clinics, including mobile clinics, as current leases for these facilities expire. Finally, based on concerns raised by VA, the veterans service organizations, and RCS field staff that full-scale health clinics operating in Vet Centers would be costly and difficult to administer, as well as threaten Vet Centers' traditional mission, the health care pilot program outlined in section 7 of the bill as introduced was reduced in scope. Section 7 originally called for VA to assign between 1/2 FTEE and 3 FTEE to provide health care services at between 12 and 15 Vet Centers. The revised section (section 8 of the Committee bill) calls for basic ambulatory care and screening services to be provided by at least 1/2 FTEE at a minimum of 10 sites. The Committee believes that the revised pilot program, though reduced in size, will yield valuable information concerning the feasibility of operating health clinics in Vet Center settings and will encourage VA to expand the program to other Vet Centers, if appropriate. 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 (CBO), estimates that the costs resulting from the enactment of the Committee bill (as compared to costs under current law), as scored against the current CBO baseline during the remainder of fiscal year 1994 and for the first four full years following the year of enactment, would increase the federal budget by $7 million. The cost estimate provided by CBO follows: U.S. CONGRESS, CONGRESSIONAL BUDGET OFFICE, Hon. JOHN D. ROCKEFELLER IV, DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for S. 1226, the Readjustment Counseling Service Amendments of 1993, as amended and ordered reported by the Senate Committee on Veterans' Affairs, November 3, 1993. Enactment of S. 1226 would not affect direct spending or receipts. Therefore, pay-as-you-go procedures would not apply to the bill. If you wish further details on this estimate, we will be pleased to provide them. Sincerely, ROBERT D. REISCHAUER, Director. CONGRESSIONAL BUDGET OFFICE COST ESTIMATE 1. Bill number: S. 1226 2. Bill title: The Readjustment Counseling Service Amendments of 1993. 3. Bill status: As amended and ordered reported by the Senate Committee on Veterans' Affairs, November 3, 1993. 4. Bill purpose: To expand eligibility for readjustment counseling, to authorize the Department of Veterans Affairs (VA) to provide outpatient medical care in readjustment counseling centers (Vet Centers), and for other purposes. 5. Estimated cost to the Federal Government: Basis of estimate: The following section by section cost analysis addresses only those sections of the bill that could be expected to result in a significant budgetary impact. The estimate assumes that all authorized amounts would be fully appropriated and that outlays of these funds would occur at historical spending rates. Section 4: This section would expand eligibility for readjustment counseling to any veterans who served in combat. It would also authorize the VA to provide bereavement counseling to the survivors of veterans killed in combat or dying from service-connected causes. Under current law, all veterans with combat service after August 1, 1964, are eligible for counseling. The number of World War II and Korean Conflict veterans who would seek counseling is expected to be negligible. The survivors of veterans who die while under treatment at VA expense are eligible for bereavement counseling under current law. Few eligible survivors request such counseling. Because the survivors who would be made eligible by this provision would not have an ongoing relationship with VA at the time of the veteran's death, it is expected that the new eligibles would participate in even smaller numbers than current eligibles. Therefore, the number of survivors seeking bereavement counseling would be too small to increase costs significantly. Section 8. This section would require VA to conduct a pilot program to provide outpatient medical care services in Vet Centers. The pilot program would be conducted in at least 10 Vet Centers for not less than 20 hours per week per center. The program would have to begin within 4 months of enactment of S. 1226 and would run for two years from the date of implementation. This estimate assumes that VA could meet the implementation schedule required by the bill. Assuming an enactment date of January 1, 1994, the schedule would require that the pilot program operate for 5 months in 1994, 12 months in 1995, and 7 months in 1996. The cost estimate is based on data from VA on the cost of providing certain ambulatory services-primarily diagnostic and screening services-in 10 Vet Centers for 20 hours per week. The estimate does not include the cost of any increase in VA inpatient care that could result from medical conditions diagnosed in Vet Centers, because data on the incidence of serious disease for this population is not available. 6. Pay-as-you-go considerations: The Balanced Budget and Emergency Deficit Control Act of 1985 sets up pay-as-you-go procedures for legislation affecting direct spending or receipts through 1998. S. 1226 would not affect direct spending or receipts. Therefore, this bill has no pay-as-you-go implications. 7. Estimated cost to state and local governments: None. 8. Estimate comparison: None. 9. Previous CBO estimate: None. 10. Estimate prepared by: K. W. Shepherd. 11. Estimate approved by: C. G. Nuckols, 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 which would be incurred in carrying out the Committee bill. The Committee finds that the Committee bill would not entail any significant regulation of the individuals or businesses or result in any significant impact on the personal privacy of any individuals and that the paperwork resulting from enactment would be minimal. TABULATION OF VOTES CAST IN COMMITTEE In compliance with paragraph 7 of Rule XXVI of the Standing Rules of the Senate, the following is a tabulation of votes cast in person or by proxy by members of the Committee on Veterans' Affairs at a November 3, 1993, meeting. On that date, the Committee voted by voice to report S. 1226 favorably to the Senate with an amendment, proposed by Mr. Rockefeller, in the nature of a substitute. AGENCY REPORTS On July 16, 1993, the Committee Chairman asked the Secretary of Veterans Affairs and the Director of the Office of Management and Budget for reports setting forth agency views on S. 1226. The following letter was received from Secretary Brown: THE SECRETARY OF VETERANS AFFAIRS, The Hon. JOHN D. ROCKEFELLER IV, DEAR MR. CHAIRMAN: As you have requested, we are providing you with our views on S. 1226, a bill "to amend title 38, United States Code, to provide for the organization and administration of the Readjustment Counseling Service, to improve eligibility for readjustment counseling and related counseling, and for other purposes." This bill contains a number of different provisions affecting the Readjustment Counseling Service and counseling services. We generally support, in whole or in part, most of the provisions of the bill. However, we are concerned about the requirement that we conduct a pilot program to furnish outpatient care through Vet Centers. Section 2 of the bill is aimed at preserving the existing organizational and administrative structure of the Readjustment Counseling Service. The Department provides readjustment counseling services through unique entities known as Vet Centers. These community-based facilities have been very successful at meeting the needs of Vietnam and post-Vietnam era war zone veterans. Vet Centers work closely with local VA medical centers, but they are administered independently from those centers. This bill seeks to insure the continuance of that independence. The bill would statutorily establish the current organizational and administrative structure of the Readjustment Counseling Service. It would provide that the Secretary may alter that structure only after providing your committee, and its counterpart in the House, with a report regarding any proposed changes. The Department would have to wait at least 60 days after submitting the report before implementing the proposed changes. Finally, the bill would require that each year, the President's budget must specifically state the amount requested for readjustment counseling, including the amount requested to fund the Advisory Committee on Veteran Readjustment Counseling. At this time, the Readjustment Counseling Service is working well under the existing structure, and we have no plans to institute any changes. If at some point in time we determine that the organization does need change, the Department would inform the Congress of the plans, and we would work with the Congress, Veterans Service Organizations, and other interested parties prior to implementing such plans. Further, each year in the President's budget, the Department identifies the amount requested for the Readjustment Counseling Service. It is therefore our view that these provisions of the bill are unnecessary. Section 3 of the bill would elevate the position of the Director of the Readjustment Counseling Service to that of an Assistant Chief Medical Director. It would also establish the qualifications for that position. For all practical purposes, the current Director serves much like an Assistant Chief Medical Director, and we do not oppose that change. Section 4 would make all veterans eligible for readjustment counseling services. The law currently authorizes the Department to provide these services only to Vietnam era veterans, and veterans who served in the Persian Gulf, Lebanon, Panama, and Grenada. The Department supports extending these services to wartime veterans who served in areas of conflict, particularly those who served in World War II and Korea, but we don't believe it would be appropriate to expand the program to all veterans. Since their inception in 1979, the Vet Centers have primarily addressed the needs of veterans who served in war zones. Although all Vietnam Era veterans are eligible for services, most demand has been from those who actually served in Vietnam. Over the years eligibility has been extended to others who served in the Persian Gulf, Panama, Grenada, and Lebanon. The focus of the program on war zone veterans recognizes the special readjustment needs those individuals have, including post-traumatic stress disorder resulting from combat area experiences. That focus has also served to distinguish Vet Centers, and make them unique from other mental health clinics which seek to meet the needs of a much wider population. To extend eligibility for services to all veterans would not only require very significant infusions of resources, but could fundamentally change the nature of Vet Centers and the counseling program. In our view, veterans who served in combat are deserving of the special attention that the Readjustment Counseling Service now provides, and we should not detract from that program by trying to meet the much broader readjustment needs of the entire veteran population. Section 4 would also authorize the Department to provide bereavement counseling in Vet Centers to the families of all veterans who died while on active duty, or who die as a result of a service connected disability. The Department supports a limited bereavement counseling role. Over the years, Gold Star parents, spouses, and children of Vietnam veterans have occasionally come to Vet Centers seeking assistance in resolving psychological issues arising from the loss of a family member killed in action in Vietnam. We believe it would be reasonable to specifically authorize the Department to provide counseling services for next-of-kin of veterans who died in a war zone or as a result of injuries or illness incurred in a war zone. That would be manageable in terms of resources, and would not change the nature of Vet Centers as entities serving the specific needs of those who served in a war area. We cannot, however, support as broad an authority as provided in this bill. Section 5 would statutorily make Vet Center records confidential, and would permit disclosure only with the consent of the veteran, except in very limited circumstances. The bill would authorize disclosure without consent only to medical personnel in a medical emergency, to other VA personnel to avoid imminent danger to the veteran or another, or if a court orders disclosure for good cause shown. Since the inception of the Vet Centers in 1979, in compliance with laws applicable to VA beneficiary records and medical records, the Department has generally followed a policy of releasing Vet Center records only with the consent of the veteran. We continue to support the principle of confidentiality for patient records in the Readjustment Counseling Service. However, we are concerned that without further analysis and specifications, the language of Section 5 might function in some situations in a way that Congress would not intend. We would like to work with committee staff to draft language which would be more appropriate in that it might take account of certain contingencies such as litigation, General Counsel's responsibilities for advising agency personnel, reporting of suspected child abuse, and other similar matters. Section 6 would statutorily establish an Advisory Committee on Readjustment Counseling. In essence, it would provide a statutory basis for the current Advisory Committee on the Readjustment of Vietnam and Other War Veterans. The section would provide that members of the current committee would become members of the new committee. The bill contains many detailed provisions pertaining to the membership on the committee, its operation, and its functions. |