4) of title 38 to include basic pay as
determined under section 7404(a) of title 38 and market pay as
determined under the new section 7481. Section 302 would
require the Secretary to evaluate the amount of market pay
payable to a Director not less frequently than once every 2
years and may adjust market pay as a result of such evaluation.
Section 302 require the Secretary not less than once every 2
years to set forth a Department-wide total annual pay minimum
and maximum which must be published in the Federal Register.
Section 302 would prohibit the Secretary from delegating the
authority to determine the Department-wide minimum and maximum
total annual pay.
VA supports sections 301 and 302, and the latter provision
matches a proposal put forward in February 2015 in VA 's Fiscal
Year 2016 budget submission. VA believes that there are three
primary factors that warrant a separate compensation system for
Medical Directors and VISN Directors. First, existing pay
compression within the current Senior Executive Service (SES)
pay system and the closely proximate rates of pay for direct
reports to Medical Center Directors and VISN Directors have
resulted in declining Director applicant pools. Second, a high
number of existing (an estimated 84 percent by FY 2018)
Directors are or will soon be eligible for retirement. Third,
private sector pay for health care leadership positions is
highly competitive.
In addition, there are limited pay incentives for
experienced Medical Center Directors and VISN Directors to
voluntarily move to fill more demanding positions. Due to the
SES pay compression between experienced Medical Center
Directors and VISN Directors, the small pay raise, if any, that
VHA is able to offer in a reassignment may cause the candidate
to be disadvantaged financially. The most significant cost
disparities occur due to housing costs and in some cases,
higher tax rates (e.g., New York, California). With current
executive pay authorities, a move for the good of the
organization most of the time means a move to the financial
detriment of the Director and their family. On average, it has
taken over 6 months to fill Medical Center Director and VISN
Director positions, with many being re-announced multiple times
for positions in both rural and major metropolitan areas. The
reluctance on the part of these senior leaders to relocate is
understandable. It is imperative that VHA have the ability to
implement pay to retain eligible leaders, reward mobility, and
ensure knowledge transfer to the next generation of Medical
Center Directors and VISN Directors. VA estimates that
enactment of section 301 would involve no cost and that
enactment of section 302 would cost $8.8 million in FY 2016,
$46 million over 5 years, and $93.2 million over 10 years.
Section 401(a) would require the Secretary, not later than
1 year after the date of enactment of the Act, to conduct a 2-
year pilot program to assess the feasibility and advisability
of implementing in rural areas and highly rural areas with a
large percentage of Veterans a nurse advice line to furnish to
Veterans medical advice, appointment and cancellation services,
and information on the availability of benefits from VA.
Section 401(b) would require the pilot program to establish
a nurse advice line that operates free of charge, is based on
and improves upon the Department of Defense TRICARE advice
line, complies with call center requirements set forth by URAC,
uses a process for determinations of caller eligibility, allows
for information sharing between VA and the nurse advise line,
and maintains quality controls to ensure calls are answered by
a customer service representative within 30 seconds with an
abandonment rate of less than 5 percent.
Section 401(c) would require the nurse advice line to
provide an array of services including: medical advice from
licensed registered nurses who assess the caller's symptoms
using a proprietary clinical algorithm meeting specified
criteria, information to address basic questions regarding
eligibility for VA benefits, and use of an appointment clerk to
facilitate scheduling of appointments for health care from the
Department.
Section 401(d) would require, not later than 120 days after
the date of completion of the pilot program, the Secretary to
submit to Congress a report providing specified information
regarding the pilot program.
VA does not support section 401 as VA already provides
telephone services for clinical care. Specifically, VHA
Directive 2007-033, Telephone Service for Clinical Care,
requires telephone services for clinical care to be made
available to all Veterans receiving care at VHA facilities to
include 24/7 telephone access to clinical staff trained to
provide health care advice and information. Each facility is
responsible for providing access for Veteran clinical concerns
consistent with VHA Directive 2007-033. Veteran telephone
access to clinical care during business hours is facility
based, managed, and resourced. Veterans are able to call their
local facility and speak with clinical staff to address and
manage their concerns. VA staff members working with Veterans
are responsible for following evidence-based guidance including
during in-person and telephone contact. VA estimates that
enactment of section 401 would cost $75 million in FY 2016,
$385 million over 5 years, and $770 million over 10 years.

S. 1885, VETERANS HOUSING STABILITY ACT OF 2015

Section 5 of S. 1885 would amend section 2041 of title 38
U.S.C. to expand eligibility for the services provided under
that section as well as the scope of services provided. Under
section 2041, VA may enter into agreements to sell, lease, or
donate real property acquired by the Secretary as a result of a
default on a loan made, insured, or guaranteed by VA to
qualified nonprofit organizations or state or local governments
that agree to use the properties to shelter homeless Veterans
and their families. Section 5 would permit such entities to
continue assisting homeless Veterans and their families, as
under current section 2041, but would also expand section 2041
to include Veterans and their families who are at risk of
becoming homeless and very low-income Veteran families (as
defined in section 2044(f) of title 38). Rather than limiting
the entities' assistance to shelter, as is currently the case,
the entities would also be able to assist such Veterans and
their families in acquiring and transitioning to permanent
housing, and in maintaining occupancy in permanent housing.
Section 5 would also require the entity to expand the range of
services it provides to the Veterans that it houses by ensuring
that such Veterans receive referrals for the benefits and
services to which the Veterans may be entitled or eligible
under title 38.
VA does not object to section 5 but has a technical
concern. Section 5(a)(2)(C) would amend subsection (a)(3)(B) of
section 2041 to strike ``solely as a shelter primarily for
homeless Veterans and their families'' and insert ``to provide
permanent or transitional housing for Veterans and families
described in paragraph (1).'' By striking ``shelter,'' section
5(a)(2)(C) would require the entity to agree to use the
property in a manner more narrow than the overall purpose of
the bill as expressed in section 5(a)(2)(A), which includes
assisting eligible individuals ``in acquiring shelter.''
Therefore, VA recommends that line 2 of page 12 of the draft
bill be revised to include ``shelter or'' before ``permanent or
transitional housing.'' VA estimates that enactment of section
5 would result in new benefit loan subsidy costs of $16.6
million for FY 2016. The provision would expire at the end of
2016. VA estimates that enactment would not increase general
operating expenses costs.
Section 8 would amend section 2012 of title 38 to require
VA to annually review each Homeless Provider Grant and Per Diem
(GPD) program grant recipient and eligible entity that received
a per diem payment and evaluate each grantee's success in
assisting Veterans to obtain, transition into, and retain
permanent housing and increasing Veteran income through
obtaining employment or income-related benefits. VA would only
be able to continue providing per diem to the grantee if VA
determines that the grantee's performance merits continuation
of the per diem. Section 8 would also require VA to establish
uniform performance targets for all GPD grantees in order to
conduct its review and evaluation.
VA supports section 8 and has a minor technical concern.
Currently, the GPD program has in place an annual inspection
protocol which includes an evaluation of certain performance
metrics established by VA. When grantees fail to meet the
annual inspection requirements the GPD program begins
corrective action process that can lead to stopping per diem if
corrections are not implemented. VA believes the current annual
inspections process could be changed to incorporate the
criteria specified in, and new uniform performance targets
required by, section 8. These changes would further help VA to
tie continued per diem payment to grantee performance. VA's
minor technical concern relates to lines 5 and 6 of page 16 of
the bill, which state that VA would evaluate performance with
respect to success ``in assisting Veterans obtain, transition
into, and retain permanent housing.'' VA recommends inserting
the word ``to'' before the word ``obtain.'' VA estimates that
the enactment of section 8 would be cost neutral.
------

On May 13, 2015, Anthony Kurta, Deputy Assistant Secretary
of Defense, Military Personnel Policy, Department of Defense,
appeared before the Committee on Veterans' Affairs and
submitted testimony on various bills incorporated into the
Committee bill. An excerpt from that testimony is reprinted
below:

STATEMENT OF ANTHONY KURTA, DEPUTY ASSISTANT SECRETARY OF DEFENSE,
MILITARY PERSONNEL POLICY, U.S. DEPARTMENT OF DEFENSE

Good afternoon, Chairman Isakson, Ranking Member
Blumenthal, and esteemed members of the Committee. I am pleased
to appear before you today to discuss pending benefits
legislation.
Per the agenda for today's hearing, the committee requested
the Department of Defense's view on a series of bills and
proposals. Since both funding and administration of the Post-9/
11 GI Bill fall under the purview of the Department of Veterans
Affairs, I will focus my comments only on those proposals that
will affect the Department of Defense and generally defer to
the Departments of Labor and Veterans Affairs to provide
responses on those with no significant DOD impacts. This
statement will follow the order on the printed agenda.

S. 602, GI BILL FAIRNESS ACT OF 2015

The committee asked for comments on S. 602, ``GI Bill
Fairness Act of 2015,'' a bill that would consider active duty
performed under the authority of title10, United States Code,
section 12301(h), as qualifying active duty for the purposes of
Post-9/11 GI Bill Education Benefits. Reserve component members
wounded in combat are often given orders to active duty under
this provision to receive authorized medical care; to be
medically evaluated for disability; or to complete a required
health care study. However, as currently written, section
3301(1)(B), of title 38, United States Code, does not include
active duty performed under 12301(h) as qualifying active duty
for purposes of Post-9/11 GI Bill educational assistance.
Currently, when a member of the Reserve Component on active
duty sustains an injury due to military operations, the
Servicemember is not discharged, but remains in the Selected
Reserve on active duty under 12301(h), title 10, United States
Code. None of the time spent in recovery under this status is
qualifying time for purposes of the Post-9/11 GI Bill. In this
case, the Servicemember would return to Selected Reserve status
with less qualifying time than those who served an entire
period of active duty without an intervening injury. As a
result, the Servicemember would not receive an educational
benefit equivalent to the other members of his or her cohort.
In effect, the Servicemember is being penalized for having
being wounded or injured in theater. This legislation would
correct this inequity by simply extending eligibility for the
Post-9/11 GI Bill to service under 12301(h).
DOD recognizes the inequity of not including this active
duty time for purposes of Post-9/11 GI Bill benefits, and has
included a provision similar to this bill in our FY 2016
legislative proposal package as section 514. However, the DOD
proposal would include only active duty performed after
enactment. In contrast, S. 602 would be retroactive;
categorizing all duty performed under 12301(h) since September
11, 2001, as qualifying active duty for purposes of the Post-9/
11 GI Bill. We estimate that approximately 5,000 Reserve
Component members performed active duty under 12301(h) each
year since September 11, 2001. Accordingly, we believe that
S. 602 would generate an additional cost to the Department of
Veterans Affairs. Given that both the funding and
administration of the Post-9/11 GI Bill fall under the purview
of the Department of Veterans Affairs, we would defer to that
agency to determine the costs and effects of the bill on their
Department.

* * * * * * *

------

On October 6, 2015, Hon. Lawrence B. Hagel, Chief Judge of
the U.S. Court of Appeals for Veterans Claims submitted the
following written testimony:

STATEMENT OF HON. LAWRENCE B. HAGEL, CHIEF JUDGE, U.S. COURT OF APPEALS
FOR VETERANS CLAIMS

Mr. Chairman and Distinguished Members of the Committee:
Thank you for the opportunity to comment on S. 1754, a bill
that would amend 38 U.S.C. Sec. 7253(a), to make permanent the
authorization for an increase in the number of judges on the
U.S. Court of Appeals for Veterans Claims (Court), from seven
to nine. Succinctly stated, the Court supports this legislation
and urges its passage.
The decision by Congress several years ago to expand the
Court temporarily to nine judges came in response to a
significant increase in the Court's caseload, and a perception
that the rise was not simply a spike but in fact a trend.
Effective December 31, 2009, authorization permitted the Court
to grow to nine active judges, and we reached that full
complement in December 2012. We were fortunate to operate with
nine judges for almost three years until the retirement of one
of our colleagues one month ago. With full staffing the Court
has been able to conduct effective, efficient, and expeditious
judicial review. Your support in providing the resources to
handle our heavy caseload is very much appreciated.
Under current law we will operate with eight judges until
the next retirement, and then we revert to seven judges, our
current permanent authorization. The reality is that two
judges' terms expire within days of each other in
December 2016, so absent legislation the Court will dip to six
judges at that time. With the unpredictability of the judicial
nomination and appointment process, and another retirement
likely in 2017, there is a very real possibility that the Court
will shrink to five judges just two years from now. Passage of
S. 1754 would permit a judicial appointment now to bring us
back up to nine judges, and would prevent the Court from
dropping to a critically low number of judges in the near
future.
Since its creation in 1988, the Court has become one of the
Nation's busiest Federal courts based on the numbers of appeals
filed and decided per judge. Up until about ten years ago the
Court received roughly 2,200 appeals annually. That number
began to rise significantly starting in FY 2005, reaching over
4,700 appeals filed in FY 2009. Since that time, annual appeals
filed have not fallen below 3,500 and although we are still
tabulating FY 2015 numbers, we estimate that over 4,400 appeals
were filed. This is double the number of appeals filed annually
during the Court's first 15 years from 1989 to 2004.
For cases decided, the Court terminated in the neighborhood
of 4,400 appeals in FY 2015. That is in addition to acting on
nearly 3,000 applications for attorney fees, hundreds of
petitions for extraordinary relief, and thousands of procedural
motions. We continue to be one of the busiest national courts,
but we are efficiently handling this formidable caseload.
Generally speaking, appeals filed at the Court come from
veterans who are dissatisfied with a decision of the Board of
Veterans' Appeals (Board). Much emphasis and financial support
has been placed toward increasing the numbers of personnel at
the Department of Veterans Affairs, and toward improving claims
processing times. Up from 41,910 decisions in FY 2013, the
Board issued 55,532 decisions in FY 2014, and the Board
estimates that it will decide at least the same number in FY
2015. Although it is difficult to predict with certainty what
our caseload will be in the future, it seems likely,
considering the number of claims filed annually with VA and the
increased productivity by the Board, that the number of appeals
filed at the Court will also rise further and stay high.
Over the past several years the Court has striven to create
efficiencies in how we conduct judicial review of veterans'
appeals. We have adopted an electronic case filing and
management system. We are constantly improving our pre-briefing
mediation program to resolve cases earlier in the process, to
hone the issues on appeal, and to stretch our judicial
resources to the greatest extent possible. We have an active
bar, and we engage frequently with our practitioners to discuss
ways to further improve our process. Everyone involved in
judicial review of veterans' appeals shares a common goal of
wanting to honor our veterans and provide full, fair, and
prompt decisions on their appeals. Authorization for nine
active judges would be a significant factor in furthering that
goal.

In closing, on behalf of the Court, I express my
appreciation for your past and continued support, and for the
opportunity to provide this statement.

SUPPLEMENTAL VIEWS OF HON. RICHARD BLUMENTHAL, RANKING MEMBER, HON.
PATTY MURRAY, HON. BERNIE SANDERS, HON. SHERROD BROWN, HON. JON TESTER,
AND HON. MAZIE K. HIRONO

On December 9, 2015, the Senate Committee on Veterans'
Affairs (hereinafter, ``the Committee'') voted, by voice vote,
to approve S. 425, as amended, a bill to provide for a five-
year extension to the homeless veterans reintegration programs
of the Department of Veterans Affairs (hereinafter, ``VA'' or
``Department'') and to provide clarification regarding
eligibility for services under such programs. We strongly
support the Committee's intent, expressed on December 9, 2015
that employment discrimination on the basis of race, color,
religion, sex, sexual orientation, gender identity, national
origin, disability, veteran status, or other protected category
or activity has no place in the health care that VA provides.
We reaffirm in these supplemental views our expectation that
all entities providing health care to veterans will meet the
highest standards of nondiscrimination, civil rights
protections and equality of employment opportunity.
Section 461(a) of the bill would add a new Sec. 1703A to 38
U.S.C. chapter 17. That section includes a provision,
Sec. 1703A(h)(2)(A), which was modified during the Committee
meeting to fully exempt extended-care providers that enter into
``Veterans Extended Care Agreements'' from laws to which
providers under Medicare are not subject. Similarly,
Sec. 462(b) of the bill adds a new subparagraph 4(B) to 38
U.S.C. Sec. 1745(a), which ensures similar status for state
veterans homes that provide nursing-home care by agreement with
VA. The Veterans Extended Care Agreements authorized by this
bill arrange for eligible extended-care providers to provide
direct health care services for veterans for which VA will
reimburse the providers for those services. This is distinct
from the arrangement under Medicare and Medicaid, where the
Federal Government provides financial assistance to the
individuals to whom health-care providers furnish services. It
is also different from the arrangement used by the Department
of Defense (hereinafter, ``DOD'') through the TRICARE health
system, whereby health-care providers do not directly contract
with DOD but rather are part of health-care networks
administered by Managed Care Support Contractors.
This bill exempts extended-care providers from complying
with the Vietnam Era Veterans' Readjustment Assistance Act of
1974, as amended, section 4212 of title 38 U.S.C. (hereinafter,
``VEVRAA''). VEVRAA is the only Federal statute that promotes
employment opportunities for protected veterans who work for or
apply to work for covered Federal contractors and
subcontractors that have at least $150,000 in contracts. The
VEVRAA regulations provide explicit, comprehensive protection
from discrimination in all aspects of the employment
relationship--including advertising and recruitment, the
application process and initial hiring, training opportunities,
performance evaluations, promotions, benefits, compensation,
discharge, and all other terms and conditions of employment.
For Federal contractors that have at least 50 employees, VEVRAA
also requires that they measure progress toward achieving equal
employment opportunity for veterans against an established
benchmark, periodically review their personnel processes to
ensure that they do not stereotype protected veterans in a way
that limits their access to all jobs for which they are
qualified; and periodically assess any qualification standards
that tend to screen out qualified veterans to ensure the
standards are job-related for the position in question and
consistent with business necessity. The Office of Federal
Contract Compliance Programs (hereinafter, ``OFCCP'') within
the Department of Labor (hereinafter, ``DOL'') enforces VEVRAA.
If OFCCP finds that a covered contractor has engaged in
unlawful discrimination against a protected veteran, it can
require the contractor to provide ``make-whole relief'' to the
veteran, including back pay and an offer of employment. A
covered contractor that refuses to comply with the statute and
its regulations may be subject to disbarment from future
contracts.
A consequence of enactment of this bill would mean
extended-care providers who enter into agreements during the
two years for which they are authorized will not have to file
annual Federal Contractor Veterans' Employment Reports. The
information from these reports is valuable for contractors, the
public, and policymakers who want to assess contractors'
progress in hiring veterans. In 2012, Congress amended VEVRAA
in 2012 to require DOL to make this data public further
indicating the value of this information. As DOL has explained
in its Annual Report from Federal Contractors in 2014----

Information on the total number and proportion of
protected veterans employed and newly hired in Federal
contractor workforces from year to year will show
trends in the employment of protected veterans, and
analyses of those trends can be used to assess the
extent to which Federal contractors are providing
employment opportunities to protected veterans.

In addition to VEVRAA, two other key civil rights
protections would no longer protect employees who work for
providers with Veterans Extended Care Agreements under this
bill:

Executive Order (hereinafter, ``E.O.'') 11246,
which prohibits contractors with more than $10,000 in Federal
contracts from discriminating against employees or applicants
because of race, color, religion, sex, sexual orientation,
gender identity, or national origin, or because they inquired
about, discussed or disclosed information about compensation,
and requires contractors to take affirmative action to ensure
equal employment opportunity; and
Section 503 of the Rehabilitation Act of 1973
(``Section 503''), which prohibits contractors with more than
$10,000 in Federal contracts from discriminating in employment
on the basis of disability and requires them to take
affirmative action to ensure equal employment opportunity for
individuals with disabilities.

Like VEVRAA, these two laws and their implementing
regulations were adopted to ensure that Federal dollars
establish reasonable standards for contractors by requiring not
only that they not discriminate in their employment practices,
but also that they take positive steps to ensure equal
employment opportunity. These requirements include assigning
responsibility and accountability for the implementation of
equal employment opportunity to an official who has the
authority, resources, support of and access to top management
to ensure effective implementation; sending notices of
contractors' equal employment opportunity obligations to each
labor union with which they have a collective bargaining
agreement; and reviewing personnel activity to eliminate
unnecessary causes of disparities.
Section 503 requirements are particularly useful for
veterans with disabilities as they require contractors with 50
or more employees and a contract of $50,000 or more to
undertake appropriate outreach activities that are reasonably
designed effectively to recruit qualified individuals with
disabilities. These activities include reaching out to the
Veterans' Service Organizations and the disabled veterans'
outreach program specialists in the American Jobs Center
nearest the contractor's establishment. This bill would exempt
the extended-care providers who often provide health care and
rehabilitation services to veterans with disabilities so that
they can return to the civilian workforce, from having to take
at least the same steps to employ veterans with disabilities
who are able to work as other Federal contractors do.
E.O. 11246 and Section 503 are important because they
provide protection from discrimination on the bases of race,
religion, sex, sexual orientation, gender identity, national
origin, and disability. Indeed, the commitment to civil rights
protections that they embody is consistent with VA's long
history of embracing the diversity that has made our Nation
great.
OFCCP plays a vital role and unique role in combating
unlawful employment discrimination by Federal contractors on
the basis of sex, race, national origin, color, sexual
orientation, gender identity and disability; as well as
requiring non-discrimination and affirmative action for special
and disabled veterans of war in which a campaign badge has been
authorized. Notably, no other applicable anti-discrimination
law requires contractors to ensure they have a workforce that
includes protected veterans and qualified individuals with
disabilities. No other Federal law explicitly makes it unlawful
for employers to discriminate in employment on the basis of
sexual orientation. Finally, no other anti-discrimination law
carries with it the possibility--albeit remote--that a
contractor will be debarred from future Federal contracts if it
engages in ongoing, repeated, and egregious discrimination.
We are gravely concerned that claims made about the burdens
of compliance, suggesting it will undermine the ability of
providers that enter into Veterans Extended Care Agreements to
deliver high-quality, timely, and efficient care to veterans,
are devoid of evidence-based data. Many health-care facilities,
including extended-care facilities, have been subject to these
laws for years and have succeeded in complying with them.
Despite these concerns, we support the temporary use of
Veterans Extended Care Agreements under this bill as an interim
step to promote quick delivery of much-needed extended health
care to veterans as VA and Congress work together to reform
care delivered by VA. However, more permanent contractual
agreements that VA enters into with health-care providers
should restore employee protections unless the concerns,
outlined in these Supplemental Views, are alleviated by a
strong showing using fact-based evidence that the costs of
complying with VEVRAA, Section 503, and E.O. 11246 would make
it impossible for extended care providers to provide care to
veterans unless they were exempted from these laws.

* * * * * * *

Changes in Existing Law

In compliance with paragraph 12 of Rule XXVI of the
Standing Rules of the Senate, 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).

Title 38. Veterans' Benefits

* * * * * * *

Part I. General Provisions

* * * * * * *

Chapter 5. Authority and Duties of The Secretary

* * * * * * *

SUBCHAPTER I. GENERAL AUTHORITIES

Sec.

* * * * * * *

SUBCHAPTER II. SPECIFIED FUNCTIONS

* * * * * * *

527. Evaluation and data collection.
527A. Program of internal audits.

* * * * * * *

Subchapter II. Specified Functions

* * * * * * *

SEC. 527A. PROGRAM OF INTERNAL AUDITS

(a) Program Required.--(1) The Secretary shall carry out a
program of internal audits and self-analysis to improve the
furnishing of benefits and health care to veterans and their
families.
(2) The Secretary shall carry out the program required by
paragraph (1) through an office the Secretary shall establish
for purposes of the program within the office of the Secretary
that is interdisciplinary and independent of--
(A) the other offices within the office of the
Secretary; and
(B) the covered administrations (or functions of such
administrations), staff organizations, and staff
offices identified under subsection (b)(1)(A).
(b) Program Requirements.--(1) In carrying out the program
required by subsection (a), the Secretary shall--
(A) conduct periodic risk assessments of the
Department to identify those covered administrations
(or functions of such administrations), staff
organizations, and staff offices of the Department the
audit of which would lead towards the greatest
improvement in the furnishing of benefits and health
care to veterans and their families;
(B) develop plans that are informed by the risk
assessments conducted under paragraph (1) to conduct
internal audits of the covered administrations (or
functions of such administrations), staff
organizations, and staff offices identified under
subparagraph (A); and
(C) conduct internal audits in accordance with the
plans developed pursuant to subparagraph (B).
(2) The Secretary shall carry out under the program
required by subsection (a) an audit of not fewer than five
covered administrations (or functions of such administrations),
staff organizations, or staff offices of the Department each
year.
(3) In identifying covered administrations (or functions of
such administrations), staff organizations, and staff offices
of the Department under paragraph (1)(A), the Secretary shall
accord priority to the covered administrations and functions of
such administrations.
(4)(A) For purposes of this subsection, the covered
administrations of the Department are the following:
(i) The National Cemetery Administration.
(ii) The Veterans Benefits Administration.
(iii) The Veterans Health Administration.
(B) For purposes this subsection, the covered staff
organizations of the Department are the following:
(i) The Office of Acquisition, Logistics, and
Construction.
(ii) The Advisory Committee Management Office.
(iii) The Board of Veterans' Appeals.
(iv) The Center for Faith-Based and Neighborhood
Partnerships.
(v) The Center for Minority Veterans.
(vi) The Center for Women Veterans.
(vii) The Office of General Counsel.
(viii) The Office of Regulation Policy and
Management.
(ix) The Office of Employment Discrimination
Complaint Adjudication.
(x) The Office of Interagency Care and Benefits
Coordination.
(xi) The Office of Small and Disadvantaged Business
Utilization.
(xii) The Office of Survivors Assistance.
(xiii) The Veterans' Service Organizations Liaison.
(C) For purposes of this subsection, the covered staff
offices of the Department are the following:
(i) The office of the Assistant Secretary for
Congressional and Legislative Affairs.
(ii) The office of the Assistant Secretary for Human
Resources and Administration.
(iii) The office of the Assistant Secretary for
Information and Technology.
(iv) The Office of Management.
(v) The office of the Assistant Secretary for
Operations, Security, and Preparedness.
(vi) The office of the Assistant Secretary for Policy
and Planning.
(vii) The office of the Assistant Secretary for
Public and Intergovernmental Affairs.
(c) Reports.--(1)(A) Not later than 90 days after
completing an audit under the program required by subsection
(a), the Secretary shall submit to the appropriate committees
of Congress a report on the audit.
(B) Each report submitted under subparagraph (A) with
respect to an audit shall include the following:
(i) A summary of the audit.
(ii) The findings of the Secretary with respect to
the audit.
(iii) Such recommendations as the Secretary may have
for legislative or administrative action to improve the
furnishing of benefits and health care to veterans and
their families.
(iv) Plans to carry out the recommendations submitted
under clause (iii), including timelines for completion
of such plans.
(2)(A) Not later than September 1 of each year, the
Secretary shall submit to the appropriate committees of
Congress a report on the administration of this section.
(B) Each report submitted under subparagraph (A) shall
include the following:
(i) A detailed description of each matter for which a
recommendation was submitted under clause (iii) of
paragraph (1)(B) and with respect to which plans that
were submitted under clause (iv) of such paragraph have
not been completed.
(ii) A plan for the conduct of audits under this
section during the first fiscal year beginning after
the fiscal year in which the report is submitted, which
shall include the following:
(I) A description of any risk assessments the
Secretary plans to conduct in such fiscal year.
(II) A summary of each audit the Secretary
plans to conduct in such fiscal year, including
a description of the subject matter of the
audit and identification of the administration,
office, or function to be audited.
(3) In this subsection, the term ``appropriate committees
of Congress'' includes--
(A) the Committee on Veterans' Affairs, the Committee
on Appropriations, and the Committee on Homeland
Security and Governmental Affairs of the Senate; and
(B) the Committee on Veterans' Affairs, the Committee
on Appropriations, and the Committee on Oversight and
Government Reform of the House of Representatives.

* * * * * * *

Part II. General Benefits

* * * * * * *

Chapter 15. Pension for Non-Service-Connected Disability or Death or
for Service

* * * * * * *

Subchapter IV. Army, Navy, Air Force, and Coast Guard Medal of Honor
Roll

SEC. 1562. SPECIAL PROVISIONS RELATING TO PENSION

(a) The Secretary shall pay monthly to each living person
whose name has been entered on the Army, Navy, Air Force, and
Coast Guard Medal of Honor Roll, and a copy of whose
certificate has been delivered to the Secretary under
subsection (d) of section 1134a of title 10, a special pension
at the rate of [$1,000] $3,000, as adjusted from time to time
under subsection (e), beginning as of the date on which the
person's name is entered on the Army, Navy, Air Force, and
Coast Guard Medal of Honor Roll under subsection (b) of such
section.

* * * * * * *

Chapter 17. Hospital, Nursing Home, Domiciliary, and Medical Care

SUBCHAPTER I. GENERAL

Sec.

* * * * * * *

1703. Contracts for hospital care and medical services in non-
Department facilities.
1703A. Veterans Extended Care Agreements with certain health care
providers.

* * * * * * *

Subchapter I. General

* * * * * * *

SEC. 1703A. VETERANS EXTENDED CARE AGREEMENTS WITH CERTAIN HEALTH CARE
PROVIDERS

(a) Agreements to Furnish Extended Care.--(1) In addition
to the authority of the Secretary under this chapter to furnish
extended care at facilities of the Department and under
contracts or sharing agreements entered into under authorities
other than this section, the Secretary may furnish extended
care through the use of agreements entered into under this
section. An agreement entered into under this section may be
referred to as a ``Veterans Extended Care Agreement''.
(2) The Secretary may enter into agreements to furnish
extended care under this section with eligible providers that
are certified under subsection (d) if the Secretary is not
feasibly able to furnish extended care at facilities of the
Department.
(3) An eligible provider, at its discretion, may opt to
enter into an agreement under this section instead of a
contract or sharing agreement under authorities other than this
section.
(b) Receipt of Extended Care.--(1) Eligibility of a veteran
for extended care under this section shall be determined as if
such care were furnished in a facility of the Department and
provisions of this title applicable to veterans receiving
extended care in a facility of the Department shall apply to
veterans receiving such care under this section.
(2) In carrying out this section, the Secretary--
(A) may not direct veterans seeking extended care to
health care providers that have entered into contracts
or sharing agreements under authorities other than this
section; and
(B) shall ensure that veterans have the option to
determine whether to receive extended care from a
health care provider described in subparagraph (A) or
an eligible provider that has entered into an agreement
under this section.
(c) Eligible Providers.--For purposes of this section, an
eligible provider is one of the following:
(1) A provider of services that has enrolled and
entered into a provider agreement under section 1866(a)
of the Social Security Act (42 U.S.C. 1395cc(a)).
(2) A physician or supplier that has enrolled and
entered into a participation agreement under section
1842(h) of such Act (42 U.S.C. 1395u(h)).
(3) A provider of items and services receiving
payment under a State plan under title XIX of such Act
(42 U.S.C. 1396 et seq.) or a waiver of such a plan.
(4) A provider that is--
(A) an Aging and Disability Resource Center,
an area agency on aging, or a State agency (as
defined in section 102 of the Older Americans
Act of 1965 (42 U.S.C. 3002)); or
(B) a center for independent living (as
defined in section 702 of the Rehabilitation
Act of 1973 (29 U.S.C. 796a)).
(5) Such other health care providers as the Secretary
considers appropriate for purposes of this section.
(d) Certification of Eligible Providers.--(1) The Secretary
shall establish a process for the certification of eligible
providers under this section that shall, at a minimum, set
forth the following.
(A) Procedures for the submittal of applications for
certification and deadlines for actions taken by the
Secretary with respect to such applications.
(B) Standards and procedures for approval and denial
of certification, duration of certification, revocation
of certification, and recertification.
(C) Procedures for assessing eligible providers based
on the risk of fraud, waste, and abuse of such
providers similar to the level of screening under
section 1866(j)(2)(B) of the Social Security Act (42
U.S.C. 1395cc(j)(2)(B)) and the standards set forth
under section 9.104 of title 48, Code of Federal
Regulations, or any successor regulation.
(2) The Secretary shall deny or revoke certification to an
eligible provider under this subsection if the Secretary
determines that the eligible provider is currently--
(A) excluded from participation in a Federal health
care program (as defined in section 1128B(f) of the
Social Security Act (42 U.S.C. 1320a-7b(f))) under
section 1128 or 1128A of the Social Security Act (42
U.S.C. 1320a-7 and 1320a-7a); or
(B) identified as an excluded source on the list
maintained in the System for Award Management, or any
successor system.
(e) Terms of Agreements.--Each agreement entered into with
an eligible provider under this section shall include
provisions requiring the eligible provider to do the following:
(1) To accept payment for extended care furnished
under this section at rates established by the
Secretary for purposes of this section, which shall be,
to the extent practicable, the rates paid by the United
States for such care to providers of services and
suppliers under the Medicare program under title XVIII
of the Social Security Act (42 U.S.C. 1395 et seq.).
(2) To accept payment under paragraph (1) as payment
in full for extended care furnished under this section
and to not seek any payment for such care from the
recipient of such care.
(3) To furnish under this section only the extended
care authorized by the Department under this section
unless the eligible provider receives prior written
consent from the Department to furnish extended care
outside the scope of such authorization.
(4) To bill the Department for extended care
furnished under this section in accordance with a
methodology established by the Secretary for purposes
of this section.
(5) Not to seek to recover or collect from a health-
plan contract or third party, as those terms are
defined in section 1729 of this title, for any extended
care for which payment is made by the Department under
this section.
(6) To provide medical records for veterans furnished
extended care under this section to the Department in a
time frame and format specified by the Secretary for
purposes of this section.
(7) To meet such other terms and conditions,
including quality of care assurance standards, as the
Secretary may specify for purposes of this section.
(f) Termination of Agreements.--(1) An eligible provider
may terminate an agreement with the Secretary under this
section at such time and upon such notice to the Secretary as
the Secretary may specify for purposes of this section.
(2) The Secretary may terminate an agreement with an
eligible provider under this section at such time and upon such
notice to the eligible provider as the Secretary may specify
for purposes of this section, if the Secretary--
(A) determines that the eligible provider failed to
comply substantially with the provisions of the
agreement or with the provisions of this section and
the regulations prescribed thereunder;
(B) determines that the eligible provider is--
(i) excluded from participation in a Federal
health care program (as defined in section
1128B(f) of the Social Security Act (42 U.S.C.
1320a-7b(f))) under section 1128 or 1128A of
the Social Security Act (42 U.S.C. 1320a-7 and
1320a-7a); or
(ii) identified as an excluded source on the
list maintained in the System for Award
Management, or any successor system;
(C) ascertains that the eligible provider has been
convicted of a felony or other serious offense under
Federal or State law and determines that the continued
participation of the eligible provider would be
detrimental to the best interests of veterans or the
Department; or
(D) determines that it is reasonable to terminate the
agreement based on the health care needs of a veteran
or veterans.
(g) Periodic Review of Certain Agreements.--(1) Not less
frequently than once every two years, the Secretary shall
review each Veterans Extended Care Agreement of material size
entered into during the two-year period preceding the review to
determine whether it is feasible and advisable to furnish the
extended care furnished under such agreement at facilities of
the Department or through contracts or sharing agreements
entered into under authorities other than this section.
(2)(A) Subject to subparagraph (B), a Veterans Extended
Care Agreement is of material size as determined by the
Secretary for purposes of this section.
(B) A Veterans Extended Care Agreement entered into after
September 30, 2016, is of material size if the purchase of
extended care under the agreement exceeds $1,000,000 annually.
The Secretary may adjust such amount to account for changes in
the cost of health care based upon recognized health care
market surveys and other available data and shall publish any
such adjustments in the Federal Register.
(h) Exclusion of Certain Federal Contracting Provisions.--
(1) An agreement under this section may be entered into without
regard to any law that would require the Secretary to use
competitive procedures in selecting the party with which to
enter into the agreement.
(2)(A) Except as provided in subparagraph (B) and unless
otherwise provided in this section or regulations prescribed
pursuant to this section, an eligible provider that enters into
an agreement under this section is not subject to, in the
carrying out of the agreement, any law that providers of
services and suppliers under the Medicare program under title
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) are
not subject to.
(B) Notwithstanding subparagraph (A), an eligible provider
that enters into an agreement under this section shall be
subject to all laws regarding integrity, ethics, fraud, or that
subject a person to civil or criminal penalties as if such laws
were incorporated into its provider agreements.
(i) Quality of Care.--The Secretary shall establish through
regulation a system or systems for--
(1) monitoring the quality of extended care furnished
to veterans under this section; and
(2) assessing the quality of extended care furnished
by an eligible provider under this section prior to the
renewal of a Veterans Extended Care Agreement with the
eligible provider.
(j) Dispute Resolution.--(1) The Secretary shall establish
administrative procedures for eligible providers with which the
Secretary has entered an agreement under this section to
present any dispute arising under or related to the agreement.
(2) Before using any dispute resolution mechanism under
chapter 71 of title 41 with respect to a dispute arising under
an agreement under this section, an eligible provider must
first exhaust the administrative procedures established by the
Secretary under paragraph (1).
(k) Sunset.--The Secretary may not furnish extended care
through the use of an agreement entered into under this section
after the date that is two years after the date of the
enactment of the Jason Simcakoski Memorial Act.

* * * * * * *

Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical
Treatment

* * * * * * *

SEC. 1720G. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS

(a) Program of Comprehensive Assistance for Family
Caregivers.--(1)(A) The Secretary shall establish a program of
comprehensive assistance for family caregivers of eligible
veterans.
(B) * * *
(2) * * *
(A) * * *
[(B) has a serious injury (including traumatic brain
injury, psychological trauma, or other mental disorder)
incurred or aggravated in the line of duty in the
active military, naval, or air service on or after
September 11, 2001; and]
(B) for assistance provided under this subsection--
(i) before the date on which the Secretary
submits to Congress a certification that the
Department has fully implemented the
information technology system required by
section 452(a) of the Jason Simcakoski Memorial
Act, has a serious injury (including traumatic
brain injury, psychological trauma, or other
mental disorder) incurred or aggravated in the
line of duty in the active military, naval, or
air service on or after September 11, 2001;
(ii) during the two-year period beginning on
the date specified in clause (i), has a serious
injury (including traumatic brain injury,
psychological trauma, or other mental disorder)
incurred or aggravated in the line of duty in
the active military, naval, or air service--
(I) on or before May 7, 1975; or
(II) on or after September 11, 2001;
or
(iii) after the date that is two years after
the date specified in clause (i), has a serious
injury (including traumatic brain injury,
psychological trauma, or other mental disorder)
incurred or aggravated in the line of duty in
the active military, naval, or air service; and
(C) * * *
(i) * * *
(ii) a need for supervision or protection
based on symptoms or residuals of neurological
or other impairment or injury[; or] ;
(iii) a need for regular or extensive
instruction or supervision without which the
ability of the veteran to function in daily
life would be seriously impaired; or
(iv) [(iii)] such other matters as the
Secretary considers appropriate.
(3)(A) * * *
(i) * * *

* * * * * * *

(ii) * * *

* * * * * * *

(IV) medical care under section 1781 of this
title[; and] ;
(V) a monthly personal caregiver stipend[.] ;
and
(VI) through the use of contracts with, or
the provision of grants to, public or private
entities--
(aa) financial planning services
relating to the needs of injured
veterans and their caregivers; and
(bb) legal services, including legal
advice and consultation, relating to
the needs of injured veterans and their
caregivers.
(C)(i) * * *

* * * * * * *

(iii) In determining the amount and degree of personal care
services provided under clause (i) with respect to an eligible
veteran whose need for personal care services is based in whole
or in part on a need for supervision or protection under
paragraph (2)(C)(ii) or regular instruction or supervision
under paragraph (2)(C)(iii), the Secretary shall take into
account the following:
(I) The assessment by the family caregiver of the
needs and limitations of the veteran.
(II) The extent to which the veteran can function
safely and independently in the absence of such
supervision, protection, or instruction.
(III) The amount of time required for the family
caregiver to provide such supervision, protection, or
instruction to the veteran.
(iv) [(iii)] If personal care services are not available
from a commercial home health entity in the geographic area of
an eligible veteran, the amount of the monthly personal
caregiver stipend payable under the schedule required by clause
(i) with respect to the eligible veteran shall be determined by
taking into consideration the costs of commercial providers of
personal care services in providing personal care services in
geographic areas other than the geographic area of the eligible
veteran with similar costs of living.
(D) In providing instruction, preparation, and training
under subparagraph (A)(i)(I) and technical support under
subparagraph (A)(i)(II) to each family caregiver who is
approved as a provider of personal care services for an
eligible veteran under paragraph (6), the Secretary shall
periodically evaluate the needs of the eligible veteran and the
skills of the family caregiver of such veteran to determine if
additional instruction, preparation, training, or technical
support under those subparagraphs is necessary.

* * * * * * *

(5) For each application submitted jointly by an eligible
veteran and family member, the Secretary shall evaluate (in
collaboration with the primary care team for the eligible
veteran to the maximum extent practicable)--

* * * * * * *

(11)(A) In providing assistance under this subsection to
family caregivers of eligible veterans, the Secretary may enter
into contracts, provider agreements, and memoranda of
understanding with Federal agencies, States, and private,
nonprofit, and other entities to provide such assistance to
such family caregivers.
(B) The Secretary may provide assistance under this
paragraph only if such assistance is reasonably accessible to
the family caregiver and is substantially equivalent or better
in quality to similar services provided by the Department.
(C) The Secretary may provide fair compensation to Federal
agencies, States, and other entities that provide assistance
under this paragraph.

* * * * * * *

(d) Definitions.--In this section:

* * * * * * *

(4) * * *
(A) Assistance with one or more [independent]
activities of daily living.
(B) Supervision or protection based on
symptoms or residuals of neurological or other
impairment or injury.
(C) Regular or extensive instruction or
supervision without which the ability of the
veteran to function in daily life would be
seriously impaired.
(D) [(B)] Any other non-institutional
extended care (as such term is used in section
1701(6)(E) of this title).

* * * * * * *

Subchapter V. Payments to State Homes

* * * * * * *

SEC. 1745. NURSING HOME CARE AND MEDICATIONS FOR VETERANS WITH SERVICE-
CONNECTED DISABILITIES

(a)(1) The Secretary shall enter into [a contract (or
agreement under section 1720(c)(1) of this title)] an agreement
with each State home for payment by the Secretary for nursing
home care provided in the home, in any case in which such care
is provided to any veteran as follows:

* * * * * * *

(2) Payment under each [contract (or agreement)] agreement
between the Secretary and a State home under paragraph (1)
shall be based on a methodology, developed by the Secretary in
consultation with the State home, to adequately reimburse the
State home for the care provided by the State home under the
[contract (or agreement)] agreement.
(3) * * *
(4)(A) An agreement under paragraph (1) may be entered into
without regard to any law that would require the Secretary to
use competitive procedures in selecting the party with which to
enter into the agreement.
(B)(i) Except as provided in clause (ii) and unless
otherwise provided in this section or regulations prescribed
pursuant to this section, a State home that enters into an
agreement under paragraph (1) is not subject to, in the
carrying out of the agreement, any law that a provider
described in subparagraph (C) is not subject to under the
original Medicare fee-for-service program under parts A and B
of title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) or the Medicaid program under title XIX of such Act (42
U.S.C. 1396 et seq.).
(ii) Notwithstanding clause (i), a State home that enters
into an agreement under paragraph (1) shall be subject to all
laws regarding integrity, ethics, fraud, or that subject a
person to civil or criminal penalties as if such laws were
incorporated into its provider agreements.
(C) A provider described in this subparagraph is one of the
following:
(i) A provider of services that has enrolled and
entered into a provider agreement under section 1866(a)
of the Social Security Act (42 U.S.C. 1395cc(a)).
(ii) A physician or supplier that has enrolled and
entered into a participation agreement under section
1842(h) of such Act (42 U.S.C. 1395u(h)).
(iii) A provider of items and services receiving
payment under a State plan under title XIX of such Act
(42 U.S.C. 1396 et seq.) or a waiver of such a plan.
(5) The Secretary may not furnish nursing home care under
an agreement entered into under paragraph (1) after the date
that is two years after the date of the enactment of the Jason
Simcakoski Memorial Act.

* * * * * * *

Chapter 20. Benefits for Homeless Veterans

SUBCHAPTER I. PURPOSE; DEFINITIONS; ADMINISTRATIVE MATTERS

Sec.

* * * * * * *

SUBCHAPTER II. COMPREHENSIVE SERVICE PROGRAMS

2011. Grants.
2012. Per diem payments.
2013. Program to improve retention of housing by formerly
homeless veterans and veterans at risk of becoming
homeless.
2014 [2013]. Authorization of appropriations.

SUBCHAPTER III. TRAINING AND OUTREACH

* * * * * * *

2022. Coordination of outreach services for veterans at risk of
homelessness.
2022A. Partnerships with public and private entities to provide
legal services to homeless veterans and veterans at
risk of homelessness.

* * * * * * *

SUBCHAPTER VII. OTHER PROVISIONS

* * * * * * *

[2065. Annual report on assistance to homeless veterans.]
2066. Advisory Committee on Homeless Veterans.
2067. National Center on Homelessness Among Veterans.

Subchapter I. Purpose; Definitions; Administrative Matters

* * * * * * *

SEC. 2002. DEFINITIONS

In this chapter:
(1) The term ``homeless veteran'' means a veteran who
is homeless (as that term is defined [in section 103(a)
of the McKinney-Vento Homeless Assistance Act (42
U.S.C. 11302(a))] in subsection (a) or (b) of section
103 of the McKinney-Vento Homeless Assistance Act (42
U.S.C. 11302)).

* * * * * * *

Subchapter II. Comprehensive Service Programs

* * * * * * *

SEC. 2012. PER DIEM PAYMENTS

(a) Per Diem Payments for Furnishing Services to Homeless
Veterans.--(1) Subject to the availability of appropriations
provided for such purpose and except as otherwise provided in
this section, the Secretary, pursuant to such criteria as the
Secretary shall prescribe, shall provide to a recipient of a
grant under section 2011 of this title (or an entity eligible
to receive a grant under that section which after November 10,
1992, establishes a program that the Secretary determines
carries out the purposes described in that section) per diem
payments for services furnished to any homeless veteran--

* * * * * * *

(2)(A) [The rate] Except as otherwise provided in
subparagraph (B), the rate for such per diem payments shall be
the daily cost of care estimated by the grant recipient or
eligible entity adjusted by the Secretary [under subparagraph
(B). In no case may the rate determined under this paragraph
exceed the rate authorized for State homes for domiciliary care
under subsection (a)(1)(A) of section 1741 of this title, as
the Secretary may increase from time to time under subsection
(c) of that section.] under subparagraph (C).
(B)(i) Except as provided in clause (ii), in no case may
the rate determined under this paragraph exceed the rate
authorized for State homes for domiciliary care under
subsection (a)(1)(A) of section 1741 of this title, as the
Secretary may increase from time to time under subsection (c)
of that section.
(ii) In the case of services furnished to a homeless
veteran who is placed in housing that will become permanent
housing for the veteran upon termination of the furnishing of
such services to such veteran, the maximum rate of per diem
authorized under this section is 150 percent of the rate
described in clause (i).
(C) [(B)] The Secretary shall adjust the rate estimated by
the grant recipient or eligible entity under subparagraph (A)
to exclude other sources of income described [in subparagraph
(D)] in subparagraph (E) that the grant recipient or eligible
entity certifies to be correct.
(D) [(C)] Each grant recipient or eligible entity shall
provide to the Secretary such information with respect to other
sources of income as the Secretary may require to make the
adjustment [under subparagraph (B)] under subparagraph (C).
(E) [(D)] The other sources of income referred to [in
subparagraphs (B) and (C)] in subparagraphs (C) and (D) are
payments to the grant recipient or eligible entity for
furnishing services to homeless veterans under programs other
than under this subchapter, including payments and grants from
other departments and agencies of the United States, from
departments or agencies of State or local government, and from
private entities or organizations.

* * * * * * *

(e) Review and Conditional Renewal.--(1) Each year, the
Secretary shall review each grant recipient and eligible entity
that received a per diem payment under this section for a
service furnished to a veteran during the one-year period
preceding the review to evaluate the performance of the grant
recipient or eligible entity during that period with respect
to--
(A) the success of the grant recipient or eligible
entity in assisting veterans to obtain, transition
into, and retain permanent housing; and
(B) increasing the income of veterans, whether by
helping veterans obtain employment or by helping
veterans obtain income-related benefits to which such
veterans may be eligible or entitled.
(2) For any grant recipient or eligible entity whose
performance was evaluated for a year under paragraph (1), the
Secretary may only provide per diem under this section to that
grant recipient or eligible entity in the following year if the
Secretary determines that such performance merits continued
receipt of per diem under this section.
(3) The Secretary shall establish uniform performance
targets throughout the United States for all grant recipients
and eligible entities that receive per diem payments under this
section for purposes of evaluating the performance of each such
grant recipient and eligible entity under this subsection.

* * * * * * *

SEC. 2013. PROGRAM TO IMPROVE RETENTION OF HOUSING BY FORMERLY HOMELESS
VETERANS AND VETERANS AT RISK OF BECOMING HOMELESS

(a) Program Required.--The Secretary shall carry out a
program under which the Secretary shall provide case management
services to improve the retention of housing by veterans who
were previously homeless and are transitioning to permanent
housing and veterans who are at risk of becoming homeless.
(b) Grants.--(1) The Secretary shall carry out the program
through the award of grants.
(2)(A) In awarding grants under paragraph (1), the
Secretary shall give priority to organizations that demonstrate
a capability to provide case management services as described
in subsection (a), particularly organizations that are
successfully providing or have successfully provided
transitional housing services using amounts provided by the
Secretary under sections 2012 and 2061 of this title.
(B) In giving priority under subparagraph (A), the
Secretary shall give extra priority to an organization
described in such subparagraph that--
(i) voluntarily stops receiving amounts provided by
the Secretary under sections 2012 and 2061 of this
title; and
(ii) converts a facility that the organization used
to provide transitional housing services into a
facility that the organization uses to provide
permanent housing that meets housing quality standards
established under section 8(o)(8)(B) of the United
States Housing Act of 1937 (42 U.S.C. 1437f(o)(8)(B)).
(C) In any case in which a facility, with respect to which
a person received a grant for construction, rehabilitation, or
acquisition under section 2011 of this title, is converted as
described in subparagraph (B)(ii), such conversion shall be
considered to have been carried out pursuant to the needs of
the Department and such person shall not be considered in non-
compliance with the terms of such grant by reason of such
conversion.

SEC. 2014 [2013]. AUTHORIZATION OF APPROPRIATIONS

* * * * * * *

Subchapter III. Training and Outreach

SEC. 2021. HOMELESS VETERANS REINTEGRATION PROGRAMS

(a) In General.--Subject to the availability of
appropriations provided for such purpose, the Secretary of
Labor shall conduct, directly or through grant or contract,
such programs as the Secretary determines appropriate to
provide job training, counseling, and placement services
(including job readiness and literacy and skills training) to
expedite the [reintegration of homeless veterans into the labor
force.] reintegration into the labor force of--
(1) homeless veterans;
(2) veterans participating in the Department of
Veterans Affairs supported housing program for which
rental assistance is provided pursuant to section
8(o)(19) of the United States Housing Act of 1937 (42
U.S.C. 1437f(o)(19));
(3) Indians who are veterans and receiving assistance
under the Native American Housing Assistance and Self
Determination Act of 1996 (25 U.S.C. 4101 et seq.); and
(4) veterans who are transitioning from being
incarcerated.

* * * * * * *

SEC. 2022A. PARTNERSHIPS WITH PUBLIC AND PRIVATE ENTITIES TO PROVIDE
LEGAL SERVICES TO HOMELESS VETERANS AND VETERANS AT
RISK OF HOMELESSNESS

(a) Partnerships Authorized.--Subject to the availability
of funds for that purpose, the Secretary may enter into
partnerships with public or private entities to fund a portion
of the general legal services specified in subsection (c) that
are provided by such entities to homeless veterans and veterans
at risk of homelessness.
(b) Locations.--(1) The Secretary shall ensure that, to the
extent practicable, partnerships under this section are made
with entities equitably distributed across the geographic
regions of the United States, including rural communities,
tribal lands of the United States, Native Americans, and tribal
organizations.
(2) In this subsection, the terms ``Native American'' and
``tribal organization'' have the meanings given such terms in
section 3765 of this title.
(c) Legal Services.--Legal services specified in this
subsection include legal services provided by public or private
entities that address the needs of homeless veterans and
veterans at risk of homelessness, such as the following:
(1) Legal services related to housing, including
eviction defense and representation in landlord-tenant
cases.
(2) Legal services related to family law, including
assistance in court proceedings for child support,
divorce, and estate planning.
(3) Legal services related to income support,
including assistance in obtaining public benefits.
(4) Legal services related to criminal defense,
including defense in matters symptomatic of
homelessness, such as outstanding warrants, fines, and
driver's license revocation, to reduce recidivism and
facilitate the overcoming of reentry obstacles in
employment or housing.
(d) Consultation.--In developing and carrying out
partnerships under this section, the Secretary shall, to the
extent practicable, consult with public and private entities--
(1) for assistance in identifying and contacting
organizations described in subsection (c); and
(2) to coordinate appropriate outreach relationships
with such organizations.
(e) Reports.--The Secretary may require entities that have
entered into partnerships under this section to submit to the
Secretary periodic reports on legal services provided to
homeless veterans and veterans at risk of homelessness pursuant
to such partnerships.

* * * * * * *

Subchapter VII. Other Provisions

* * * * * * *

SEC. 2062. DENTAL CARE

(a) * * *

* * * * * * *

[(b) Eligible Veterans.--Subsection (a) applies to a
veteran--
[(1) who is enrolled for care under section 1705(a)
of this title; and
[(2) who, for a period of 60 consecutive days, is
receiving care (directly or by contract) in any of the
following settings:
[(A) A domiciliary under section 1710 of this
title.
[(B) A therapeutic residence under section
2032 of this title.
[(C) Community residential care coordinated
by the Secretary under section 1730 of this
title.
[(D) A setting for which the Secretary
provides funds for a grant and per diem
provider.
[(3) For purposes of paragraph (2), in determining
whether a veteran has received treatment for a period
of 60 consecutive days, the Secretary may disregard
breaks in the continuity of treatment for which the
veteran is not responsible.]
(b) Eligible Veterans.--(1) Subsection (a) applies to a
veteran who--
(A) is enrolled for care under section 1705(a) of
this title; and
(B) for a period of 60 consecutive days, is
receiving--
(i) assistance under section 8(o) of the
United States Housing Act of 1937 (42 U.S.C.
1437f(o)); or
(ii) care (directly or by contract) in any of
the following settings:
(I) A domiciliary under section 1710
of this title.
(II) A therapeutic residence under
section 2032 of this title.
(III) Community residential care
coordinated by the Secretary under
section 1730 of this title.
(IV) A setting for which the
Secretary provides funds for a grant
and per diem provider.
(2) For purposes of paragraph (1), in determining whether a
veteran has received assistance or care for a period of 60
consecutive days, the Secretary may disregard breaks in the
continuity of assistance or care for which the veteran is not
responsible.

* * * * * * *

[SEC. 2065. ANNUAL REPORT ON ASSISTANCE TO HOMELESS VETERANS

[(a) Annual Report.--Not later than June 15 of each year,
the Secretary shall submit to the Committees on Veterans'
Affairs of the Senate and House of Representatives a report on
the activities of the Department during the calendar year
preceding the report under programs of the Department under
this chapter and other programs of the Department for the
provision of assistance to homeless veterans.
[(b) General Contents of Report.--Each report under
subsection (a) shall include the following:
[(1) The number of homeless veterans provided
assistance under the programs referred to in subsection
(a).
[(2) The cost to the Department of providing such
assistance under those programs.
[(3) The Secretary's evaluation of the effectiveness
of the programs of the Department in providing
assistance to homeless veterans, including--
[(A) residential work-therapy programs;
[(B) programs combining outreach, community-
based residential treatment, and case-
management; and
[(C) contract care programs for alcohol and
drug-dependence or use disabilities.
[(4) The Secretary's evaluation of the effectiveness
of programs established by recipients of grants under
section 2011 of this title and a description of the
experience of those recipients in applying for and
receiving grants from the Secretary of Housing and
Urban Development to serve primarily homeless persons
who are veterans.
[(5) Information on the efforts of the Secretary to
coordinate the delivery of housing and services to
homeless veterans with other Federal departments and
agencies, including--
[(A) the Department of Defense;
[(B) the Department of Health and Human
Services;
[(C) the Department of Housing and Urban
Development;
[(D) the Department of Justice;
[(E) the Department of Labor;
[(F) the Interagency Council on Homelessness;
[(G) the Social Security Administration; and
[(H) any other Federal department or agency
with which the Secretary coordinates the
delivery of housing and services to homeless
veterans.
[(6) Any other information on those programs and on
the provision of such assistance that the Secretary
considers appropriate.
[(c) Health Care Contents of Report.--Each report under
subsection (a) shall include, with respect to programs of the
Department addressing health care needs of homeless veterans,
the following:
[(1) Information about expenditures, costs, and
workload under the program of the Department known as
the Health Care for Homeless Veterans program (HCHV).
[(2) Information about the veterans contacted through
that program.
[(3) Information about program treatment outcomes
under that program.
[(4) Information about supported housing programs.
[(5) Information about the Department's grant and per
diem provider program under subchapter II of this
chapter.
[(6) The findings and conclusions of the assessments
of the medical needs of homeless veterans conducted
under section 2034(b) of this title.
[(7) Other information the Secretary considers
relevant in assessing those programs.
[(d) Benefits Content of Report.--Each report under
subsection (a) shall include, with respect to programs and
activities of the Veterans Benefits Administration in
processing of claims for benefits of homeless veterans during
the preceding year, the following:
[(1) Information on costs, expenditures, and workload
of Veterans Benefits Administration claims evaluators
in processing claims for benefits of homeless veterans.
[(2) Information on the filing of claims for benefits
by homeless veterans.
[(3) Information on efforts undertaken to expedite
the processing of claims for benefits of homeless
veterans.
[(4) Other information that the Secretary considers
relevant in assessing the programs and activities.]

* * * * * * *

SEC. 2067. NATIONAL CENTER ON HOMELESSNESS AMONG VETERANS

(a) In General.--(1) The Secretary shall establish and
operate a center to carry out the functions described in
subsection (b).
(2) The center established under paragraph (1) shall be
known as the ``National Center on Homelessness Among
Veterans''.
(3) To the degree practicable, the Secretary shall operate
the center established under paragraph (1) independently of the
other programs of the Department that address homelessness
among veterans.
(b) Functions.--The functions described in this subsection
are as follows:
(1) To carry out and promote research into the causes
and contributing factors to veteran homelessness.
(2) To assess the effectiveness of programs of the
Department to meet the needs of homeless veterans.
(3) To identify and disseminate best practices with
regard to housing stabilization, income support,
employment assistance, community partnerships, and such
other matters as the Secretary considers appropriate
with respect to addressing veteran homelessness.
(4) To integrate evidence-based and best practices,
policies, and programs into programs of the Department
for homeless veterans and veterans at risk of
homelessness and to ensure that the staff of the
Department and community partners can implement such
practices, policies, and programs.
(5) To serve as a resource center for, and promote
and seek to coordinate the exchange of information
regarding, all research and training activities carried
out by the Department and by other Federal and non-
Federal entities with respect to veteran homelessness.

* * * * * * *

Part III. Readjustment and Related Benefits

* * * * * * *

Chapter 33. Post-9/11 Educational Assistance

SUBCHAPTER I. DEFINITIONS

Sec.

* * * * * * *

SUBCHAPTER III. ADMINISTRATIVE PROVISIONS

* * * * * * *

3326. Election to receive educational assistance.

Subchapter I. Definitions

SEC. 3301. DEFINITIONS

In this chapter:
(1) * * *
(A) * * *
(B) In the case of members of the reserve
components of the Armed Forces, service on
active duty under a call or order to active
duty under section 688, 12301(a), 12301(d),
12301(g), 12301(h), 12302, or 12304 of title 10
or section 712 of title 14.

* * * * * * *

Subchapter II. Educational Assistance

* * * * * * *

SEC. 3312. EDUCATIONAL ASSISTANCE: DURATION.

* * * * * * *

(d) Discontinuation of Education Due to Closure of
Educational Institution.--
(1) In general.--Any payment of educational
assistance described in paragraph (2) shall not--
(A) be charged against any entitlement to
educational assistance of the individual
concerned under this chapter; or
(B) be counted against the aggregate period
for which section 3695 of this title limits the
individual's receipt of educational assistance
under this chapter.
(2) Description of payment of educational
assistance.--Subject to paragraph (3), the payment of
educational assistance described in this paragraph is
the payment of such assistance to an individual for
pursuit of a course or courses under this chapter if
the Secretary finds that the individual--
(A) was forced to discontinue such course
pursuit as a result of a permanent closure of
an educational institution; and
(B) did not receive credit, or lost training
time, toward completion of the program of
education being pursued at the time of such
closure.
(3) Period for which payment not charged.--The period
for which, by reason of this subsection, educational
assistance is not charged against entitlement or
counted toward the applicable aggregate period under
section 3695 of this title shall not exceed the
aggregate of--
(A) the portion of the period of enrollment
in the course or courses from which the
individual failed to receive credit or with
respect to which the individual lost training
time, as determined under paragraph (2)(B), and
(B) the period by which a monthly stipend is
extended under section 3680(a)(2)(B) of this
title.

* * * * * * *

SEC. 3317. PUBLIC-PRIVATE CONTRIBUTIONS FOR ADDITIONAL EDUCATIONAL
ASSISTANCE

(a) Establishment of Program.--In instances where the
educational assistance provided pursuant to section
3313(c)(1)(A) does not cover the full cost of established
charges (as specified in section 3313), the Secretary shall
carry out a program under which colleges and universities can,
voluntarily, enter into an agreement with the Secretary to
cover a portion of those established charges not otherwise
covered under section 3313(c)(1)(A), which contributions shall
be matched by equivalent contributions toward such costs by the
Secretary. The program shall only apply to covered individuals
described [in paragraphs (1) and (2)] in paragraphs (1), (2),
and (9) of section 3311(b).

* * * * * * *

SEC. 3319. AUTHORITY TO TRANSFER UNUSED EDUCATION BENEFITS TO FAMILY
MEMBERS

* * * * * * *

(b) * * *
(1) [six years] ten years of service in the Armed
Forces and enters into an agreement to serve at least
[four more years] two more years as a member of the
uniformed services; or

* * * * * * *

(g) * * *
(1) * * *
(A) [six years] ten years of service in the
Armed Forces; or

* * * * * * *

(h) * * *

* * * * * * *

(3) * * *
(A) * * *
(B) in the case of a child, at the same rate
as such entitlement would otherwise be payable
under this chapter to the individual making the
transfer as if the individual were not on
active duty, except that the amount of the
monthly stipend described in subsection
(c)(1)(B) or (g)(3)(A)(ii) of section 3313, as
the case may be, shall be payable in an amount
equal to 50 percent of the amount of such
stipend that would otherwise be payable under
this chapter to the individual making the
transfer.

* * * * * * *

(5) * * *

* * * * * * *

(B) Primary caregivers of seriously injured
members of the [armed forces] Armed Forces and
veterans.--

* * * * * * *

Subchapter III. Administrative Provisions

* * * * * * *

SEC. 3326. ELECTION TO RECEIVE EDUCATIONAL ASSISTANCE

(a) Individuals Eligible to Elect Participation in Post-9/
11 Educational Assistance.--An individual may elect to receive
educational assistance under this chapter if such individual--
(1) as of August 1, 2009--
(A) is entitled to basic educational
assistance under chapter 30 of this title and
has used, but retains unused, entitlement under
that chapter;
(B) is entitled to educational assistance
under chapter 107, 1606, or 1607 of title 10
and has used, but retains unused, entitlement
under the applicable chapter;
(C) is entitled to basic educational
assistance under chapter 30 of this title but
has not used any entitlement under that
chapter;
(D) is entitled to educational assistance
under chapter 107, 1606, or 1607 of title 10
but has not used any entitlement under such
chapter;
(E) is a member of the Armed Forces who is
eligible for receipt of basic educational
assistance under chapter 30 this title and is
making contributions toward such assistance
under section 3011(b) or 3012(c) of this title;
or
(F) is a member of the Armed Forces who is
not entitled to basic educational assistance
under chapter 30 of this title by reason of an
election under section 3011(c)(1) or 3012(d)(1)
of this title; and
(2) as of the date of the individual's election under
this paragraph, meets the requirements for entitlement
to educational assistance under this chapter.
(b) Cessation of Contributions Toward GI Bill.--Effective
as of the first month beginning on or after the date of an
election under subsection (a) of an individual described by
paragraph (1)(E) of that subsection, the obligation of the
individual to make contributions under section 3011(b) or
3012(c) of this title, as applicable, shall cease, and the
requirements of such section shall be deemed to be no longer
applicable to the individual.
(c) Revocation of Remaining Transferred Entitlement.--
(1) Election to revoke.--If, on the date an
individual described in paragraph (1)(A) or (1)(C) of
subsection (a) makes an election under that subsection,
a transfer of the entitlement of the individual to
basic educational assistance under section 3020 of this
title is in effect and a number of months of the
entitlement so transferred remain unutilized, the
individual may elect to revoke all or a portion of the
entitlement so transferred that remains unutilized.
(2) Availability of revoked entitlement.--Any
entitlement revoked by an individual under this
paragraph shall no longer be available to the dependent
to whom transferred, but shall be available to the
individual instead for educational assistance under
chapter 33 of this title in accordance with the
provisions of this section.
(3) Availability of unrevoked entitlement.--Any
entitlement described in paragraph (1) that is not
revoked by an individual in accordance with that
paragraph shall remain available to the dependent or
dependents concerned in accordance with the current
transfer of such entitlement under section 3020 of this
title.
(d) Post-9/11 Educational Assistance.--
(1) In general.--Subject to paragraph (2) and except
as provided in subsection (e), an individual making an
election under subsection (a) shall be entitled to
educational assistance under this chapter in accordance
with the provisions of this chapter, instead of basic
educational assistance under chapter 30 of this title,
or educational assistance under chapter 107, 1606, or
1607 of title 10, as applicable.
(2) Limitation on entitlement for certain
individuals.--In the case of an individual making an
election under subsection (a) who is described by
paragraph (1)(A) of that subsection, the number of
months of entitlement of the individual to educational
assistance under this chapter shall be the number of
months equal to--
(A) the number of months of unused
entitlement of the individual under chapter 30
of this title, as of the date of the election,
plus
(B) the number of months, if any, of
entitlement revoked by the individual under
subsection (c)(1).
(e) Continuing Entitlement to Educational Assistance Not
Available Under 9/11 Assistance Program.--
(1) In general.--In the event educational assistance
to which an individual making an election under
subsection (a) would be entitled under chapter 30 of
this title, or chapter 107, 1606, or 1607 of title 10,
as applicable, is not authorized to be available to the
individual under the provisions of this chapter the
individual shall remain entitled to such educational
assistance in accordance with the provisions of the
applicable chapter.
(2) Charge for use of entitlement.--The utilization
by an individual of entitlement under paragraph (1)
shall be chargeable against the entitlement of the
individual to educational assistance under this chapter
at the rate of one month of entitlement under this
chapter for each month of entitlement utilized by the
individual under paragraph (1) (as determined as if
such entitlement were utilized under the provisions of
chapter 30 of this title, or chapter 107, 1606, or 1607
of title 10, as applicable).
(f) Additional Post-9/11 Assistance for Members Having Made
Contributions Toward GI Bill.--
(1) Additional assistance.--In the case of an
individual making an election under subsection (a) who
is described by subparagraph (A), (C), or (E) of
paragraph (1) of that subsection, the amount of
educational assistance payable to the individual under
this chapter as a monthly stipend payable under
paragraph (1)(B) of section 3313(c) of this title, or
under paragraphs (2) through (7) of that section (as
applicable), shall be the amount otherwise payable as a
monthly stipend under the applicable paragraph
increased by the amount equal to--
(A) the total amount of contributions toward
basic educational assistance made by the
individual under section 3011(b) or 3012(c) of
this title, as of the date of the election,
multiplied by
(B) the fraction--
(i) the numerator of which is--
(I) the number of months of
entitlement to basic
educational assistance under
chapter 30 of this title
remaining to the individual at
the time of the election; plus
(II) the number of months, if
any, of entitlement under
chapter 30 revoked by the
individual under subsection
(c)(1); and
(ii) the denominator of which is 36
months.
(2) Months of remaining entitlement for certain
individuals.--In the case of an individual covered by
paragraph (1) who is described by subsection (a)(1)(E),
the number of months of entitlement to basic
educational assistance remaining to the individual for
purposes of paragraph (1)(B)(i)(II) shall be 36 months.
(3) Timing of payment.--The amount payable with
respect to an individual under paragraph (1) shall be
paid to the individual together with the last payment
of the monthly stipend payable to the individual under
paragraph (1)(B) of section 3313(c) of this title, or
under subsections (2) through (7) of that section (as
applicable), before the exhaustion of the individual's
entitlement to educational assistance under this
chapter.
(g) Continuing Entitlement to Additional Assistance for
Critical Skills or Speciality and Additional Service.--An
individual making an election under subsection (a)(1) who, at
the time of the election, is entitled to increased educational
assistance under section 3015(d) of this title, or section
16131(i) of title 10, or supplemental educational assistance
under subchapter III of chapter 30 of this title, shall remain
entitled to such increased educational assistance or
supplemental educational assistance in the utilization of
entitlement to educational assistance under this chapter, in an
amount equal to the quarter, semester, or term, as applicable,
equivalent of the monthly amount of such increased educational
assistance or supplemental educational assistance payable with
respect to the individual at the time of the election.
(h) Alternative Election by Secretary.--
(1) In general.--In the case of an individual who, on
or after January 1, 2016, submits to the Secretary an
election under this section that the Secretary
determines is clearly against the interests of the
individual, or who fails to make an election under this
section, the Secretary may make an alternative election
on behalf of the individual that the Secretary
determines is in the best interests of the individual.
(2) Notice.--If the Secretary makes an election on
behalf of an individual under this subsection, the
Secretary shall notify the individual by not later than
seven days after making such election and shall provide
the individual with a 30-day period, beginning on the
date of the individual's receipt of such notice, during
which the individual may modify or revoke the election
made by the Secretary on the individual's behalf. The
Secretary shall include, as part of such notice, a
clear statement of why the alternative election made by
the Secretary is in the best interests of the
individual as compared to the election submitted by the
individual. The Secretary shall provide the notice
required under this paragraph by electronic means
whenever possible.
(i) Irrevocability of Elections.--An election under
subsection (a) or (c)(1) is irrevocable.

* * * * * * *

Chapter 36. Administration of Educational Benefits

* * * * * * *

Subchapter I. State Approving Agencies

* * * * * * *

SEC. 3672. APPROVAL OF COURSES

(a) * * *
(b)(1) * * *
(2)(A) Subject to sections 3675(b)(1) and (b)(2), 3680A,
3684, and 3696 of this title, [the following programs are
deemed to be approved for purposes of this chapter:] a program
of education is deemed to be approved for purposes of this
chapter if a State approving agency determines that the program
is one of the following programs:
(i) [An accredited] Except as provided in
subparagraph (C), an accredited standard college degree
program offered at a public or not-for-profit
proprietary educational institution that is accredited
by an agency or association recognized for that purpose
by the Secretary of Education.

* * * * * * *

(C) A course that is described in both subparagraph (A)(i)
of this paragraph and in paragraph (14) or (15) of section
3676(c) of this title shall not be deemed to be approved for
purposes of this chapter unless--
(i) a State approving agency, or the Secretary when
acting in the role of a State approving agency,
determines that the course meets the applicable
criteria in such paragraphs; or
(ii) the Secretary issues a waiver for such course
under section 3676(f)(1) of this title.

* * * * * * *

SEC. 3675. APPROVAL OF ACCREDITED COURSES

(a)(1) [The Secretary or a State approving agency] A State
approving agency, or the Secretary when acting in the role of a
State approving agency, may approve accredited programs
(including non-degree accredited programs) [offered by
proprietary for-profit educational institutions] not covered by
section 3672 of this title when--

* * * * * * *

(b) As a condition of approval under this section, [the
Secretary or the State approving agency] the State approving
agency, or the Secretary when acting in the role of a State
approving agency must find the following:
(1) The educational institution keeps adequate
records, as prescribed by [the Secretary or the State
approving agency] the State approving agency, or the
Secretary when acting in the role of a State approving
agency, to show the progress and grades of the eligible
person or veteran and to show that satisfactory
standards relating to progress and conduct are
enforced.

* * * * * * *

(3) The educational institution and its approved
courses meet the criteria of paragraphs (1), (2), [and
(3)] (3), (14), (15), and (16) of section 3676(c) of
this title (or, with respect to such paragraphs (14)
and (15), the requirements under such paragraphs are
waived pursuant to subsection (f)(1) of section 3676 of
this title).

* * * * * * *

SEC. 3676. APPROVAL OF NONACCREDITED COURSES

* * * * * * *

(14) In the case of a course designed to prepare an
individual for licensure or certification in a State,
the course--
(A) meets any instructional curriculum
licensure or certification requirements of such
State; and
(B) in the case of a course designed to
prepare an individual for licensure to practice
law in a State, is accredited by an accrediting
agency or association recognized by the
Secretary of Education under subpart 2 of part
H of title IV of the Higher Education Act of
1965 (20 U.S.C. 1099b).
(15) In the case of a course designed to prepare an
individual for employment pursuant to standards
developed by a board or agency of a State in an
occupation that requires approval, licensure, or
certification, the course--
(A) meets such standards; and
(B) in the case of a course designed to
prepare an individual for licensure to practice
law in a State, is accredited by an accrediting
agency or association recognized by the
Secretary of Education under subpart 2 of part
H of title IV of the Higher Education Act of
1965 (20 U.S.C. 1099b).
(16) [(14)] Such additional criteria as may be deemed
necessary by the State approving agency if the
Secretary, in consultation with the State approving
agency and pursuant to regulations prescribed to carry
out this paragraph, determines such criteria are
necessary and treat public, private, and proprietary
for-profit educational institutions equitably.

* * * * * * *

(f)(1) The Secretary may waive the requirements of
paragraph (14) or (15) of subsection (c) in the case of a
course of education offered by an educational institution
(either accredited or not accredited) if the Secretary
determines all of the following:
(A) The course did not meet the requirements of such
paragraph at any time during the two-year period
preceding the date of the waiver.
(B) The waiver furthers the purposes of the
educational assistance programs administered by the
Secretary or would further the education interests of
individuals eligible for assistance under such
programs.
(C) The educational institution does not provide any
commission, bonus, or other incentive payment based
directly or indirectly on success in securing
enrollments or financial aid to any persons or entities
engaged in any student recruiting or admission
activities or in making decisions regarding the award
of student financial assistance, except for the
recruitment of foreign students residing in foreign
countries who are not eligible to receive Federal
student assistance.
(2) Not later than 30 days after the date on which the
Secretary issues a waiver under paragraph (1), the Secretary
shall submit to Congress notice of such waiver and a
justification for issuing such waiver.

* * * * * * *

SEC. 3679. DISAPPROVAL OF COURSES

* * * * * * *

(d) Notwithstanding any other provision of this chapter,
the Secretary or the applicable State approving agency shall
disapprove a course of education described in paragraph (14) or
(15) of section 3676(c) of this title unless the educational
institution providing the course of education--
(1) publicly discloses any conditions or additional
requirements, including training, experience, or
examinations, required to obtain the license,
certification, or approval for which the course of
education is designed to provide preparation; and
(2) makes each disclosure required by paragraph (1)
in a manner that the Secretary considers prominent.

Subchapter II. Miscellaneous Provisions

SEC. 3680. PAYMENT OF EDUCATIONAL ASSISTANCE OR SUBSISTENCE ALLOWANCES

(a) Period for Which Payment May Be Made.--[Payment of] (1)
Except as provided in paragraph (2), payment of educational
assistance or subsistence allowances to eligible veterans or
eligible persons pursuing a program of education or training,
other than a program by correspondence, in an educational
institution under chapter 31, 34, or 35 of this title shall be
paid as provided in this section and, as applicable, in section
3108, 3482, 3491, or 3532 of this title. Such payments shall be
paid only for the period of such veterans' or persons'
enrollment in, and pursuit of, such program, but no amount
shall be paid--
(A) [(1)] to any eligible veteran or eligible person
for any period when such veteran or person is not
pursuing such veteran's or person's course in
accordance with the regularly established policies and
regulations of the educational institution, with the
provisions of such regulations as may be prescribed by
the Secretary pursuant to subsection (g) of this
section, and with the requirements of this chapter or
of chapter 34 or 35 of this title, but payment may be
made for an actual period of pursuit of one or more
unit subjects pursued for a period of time shorter than
the enrollment period at the educational institution;
(B) [(2)] to any eligible veteran or person for
auditing a course; or
(C) [(3)] to any eligible veteran or person for a
course for which the grade assigned is not used in
computing the requirements for graduation including a
course from which the student withdraws unless--
(i) [(A)] the eligible veteran or person
withdraws because he or she is ordered to
active duty; or
(ii) [(B)] the Secretary finds there are
mitigating circumstances, except that, in the
first instance of withdrawal (without regard to
withdrawals [described in subclause (A) of this
clause] described in clause (i)) by the
eligible veteran or person from a course or
courses with respect to which the veteran or
person has been paid assistance under this
title, mitigating circumstances shall be
considered to exist with respect to courses
totaling not more than six semester hours or
the equivalent thereof.
[Notwithstanding the foregoing, the Secretary may, subject to
such regulations as the Secretary shall prescribe, continue to
pay allowances to eligible veterans and eligible persons
enrolled in courses set forth in clause (1) of this subsection
during periods when schools are temporarily closed under an
established policy based on an Executive order of the President
or due to an emergency situation. However, the total number of
weeks for which allowances may continue to be so payable in any
12-month period may not exceed 4 weeks.]
(2) Notwithstanding paragraph (1), the Secretary may,
pursuant to such regulations as the Secretary shall prescribe,
continue to pay allowances to eligible veterans and eligible
persons enrolled in courses set forth in paragraph (1)(A)--
(A) during periods when schools are temporarily
closed under an established policy based on an
Executive order of the President or due to an emergency
situation, except that the total number of weeks for
which allowances may continue to be so payable in any
12-month period may not exceed four weeks; or
(B) solely for the purpose of awarding a monthly
housing stipend described in section 3313 of this
title, during periods following a permanent school
closure, except that payment of such a stipend may only
be continued until the earlier of--
(i) the date of the end of the term, quarter,
or semester during which the school closure
occurred; and
(ii) the date that is 4 months after the date
of the school closure.

* * * * * * *

SEC. 3684. REPORTS BY VETERANS, ELIGIBLE PERSONS, AND INSTITUTIONS;
REPORTING FEE

(a)(1) Except as provided in paragraph (2) of this
subsection, the veteran or eligible person and the educational
institution offering a course in which such veteran or eligible
person is enrolled under chapter 31, 32, 33, 34, 35, or 36 of
this title shall, without delay, report to the Secretary, in
the form prescribed by the Secretary, such enrollment and any
interruption or termination of the education of each such
veteran or eligible person. The date of such interruption or
termination will be the last date of pursuit, or, in the case
of correspondence training, the last date a lesson was serviced
by a school.

* * * * * * *

(4) For purposes of this subsection, the term ``educational
institution'' may include a group, district, or consortium of
separately accredited educational institutions located in the
same State that are organized in a manner that facilitates the
centralized reporting of the enrollments in such group,
district, or consortium of institutions.

* * * * * * *

SEC. 3693. COMPLIANCE SURVEYS

[(a) Except as provided in subsection (b) of this section,
the Secretary shall conduct an annual compliance survey of each
institution offering one or more courses approved for the
enrollment of eligible veterans or persons if at least 300
veterans or persons are enrolled in such course or courses
under provisions of this title or if any such course does not
lead to a standard college degree. Such compliance survey shall
be designed to ensure that the institution and approved courses
are in compliance with all applicable provisions of chapters 30
through 36 of this title. The Secretary shall assign at least
one education compliance specialist to work on compliance
surveys in any year for each 40 compliance surveys required to
be made under this section for such year.]
(a)(1)(A) Except as provided in subsection (b), the
Secretary shall conduct an annual compliance survey of
educational institutions and training establishments offering
one or more courses approved for the enrollment of eligible
veterans or persons if at least 20 such veterans or persons are
enrolled in any such course.
(B) The Secretary shall--
(i) design the compliance surveys to ensure that such
institutions or establishments, as the case may be, and
approved courses are in compliance with all applicable
provisions of chapters 30 through 36 of this title;
(ii) survey each such educational institution and
training establishment not less than once during every
two-year period; and
(iii) assign not fewer than one education compliance
specialist to work on compliance surveys in any year
for each 40 compliance surveys required to be made
under this section for such year.
(2) The Secretary, in consultation with the State approving
agencies, shall--
(A) annually determine the parameters of the surveys
required under paragraph (1); and
(B) not later than September 1 of each year, make
available to the State approving agencies a list of the
educational institutions and training establishments
that will be surveyed during the fiscal year following
the date of making such list available.
(b) The Secretary may waive the requirement in [subsection
(a) of this section for an annual compliance survey] subsection
(a)(1) for a compliance survey with respect to an [institution]
educational institution or training establishment if the
Secretary determines, based on the [institution's demonstrated
record of compliance] record of compliance of such institution
or establishment with all the applicable provisions of chapters
30 through 36 of this title, that the waiver would be
appropriate and in the best interest of the United States
Government.
(c) In this section, the terms ``educational institution''
and ``training establishment'' have the meaning given such
terms in section 3452 of this title.

* * * * * * *

Part IV. General Administrative Provisions

Chapter 51. Claims, Effective Dates, and Payments

* * * * * * *

Subchapter I. Claims

* * * * * * *

SEC. 5101. CLAIMS AND FORMS

(a)(1) [A specific] (A) Except as provided in subparagraph
(B), a specific claim in the form prescribed by the Secretary
(or jointly with the Commissioner of Social Security, as
prescribed by section 5105 of this title) must be filed in
order for benefits to be paid or furnished to any individual
under the laws administered by the Secretary.
(B)(i) The Secretary may pay benefits under chapters 13 and
15 and sections 2302, 2307, and 5121 of this title to a
survivor of a veteran who has not filed a formal claim if the
Secretary determines that the record contains sufficient
evidence to establish the entitlement of the survivor to such
benefits.
(ii) For purposes of this subparagraph and section 5110 of
this title, the date on which the Secretary is notified of the
death of the veteran shall be treated as the date of the
receipt of the survivor's application for benefits described in
clause (i).

* * * * * * *

Part V. Boards, Administrations, and Services

* * * * * * *

Chapter 72. United States Court of Appeals for
Veterans Claims

* * * * * * *

Subchapter I. Organization and Jurisdiction

* * * * * * *

SEC. 7253. COMPOSITION

* * * * * * *

(i) Additional Temporary Expansion of Court.--(1) * * *
(2) Effective as of [January 1, 2013] January 1, 2021, an
appointment may not be made to the Court if the appointment
would result in there being more judges of the Court than the
authorized number of judges of the Court specified in
subsection (a).

* * * * * * *

Chapter 73. Veterans Health Administration--Organization and Functions

SUBCHAPTER I. ORGANIZATION

Sec.

* * * * * * *

7309A. Pain management boards.
7309B. Office of Patient Advocacy.

* * * * * * *

Subchapter I. Organization

* * * * * * *

SEC. 7306. OFFICE OF THE UNDER SECRETARY FOR HEALTH

(a) * * *

* * * * * * *

(4) Such Medical Directors and Directors of Veterans
Integrated Service Networks as may be appointed to suit
the needs of the Department[, who shall be either a
qualified doctor of medicine or a qualified doctor of
dental surgery or dental medicine].

* * * * * * *

SEC. 7309A. PAIN MANAGEMENT BOARDS

(a) Establishment.--The Secretary shall establish in each
Veterans Integrated Service Network a Pain Management Board (in
this section referred to as a ``Board'').
(b) Activities.--(1) Each Board may--
(A) consult with health care professionals and other
employees of the Department located in the Veterans
Integrated Service Network covered by the Board,
patients who are being treated at medical facilities of
the Department located in such Veterans Integrated
Service Network, and family members of such patients
with respect to the pain management resources and best
practices of the Department;
(B) oversee compliance by the health care
professionals and other employees of the Department
with the best practices of the Department, including by
issuing recommendations to improve compliance with
those best practices;
(C) provide oversight of the pain management
practices of the pain management teams of each medical
facility of the Department and the health care
professionals and other employees of the Department
that are located in the Veterans Integrated Service
Network covered by the Board;
(D) host educational events, as the Board considers
appropriate, for individuals specified in subparagraph
(A) on pain management and treatment that may include
the sharing of updated research and best practices from
medical experts, other health care systems, and such
other Federal agencies as the Board considers necessary
to carry out this subparagraph; and
(E) host public events, as the Board considers
appropriate, during which health care professionals
discuss and share best practices on pain management and
complementary and integrative health.
(2)(A) Each Board may provide treatment recommendations for
patients with complex clinical pain who are being treated at a
medical facility of the Department located in the Veterans
Integrated Service Network covered by the Board, and assist in
facilitating communication between such patients and their
health care providers, regardless of whether such treatment is
on an in-patient or out-patient basis, and for whom a request
for such recommendations, subject to subparagraph (C), has been
made by an individual described in subparagraph (B).
(B) An individual described in this subparagraph is one of
the following individuals:
(i) The patient.
(ii) The spouse of the patient.
(iii) A family member of the patient or another
individual if such family member or individual has been
designated by the patient to make health care decisions
for the patient or to receive health care information
with respect to the patient.
(iv) A physician of the patient.
(v) An employee of the medical facility of the
Department described in subparagraph (A).
(C) An individual described in subparagraph (B) may not
request treatment recommendations under subparagraph (A) unless
the individual--
(i) has requested treatment recommendations from the
pain management team of the medical facility of the
Department at which the patient is receiving treatment;
and
(ii) has received treatment recommendations from such
team and is not satisfied with those treatment
recommendations.
(D) Treatment recommendations provided under subparagraph
(A) shall assist the patient and health care provider in
determining the best treatment plan for the patient and shall
not dictate the treatment plan used by the health care
provider.
(3) Based on treatment recommendations developed under
paragraph (2)(A), consultations conducted under paragraph
(1)(A), and educational and public events hosted under
subparagraphs (D) and (E) of paragraph (1), each Board may
provide to health care professionals of the Department located
in the Veterans Integrated Service Network covered by the Board
recommendations on the best practices regarding pain management
in cases of complex clinical pain.
(4)(A) Not later than January 31 of each year, 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 comprehensive
information from each Board (with all personally identifiable
information of patients redacted) on pain management practices
carried out in the Veterans Integrated Service Network covered
by the Board.
(B) Each report submitted by the Secretary under
subparagraph (A) shall include, for the year preceding the
submittal of the report--
(i) a summary and explanation of the treatment
recommendations provided under paragraph 2(A) during
such year; and
(ii) the recommendations for best practices provided
to health care professionals under paragraph (3) during
such year.
(5) The Federal Advisory Committee Act (5 U.S.C. App.)
shall not apply to any Board.
(c) Membership.--(1) Each Board shall include the following
individuals appointed by the Secretary:
(A) A board certified pain medicine specialist.
(B) A trained and qualified member of the primary
care team of a medical facility of the Department with
experience in pain care, such as a nurse practitioner.
(C) A pain psychologist.
(D) A pain social worker.
(E) A clinical pharmacist.
(F) A pain point of contact for a Veterans Integrated
Service Network.
(G) A physician with addiction and psychopharmacology
expertise and experience.
(H) An allied health care professional.
(I) A clinician with expertise in complementary and
integrative health.
(J) A clinical behavioral therapist.
(K) A patient advocate.
(L) A representative of the labor interests of
employees of the Department who are responsible for
prescribing drugs.
(M) Two current or former clinical patients who are
representative of the demographic of patients served by
the Veterans Integrated Service Network covered by the
Board.
(N) A family member of a current or former clinical
patient who is representative of the demographic of
patients served by the Veterans Integrated Service
Network covered by the Board.
(2) The Secretary shall determine the terms of service of
the members of each Board, taking into consideration the
clinical duties of members who are employees of the Department.
(3)(A) Members of each Board shall serve without pay and,
except as provided in subparagraph (B), members who are full-
time officers or employees of the United States may not receive
additional pay, allowances, or benefits by reason of their
service on the Board.
(B) Members may receive travel expenses, including per diem
in lieu of subsistence, for travel in connection with their
duties as members of the Board.
(C)(i) Except as provided in clause (ii), any member who
has clinical duties as an officer or employee of the United
States shall be relieved of such duties during periods in which
such relief is necessary for the member to carry out the duties
of the Board.
(ii) The Secretary shall ensure that carrying out the
duties of the Board does not prevent any member who has
clinical duties as an employee of the Department from
furnishing direct clinical care as appropriate to maintain
quality patient care.
(d) Participation of Certain Members.--(1) In carrying out
the activities of a Board under subsection (b), any member
appointed under subsection (c)(1) solely based on
qualifications under subparagraph (K), (L), (M), or (N) of
subsection (c)(1)--
(A) may not have access to specific information
identifying a patient and other confidential
information relating to a patient; and
(B) except as provided in paragraph (2), may not
participate in providing treatment recommendations
under subsection (b)(2)(A).
(2) In carrying out the activities of the Board under
subsection (b), a member appointed under subsection (c)(1)
solely based on qualifications under subparagraph (K) of
subsection (c)(1) may be present during the provision of
treatment recommendations under subsection (b)(2)(A) with the
consent and upon the request of the patient for which such
treatment recommendations are provided for purposes of
representing the interests of the patient.
(e) Employment Protections.--No adverse personnel action
may be made against an employee of the Department in connection
with a communication by the employee with a member of a Board
relating to the activities of the Board under subsection (b)
and any such communication shall be covered by the employment
and whistleblower protections otherwise applicable to
communications by employees of the Department.
(f) Resources of Department.--The Secretary shall make
available to each Board the resources and personnel of the
Department necessary for the Board to carry out the activities
of the Board under subsection (b), including resources and
personnel of the General Counsel of the Department.

SEC. 7309B. OFFICE OF PATIENT ADVOCACY

(a) Establishment.--There is established in the Department
within the Office of the Under Secretary for Health an office
to be known as the ``Office of Patient Advocacy'' (in this
section referred to as the ``Office'').
(b) Head.--(1) The Director of the Office of Patient
Advocacy shall be the head of the Office.
(2) The Director of the Office of Patient Advocacy shall be
appointed by the Under Secretary for Health from among
individuals qualified to perform the duties of the position and
shall report directly to the Under Secretary for Health.
(c) Function.--(1) The function of the Office is to carry
out the Patient Advocacy Program of the Department.
(2) In carrying out the Patient Advocacy Program of the
Department, the Director shall ensure that patient advocates of
the Department--
(A) advocate on behalf of veterans with respect to
health care received and sought by veterans under the
laws administered by the Secretary;
(B) carry out the responsibilities specified in
subsection (d); and
(C) receive training in patient advocacy.
(d) Patient Advocacy Responsibilities.--The
responsibilities of each patient advocate at a medical facility
of the Department are the following:
(1) To resolve complaints by veterans with respect to
health care furnished under the laws administered by
the Secretary that cannot be resolved at the point of
service or at a higher level easily accessible to the
veteran.
(2) To present at various meetings and to various
committees the issues experienced by veterans in
receiving such health care at such medical facility.
(3) To express to veterans their rights and
responsibilities as patients in receiving such health
care.
(4) To manage the Patient Advocate Tracking System of
the Department at such medical facility.
(5) To compile data at such medical facility of
complaints made by veterans with respect to the receipt
of such health care at such medical facility and the
satisfaction of veterans with such health care at such
medical facility to determine whether there are trends
in such data.
(6) To ensure that a process is in place for the
distribution of the data compiled under paragraph (5)
to appropriate leaders, committees, services, and staff
of the Department.
(7) To identify, not less frequently than quarterly,
opportunities for improvements in the furnishing of
such health care to veterans at such medical facility
based on complaints by veterans.
(8) To ensure that any significant complaint by a
veteran with respect to such health care is brought to
the attention of appropriate staff of the Department to
trigger an assessment of whether there needs to be a
further analysis of the problem at the facility-wide
level.
(9) To support any patient advocacy programs carried
out by the Department.
(10) To ensure that all appeals and final decisions
with respect to the receipt of such health care are
entered into the Patient Advocate Tracking System of
the Department.
(11) To understand all laws, directives, and other
rules with respect to the rights and responsibilities
of veterans in receiving such health care, including
the appeals processes available to veterans.
(12) To ensure that veterans receiving mental health
care, or the surrogate decision makers for such
veterans, are aware of the rights of veterans to seek
representation from systems established under section
103 of the Protection and Advocacy for Mentally Ill
Individuals Act of 1986 (42 U.S.C. 10803) to protect
and advocate the rights of individuals with mental
illness and to investigate incidents of abuse and
neglect of such individuals.
(13) To fulfill requirements established by the
Secretary with respect to the inspection of controlled
substances.
(14) To document potentially threatening behavior and
report such behavior to appropriate authorities.
(e) Training.--In providing training to patient advocates
under subsection (c)(2)(C), the Director shall ensure that such
training is consistent throughout the Department.
(f) Controlled Substance Defined.--In this section, the
term ``controlled substance'' has the meaning given that term
in section 102 of the Controlled Substances Act (21 U.S.C.
802).

* * * * * * *

Chapter 74. Veterans Health Administration--Personnel

SUBCHAPTER I. APPOINTMENTS

Sec.

* * * * * * *

SUBCHAPTER VII. PAY FOR MEDICAL DIRECTORS AND DIRECTORS OF VETERANS
INTEGRATED SERVICE NETWORKS

7481. Pay for Medical Directors and Directors of Veterans
Integrated Service Networks.

* * * * * * *

Subchapter II. Collective Bargaining and Personnel Administration

* * * * * * *

SEC. 7423. PERSONNEL ADMINISTRATION: FULL-TIME EMPLOYEES

(a)(1) Except as provided in paragraph (2), the hours [(a)
The hours] of employment in carrying out responsibilities under
this title of any employee who is appointed in the
Administration under any provision of this chapter on a full-
time basis in a position listed in section 7421(b) of this
title (other than an intern or resident appointed pursuant to
section 7406 of this title) and who accepts responsibilities
for carrying out professional services for remuneration other
than those assigned under this title shall consist of not less
than 80 hours in a biweekly pay period (as that term is used in
section 5504 of title 5).
(2) The Secretary may modify the hours of employment for a
physician or physician assistant appointed in the
Administration under any provision of this chapter on a full-
time basis to be more than or less than 80 hours in a biweekly
pay period if the total hours of employment for such employee
in a calendar year does not exceed 2,080 hours.

* * * * * * *

SEC. 7451. NURSES AND OTHER HEALTH-CARE PERSONNEL: COMPETITIVE PAY

(a)(1) * * *
(2) * * *
(A) Registered nurse.
(B) Physician assistant.
(C) [(B)] Such positions referred to in paragraphs
(1) and (3) of section 7401 of this title (other than
the positions of physician, dentist, [and registered
nurse] registered nurse, and physician assistant) as
the Secretary may determine upon the recommendation of
the Under Secretary for Health.

* * * * * * *

Subchapter VII. Pay For Medical Directors and Directors of Veterans
Integrated Service Networks

SEC. 7481. PAY FOR MEDICAL DIRECTORS AND DIRECTORS OF VETERANS
INTEGRATED SERVICE NETWORKS

(a) Elements of Pay.--Pay for a Medical Director or
Director of a Veterans Integrated Service Network appointed
under section 7306(a)(4) of this title (in this section
referred to as a ``Director'') shall consist of basic pay set
forth under section 7404(a) of this title and market pay
determined under subsection (b).
(b) Market Pay.--(1) Each Director is eligible for market
pay determined under this subsection.
(2) The amount of market pay payable to a Director under
this section shall be determined by the Secretary on a case-by-
case basis and shall consist of pay intended to reflect needs
of the Department with respect to the recruitment and retention
(as determined by the Secretary) of such Director.
(3) In determining the amount of market pay payable to a
Director under this section, the Secretary shall--
(A) consult not less than two national surveys on pay
for hospital directors, medical facility directors, or
other similar positions, whether prepared by private,
public, or quasi-public entities, to make a general
assessment of the range of potential pay for the
Director; and
(B) take into account--
(i) the experience of the Director in
managing facilities or program offices of the
Department, including the complexity of such
facilities or offices;
(ii) the complexity of the facility or
facilities to be managed by the Director;
(iii) the labor market, in such geographic
area as the Secretary considers relevant, for
hospital directors, medical facility directors,
and other similar positions;
(iv) the experience of the Director in
managing medical facilities for other Federal
agencies, private entities, or non-profit
entities; and
(v) such other considerations as the
Secretary considers appropriate.
(4)(A) The Secretary shall evaluate the amount of market
pay payable to a Director under this section not less
frequently than once every two years and may adjust the market
pay payable to such Director as a result of such evaluation.
(B) A Director whose market pay is evaluated under
subparagraph (A) shall receive written notice of the results of
such evaluation.
(c) Requirements and Limitations on Total Pay.--(1) Not
less frequently than once every two years, the Secretary shall
set forth a Department-wide minimum and maximum amount for
total annual pay under subsection (a) that may be paid to a
Director and shall publish each such amount in the Federal
Register.
(2) The minimum and maximum amounts set forth under
paragraph (1) shall take effect not earlier than the date that
is 60 days after the publication of such amounts under such
paragraph.
(3) The sum of the basic pay set forth under section
7404(a) of this title and market pay determined under
subsection (b) for a Director for a calendar year--
(A) may not be less than the most recent minimum
amount set forth under paragraph (1) before the
beginning of such calendar year; and
(B) may not be more than the most recent maximum
amount set forth under such paragraph before the
beginning of such calendar year.
(4) The total amount of compensation paid to a Director
under this title in any calendar year may not exceed the amount
of annual compensation (excluding expenses) of the President
under section 102 of title 3.
(5) The Secretary may not delegate to an officer or
employee of the Department the requirement of the Secretary to
set forth a Department-wide minimum and maximum amount under
paragraph (1).
(d) Treatment of Pay.--Pay under this section shall be
considered pay for all purposes, including retirement benefits
under chapters 83 and 84 of title 5 and other benefits.
(e) Ancillary Effects of Decreases in Pay.--(1) A decrease
in pay of a Director resulting from an adjustment in the amount
of market pay of the Director under subsection (b) shall not be
treated as an adverse action.
(2) A decrease in the amount of pay of a Director resulting
from an involuntary reassignment in connection with a
disciplinary action taken against the Director is not subject
to appeal or judicial review.

* * * * * * *

Carl Levin and Howard P. ``Buck'' McKeon National Defense Authorization
Act For Fiscal Year 2015

(Public Law 113-291; 37 U.S.C. 403 note)

* * * * * * *

Division A--Department of Defense Authorizations

* * * * * * *

Title VI--Compensation and Other Personnel Benefits

Subtitle A--Pay and Allowances

* * * * * * *

SEC. 604. MODIFICATION OF COMPUTATION OF BASIC ALLOWANCE FOR HOUSING
INSIDE THE UNITED STATES.

(a) * * *
[(b) Special Rule.--Any reduction authorized by paragraph
(3) of subsection (b) of section 403 of title 37, United States
Code, as amended by subsection (a), shall not apply with
respect to benefits paid by the Secretary of Veterans Affairs
under the laws administered by the Secretary, including
pursuant to sections 3108 and 3313 of title 38, United States
Code. Such benefits that are determined in accordance with such
section 403 shall be subject to paragraph (3) of such section
as such paragraph was in effect on the day before the date of
the enactment of this Act.]

* * * * * * *

Caregivers and Veterans Omnibus Health Services Act of 2010

(Public Law 111-163; 38 U.S.C. 1720G note)

* * * * * * *

Title I. Caregiver Support

SEC. 101. ASSISTANCE AND SUPPORT SERVICES FOR CAREGIVERS.

* * * * * * *

(2) * * *
(A) With respect to the program of
comprehensive assistance for family caregivers
required by subsection (a)(1) of such section
1720G and the program of general caregiver
support services required by subsection (b)(1)
of such section--

* * * * * * *

(iv) an assessment of the
effectiveness and the efficiency of the
implementation of such programs,
including a description of any barriers
to accessing and receiving care and
services under such programs; and

* * * * * * *

(B) With respect to the program of
comprehensive assistance for family caregivers
required by such subsection (a)(1)--
(i) a description of the outreach
activities carried out by the Secretary
under such program[; and] ;
(ii) an assessment of the manner in
which resources are expended by the
Secretary under such program,
particularly with respect to the
provision of monthly personal caregiver
stipends under paragraph (3)(A)(ii)(v)
of such subsection (a)[.] ; and
(iii) an evaluation of the
sufficiency and consistency of the
training provided to family caregivers
under such program in preparing family
caregivers to provide care to veterans
under such program.

* * * * * * *

Post-9/11 Veterans Educational Assistance Act of 2008

(Public Law 110-252; 38 U.S.C. 3301 note)

* * * * * * *

SEC. 5003.

(a) Educational Assistance Authorized.--

* * * * * * *

[(c) Applicability to Individuals Under Montgomery Gi Bill
Program.--
[(1) Individuals Eligible to Elect Participation in
Post-9/11 Educational Assistance.--An individual may
elect to receive educational assistance under chapter
33 of title 38, United States Code (as added by
subsection (a)), if such individual--
[(A) as of August 1, 2009--
[(i) is entitled to basic educational
assistance under chapter 30 of title
38, United States Code, and has used,
but retains unused, entitlement under
that chapter;
[(ii) is entitled to educational
assistance under chapter 107, 1606, or
1607 of title 10, United States Code,
and has used, but retains unused,
entitlement under the applicable
chapter;
[(iii) is entitled to basic
educational assistance under chapter 30
of title 38, United States Code, but
has not used any entitlement under that
chapter;
[(iv) is entitled to educational
assistance under chapter 107, 1606, or
1607 of title 10, United States Code,
but has not used any entitlement under
such chapter;
[(v) is a member of the Armed Forces
who is eligible for receipt of basic
educational assistance under chapter 30
of title 38, United States Code, and is
making contributions toward such
assistance under section 3011(b) or
3012(c) of such title; or
[(vi) is a member of the Armed Forces
who is not entitled to basic
educational assistance under chapter 30
of title 38, United States Code, by
reason of an election under section
3011(c)(1) or 3012(d)(1) of such title;
and
[(B) as of the date of the individual's
election under this paragraph, meets the
requirements for entitlement to educational
assistance under chapter 33 of title 38, United
States Code (as so added).
[(2) Cessation of Contributions Toward Gi Bill.--
Effective as of the first month beginning on or after
the date of an election under paragraph (1) of an
individual described by subparagraph (A)(v) of that
paragraph, the obligation of the individual to make
contributions under section 3011(b) or 3012(c) of title
38, United States Code, as applicable, shall cease, and
the requirements of such section shall be deemed to be
no longer applicable to the individual.
[(3) Revocation of Remaining Transferred
Entitlement.--
[(A) Election to revoke.--If, on the date an
individual described in subparagraph (A)(i) or
(A)(iii) of paragraph (1) makes an election
under that paragraph, a transfer of the
entitlement of the individual to basic
educational assistance under section 3020 of
title 38, United States Code, is in effect and
a number of months of the entitlement so
transferred remain unutilized, the individual
may elect to revoke all or a portion of the
entitlement so transferred that remains
unutilized.
[(B) Availability of revoked entitlement.--
Any entitlement revoked by an individual under
this paragraph shall no longer be available to
the dependent to whom transferred, but shall be
available to the individual instead for
educational assistance under chapter 33 of
title 38, United States Code (as so added), in
accordance with the provisions of this
subsection.
[(C) Availability of unrevoked entitlement.--
Any entitlement described in subparagraph (A)
that is not revoked by an individual in
accordance with that subparagraph shall remain
available to the dependent or dependents
concerned in accordance with the current
transfer of such entitlement under section 3020
of title 38, United States Code.
[(4) Post-9/11 Educational Assistance.--
[(A) In general.--Subject to subparagraph (B)
and except as provided in paragraph (5), an
individual making an election under paragraph
(1) shall be entitled to educational assistance
under chapter 33 of title 38, United States
Code (as so added), in accordance with the
provisions of such chapter, instead of basic
educational assistance under chapter 30 of
title 38, United States Code, or educational
assistance under chapter 107, 1606, or 1607 of
title 10, United States Code, as applicable.
[(B) Limitation on entitlement for certain
individuals.--In the case of an individual
making an election under paragraph (1) who is
described by subparagraph (A)(i) of that
paragraph, the number of months of entitlement
of the individual to educational assistance
under chapter 33 of title 38, United States
Code (as so added), shall be the number of
months equal to--
[(i) the number of months of unused
entitlement of the individual under
chapter 30 of title 38, United States
Code, as of the date of the election,
plus
[(ii) the number of months, if any,
of entitlement revoked by the
individual under paragraph (3)(A).
[(5) Continuing Entitlement to Educational Assistance
Not Available Under 9/11 Assistance Program.--
[(A) In general.--In the event educational
assistance to which an individual making an
election under paragraph (1) would be entitled
under chapter 30 of title 38, United States
Code, or chapter 107, 1606, or 1607 of title
10, United States Code, as applicable, is not
authorized to be available to the individual
under the provisions of chapter 33 of title 38,
United States Code (as so added), the
individual shall remain entitled to such
educational assistance in accordance with the
provisions of the applicable chapter.
[(B) Charge for use of entitlement.--The
utilization by an individual of entitlement
under subparagraph (A) shall be chargeable
against the entitlement of the individual to
educational assistance under chapter 33 of
title 38, United States Code (as so added), at
the rate of one month of entitlement under such
chapter 33 for each month of entitlement
utilized by the individual under subparagraph
(A) (as determined as if such entitlement were
utilized under the provisions of chapter 30 of
title 38, United States Code, or chapter 107,
1606, or 1607 of title 10, United States Code,
as applicable).
[(6) Additional Post-9/11 Assistance for Members
Having Made Contributions Toward Gi Bill.--
[(A) Additional assistance.--In the case of
an individual making an election under
paragraph (1) who is described by clause (i),
(iii), or (v) of subparagraph (A) of that
paragraph, the amount of educational assistance
payable to the individual under chapter 33 of
title 38, United States Code (as so added), as
a monthly stipend payable under paragraph
(1)(B) of section 3313(c) of such title, or
under paragraphs (2) through (7) of that
section (as applicable), shall be the amount
otherwise payable as a monthly stipend under
the applicable paragraph increased by the
amount equal to--
[(i) the total amount of
contributions toward basic educational
assistance made by the individual under
section 3011(b) or 3012(c) of title 38,
United States Code, as of the date of
the election, multiplied by
[(ii) the fraction--
[(I) the numerator of which
is--
[(aa) the number of
months of entitlement
to basic educational
assistance under
chapter 30 of title 38,
United States Code,
remaining to the
individual at the time
of the election; plus
[(bb) the number of
months, if any, of
entitlement under such
chapter 30 revoked by
the individual under
paragraph (3)(A); and
[(II) the denominator of
which is 36 months.
[(B) Months of remaining entitlement for
certain individuals.--In the case of an
individual covered by subparagraph (A) who is
described by paragraph (1)(A)(v), the number of
months of entitlement to basic educational
assistance remaining to the individual for
purposes of subparagraph (A)(ii)(I)(aa) shall
be 36 months.
[(C) Timing of payment.--The amount payable
with respect to an individual under
subparagraph (A) shall be paid to the
individual together with the last payment of
the monthly stipend payable to the individual
under paragraph (1)(B) of section 3313(c) of
title 38, United States Code (as so added), or
under paragraphs (2) through (7) of that
section (as applicable), before the exhaustion
of the individual's entitlement to educational
assistance under chapter 33 of such title (as
so added).
[(7) Continuing Entitlement to Additional Assistance
for Critical Skills or Speciality and Additional
Service.--An individual making an election under
paragraph (1)(A) who, at the time of the election, is
entitled to increased educational assistance under
section 3015(d) of title 38, United States Code, or
section 16131(i) of title 10, United States Code, or
supplemental educational assistance under subchapter
III of chapter 30 of title 38, United States Code,
shall remain entitled to such increased educational
assistance or supplemental educational assistance in
the utilization of entitlement to educational
assistance under chapter 33 of title 38, United States
Code (as so added), in an amount equal to the quarter,
semester, or term, as applicable, equivalent of the
monthly amount of such increased educational assistance
or supplemental educational assistance payable with
respect to the individual at the time of the election.
[(8) Irrevocability of Elections.--An election under
paragraph (1) or (3)(A) is irrevocable.]

* * * * * * *

Veterans Access, Choice, and Accountability Act of 2014

(Public Law 113-146; 38 U.S.C. 7302 note)

* * * * * * *

Title III. Health Care Staffing, Recruitment, and Training Matters

SEC. 301. TREATMENT OF STAFFING SHORTAGE AND BIENNIAL REPORT ON
STAFFING OF MEDICAL FACILITIES OF THE DEPARTMENT OF
VETERANS AFFAIRS.

(a) Staffing Shortages.--

* * * * * * *

(b) Increase of Graduate Medical Education Residency
Positions.--

* * * * * * *

(2) [Five-year] Ten-year increase.--
(A) In general.--In carrying out section
7302(e) of title 38, United States Code, as
added by paragraph (1), during the [5-year
period] 10-year period beginning on the day
that is 1 year after the date of the enactment
of this Act, the Secretary of Veterans Affairs
shall increase the number of graduate medical
education residency positions at medical
facilities of the Department by up to 1,500
positions.

* * * * * * *

(3) Report.--
(A) In general.--Not later than 60 days after
the date of the enactment of this Act, and not
later than October 1 each year thereafter
[until 2019] until 2024, 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 on graduate medical education residency
positions at medical facilities of the
Department.

* * * * * * *

[all]