[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 1030 Reference Change House (RCH)]
103d CONGRESS
2d Session
S. 1030
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 27, 1994
Rereferred to the Committee on Veterans' Affairs
_______________________________________________________________________
AN ACT
To amend title 38, United States Code, to improve the Department of
Veterans Affairs program of sexual trauma services for veterans, to
improve certain Department of Veterans Affairs programs for women
veterans, to extend the period of entitlement to inpatient care for
veterans exposed to Agent Orange or ionizing radiation, to establish a
hospice care pilot program, to establish a rural health care clinics
program, to authorize the Secretary of Veterans Affairs to provide per
diem payments and construction grants to State homes for adult day
health care services, to establish an education debt reduction program,
and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Veterans Health
Programs Improvement Act of 1994''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--WOMEN VETERANS
Sec. 101. Department of Veterans Affairs sexual trauma services
program.
Sec. 102. Reports relating to determinations of service connection for
sexual trauma.
Sec. 103. Coordinators of women's services.
Sec. 104. Women's health services.
Sec. 105. Expansion of research relating to women veterans.
Sec. 106. Mammography quality standards.
TITLE II--GENERAL HEALTH CARE SERVICES
Sec. 201. Extension of period of eligibility for medical care for
exposure to dioxin or ionizing radiation.
Sec. 202. Extension of period of eligibility for priority health care
for veterans of the Persian Gulf War.
Sec. 203. Programs for furnishing hospice care to veterans.
Sec. 204. Rural health-care clinic program.
Sec. 205. Payment to States of per diem for veterans receiving adult
day health care.
Sec. 206. Revision of authority on use of tobacco products in
department facilities.
TITLE III--MISCELLANEOUS
Subtitle A--Education Debt Reduction Program
Sec. 301. Short title.
Sec. 302. Program of assistance in the payment of education debts
incurred by certain Veterans Health
Administration employees.
Subtitle B--Other Provisions
Sec. 311. Extension of authority of Advisory Committee on Education.
Sec. 312. Extension of authority to maintain regional office in the
Philippines.
TITLE I--WOMEN VETERANS
SEC. 101. DEPARTMENT OF VETERANS AFFAIRS SEXUAL TRAUMA SERVICES
PROGRAM.
(a) Authority To Provide Services for Sexual Trauma.--(1)
Subsection (a)(1) of section 1720D of title 38, United States Code is
amended--
(A) by inserting ``(A)'' before ``During the period''; and
(B) by adding at the end the following:
``(B) During the period referred to in subparagraph (A), the
Secretary may provide appropriate care and services to a veteran for an
injury, illness, or other psychological condition which the Secretary
determines to be the result of a physical assault, battery, or
harassment referred to in that subparagraph.''.
(2) Subsection (c)(1) of such section is amended to read as
follows:
``(1) The Secretary shall give priority to the establishment and
operation of the program to provide counseling and care and services
under subsection (a). In the case of a veteran eligible for counseling
and care and services under subsection (a)(1), the Secretary shall
ensure that the veteran is furnished counseling under this section in a
way that is coordinated with the furnishing of such care and services
under this chapter.''.
(3) Subsection (d) of such section is amended by inserting ``and
care and services'' after ``counseling'' each place it appears.
(b) Authority To Provide Services by Contract.--Subsection (a)(3)
of such section is amended--
(1) by inserting ``(A)'' before ``In furnishing'';
(2) in subparagraph (A), as so designated--
(i) by striking out ``(A)'' and inserting in lieu
thereof ``(i)''; and
(ii) by striking out ``(B)'' and inserting in lieu
thereof ``(ii)''; and
(3) by adding at the end the following:
``(B) The Secretary may provide care and services to a veteran
under paragraph (1)(B) pursuant to a contract with a qualified non-
Department health professional or facility if Department facilities are
not capable of furnishing such care and services to that veteran
economically because of geographic inaccessibility.''.
(c) Extension of Authority To Provide Sexual Trauma Services.--
Subsection (a) of such section, as amended by subsections (a) and (b)
of this section, is further amended--
(1) by striking out ``December 31, 1995,'' in paragraph
(1)(A) and inserting in lieu thereof ``December 31, 1998,'';
and
(2) by striking out ``December 31, 1994,'' in paragraph (3)
and inserting in lieu thereof ``December 31, 1998,''.
(d) Period of Eligibility To Seek Services.--(1) Such subsection,
as amended by subsections (a), (b), and (c) of this section, is further
amended--
(A) by striking out paragraph (2); and
(B) by redesignating paragraph (3) as paragraph (2).
(2) Section 102(b) of the Veterans Health Care Act of 1992 (Public
Law 102-585; 106 Stat. 4946; 38 U.S.C. 1720D note) is repealed.
(e) Repeal of Limitation on Period of Receipt of Services.--Section
1720D of title 38, United States Code (as amended by subsections (a)
through (d) of this section), is further amended--
(1) by striking out subsection (b); and
(2) by redesignating subsections (c), (d), and (e) as
subsections (b), (c), and (d), respectively.
(f) Increased Priority of Care.--Section 1712(i) of title 38,
United States Code, is amended--
(1) in paragraph (1)--
(A) by inserting ``(A)'' after ``To a veteran'';
and
(B) by inserting ``, or (B) who is eligible for
counseling and care and services under section 1720D of
this title, for the purposes of such counseling and
care and services'' before the period at the end; and
(2) in paragraph (2)--
(A) by striking out ``, (B)'' and inserting in lieu
thereof ``or (B)''; and
(B) by striking out ``, or (C)'' and all that
follows through ``such counseling''.
(g) Program Revision.--(1) Section 1720D of title 38, United States
Code (as amended by subsections (a) through (e) of this section), is
further amended--
(A) by striking out ``woman'' in subsection (a)(1)(A);
(B) by striking out ``women'' in subsection (b)(2)(C) and
in the first sentence of subsection (c); and
(C) by striking out ``women'' in subsection (c)(2) and
inserting in lieu thereof ``individuals''.
(2)(A) The heading of such section is amended to read as follows:
``Sec. 1720D. Counseling, care, and services for sexual trauma''.
(B) The item relating to such section in the table of sections at
the beginning of chapter 17 of such title is amended to read as
follows:
``1720D. Counseling, care, and services for sexual trauma.''.
(h) Information on Counseling by Telephone.--(1) Paragraph (1) of
section 1720D(c) of title 38, United States Code, as redesignated by
subsection (d) of this section, is amended by striking out ``may'' and
inserting in lieu thereof ``shall''.
(2) In providing information on counseling available to veterans
through the information system required under section 1720D(c)(1) of
title 38, United States Code, as amended by this section, the Secretary
of Veterans Affairs shall ensure--
(A) that the telephone system described in such section is
operated by Department of Veterans Affairs personnel who are
trained in the provision to persons who have experienced sexual
trauma of information about the counseling and care and
services relating to sexual trauma that are available to
veterans in the communities in which such veterans reside,
including counseling and care and services available under
programs of the Department (including the care and services
available under section 1720D of such title) and from non-
Department agencies or organizations;
(B) that such personnel are provided with information on
the counseling and care and services relating to sexual trauma
that are available to veterans and the locations in which such
care and services are available;
(C) that such personnel refer veterans seeking such
counseling and care and services to appropriate providers of
such counseling and care and services (including counseling and
care and services that are available in the communities in
which such veterans reside);
(D) that the telephone system is operated in a manner that
protects the confidentiality of persons who place telephone
calls to the system; and
(E) that the telephone system operates at all times.
(3) The Secretary shall ensure that information about the
availability of the telephone system is visibly posted in Department
medical facilities and is advertised through public service
announcements, pamphlets, and other means.
(4) Not later than 18 months after the date of the enactment of
this Act, the Secretary shall submit to Congress a report on the
operation of the telephone system required under section 1720D(c)(1) of
title 38, United States Code (as so amended). The report shall set
forth the following:
(A) The number of telephone calls placed to the system
during the period covered by the report, with a separate
display of (i) the number of calls placed to the system from
each State (as such term is defined in section 101(20) of title
38, United States Code) during that period, and (ii) the number
of persons who placed more than one call to the system during
that period.
(B) The types of sexual trauma described to personnel
operating the system by persons placing calls to the system.
(C) A description of the difficulties, if any, experienced
by persons placing calls to the system in obtaining counseling
and care and services for sexual trauma in the communities in
which such persons live, including counseling and care and
services available from the Department and from non-Department
agencies and organizations.
(D) A description of the training provided to the personnel
operating the system.
(E) The recommendations and plans of the Secretary for the
improvement of the system.
(5) The Secretary shall commence operation of the telephone system
required under section 1720D(c)(1) of title 38, United States Code (as
so amended), not later than 180 days after the date of the enactment of
this Act.
SEC. 102. REPORTS RELATING TO DETERMINATIONS OF SERVICE CONNECTION FOR
SEXUAL TRAUMA.
(a) Report.--(1) The Secretary of Veterans Affairs shall submit to
the Committees on Veterans' Affairs of the Senate and House of
Representatives a report containing the Secretary's assessment of--
(A) the difficulties that veterans encounter in obtaining
from the Department of Veterans Affairs determinations that
disabilities relating to sexual trauma resulting from events
that occurred during active duty are service-connected
disabilities; and
(B) the extent to which Department personnel fail to make
determinations that such disabilities are service-connected
disabilities.
(2) The Secretary shall include in the report the Secretary's
recommendations for actions to be taken to respond in a fair manner to
the difficulties described in the report and to eliminate failures to
make determinations that such disabilities are service-connected
disabilities.
(3) The report required by this subsection shall be submitted not
later than June 30, 1994.
(b) Follow-Up Reports.--Not later than June 30 of each of 1995 and
1996, the Secretary shall submit to the committees referred to in
paragraph (1) of subsection (a) a report on the actions taken by the
Secretary to implement the recommendations referred to in paragraph (2)
of that subsection.
(c) Definition.--In this section, the term ``sexual trauma'' means
the immediate and long-term physical or psychological trauma resulting
from rape, sexual assault, aggravated sexual abuse (as such term is
described in section 2241 of title 18, United States Code), sexual
harassment, or other act of sexual violence.
SEC. 103. COORDINATORS OF WOMEN'S SERVICES.
(a) Requirement of Full-time Service.--Section 108 of the Veterans
Health Care Act of 1992 (Public Law 102-585; 106 Stat. 4948; 38 U.S.C.
1710 note) is amended--
(1) by inserting ``(a)'' before ``The Secretary''; and
(2) by adding at the end the following:
``(b) Each official who serves in the position of coordinator of
women's services under subsection (a) shall so serve on a full-time
basis.''.
(b) Additional Responsibilities.--Subsection (a) of such section
(as designated by subsection (a) of this section) is further amended--
(1) by redesignating paragraph (5) as paragraph (6); and
(2) by inserting after paragraph (4) the following new
paragraph (5):
``(5) Facilitating communication between women veterans
coordinators under the jurisdiction of such regional
coordinator and the Under Secretary for Health and the
Secretary.''.
(c) Support for Women's Services Coordinators.--The Secretary of
Veterans Affairs shall take appropriate actions to ensure that--
(1) sufficient funding is provided to each Department of
Veterans Affairs facility in order to permit the coordinator of
women's services to carry out the responsibilities of the
coordinator at the facility;
(2) sufficient clerical and communications support is
provided to each such coordinator for that purpose; and
(3) each such coordinator has direct access to the Director
or Chief of Staff of the facility to which the coordinator is
assigned.
SEC. 104. WOMEN'S HEALTH SERVICES.
(a) Women's Health Services.--Section 1701 of title 38, United
States Code, is amended--
(1) in paragraph (6)(A)(i), by inserting ``women's health
services,'' after ``preventive health services,''; and
(2) by adding at the end the following:
``(10) The term `women's health services' means health care
services provided to women, including counseling and services relating
to the following:
``(A) Papanicolaou tests (pap smears).
``(B) Breast examinations and mammography.
``(C) Maternity care, including pre-natal care, delivery,
and post-natal care.
``(D) Menopause.''.
(b) Contracts for Women's Health Services.--Section 1703(a) of such
title is amended by adding at the end the following:
``(9) Women's health services for veterans on an ambulatory
or outpatient basis.''.
(c) Repeal of Superseded Authority.--Section 106 of the Veterans
Health Care Act of 1992 (Public Law 102-585; 38 U.S.C. 1710 note) is
amended--
(1) by striking out subsection (a); and
(2) by striking out ``(b) Responsibilities of Directors of
Facilities.--'' before ``The Secretary''.
(d) Report on Health Care and Research.--Section 107(b) of such Act
(38 U.S.C. 1710 note) is amended--
(1) in paragraph (1), by inserting ``and women's health
services (as such term is defined in section 1701(10) of title
38, United States Code)'' after ``section 106 of this Act'';
(2) in paragraph (2), by striking out ``and (B)'' and
inserting in lieu thereof ``(B) the type and amount of services
provided by such personnel, including information on the
numbers of inpatient stays and the number of outpatient visits
through which such services were provided, and (C)'';
(3) by redesignating paragraph (4) as paragraph (7);
(4) by adding after paragraph (3) the following new
paragraphs:
``(4) A description of the personnel of the Department who
provided such services to women veterans, including the number
of employees (including both the number of individual employees
and the number of full-time employee equivalents) and the
professional qualifications or specialty training of such
employees and the Department facilities to which such personnel
were assigned.
``(5) A description of any actions taken by the Secretary
to ensure the retention of the personnel described in paragraph
(4), and any actions undertaken to recruit additional such
personnel or personnel to replace such personnel.
``(6) An assessment by the Secretary of any difficulties
experienced by the Secretary in the furnishing of such services
and the actions taken by the Secretary to resolve such
difficulties.''; and
(5) by adding after paragraph (7), as redesignated by
paragraph (3) of this subsection, the following:
``(8) A description of the actions taken by the Secretary
to foster and encourage the expansion of such research.''.
SEC. 105. EXPANSION OF RESEARCH RELATING TO WOMEN VETERANS.
(a) Health Research.--Section 109(a) of the Veterans Health Care
Act of 1992 (Public Law 102-585; 38 U.S.C. 7303 note) is amended--
(1) by inserting ``(1)'' before ``The Secretary'';
(2) in paragraph (1), as so designated, by striking out
``veterans who are women'' and inserting in lieu thereof
``women veterans''; and
(3) by adding at the end the following:
``(2) In carrying out this section, the Secretary shall consult
with the following:
``(A) The Director of the Nursing Service.
``(B) Officials of the Central Office assigned
responsibility for women's health programs and sexual trauma
services.
``(C) The members of the Advisory Committee on Women
Veterans established under section 542 of title 38, United
States Code.
``(D) Members of appropriate task forces and working groups
within the Department of Veterans Affairs (including the Women
Veterans Working Group and the Task Force on Treatment of Women
Who Suffer Sexual Abuse).
``(3) The Secretary shall foster and encourage research under this
section on the following matters as they relate to women:
``(A) Breast cancer.
``(B) Gynecological and reproductive health, including
gynecological cancer, infertility, sexually-transmitted
diseases, and pregnancy.
``(C) Human Immunodeficiency Virus and Acquired Immune
Deficiency Syndrome.
``(D) Mental health, including post-traumatic stress
disorder and depression.
``(E) Diseases related to aging, including menopause,
osteoporosis, and Alzheimer's Disease.
``(F) Substance abuse.
``(G) Sexual violence and related trauma.
``(H) Exposure to toxic chemicals and other environmental
hazards.
``(4) The Secretary shall, to the maximum extent practicable,
ensure that personnel of the Department of Veterans Affairs engaged in
the research referred to in paragraph (1) include the following:
``(A) Personnel of the geriatric research, education, and
clinical centers designated pursuant to section 7314 of title
38, United States Code.
``(B) Personnel of the National Center for Post-Traumatic
Stress Disorder established pursuant to section 110(c) of the
Veterans Health Care Act of 1984 (Public Law 98-528; 98 Stat.
2692).
``(5) The Secretary shall, to the maximum extent practicable,
ensure that personnel of the Department engaged in research relating to
the health of women veterans are advised and informed of such research
engaged in by other personnel of the Department.''.
(b) Population Study.--Section 110(a) of such Act (38 U.S.C. 1710
note) is amended--
(1) in paragraph (1), by striking out the second sentence;
and
(2) by amending paragraph (3) to read as follows:
``(3)(A) Subject to subparagraph (B), the study shall be based on--
``(i) an appropriate sample of veterans who are women and
of women who are serving on active military, naval, or air
service; and
``(ii) an examination of the medical and demographic
histories of the women comprising such sample.
``(B) The sample referred to in subparagraph (A) shall, to the
maximum extent practicable, constitute a representative sampling (as
determined by the Secretary) of the ages, the ethnic, social and
economic backgrounds, the enlisted and officer grades, and the branches
of service of all veterans who are women and women who are serving on
such duty.
``(C) In carrying out the examination referred to in subparagraph
(A)(ii), the Secretary shall determine the number of women of the
sample who have used medical facilities of the Department, nursing home
facilities of or under the jurisdiction of the Department, and
outpatient care facilities of or under the jurisdiction of the
Department.''.
SEC. 106. MAMMOGRAPHY QUALITY STANDARDS.
(a) Performance of Mammograms.--Mammograms may not be performed at
a Department of Veterans Affairs facility unless that facility is
accredited for that purpose by a private nonprofit organization
designated by the Secretary of Veterans Affairs. The organization
designated by the Secretary under this subsection shall meet the
standards for accrediting bodies established by the Secretary of Health
and Human Services under section 354(e) of the Public Health Service
Act (42 U.S.C. 263b(e)).
(b) Quality Standards.--(1)(A) The Secretary of Veterans Affairs
shall prescribe quality assurance and quality control standards
relating to the performance and interpretation of mammograms and use of
mammogram equipment and facilities by personnel of the Department of
Veterans Affairs. Such standards shall be no less stringent than the
standards prescribed by the Secretary of Health and Human Services
under section 354(f) of the Public Health Service Act.
(B) In prescribing such standards, the Secretary of Veterans
Affairs shall consult with the Secretary of Health and Human Services.
(2) The Secretary of Veterans Affairs shall prescribe such
standards not later than 120 days after the Secretary of Health and
Human Services prescribes quality standards under such section 354(f).
(c) Inspection of Department Equipment.--(1) The Secretary of
Veterans Affairs shall, on an annual basis, inspect the equipment and
facilities utilized by and in Department of Veterans Affairs health-
care facilities for the performance of mammograms in order to ensure
the compliance of such equipment and facilities with the standards
prescribed under subsection (b). Such inspection shall be carried out
in a manner consistent with the inspection of certified facilities by
the Secretary of Health and Human Services under section 354(g) of the
Public Health Services Act.
(2) The Secretary of Veterans Affairs may not delegate the
responsibility of such secretary under paragraph (1) to a State agency.
(d) Application of Standards to Contract Providers.--The Secretary
of Veterans Affairs shall ensure that mammograms performed for the
Department of Veterans Affairs under contract with any non-Department
facility or provider conform to the quality standards prescribed by the
Secretary of Health and Human Services under section 354 of the Public
Health Service Act.
(e) Report.--(1) The Secretary shall submit to the Committees on
Veterans' Affairs of the Senate and House of Representatives a report
on the quality standards prescribed by the Secretary under subsection
(b)(1).
(2) The Secretary shall submit the report not later than 180 days
after the date on which the Secretary prescribes such regulations.
(f) Definition.--In this section, the term ``mammogram'' shall have
the meaning given such term in section 354(a)(5) of the Public Health
Service Act (42 U.S.C. 263b(a)).
TITLE II--GENERAL HEALTH CARE SERVICES
SEC. 201. EXTENSION OF PERIOD OF ELIGIBILITY FOR MEDICAL CARE FOR
EXPOSURE TO DIOXIN OR IONIZING RADIATION.
Section 1710(e)(3) of title 38, United States Code, is amended by
striking out ``June 30, 1994'' and inserting in lieu thereof ``December
31, 2003''.
SEC. 202. EXTENSION OF PERIOD OF ELIGIBILITY FOR PRIORITY HEALTH CARE
FOR VETERANS OF THE PERSIAN GULF WAR.
(a) Inpatient Care.--Section 1710(e)(3) of title 38, United States
Code, is amended by striking out ``after December 31, 1994'' and
inserting in lieu thereof ``after September 30, 2003''.
(b) Outpatient Care.--Section 1712(a)(1)(D) of such title is
amended by striking out ``before December 31, 1994'' and inserting in
lieu thereof ``before October 1, 2003''.
SEC. 203. PROGRAMS FOR FURNISHING HOSPICE CARE TO VETERANS.
(a) Establishment of Programs.--Chapter 17 of title 38, United
States Code, is amended by adding at the end the following:
``subchapter vii--hospice care pilot program; hospice care services
``Sec. 1761. Definitions
``For the purposes of this subchapter--
``(1) The term `terminally ill veteran' means any veteran--
``(A) who is (i) entitled to receive hospital care
in a medical facility of the Department under section
1710(a)(1) of this title, (ii) eligible for hospital or
nursing home care in such a facility and receiving such
care, (iii) receiving care in a State home facility for
which care the Secretary is paying per diem under
section 1741 of this title, or (iv) transferred to a
non-Department nursing home for nursing home care under
section 1720 of this title and receiving such care; and
``(B) who has a medical prognosis (as certified by
a Department physician) of a life expectancy of six
months or less.
``(2) The term `hospice care services' means (A) the care,
items, and services referred to in subparagraphs (A) through
(H) of section 1861(dd)(1) of the Social Security Act (42
U.S.C. 1395x(dd)(1)), and (B) personal care services.
``(3) The term `hospice program' means any program that
satisfies the requirements of section 1861(dd)(2) of the Social
Security Act (42 U.S.C. 1395x(dd)(2)).
``(4) The term `medical facility of the Department' means a
facility referred to in section 1701(4)(A) of this title.
``(5) The term `non-Department facility' means a facility
(other than a medical facility of the Department) at which care
to terminally ill veterans is furnished, regardless of whether
such care is furnished pursuant to a contract, agreement, or
other arrangement referred to in section 1762(b)(1)(D) of this
title.
``(6) The term `personal care services' means any care or
service furnished to a person that is necessary to maintain a
person's health and safety within the home or nursing home of
the person, including care or services related to dressing and
personal hygiene, feeding and nutrition, and environmental
support.
``Sec. 1762. Hospice care: pilot program requirements
``(a)(1) During the period beginning on October 1, 1993, and ending
on December 31, 1998, the Secretary shall conduct a pilot program in
order--
``(A) to assess the feasibility and desirability of
furnishing hospice care services to terminally ill veterans;
and
``(B) to determine the most efficient and effective means
of furnishing such services to such veterans.
``(2) The Secretary shall conduct the pilot program in accordance
with this section.
``(b)(1) Under the pilot program, the Secretary shall--
``(A) designate not less than 15 nor more than 30 medical
facilities of the Department at or through which to conduct
hospice care services demonstration projects;
``(B) designate the means by which hospice care services
shall be provided to terminally ill veterans under each
demonstration project pursuant to subsection (c);
``(C) allocate such personnel and other resources of the
Department as the Secretary considers necessary to ensure that
services are provided to terminally ill veterans by the
designated means under each demonstration project; and
``(D) enter into any contract, agreement, or other
arrangement that the Secretary considers necessary to ensure
the provision of such services by the designated means under
each such project.
``(2) In carrying out the responsibilities referred to in paragraph
(1) the Secretary shall take into account the need to provide for and
conduct the demonstration projects so as to provide the Secretary with
such information as is necessary for the Secretary to evaluate and
assess the furnishing of hospice care services to terminally ill
veterans by a variety of means and in a variety of circumstances.
``(3) In carrying out the requirement described in paragraph (2),
the Secretary shall ensure, to the maximum extent feasible, that--
``(A) the medical facilities of the Department selected to
conduct demonstration projects under the pilot program include
facilities located in urban areas of the United States and
rural areas of the United States;
``(B) the full range of affiliations between medical
facilities of the Department and medical schools is represented
by the facilities selected to conduct demonstration projects
under the pilot program, including no affiliation, minimal
affiliation, and extensive affiliation;
``(C) such facilities vary in the number of beds that they
operate and maintain; and
``(D) the demonstration projects are located or conducted
in accordance with any other criteria or standards that the
Secretary considers relevant or necessary to furnish and to
evaluate and assess fully the furnishing of hospice care
services to terminally ill veterans.
``(c)(1) Subject to paragraph (2), hospice care to terminally ill
veterans shall be furnished under a demonstration project by one or
more of the following means designated by the Secretary:
``(A) By the personnel of a medical facility of the
Department providing hospice care services pursuant to a
hospice program established by the Secretary at that facility.
``(B) By a hospice program providing hospice care services
under a contract with that program and pursuant to which
contract any necessary inpatient services are provided at a
medical facility of the Department.
``(C) By a hospice program providing hospice care services
under a contract with that program and pursuant to which
contract any necessary inpatient services are provided at a
non-Department medical facility.
``(2)(A) The Secretary shall provide that--
``(i) care is furnished by the means described in paragraph
(1)(A) at not less than five medical facilities of the
Department; and
``(ii) care is furnished by the means described in
subparagraphs (B) and (C) of paragraph (1) in connection with
not less than five such facilities for each such means.
``(B) The Secretary shall provide in any contract under
subparagraph (B) or (C) of paragraph (1) that inpatient care may be
provided to terminally ill veterans at a medical facility other than
that designated in the contract if the provision of such care at such
other facility is necessary under the circumstances.
``(d)(1) Except as provided in paragraph (2), the amount paid to a
hospice program for care furnished pursuant to subparagraph (B) or (C)
of subsection (c)(1) may not exceed the amount that would be paid to
that program for such care under section 1814(i) of the Social Security
Act (42 U.S.C. 1395f(i)) if such care were hospice care for which
payment would be made under part A of title XVIII of such Act.
``(2) The Secretary may pay an amount in excess of the amount
referred to in paragraph (1) (or furnish services whose value, together
with any payment by the Secretary, exceeds such amount) to a hospice
program for furnishing care to a terminally ill veteran pursuant to
subparagraph (B) or (C) of subsection (c)(1) if the Secretary
determines, on a case-by-case basis, that--
``(A) the furnishing of such care to the veteran is
necessary and appropriate; and
``(B) the amount that would be paid to that program under
section 1814(i) of the Social Security Act would not compensate
the program for the cost of furnishing such care.
``Sec. 1763. Care for terminally ill veterans
``(a) During the period referred to in section 1762(a)(1) of this
title, the Secretary shall designate not less than 10 medical
facilities of the Department at which hospital care is being furnished
to terminally ill veterans to furnish the care referred to in
subsection (b)(1).
``(b)(1) Palliative care to terminally ill veterans shall be
furnished at the facilities referred to in subsection (a) by one of the
following means designated by the Secretary:
``(A) By personnel of the Department providing one or more
hospice care services to such veterans at or through medical
facilities of the Department.
``(B) By personnel of the Department monitoring the
furnishing of one or more of such services to such veterans at
or through non-Department facilities.
``(2) The Secretary shall furnish care by the means referred to in
each of subparagraphs (A) and (B) of paragraph (1) at not less than
five medical facilities designated under subsection (a).
``Sec. 1764. Information relating to hospice care services
``The Secretary shall ensure to the extent practicable that
terminally ill veterans who have been informed of their medical
prognosis receive information relating to the eligibility, if any, of
such veterans for hospice care and services under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.).
``Sec. 1765. Evaluation and reports
``(a) Not later than September 30, 1994, and on an annual basis
thereafter until October 1, 1999, the Secretary shall submit a written
report to the Committees on Veterans' Affairs of the Senate and House
of Representatives relating to the conduct of the pilot program under
section 1762 of this title and the furnishing of hospice care services
under section 1763 of this title. Each report shall include the
following information:
``(1) The location of the sites of the demonstration
projects provided for under the pilot program.
``(2) The location of the medical facilities of the
Department at or through which hospice care services are being
furnished under section 1763 of this title.
``(3) The means by which care to terminally ill veterans is
being furnished under each such project and at or through each
such facility.
``(4) The number of veterans being furnished such care
under each such project and at or through each such facility.
``(5) An assessment by the Secretary of any difficulties in
furnishing such care and the actions taken to resolve such
difficulties.
``(b) Not later than August 1, 1997, the Secretary shall submit to
the committees referred to in subsection (a) a report containing an
evaluation and assessment by the Director of the Health Services
Research and Development Service of the hospice care pilot program
under section 1762 of this title and the furnishing of hospice care
services under section 1763 of this title. The report shall contain
such information (and shall be presented in such form) as will enable
the committees to evaluate fully the feasibility and desirability of
furnishing hospice care services to terminally ill veterans.
``(c) The report shall include the following:
``(1) A description and summary of the pilot program.
``(2) With respect to each demonstration project conducted
under the pilot program--
``(A) a description and summary of the project;
``(B) a description of the facility conducting the
demonstration project and a discussion of how such
facility was selected in accordance with the criteria
set out in, or prescribed by the Secretary pursuant to,
subparagraphs (A) through (D) of section 1762(b)(3) of
this title;
``(C) the means by which hospice care services care
are being furnished to terminally ill veterans under
the demonstration project;
``(D) the personnel used to furnish such services
under the demonstration project;
``(E) a detailed factual analysis with respect to
the furnishing of such services, including (i) the
number of veterans being furnished such services, (ii)
the number, if any, of inpatient admissions for each
veteran being furnished such services and the length of
stay for each such admission, (iii) the number, if any,
of outpatient visits for each such veteran, and (iv)
the number, if any, of home-care visits provided to
each such veteran;
``(F) the direct costs, if any, incurred by
terminally ill veterans, the members of the families of
such veterans, and other individuals in close
relationships with such veterans in connection with the
participation of veterans in the demonstration project;
``(G) the costs incurred by the Department in
conducting the demonstration project, including an
analysis of the costs, if any, of the demonstration
project that are attributable to (i) furnishing such
services in facilities of the Department, (ii)
furnishing such services in non-Department facilities,
and (iii) administering the furnishing of such
services; and
``(H) the unreimbursed costs, if any, incurred by
any other entity in furnishing services to terminally
ill veterans under the project pursuant to section
1762(c)(1)(C) of this title.
``(3) An analysis of the level of the following persons'
satisfaction with the services furnished to terminally ill
veterans under each demonstration project:
``(A) Terminally ill veterans who receive such
services, members of the families of such veterans, and
other individuals in close relationships with such
veterans.
``(B) Personnel of the Department responsible for
furnishing such services under the project.
``(C) Personnel of non-Department facilities
responsible for furnishing such services under the
project.
``(4) A description and summary of the means of furnishing
hospice care services at or through each medical facility of
the Department designated under section 1763(a)(1) of this
title.
``(5) With respect to each such means, the information
referred to in paragraphs (2) and (3).
``(6) A comparative analysis by the Director of the
services furnished to terminally ill veterans under the various
demonstration projects referred to in section 1762 of this
title and at or through the designated facilities referred to
in section 1763 of this title, with an emphasis in such
analysis on a comparison relating to--
``(A) the management of pain and health symptoms of
terminally ill veterans by such projects and
facilities;
``(B) the number of inpatient admissions of such
veterans and the length of inpatient stays for such
admissions under such projects and facilities;
``(C) the number and type of medical procedures
employed with respect to such veterans by such projects
and facilities; and
``(D) the effectiveness of such projects and
facilities in providing care to such veterans at the
homes of such veterans or in nursing homes.
``(7) An assessment by the Director of the feasibility and
desirability of furnishing hospice care services by various
means to terminally ill veterans, including an assessment by
the Director of the optimal means of furnishing such services
to such veterans.
``(8) Any recommendations for additional legislation
regarding the furnishing of care to terminally ill veterans
that the Secretary considers appropriate.''.
(b) Clerical Amendment.--The table of sections at the beginning of
such chapter is amended by adding at the end the following:
``subchapter vii--hospice care pilot program; hospice care services
``1761. Definitions.
``1762. Hospice care: pilot program requirements.
``1763. Care for terminally ill veterans.
``1764. Information relating to hospice care services.
``1765. Evaluation and reports.''.
(c) Authority To Carry Out Other Hospice Care Programs.--The
amendments made by subsection (a) may not be construed as terminating
the authority of the Secretary of Veterans Affairs to provide hospice
care services to terminally ill veterans under any program in addition
to the programs required under the provisions added by such amendments.
(d) Authorization of Appropriations.--Funds are authorized to be
appropriated for the Department of Veterans Affairs for the purposes of
carrying out the evaluation of the hopice care pilot programs under
section 1765 of title 38, United States Code (as added by subsection
(a)), as follows:
(1) For fiscal year 1994, $1,200,000.
(2) For fiscal year 1995, $2,500,000.
(3) For fiscal year 1996, $2,200,000.
(4) For fiscal year 1997, $100,000.
SEC. 204. RURAL HEALTH-CARE CLINIC PROGRAM.
(a) Program.--(1) Chapter 17 of title 38, United States Code, is
amended by adding at the end of subchapter II the following:
``Sec. 1720E. Rural health-care clinics: pilot program
``(a) During the three-year period beginning on October 1, 1993,
the Secretary shall conduct a rural health-care clinic program in
States where significant numbers of veterans reside in areas
geographically remote from existing health-care facilities (as
determined by the Secretary). The Secretary shall conduct the program
in accordance with this section.
``(b)(1) In carrying out the rural health-care clinic program, the
Secretary shall furnish medical services to the veterans described in
subsection (c) through use of--
``(A) mobile health-care clinics equipped, operated, and
maintained by personnel of the Department; and
``(B) other types of rural clinics, including part-time
stationary clinics for which the Secretary contracts and part-
time stationary clinics operated by personnel of the
Department.
``(2) The Secretary shall furnish services under the rural health-
care clinic program in areas--
``(A) that are more than 100 miles from a Department
general health-care facility; and
``(B) that are less than 100 miles from such a facility, if
the Secretary determines that the furnishing of such services
in such areas is appropriate.
``(c) A veteran eligible to receive medical services through rural
health-care clinics under the program is any veteran eligible for
medical services under section 1712 of this title.
``(d) The Secretary shall commence operation of at least three
rural health-care clinics (at least one of which shall be a mobile
health-care clinic) in each fiscal year of the program. The Secretary
may not operate more than one mobile health-care clinic under the
authority of this section in any State in any such fiscal year.
``(e) Not later than 120 days after the date of the enactment of
this Act, the Secretary shall submit to Congress a report on the
Secretary's plans for the implementation of the pilot program required
under this section.
``(f) Not later than December 31, 1997, the Secretary shall submit
to Congress a report containing an evaluation of the program. The
report shall include the following:
``(1) A description of the program, including information
with respect to--
``(A) the number and type of rural health-care
clinics operated under the program;
``(B) the States in which such clinics were
operated;
``(C) the medical services furnished under the
program, including a detailed specification of the cost
of such services;
``(D) the veterans who were furnished services
under the program, setting forth (i) the numbers and
percentages of the veterans who had service-connected
disabilities, (ii) of the veterans having such
disabilities, the numbers and percentages who were
furnished care for such disabilities, (iii) the ages of
the veterans, (iv) taking into account the veterans'
past use of Department health-care facilities, an
analysis of the extent to which the veterans would have
received medical services from the Department outside
the program and the types of services they would have
received, and (v) the financial circumstances of the
veterans; and
``(E) the types of personnel who furnished services
to veterans under the program, including any
difficulties in the recruitment or retention of such
personnel.
``(2) An assessment by the Secretary of the cost-
effectiveness and efficiency of furnishing medical services to
veterans through various types of rural clinics (including
mobile health-care clinics operated under the pilot program
conducted pursuant to section 113 of the Veterans' Benefits and
Services Act of 1988 (Public Law 100-322; 38 U.S.C. 1712
note)).
``(3) Any plans for administrative action, and any
recommendations for legislation, that the Secretary considers
appropriate.
``(g) For the purposes of this section, the term `Department
general health-care facility' has the meaning given such term in
section 1712A(i)(2) of this title.''.
(2) The table of sections at the beginning of such chapter is
amended by inserting after the item relating to section 1720D the
following new item:
``1720E. Rural health-care clinics: pilot program.''.
(b) Authorization of Appropriations.--(1) There is authorized to be
appropriated for the Department of Veterans Affairs to carry out the
rural health-care clinics program provided for in section 1720E of
title 38, United States Code (as added by subsection (a)), the
following:
(A) For fiscal year 1994, $3,000,000.
(B) For fiscal year 1995, $6,000,000.
(C) For fiscal year 1996, $9,000,000.
(2) Amounts appropriated pursuant to such authorization may not be
used for any other purpose.
(3) No funds may be expended to carry out the rural health-care
clinics program provided for in such section 1720E unless expressly
provided for in an appropriations Act.
SEC. 205. PAYMENT TO STATES OF PER DIEM FOR VETERANS RECEIVING ADULT
DAY HEALTH CARE.
(a) Payment of Per Diem for Veterans Receiving Adult Day Care.--
Section 1741 of title 38, United States Code, is amended--
(1) by inserting ``(1)'' after ``(a)'';
(2) by redesignating paragraphs (1) and (2) as
subparagraphs (A) and (B), respectively; and
(3) by adding at the end the following new paragraph (2):
``(2) The Secretary may pay each State per diem at a rate
determined by the Secretary for each veteran receiving adult day health
care in a State home, if such veteran is eligible for such care under
laws administered by the Secretary.''.
(b) Assistance to States for Construction of Adult Day Care
Facilities.--(1) Section 8131(3) of title 38, United States Code, is
amended by inserting ``adult day health,'' before ``or hospital care''.
(2) Section 8132 of such title is amended by inserting ``adult day
health,'' before ``or hospital care''.
(3) Section 8135(b) of such title is amended--
(A) in paragraph (2)(C), by inserting ``or adult day health
care facilities'' after ``domiciliary beds''; and
(B) in paragraph (3)(A), by inserting ``or construction
(other than new construction) of adult day health care
buildings'' before the semicolon.
SEC. 206. REVISION OF AUTHORITY ON USE OF TOBACCO PRODUCTS IN
DEPARTMENT FACILITIES.
Section 526(a) of the Veterans Health Care Act of 1992 (Public Law
102-585; 38 U.S.C. 1715 note) is amended--
(1) in paragraph (1), by striking out ``establishes and
maintains--'' and inserting in lieu thereof ``may establish and
maintain--''; and
(2) in paragraph (2), by striking out ``provides access''
and all that follows through ``paragraph (1)'' and inserting in
lieu thereof ``if such an area is established, provides access
to the area''.
TITLE III--MISCELLANEOUS
Subtitle A--Education Debt Reduction Program
SEC. 301. SHORT TITLE.
This subtitle may be cited as the ``Department of Veterans Affairs
Health Professionals Education Debt Reduction Act''.
SEC. 302. PROGRAM OF ASSISTANCE IN THE PAYMENT OF EDUCATION DEBTS
INCURRED BY CERTAIN VETERANS HEALTH ADMINISTRATION
EMPLOYEES.
(a) Program.--(1) Chapter 76 of title 38, United States Code, is
amended by adding at the end the following:
``SUBCHAPTER VI--EDUCATION DEBT REDUCTION PROGRAM
``Sec. 7661. Authority for program
``(a) The Secretary shall carry out an education debt reduction
program under this subchapter. The program shall be known as the
Department of Veterans Affairs Education Debt Reduction Program
(hereafter in this chapter referred to as the `Education Debt Reduction
Program'). The purpose of the program is to assist personnel serving in
health-care positions in the Veterans Health Administration in reducing
the amount of debt incurred by such personnel in completing educational
programs that qualify such personnel for such service.
``(b)(1) Subject to paragraph (2), assistance under the Education
Debt Reduction Program shall be in addition to the assistance available
to individuals under the Educational Assistance Program established
under this chapter.
``(2) An individual may not receive assistance under both the
Education Debt Reduction Program and the Educational Assistance Program
for the same period of service in the Department.
``Sec. 7662. Eligibility; application
``(a) An individual eligible to participate in the Education Debt
Reduction Program is any individual (other than a physician or dentist)
who--
``(1) serves in a position in the Veterans Health
Administration under an appointment under section 7402(b) of
this title;
``(2) serves in an occupation, specialty, or geographic
area for which the recruitment or retention of an adequate
supply of qualified health-care personnel is especially
difficult (as determined by the Secretary);
``(3) has pursued or is pursuing, as the case may be--
``(A) a two-year or four-year course of education
or training at a qualifying undergraduate institution
which course qualified or will qualify, as the case may
be, the individual for appointment in a position
referred to in paragraph (1); or
``(B) a course of education at a qualifying
graduate institution which course qualified or will
qualify, as the case may be, the individual for
appointment in such a position; and
``(4) owes any amount of principal or interest under a loan
or other obligation the proceeds of which were used or are
being used, as the case may be, by or on behalf of the
individual to pay tuition or other costs incurred by the
individual in the pursuit of a course of education or training
referred to in paragraph (3).
``(b) Any eligible individual seeking to participate in the
Education Debt Reduction Program shall submit an application to the
Secretary relating to such participation.
``Sec. 7663. Agreement
``(a) The Secretary shall enter into an agreement with each
individual selected to participate in the Education Debt Reduction
Program. The Secretary and the individual shall enter into such an
agreement at the beginning of each year for which the individual is
selected to so participate.
``(b) An agreement between the Secretary and an individual selected
to participate in the Education Debt Reduction Program shall be in
writing, shall be signed by the individual, and shall include the
following provisions:
``(1) The Secretary's agreement to provide assistance on
behalf of the individual under the program upon the completion
by the individual of a one-year period of service in a position
referred to in section 7662(a) of this title which period
begins on the date of the signing of the agreement (or such
later date as is jointly agreed upon by the Secretary and the
individual).
``(2) The individual's agreement that the Secretary shall
pay any assistance provided under the program to the holder (as
designated by the individual) of any loan or other obligation
of the individual referred to in section 7662(a)(4) of this
title in order to reduce or satisfy the unpaid balance
(including principal and interest) due on such loan or other
obligation.
``(3) The individual's agreement that assistance shall not
be paid on behalf of the individual under the program for a
year unless and until the individual completes the one-year
period of service referred to in paragraph (1).
``(4) The individual's agreement that assistance shall not
be paid on behalf of the individual under the program for a
year unless the individual maintains (as determined by the
Secretary) an acceptable level of performance during the
service referred to in paragraph (3).
``Sec. 7664. Amount of assistance
``(a) Subject to subsection (b), the amount of assistance provided
to an individual under the Education Debt Reduction Program for a year
may not exceed $4,000 (adjusted in accordance with section 7631 of this
title).
``(b) The total amount of assistance received by an individual
under the Education Debt Reduction Program may not exceed $12,000 (as
so adjusted).''.
(2) The table of sections at the beginning of such chapter is
amended by adding at the end the following:
``SUBCHAPTER VI--EDUCATION DEBT REDUCTION PROGRAM
``7661. Authority for program.
``7662. Eligibility; application.
``7663. Agreement.
``7664. Amount of assistance.''.
(b) Conforming Amendments.--Section 7631 of title 38, United States
Code, is amended--
(1) in subsection (a), by striking out ``and the maximum
Selected Reserve member stipend amount'' and inserting in lieu
thereof ``the maximum Selected Reserve stipend amount, and the
education debt reduction amount and limitation''; and
(2) in subsection (b)--
(A) by redesignating paragraph (4) as paragraph
(5); and
(B) by inserting after paragraph (3) the following
new paragraph (4):
``(4) The term `education debt reduction amount and
limitation' means the maximum amount of assistance, and the
limitation applicable to such assistance, for a person
receiving assistance under subchapter VI of this chapter, as
specified in section 7663 of this title and as previously
adjusted (if at all) in accordance with this subsection.''.
(c) Regulations.--The Secretary of Veterans Affairs shall prescribe
regulations necessary to carry out the Education Debt Reduction Program
established under subchapter VI of chapter 76 of title 38, United
States Code (as added by subsection (a)). The Secretary shall prescribe
such regulations not later than 90 days after the date of the enactment
of this Act.
(d) Report.--Section 7632 of title 38, United States Code, is
amended--
(1) in the matter above paragraph (1), by inserting ``and
the Education Debt Reduction Program'' before the period at the
end;
(2) in paragraph (1)--
(A) by inserting ``and the Education Debt Reduction
Program'' after ``Educational Assistance Program'';
(B) by striking out ``Program and'' and inserting
in lieu thereof ``Program,''; and
(C) by inserting ``, and the Education Debt
Reduction Program'' before ``separately'';
(3) in paragraph (3), by striking out ``the Educational
Assistance Program (or predecessor program) has'' and inserting
in lieu thereof ``each of the Educational Assistance Program
(or predecessor program) and the Education Debt Reduction
Program have'';
(4) in paragraph (4)--
(A) by striking out ``and per'' and inserting in
lieu thereof ``, per''; and
(B) by inserting ``, and per participant in the
Education Debt Reduction Program'' before the period at
the end.
(e) Authorization of Appropriations.--(1) There is authorized to be
appropriated for the Department of Veterans Affairs $10,000,000 for
each of fiscal years 1994 through 1998 to carry out the Education Debt
Reduction Program.
(2) No funds may be used to provide assistance under the program
unless expressly provided for in an appropriations Act.
(f) Exemption From Limitation.--Section 523(b) of the Veterans
Health Care Act of 1992 (Public Law 102-585; 38 U.S.C. 7601 note) shall
not apply to the Education Debt Reduction Program.
Subtitle B--Other Provisions
SEC. 311. EXTENSION OF AUTHORITY OF ADVISORY COMMITTEE ON EDUCATION.
Section 3692(c) of title 38, United States Code, is amended by
striking out ``December 31, 1994'' and inserting in lieu thereof
``December 31, 1997''.
SEC. 312. EXTENSION OF AUTHORITY TO MAINTAIN REGIONAL OFFICE IN THE
PHILIPPINES.
Section 315(b) of title 38, United States Code, is amended by
striking out ``December 31, 1994'' and inserting in lieu thereof
``September 30, 1995''.
Passed the Senate July 26 (legislative day, July 20), 1994.
Attest:
MARTHA S. POPE,
Secretary.
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