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                                                       Calendar No. 632
110th Congress                                                   Report
                                 SENATE
 2d Session                                                     110-281

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



 
            VETERANS MENTAL HEALTH IMPROVEMENTS ACT OF 2007

                                _______
                                

                 April 8, 2008.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                         [To accompany S. 2162]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (S. 2162), to 
improve the treatment and services provided by the Department 
of Veterans Affairs to veterans with post-traumatic stress 
disorder and substance use disorders, and for other purposes, 
having considered the same, reports favorably thereon with an 
amendment, and recommends that the bill (as amended) do pass.

                              Introduction

    On April 25, 2007, the Committee held an oversight hearing 
on mental health issues. Testimony was offered by: Tony Bailey, 
father of Justin Bailey, accompanied by Mary Kaye Bailey; 
Randall Omvig, father of Joshua Omvig, accompanied by Ellen 
Omvig; Patrick Campbell, Congressional Liaison, Iraq and 
Afghanistan Veterans of America; Connie L. Best, PhD, Senior 
Faculty Member, National Crime Victims Research and Treatment 
Center, Medical University of South Carolina; David Oslin, MD, 
Director, VISN 4 Mental Illness Research Education and Clinical 
Center, Department of Veterans Affairs; Jan Kemp, RN, PhD, 
Associate Director for Education, VISN 19 Mental Illness 
Research Education and Clinical Center, Department of Veterans 
Affairs; Patricia Resick, PhD, Director, Women's Division, 
National Center for Post Traumatic Stress Disorder, Department 
of Veterans Affairs, accompanied by Ira Katz, MD, PhD, Deputy 
Chief Patient Care Services Officer for Mental Health, 
Department of Veterans Affairs; and Ralph Ibson, Vice President 
for Government Relations, Mental Health America.
    On May 23, 2007, the Committee held a hearing on pending 
veterans' health legislation at which testimony was offered by: 
Gerald M. Cross, MD, FAAFP, Acting Principal Deputy Under 
Secretary for Health, Department of Veterans Affairs; Carl 
Blake, National Legislative Director, Paralyzed Veterans of 
America; Dennis M. Cullinan, Director, National Legislative 
Service, Veterans of Foreign Wars of the United States; Joy J. 
Ilem, Assistant National Legislative Director, Disabled 
American Veterans; Shannon Middleton, Deputy Director for 
Health, Veterans Affairs and Rehabilitation Commission, The 
American Legion; Bernard Edelman, Deputy Director for Policy 
and Government Affairs, Vietnam Veterans of America; Jerry 
Reed, Executive Director, Suicide Prevention Action Network USA 
(SPAN USA); John Booss, MD, American Academy of Neurology; and 
Meredith Beck, National Policy Director, Wounded Warrior 
Project.
    On October 15, 2007, following these two hearings, Chairman 
Akaka introduced S. 2162, the proposed ``Veterans Mental Health 
Improvements Act of 2007.'' S. 2162, as introduced, would 
establish peer outreach and peer support for veterans of 
Operation Enduring Freedom and Operation Iraqi Freedom, ensure 
adequate substance use disorder treatments in VA facilities, 
expand research on comorbid post-traumatic stress disorder and 
substance use disorders, and expand services for veterans' 
families. S. 2162 is cosponsored by the Committee's Ranking 
Member Senator Burr, and Senators Ensign, and Mikulski.
    On October 24, 2007, the Committee held a hearing on 
pending veterans' health legislation, including S. 2162, at 
which testimony was offered by, among others: the Honorable 
Michael J. Kussman, MD, MS, MACP, Under Secretary for Health, 
Department of Veterans Affairs, accompanied by Walter Hall, 
Assistant General Counsel, Department of Veterans Affairs; Carl 
Blake, National Legislative Director, Paralyzed Veterans of 
America; Joy J. Ilem, Assistant National Legislative Director, 
Disabled Veterans of America; Brenda Murdough, MSN, RN-C, 
Military/Veterans Initiative Coordinator, American Pain 
Foundation; and Capt. Constance Walker, USN (Ret.), President, 
Southern Maryland Chapter of the National Alliance on Mental 
Illness.

                           Committee Meeting

    After carefully reviewing the testimony from the foregoing 
hearings, the Committee met in open session on November 14, 
2007, to consider, among other legislation, S. 2162. The 
Committee voted unanimously to report favorably S. 2162 with an 
amendment in the nature of a substitute.

                     Summary of S. 2162 as Reported

    S. 2162, as reported, (hereinafter, ``the Committee bill'') 
would make numerous enhancements and expansions to VA mental 
health care and services.

         TITLE I--SUBSTANCE USE DISORDER AND MENTAL HEALTH CARE

    Section 101 would express the sense of Congress on 
substance use disorders (SUD) and mental health.
    Section 102 would require that a minimum set of services 
and treatments for SUD be available to all veterans enrolled in 
the VA health care system who need such services.
    Section 103 would require that veterans receiving care for 
SUD and a comorbid mental health disorder from VA receive such 
care concurrently from professionals with appropriate 
expertise.
    Section 104 would establish national centers of excellence 
on post-traumatic stress disorder (PTSD) and SUD.
    Section 105 would require the Secretary to carry out a 
review of all VA residential mental health care facilities and 
report to Congress on the results of that review.
    Section 106 provides that title I is a tribute to Justin 
Bailey, a veteran of the Iraq war, who died in a VA 
domiciliary.

           TITLE II--MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS

    Section 201 would establish a pilot program of peer 
outreach and support, and on the use of community mental health 
centers, the Indian Health Service and other entities to 
provide mental health services in rural areas.

                          TITLE III--RESEARCH

    Section 301 would establish a research program on comorbid 
PTSD and SUD.
    Section 302 would extend the authorization for the Special 
Committee on Post-Traumatic Stress Disorder.

             TITLE IV--ASSISTANCE FOR FAMILIES OF VETERANS

    Section 401 would clarify and expand the authority of the 
Secretary of Veterans Affairs to provide mental health services 
to families of veterans.
    Section 402 would establish a pilot program for the 
provision of readjustment and transition assistance to veterans 
and their families in cooperation with Readjustment Counseling 
Centers.

                       Background and Discussion

    S. 2162 would establish peer outreach and peer support for 
veterans of Operation Enduring Freedom and Operation Iraqi 
Freedom, ensure adequate substance use disorder treatments in 
VA facilities, expand research on comorbid post-traumatic 
stress disorder and substance use disorders, and expand 
services for veterans' families.
    In testimony before the Committee on October 24, 2007, Carl 
Blake, National Legislative Director, Paralyzed Veterans of 
America (PVA), and Joy J. Ilem, Assistant National Legislative 
Director, Disabled Veterans of America (DAV), indicated that 
the organizations which they represent support the bill in its 
entirety. S. 2162 is also supported by the American Federation 
of Government Employees. In testimony before the Committee on 
October 24, 2007, Michael J. Kussman, Under Secretary for 
Health of the Department of Veterans Affairs, submitted the 
views of the Administration on S. 2162. VA had concerns about 
certain provisions of the bill as introduced, and the reported 
version of the bill, as amended, addresses a number of those 
concerns.

        TITLE I--SUBSTANCE USE DISORDERS AND MENTAL HEALTH CARE

    Section 101 of the Committee bill would express the sense 
of Congress on substance use disorders, mental health, and on 
VA's capability and capacity to treat these conditions.
    The dangers and costs of SUD can hardly be overstated. In 
the words of Dr. David Oslin, Director of VISN 4 Mental Illness 
Research Education and Clinical Center, from testimony before 
the Committee on April 25, 2007, ``Alcohol misuse creates more 
financial burden to our society than any other health behavior, 
including smoking and obesity. Addiction is also a deadly 
disease. The toll on families, friends, and coworkers is 
incalculable.'' Other witnesses at that hearing presented 
personal stories of struggles with SUD, PTSD, and readjustment 
to civilian life after deployment abroad.
    While VA provides exemplary treatment for substance-related 
disorders at some facilities, access to quality comprehensive 
care is inconsistent. In general, VA's capacity to treat 
veterans with SUD has not kept pace with the needs of the 
veteran population. Testimony at the Committee hearings on 
April 25 and October 24, 2007, spoke to this issue.
    The findings in this section of the Committee bill are 
derived from the 2005 Department of Defense ``Survey of Health 
Related Behaviors Among Active Duty Personnel,'' the December 
2006 GAO report entitled ``Spending for Mental Health Strategic 
Plan Was Substantially Less than Planned,'' and consultation 
with VA and veterans' community experts.
    The findings provide information on a number of the issues 
addressed by this legislation. In particular, the findings 
point out that while the Veterans Health Administration has 
significantly increased health services for veterans from 1996 
through 2006, the number of veterans receiving specialized 
substance abuse treatment services decreased 18 percent during 
that time. No comparable decrease in the national rate of 
substance abuse has been observed during that time. 
Furthermore, according to the Government Accountability Office, 
the Department of Veterans Affairs significantly reduced its 
substance use disorder treatment and rehabilitation services 
between 1996 and 2006, and has made little progress since in 
restoring these services to their pre-1996 levels.
    Section 102 of the Committee bill would require that a 
minimum level of services and treatments be available to each 
veteran enrolled in VA health care who is in need of treatment 
or services for SUD. The services required are derived from 
VA's Clinical Practice Guidelines for Substance Use Disorders, 
a 1999 NIH publication entitled ``Principles of Drug Addiction 
Treatment,'' and from consultation with SUD experts.
    As discussed above, under section 101, VA has the 
capability to offer exemplary SUD treatment, but these services 
are not consistently available throughout the system. Dr. Oslin 
testified before the Committee on April 25, 2007, that 
``[t]here is a clear evidence base that this type of broad-
based public health initiative can identify veterans earlier in 
the addiction process and prevent substantial burden in the 
future.'' Some Veteran's Integrated Service Networks already 
provide comprehensive services, and this should be the norm 
throughout the VA system.
    As set forth in section 102(b) of the Committee bill, the 
services and treatments set forth in section 102(a) may be 
provided in a VA facility, or by contract or fee-basis payments 
with community based organizations.
    It is the Committee's view that VA has not moved quickly 
enough to take a comprehensive and systemic approach to SUD 
treatment. As previously mentioned, no consistent level of SUD 
services exist throughout the system. This section of the 
Committee bill, in addition to later sections which would 
expand treatment and research programs, addresses this 
deficiency.
    Section 103 of the Committee bill would require that 
veterans with a mental health disorder and comorbid SUD be 
treated concurrently by clinicians with appropriate expertise. 
SUD is frequently experienced concurrently with other mental 
and physical disorders, and is strongly associated with PTSD. 
Treatments addressing these disorders concurrently are more 
effective, especially when administered by clinicians with 
experience in both disorders.
    In testimony before the Committee on April 25, 2007, Dr. 
David Oslin stated that the concurrent treatment of PTSD and 
SUD has dramatically improved outcomes at the Philadelphia VA 
Medical Center. The Committee believes that this model should 
be replicated throughout the VA health care system. Studies 
have found that patients with psychological trauma, including 
PTSD, are often susceptible to alcohol and drug abuse. 
According to the National Institute on Drug Abuse, patients 
subjected to chronic stress, as experienced by those with PTSD, 
are prone to drug use. Research by Sinha, Fuse, Aubin and 
O'Malley in Psychopharmacology (2000), and by Brewer et al. in 
Addiction (1998) further emphasize this point.
    Section 104 of the Committee bill would add a new section 
to title 38, 7330A, entitled ``National centers of excellence 
on post-traumatic stress disorder and substance use 
disorders,'' which would require VA to establish six national 
centers of excellence on PTSD and SUD. The Committee's intent 
is that veterans diagnosed with both of these disorders receive 
comprehensive inpatient or residential care from facilities 
with exceptional therapeutic capabilities. In addition, under 
new section 7330A, VA would be required to establish a process 
to refer and aid the transition of veterans from these national 
centers to programs that provide step down rehabilitation 
treatment specific to these disorders.
    The requirement for national centers of excellence is 
predicated on the need for geographically dispersed centers 
with exceptional capabilities to provide inpatient or 
residential treatment for both PTSD and SUD. It also responds 
to the trends described in section 101 of the Committee bill. 
As thousands of servicemembers return from combat with PTSD, 
many will be at risk for SUD. By quickly intervening, VA may be 
able to reduce chronic PTSD and SUD among the veteran 
population.
    Section 105 of the Committee bill would require VA to 
conduct a review of all VA residential mental health care 
facilities, including domiciliary facilities, and to report on 
the results of that review. The report would be required to 
include, among other information, an assessment of the 
supervision and support provided in the residential mental 
health care facilities of VA, the ratio of staff members to 
patients at each facility, and an assessment of the 
appropriateness of rules and procedures for the prescription 
and administration of medications to patients.
    The requirements of this section respond to testimony 
offered at the Committee's April 25, 2007, hearing on mental 
health care in VA. The testimony of Tony Bailey about the care 
provided to his son, Justin, described inattentive staff and 
lax control of medications, among other issues.
    Justin Bailey was receiving treatment in a VA domiciliary 
facility for PTSD, SUD, and a groin injury when he died of an 
apparent overdose of medications prescribed to him by VA 
clinicians. Justin's parents, Tony and Mary Kaye Bailey, 
believe that the lack of appropriate staff supervision and 
support at the domiciliary, coupled with the facility's 
disregard for VA rules and procedures for the management of 
prescription medication, contributed to his death.
    The testimony of Justin Bailey's parents, excerpted below, 
inspired many of the provisions in the proposed legislation.

          I would like to tell you about my son, Justin Bailey, 
        who died on January 26, 2007, at the West LA VA 
        Hospital. He was 27 years old. Justin was seeking 
        treatment for PTSD and drug abuse.
          Justin joined the Marine Corps in December 1998, 
        approximately 6 months after graduating from high 
        school. He was in the infantry and was due to separate 
        from the Marines in January 2003, but was involuntarily 
        extended due to the impending war. Justin was with the 
        first wave of troops that arrived in Iraq when the war 
        started in 2003. He fought in Nasarija and returned to 
        Camp Pendleton in June, 2003.
          On the night of January 26th I learned that Justin 
        was being taken to the ER at the hospital. He had just 
        received his new prescriptions the day before. And now 
        he had died of an apparent overdose of his prescription 
        drugs.

    According to the Baileys, the report that would be required 
by this section would ensure a full accounting of VA 
domiciliary facilities and practices, with a goal of helping to 
avert future tragedies.

           TITLE II--MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS

    Section 201 of the Committee bill would require VA to carry 
out a pilot program to assess the feasibility and advisability 
of providing certain services to veterans of Operation Iraqi 
Freedom and Operation Enduring Freedom. The first component of 
the pilot program would provide peer outreach and peer support, 
and a second component would assess the use of community mental 
health centers, the Indian Health Service and other entities to 
provide mental health services in rural areas.
    Peer outreach and support, conducted with appropriate 
training as discussed below, may be effective in connecting 
veterans with mental health services. Vet Centers and 
individual VISNs have been especially successful in conducting 
this type of outreach and support. Given the unprecedented 
number of National Guard and Reserve forces from rural areas 
deployed in current conflicts, these outreach and support 
services may now be more helpful.
    The benefits of peer outreach and support need to be 
assessed. While clinicians provide essential treatments and 
therapies, they are not expected to provide the social support 
that peers can offer. The support of a strong social network of 
peers with similar experiences may complement and augment 
clinical treatment. A study by Davidson, Chinman, Sells, and 
Rowe, published in Schizophrenia Bulletin (July, 2006), 
concluded that ``peer support is still early in its development 
as a form of mental health service provision,'' and recommends 
further exploration of this ``promising, if yet unproven, 
practice.'' A number of medical facilities and VISNs are 
already conducting this type of outreach and support, and this 
pilot will build upon existing capabilities.
    The training that would be required to be provided to 
veterans conducting outreach and support under this section is 
essential. In this program, peers would not be intended to act 
in a clinical capacity, but would receive basic training in 
skills necessary for working with veterans with mental health 
concerns. VA may have the capacity to conduct this training, or 
may choose to conduct training through a non-Department entity.
    During the Committee's hearing on May 23, 2007, Carl Blake, 
of PVA, discussed successful peer outreach and support 
conducted by PVA to help veterans recovering from and adjusting 
to life after catastrophic injuries. It is the view of PVA that 
the model of veteran peers with common experiences and 
backgrounds providing non-clinical outreach and support has 
proven to be effective among this group of disabled veterans. 
The Committee believes broader use of peer outreach and support 
should be explored and assessed.
    The second component of this pilot program would be the 
provision of readjustment counseling and mental health services 
to Operation Enduring Freedom and Operation Iraqi Freedom 
veterans through community mental health centers, the 
facilities of the Indian Health Service, and other entities. 
The Committee recognizes that access to VA mental health 
services varies significantly across the country. The second 
part of the pilot program would target rural veteran 
populations whose needs are not being met. Community mental 
health centers and the Indian Health Service provide services 
in many areas where VA does not have facilities. By permitting 
veterans to receive treatment from these entities, under 
contract or agreement in the case of community mental health 
centers or other community providers, or under an existing 
memorandum of understanding in the case of the Indian Health 
Service, VA will be better able to meet the needs of rural 
veterans.
    In a number of locations, VA has already partnered with 
community mental health centers to reach rural populations. 
This part of the pilot program would build upon previous 
success.
    Capt. Constance Walker, President of the Southern Maryland 
Chapter of the National Alliance on Mental Illness, testified 
before the Committee on October 24, 2007, that ``[t]he 
likelihood of obtaining specialized services [for PTSD and 
serious mental illnesses] on a consistent basis is very small 
for veterans living in rural and frontier areas beyond a 
reasonable commute to a VA Medical Center or without access to 
an appropriately and consistently staffed VA Community Based 
Outpatient Clinic.'' The provisions of section 201 of the 
Committee bill would address this gap.
    The Committee believes that this pilot effort will preserve 
the integrity of the VA health care system while expanding 
options for veterans who cannot access VA facilities. Joy Ilem, 
of DAV, testified that non-VA entities are, on occasion, 
necessary for the provision of care, but that proper training 
and oversight of those entities is essential. The provisions in 
this section of the Committee bill would ensure VA has 
sufficient control and oversight of quality of care and patient 
privacy, among other requirements. The Committee notes that the 
American Federation of Government Employees has expressed 
strong preference for this provision of the Committee bill.

                          TITLE III--RESEARCH

    Section 301 of the Committee bill would require VA to carry 
out a research program on comorbid PTSD and SUD. This program 
would be conducted through the National Center for Post 
Traumatic Stress Disorder. The Committee bill would authorize 
$2,000,000 for the program in each fiscal year 2008 through 
2011 to fund research on PTSD and comorbid SUD.
    Research has demonstrated the destructive confluence of 
these two disorders, but research on treatments has not 
advanced sufficiently. According to recent research conducted 
by Dr. Lisa M. Najavits of Harvard Medical School, while there 
are studies that have directly compared various treatments, 
including cognitive behavioral therapy, such studies have not 
yet been conducted in substance abuse samples. The field is 
still developing its understanding of the complex issues of 
comorbid mental health and substance use disorders.
    A recent Institute of Medicine (IOM) study, entitled 
``Treatment of Posttraumatic Stress Disorder: An Assessment of 
the Evidence,'' describes the current status of research on 
treatments of PTSD. The study indicates that insufficient high 
quality and focused research has been conducted to draw 
conclusions on the efficacy of pharmacotherapies and 
psychotherapies, with the exception of exposure therapies.
    Among other points, IOM recommends that research on 
treatments for PTSD be more systematic and clearly focused with 
established definitions and goals. Furthermore, IOM recommends 
that research focus on specific veteran populations who suffer 
from PTSD in addition to other disorders, such as SUD. This 
legislation would place the National Center on PTSD in a 
position to effectively guide research in this area, and 
authorizes the necessary funding.
    The emphasis in this section of the Committee bill is not 
without precedent. Section 122 of Public Law 102-405 calls for 
VA to place a high priority on treatment programs for mental 
health care, including for PTSD and comorbid SUD. This area of 
research continues to be a priority.
    Section 302 of the Committee bill would modify section 
110(e)(2) of the Veterans' Health Care Act of 1984, P.L. 98-
528, to extend the reporting requirement for the Special 
Committee on Post-Traumatic Stress Disorder. Currently, the 
reporting requirement is set to expire in 2008; this provision 
would extend it through 2012.
    The Special Committee has served an important role in 
overseeing and guiding the treatment of PTSD within VA, and has 
become a major resource in and out of government for expertise 
on PTSD. The Committee believes that it is essential for the 
Special Committee to continue in operation beyond 2008.

             TITLE IV--ASSISTANCE FOR FAMILIES OF VETERANS

    Section 401 of the Committee bill would amend section 1701 
(5)(B) of title 38 United States Code to clarify the authority 
of the Secretary of Veterans Affairs to provide mental health 
services to families of veterans.
    The Committee recognizes that a veteran's family or legal 
guardian often plays a central role in his or her recovery 
from, or management of, mental health disorders, SUDs, and in 
the transition to civilian life. In this context, and given the 
long term trend in VA toward expanding home-based care, this 
section makes clear VA's authority to offer care to veterans' 
families, including mental health care, as well as training and 
other forms of assistance and support.
    Through oversight activities and hearings, the Committee 
has identified marked irregularity in the application of 
existing authority to offer services to veterans' families. 
This section would amend existing law to explicitly require 
that marriage and family counseling be offered to veterans' 
families.
    Testimony received by the Committee during hearings has 
repeatedly demonstrated the need for greater support for 
families. For example, at the October 2007 hearing, Capt. 
Walker testified that ``it is impossible to overstate the 
stressors that rural and frontier family caregivers are bearing 
on a daily basis as they search for limited treatment and 
rehabilitative services.''
    During the Committee's April 25, 2007, hearing, a number of 
witnesses testified to the importance of education, training, 
support, and care for families in a veteran's recovery and 
readjustment process. Two parents, Tony Bailey and Randall 
Omvig, father of Spc. Joshua Omvig, who committed suicide after 
returning from Iraq, emphasized the need to help families. 
Ralph Ibson, of Mental Health America, also testified on the 
importance of families in helping a veteran readjust, noting 
that ``VA health care, and particularly mental health care, 
would often be more effective if barriers to family involvement 
were eliminated.'' The Committee concurs with this statement.
    During the Committee's hearing in May 2007, Dennis M. 
Cullinan of Veterans of Foreign Wars of the United States, 
Shannon Middleton of The American Legion, and Jerry Reed of 
Suicide Prevention Action Network USA testified to the 
importance of providing a broader range of support and clinical 
services to families of veterans.
    Section 402 of the Committee bill would establish a pilot 
program to assess the feasibility and advisability of providing 
additional readjustment and transition assistance to veterans 
and their families in cooperation with Readjustment Counseling 
Centers. The pilot would be similar to family assistance 
programs previously conducted at ten Army facilities around the 
country. The programs have been effective in helping families 
prepare for deployments, and adjust to the deployment and 
return of servicemembers. These programs have helped families 
strengthen their relationships, resolve disagreements through 
discussion, balance professional and family responsibilities, 
and make better financial decisions. Readjustment assistance 
geared towards military families has equipped them with tools 
useful in coping with deployments and the return of 
servicemembers, especially those who have suffered physical or 
mental injuries.
    The Committee believes that similar programs, tailored to 
the needs of veterans, may prove helpful to veterans and their 
families. Targeted assistance in handling the stress of 
readjusting to civilian life, coping with physical and mental 
injuries, and maintaining family support may have the potential 
to preemptively address many of the more serious challenges 
facing veterans and their families.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the CBO, estimates that enactment of 
the Committee bill would, relative to current law, increase 
discretionary spending by $880,000,000 over the 2008-2013 
period, assuming appropriation of the necessary amounts. The 
Committee bill would not increase direct spending, based on 
information supplied by the CBO. Enactment of the Committee 
bill would not affect receipts, and would not affect the budget 
of state, local or tribal governments.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                               Congressional Budget Office,
                                     Washington, DC, April 7, 2008.
Hon. Daniel K. Akaka,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 2162, the Mental 
Health Improvements Act of 2007.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                           Peter R. Orszag,
                                                          Director.
    Enclosure.

S. 2162--Mental Health Improvements Act of 2007

    Summary: S. 2162 would require the Department of Veterans 
Affairs (VA) to expand the treatments and services available to 
veterans suffering from disorders related to post-traumatic 
stress, substance abuse, and other mental health problems. In 
total, CBO estimates that implementing S. 2162 would cost about 
$880 million over the 2008-2013 period, assuming appropriation 
of the specified and estimated amounts. Enacting the bill would 
not affect direct spending or revenues.
    S. 2162 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA); 
any costs to state, local, or tribal governments would be 
incurred voluntarily.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 2162 is shown in Table 1. The costs of 
this legislation fall within budget function 700 (veterans 
benefits and services).
    Basis of estimate: CBO assumes that the legislation will be 
enacted by the middle of calendar year 2008, that the specified 
and estimated amounts will be appropriated each year, and that 
outlays will follow historical spending patterns for the VA 
medical services program. (Funding for 2008 would have to be 
provided in a supplemental appropriations act.)

                                 TABLE 1.--ESTIMATED BUDGETARY IMPACT OF S. 2162
----------------------------------------------------------------------------------------------------------------
                                                                     By fiscal year, in millions of dollars--
                                                                 -----------------------------------------------
                                                                   2008    2009    2010    2011    2012    2013
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Estimated Authorization Level...................................      42     168     165     170     174     182
Estimated Outlays...............................................      36     155     164     168     174     180
----------------------------------------------------------------------------------------------------------------

Clinician teams

    Section 103 would require VA to ensure that veterans being 
treated for both substance use disorder and another mental 
health disorder receive treatment by a health professional 
trained in both disorders, a team of clinicians with the 
appropriate expertise, or coordinated but separate services for 
each disorder. According to VA, the average annual cost of its 
five existing teams for substance use and post-traumatic stress 
disorders (PTSD) is about $520,000. CBO estimates that 
establishing similar teams in the remaining 148 medical centers 
would cost $439 million over the 2008-2013 period, assuming 
appropriation of the necessary amounts (see Table 2).

Treatment for substance use disorders

    Section 102 would require VA to provide certain services 
and treatments to veterans suffering from substance use 
disorders, either at VA medical facilities or through contracts 
at community-based organizations. After adjusting for 
anticipated inflation, CBO estimates that implementing this 
provision would cost $378 million over the 2008-2013 period, 
assuming appropriation of the necessary amounts.
    According to VA, some of the services and treatments 
specified under the bill are already being provided. Most of 
the costs of this provision stem from providing detoxification 
and stabilization services, residential care, and intensive 
outpatient care, which are discussed below. Other services, 
such as counseling, opiate substitution therapy, other 
pharmacological treatments, and relapse prevention, would 
result in additional costs of about $20 million over the 2008-
2013 period, assuming appropriation of the necessary amounts.
    Detoxification and Stabilization Services. Based on 
information from VA, CBO estimates that to provide the 
detoxification and stabilization services specified in the 
bill, VA would need to hire 153 advanced practice nurses (one 
at each medical center) at an annual cost of $135,000 each (in 
2008 dollars). CBO estimates that implementing this provision 
would cost $118 million over the 2008-2013 period, assuming 
appropriation of the necessary amounts.

        TABLE 2.--COMPONENTS OF THE ESTIMATED CHANGES IN SPENDING SUBJECT TO APPROPRIATION UNDER S. 2162
----------------------------------------------------------------------------------------------------------------
                                                                     By fiscal year, in millions of dollars--
                                                                 -----------------------------------------------
                                                                   2008    2009    2010    2011    2012    2013
----------------------------------------------------------------------------------------------------------------
Clinician Teams:
    Estimated Authorization Level...............................      19      80      83      86      90      93
    Estimated Outlays...........................................      17      73      82      85      89      93
Treatment for Substance Use Disorders:
    Estimated Authorization Level...............................      19      71      70      73      76      79
    Estimated Outlays...........................................      17      65      70      72      75      79
Centers of Excellence:
    Estimated Authorization Level...............................       1      13       8       8       8       9
    Estimated Outlays...........................................       1      12       8       8       8       9
Research Program on Comorbid Disorders:
    Authorization Level.........................................       2       2       2       2       0       0
    Estimated Outlays...........................................       *       2       2       2       2       *
Pilot Programs:
    Estimated Authorization Level...............................       1       2       1       *       0       0
    Estimated Outlays...........................................       *       2       1       1       *       0
Report on Residential Facilities:
    Estimated Authorization Level...............................       0       1       1       0       0       0
    Estimated Outlays...........................................       0       1       1       *       *       0
    Total Changes:
        Estimated Authorization Level...........................      42     168     165     170     174     182
        Estimated Outlays.......................................      36     155     164     168     174    180
----------------------------------------------------------------------------------------------------------------
Notes: Components may not sum to totals because of rounding.
* = less than $500,000.

    Residential Care. Based on information from VA, CBO 
estimates that to provide residential care under the bill, VA 
would require an additional 110 beds nationwide at an annual 
cost of $16 million and have start-up costs of $5 million. CBO 
estimates that implementing this provision would cost $97 
million over the 2008-2013 period, assuming appropriation of 
the necessary amounts.
    Intensive Outpatient Care. According to VA, the intensive 
outpatient care required under the bill could be provided at 
both community-based outpatient clinics (CBOCs) and VA medical 
centers. Based on information from VA, CBO estimates that VA 
would hire the equivalent of 185 full-time counselors to work 
in over 1,000 CBOCs. Each counselor would provide group 
treatment (therapy of three hours a week over three months to 
50 patients at a time) to about 200 patients a year, and would 
be paid an average of $71,500 a year (in 2008 dollars).
    Based on information from VA, CBO estimates that 
establishing similar intensive outpatient care in VA medical 
centers would require VA to upgrade programs in 50 medical 
centers by hiring three additional employees at each center, at 
an average annual cost of $71,500. In addition, CBO estimates 
that VA would require additional appropriations of $1 million a 
year to initiate specialty care for substance use disorders at 
one medical center.
    In total, and after adjusting for anticipated inflation, 
CBO estimates that implementing this provision at CBOCs and 
medical centers would cost $142 million over the 2008-2013 
period, assuming appropriation of the necessary amounts.

Centers of excellence

    Section 104 would require VA to establish at least six 
centers of excellence on PTSD and substance use disorders at 
its health care facilities. The centers would provide inpatient 
or residential treatment and recovery services to veterans. 
Based on information from VA and after adjusting for inflation, 
CBO estimates that each of the six centers would have 11 
employees, annual operating costs of about $1.3 million, and 
start-up costs of $1 million. CBO estimates that implementing 
this provision would cost $46 million over the 2008-2013 
period, assuming appropriation of the necessary amounts.

Research program on comorbid disorders

    Section 301 would authorize the appropriation of $2 million 
a year over the 2008-2011 period for research into comorbid 
(i.e., occurring concurrently) substance use disorders and PTSD 
in veterans. CBO estimates that implementing this provision 
would cost $8 million over the 2008-2013 period, assuming 
appropriation of the authorized amounts.

Pilot programs

    Two sections of the bill would authorize new pilot programs 
to provide counseling, outreach, and other services to certain 
veterans. Based on information from VA, CBO estimates that 
implementing these pilot programs would cost $5 million over 
the 2008-2013 period, assuming appropriation of the specified 
and estimated amounts. Section 201 would require VA to study 
the feasibility of providing counseling, peer outreach, peer 
support, and other mental health services to veterans of 
Operation Iraqi Freedom and Operation Enduring Freedom, 
including the use of community health centers and the Indian 
Health Service to reach rural veterans. Section 402 would 
require VA to assess the feasibility of providing readjustment 
and transition assistance through private organizations, in 
collaboration with Vet Centers (community-based centers that 
provide counseling and outreach services to combat veterans and 
their families) and would authorize the appropriation of $1 
million a year over the 2008-2010 period.

Report on residential facilities

    Section 106 would require VA to conduct reviews of all its 
residential facilities for mental health care and report to the 
Congress. Based on information from VA, CBO estimates VA would 
require two employees to review 134 facilities at a cost of $2 
million over the 2008-2013 period, assuming the availability of 
appropriated funds.
    Intergovernmental and private-sector impact: S. 2162 
contains no intergovernmental or private-sector mandates as 
defined in UMRA. State, local, and tribal governments that 
provide counseling and mental health services to veterans would 
benefit from program activities authorized in the bill. Any 
costs those governments incur to comply with service agreements 
would be incurred voluntarily.
    Estimate prepared by: Federal Costs: Sunita D'Monte, Impact 
on State, Local, and Tribal Governments: Lisa Ramirez-Branum, 
Impact on the Private Sector: Victoria Liu.
    Estimate approved by: Peter H. Fontaine, Assistant Director 
for Budget Analysis.

                      Regulatory Impact Statement

    In compliance with paragraph 11(b) of rule XXVI of the 
Standing Rules of the Senate, the Committee on Veterans' 
Affairs has made an evaluation of the regulatory impact that 
would be incurred in carrying out the Committee bill. The 
Committee finds that the Committee bill would not entail any 
regulation of individuals or businesses or result in any impact 
on the personal privacy of any individuals and that the 
paperwork resulting from enactment would be minimal.

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7 of rule XXVI of the Standing 
Rules of the Senate, the following is a tabulation of votes 
cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its November 14, 2007 meeting. On that 
date, the Committee ordered S. 2162, as amended, reported 
favorably to the Senate by voice vote.

                             Agency Report

    On October 24, 2007, the Honorable Michael J. Kussman, 
Under Secretary for Health, Department of Veterans Affairs, 
appeared before the Committee and submitted testimony on, among 
other things, an earlier version of S. 2162. Excerpts of this 
statement are reprinted below:

              Statement of the Views of the Administration

 Michael J. Kussman, MD, MS, MACP, Under Secretary for Health for the 
                     Department of Veterans Affairs

    Good morning Mr. Chairman and Members of the Committee:
    Thank you for inviting me here today to present the 
Administration's views on several bills that would affect 
Department of Veterans Affairs (VA) programs that provide 
veterans benefits and services. With me today is Walter A. 
Hall, Assistant General Counsel. I will address the five bills 
on today's agenda and then I would be happy to answer any 
questions you and the Committee members may have.


           s. 2162 ``mental health improvements act of 2007''


Title I. Substance use disorders and mental health care
    Mr. Chairman, title I of this bill focuses on VA treatment 
programs for substance use disorders and mental health 
disorders, particularly PTSD. Section 102 would require the 
Secretary to ensure the provision of the following services for 
substance use disorders at every VA medical center:
     Short term motivational counseling services.
     Intensive outpatient care services.
     Relapse prevention services.
     Ongoing aftercare and outpatient counseling 
services.
     Opiate substitution therapy services.
     Pharmacological treatments aimed at reducing 
cravings for drugs and alcohol.
     Detoxification and stabilization services.
     Such other services as the Secretary deems 
appropriate.
    The Secretary could, however, exempt an individual medical 
center or Community-Based Outpatient Clinic (CBOC) from 
providing all of the mandated services. Annually the Department 
would have to report to Congress on the facilities receiving an 
exemption under this provision, including the reason for the 
exemption.
    Section 103 would require the Secretary to ensure that VA 
treatment for a veteran's substance use disorder and a co-
morbid mental health disorder is provided concurrently by a 
team of clinicians with appropriate expertise.
    Section 104 would require the Secretary to carry out a 
program to enhance VA's treatment of veterans suffering from 
substance use disorders and PTSD through facilities that 
compete for funds for this purpose. Funding awarded to a 
facility would be used for the six purposes specified in the 
bill, in addition to the conduct of peer outreach programs 
through Vet Centers to re-engage OEF/OIF veterans who miss 
multiple appointments for PTSD or a substance use disorder. 
Another specified purpose for the funds would be to establish 
collaboration between VA's urgent care clinicians and substance 
use disorder and PTSD professionals to ensure expedited 
referral of veterans who are diagnosed with these disorders.
    Not later than one year after the bill's enactment, the 
Secretary would need to submit a report to Congress on this 
program and the facilities receiving funding.
    S. 2162 would provide for funding by requiring the 
Secretary to allocate $50 million from appropriated funds 
available for medical care for each of fiscal years 2008, 2009, 
and 2010. The bill would require the total expenditure for PTSD 
and substance use disorder programs to not be less than $50 
million in excess of a specified baseline amount. (The bill 
would define the baseline as the amount of the total 
expenditures on VA's treatment programs for PTSD and substance 
use disorders for the most recent fiscal year for which final 
expenditure amounts are known, as adjusted to reflect any 
subsequent increase in applicable costs to deliver those 
programs.)
    Section 105 would require the Secretary to establish not 
less than six national centers of excellence on PTSD and 
substance use disorders. These centers would provide 
comprehensive inpatient treatment and recovery services to 
veterans newly diagnosed with these disorders. Sites for the 
centers would be limited to VA medical centers that provide 
inpatient care; that are geographically situated in an area 
with a high number of veterans that have been diagnosed with 
both PTSD and substance use disorder; and that are capable of 
treating PTSD and substance use disorders. This provision would 
also direct the Secretary to establish a process to refer and 
aid the transition of veterans receiving treatment in these 
centers to programs that provide step down rehabilitation 
treatment.
    Section 106 would require the Secretary, acting through the 
Office of the Medical Inspector (MI), to review all of VA's 
residential mental health care facilities and to submit to 
Congress a detailed report on the MI's findings.
    Section 107 would provide for title I of this bill to be 
enacted in tribute to Justin Bailey, an OIF veteran who died 
while under VA treatment for PTSD and a substance use disorder.
    While VA respects the attention this Committee is giving 
these critical issues, Title I is overly prescriptive and 
attempts to mandate the type of treatments to be provided to 
covered veterans, the treatment settings, and the composition 
of treatment teams. Treatment decisions should be based on 
professional medical judgments in light of an individual 
patient's needs, and experienced health care managers are in 
the best position to decide how best to deliver needed health 
care services at the local level. With regard to the proposed 
centers of excellence, we reiterate our concerns about disease-
specific treatment centers and models, although we appreciate 
the Committee's efforts thereby to hasten the eradication of 
those particular diseases. For all of the above reasons, we do 
not support this title.
Title II. Mental health accessibility enhancements
    Section 201 would require the Secretary to establish a 
three-year pilot program to assess the feasibility and 
advisability of providing eligible OEF/OIF veterans with peer 
outreach services, peer support services, and readjustment 
counseling services, and other mental health services. This 
pilot would begin not later than 180 days after the bill's 
enactment. Eligible veterans would include those who are 
enrolled in VA's health care system and who, for purposes of 
the pilot program, receive a referral from a VHA health 
professional to a community mental health center or to a 
facility of the Indian Health Service (IHS).
    In providing readjustment counseling services and other 
mental health services to rural veterans who do not have 
adequate access to VA services, section 201 would require the 
Secretary, acting through the Office of Rural Health, to 
contract for those services with community mental health 
centers (as defined in 42 CFR 410.2) and IHS facilities.
    Sites for the pilot would need to include at least two 
Veterans Integrated Service Networks (selected by the 
Secretary), and at least two of the sites would have to be 
located in rural areas that lack access to comprehensive VA 
mental health services.
    A center or IHS facility that participates in the pilot 
program must, to the extent practicable, provide readjustment 
counseling services and other mental health services to 
eligible veterans through the use of telehealth services. It 
would also need to provide the services using best practices 
and technologies and meet any other requirements established by 
the Secretary. A participating center or IHS facility would 
also have to comply with applicable VA protocols before 
incurring any liability on behalf of the Department and provide 
clinical information on each veteran to whom it furnishes 
services.
    The Secretary would be required to carry out a national 
program of training for (1) veterans who would provide peer 
outreach and peer support services under the pilot program; and 
(2) clinicians of participating centers or IHS facilities to 
ensure they can furnish covered services and that such services 
will be provided in a manner that accounts for factors unique 
to OEF/OIF veterans. This provision would also establish 
detailed annual reporting requirements for participating 
centers and facilities.
    As we discussed in connection with section 2 of S. 38, all 
of these services are already available to OEF/OIF veterans, 
including those who served in the National Guard or the 
Reserves. As such, no demonstrated need exists for the pilot 
program or these additional authorities, which are duplicative 
of currently existing authorities. And VA is already working 
with other entities to provide treatment to veterans at the 
local level if VA is not able to provide the needed care; 
therefore, the requirement to contract specifically with a 
community health center or IHS facility would limit the local 
VA providers' flexibility in finding the most appropriate care 
for our veterans.
Title III. Research
    Section 301 would require the Secretary to carry out a 
program of research into co-morbid PTSD and substance use 
disorder. The purpose of this program would be to address co-
morbid PTSD and substance use disorder; provide systematic 
integration of treatment for these two disorders; develop 
protocols to evaluate VA's care of veterans with these 
disorders; and, facilitate the cumulative clinical progress of 
these veterans. This provision would charge VA's National 
Center for PTSD with responsibility for carrying out and 
overseeing this program, developing the protocols and goals, 
and coordinating the research, data collection, and data 
dissemination.
    Section 301 would also authorize $2 million to be 
appropriated for each of fiscal years 2008 through 2011 to 
carry out this program and specifically require these funds be 
allocated to the National PTSD Center. The funds made available 
to the Center would be in addition to any other amounts made 
available to it under any other provision of law.
    Section 302 would continue the Special Committee on PTSD 
(which is established within VHA) through 2012; otherwise the 
Committee's mandate would terminate after 2008.
    While well-intended, this title is overly prescriptive and 
more importantly altogether unnecessary. Therefore, with the 
exception of the extension of the Special Committee, VA does 
not support the provisions in title III. VA is a world-
recognized leader in the care of both PTSD and substance use 
disorders, particularly when these conditions co-exist in an 
individual. The activities required by title III are 
essentially duplicative of VHA's ongoing efforts in this area, 
particularly the research efforts being carried out by VA's 
National PTSD Center. We would welcome the opportunity to brief 
the Committee on VA's achievements and efforts in this area, 
plus the role of the Office of Mental Health in overseeing the 
PTSD and substance abuse programs.
Title IV. Assistance for families of veterans
    In connection with the family support services authorized 
in chapter 17 of title 38, United States Code (i.e., mental 
health services, consultation, professional counseling, and 
training), section 401 would amend the statutory definition of 
``professional counseling'' to expressly include marriage and 
family counseling. This provision would also ease eligibility 
requirements for these family support services by authorizing 
the provision of these services when considered appropriate (as 
opposed to essential) for the effective treatment and 
rehabilitation of the veteran. Section 401 would further 
clarify that these services are available to family members in 
Vet Centers, VA medical centers, CBOCs, or other VA facilities 
the Secretary considers necessary.
    Section 402 would require the Secretary to carry out, 
through a non-VA entity, a three-year pilot program to assess 
the feasibility and advisability of providing ``readjustment 
and transition assistance'' to veterans and their families in 
cooperation with Vet Centers. Readjustment and transition 
assistance would be defined as readjustment and transition 
assistance that is preemptive, proactive, and principle-
centered. It would also include assistance and training for 
veterans and their families in coping with the challenges 
associated with making the transition from military to civilian 
life.
    This provision would require services furnished under the 
pilot program to be furnished by a for-profit or non-profit 
organization(s) selected by the Secretary (pursuant to an 
agreement). To participate in the pilot, a participating 
organization(s) must have demonstrated expertise and experience 
in providing those types of services.
    The pilot program would have to be carried out in 
cooperation with 10 geographically distributed Vet Centers, 
which would be responsible for promoting awareness of the 
assistance available to veterans and their families through the 
Vet Centers, the non-VA organization(s) conducting the pilot, 
and other appropriate mechanisms.
    Section 403 would establish detailed reporting requirements 
and authorize $1 million to be appropriated for each of fiscal 
years 2008 through 2010 to carry out the pilot program. Such 
amounts would remain available until expended.
    VA does not support title IV. First, it is unclear how 
these ``readjustment and transition assistance'' services are 
intended to differ from, or interact with, the readjustment 
counseling services and related mental health services already 
made available to veterans and their families through the Vet 
Centers. In our view, this provision would conflict in many 
respects with VA's existing authorities to provide readjustment 
counseling and related mental health services and lend 
confusion to what is otherwise a highly successful program 
(particularly with respect to client outreach). Indeed, client 
satisfaction with the Vet Centers is the highest of VA's 
programs (98%). The services they provide already include 
marriage and counseling services to family members as necessary 
to further the veteran's readjustment.
    We also do not understand the perceived need for reliance 
on non-VA organizations for the provision of these services. 
Let me again assure you that our Vet Centers readily contract 
with appropriate organizations and providers to ensure veterans 
and their families receive covered family support services. In 
sum, we do not see how this provision would effectively enhance 
current authorities or Vet Center activities; rather, we see 
that it has serious potential to create confusion and 
disruption for both VA and our beneficiaries.

           *       *       *       *       *       *       *


    Changes in Existing Law Made by the Committee Bill, as Reported

    In compliance with rule XXVI paragraph 12 of the Standing 
Rules of the Senate, changes in existing law made by the 
Committee bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

                      TITLE 38. VETERANS' BENEFITS

                       PART II. GENERAL BENEFITS

   CHAPTER 17. HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE


                         Subchapter I. General


SEC. 1701. DEFINITIONS.

           *       *       *       *       *       *       *


          (5) * * *
                  (B) such mental health services, 
                consultation, professional counseling, marriage 
                and family counseling, and training for the 
                members of the immediate family or legal 
                guardian of a veteran, or the individual in 
                whose household such veteran certifies an 
                intention to live, [as may be essential to] as 
                the Secretary considers appropriate for the 
                effective treatment and rehabilitation of a 
                veteran or dependent or survivor of a veteran 
                receiving care under the last sentence of 
                section 1781(b) of this title and

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *



SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL 
                    HEALTH SERVICES.

           *       *       *       *       *       *       *


    (e)(1) * * *
    (2) Not later than May 1 of each year [through 2008] 
through 2012, the Secretary shall submit to the Committees on 
Veterans' Affairs of the Senate and House of Representatives a 
report containing information updating the reports submitted 
under this subsection since the enactment of the Veterans 
Millennium Health Care and Benefits Act.

           *       *       *       *       *       *       *


Subchapter VIII. Health Care of Persons other than Veterans

           *       *       *       *       *       *       *



SEC. 1782. COUNSELING, TRAINING, AND MENTAL HEALTH SERVICES FOR 
                    IMMEDIATE FAMILY MEMBERS

    (a) Counseling for family members of veterans receiving 
service-connected treatment. In the case of a veteran who is 
receiving treatment for a service-connected disability pursuant 
to paragraph (1) or (2) of section 1710(a) of this title [38 
USCS Sec. 1 A1710(a)], the Secretary shall provide to 
individuals described in subsection (c) such consultation, 
professional counseling, marriage and family counseling, 
training, and mental health services as are necessary in 
connection with that treatment.
    (b) Counseling for family members of veterans receiving 
non-service-connected treatment. In the case of a veteran who 
is eligible to receive treatment for a non-service-connected 
disability under the conditions described in paragraph (1), 
(2), or (3) of section 1710(a) of this title [38 USCS Sec. 1 
A1710(a)], the Secretary may, in the discretion of the 
Secretary, provide to individuals described in subsection (c) 
such consultation, professional counseling, marriage and family 
counseling, training, and mental health services as are 
necessary in connection with that treatment if--
    (1) those services were initiated during the veteran's 
hospitalization; and
    (2) the continued provision of those services on an 
outpatient basis is essential to permit the discharge of the 
veteran from the hospital.

           *       *       *       *       *       *       *


             PART V. BOARDS, ADMINISTRATIONS, AND SERVICES

 CHAPTER 73. VETERANS HEALTH ADMINISTRATION-ORGANIZATION AND FUNCTIONS


Subchapter II. General Authority and Administration

           *       *       *       *       *       *       *



SEC.

7330A. NATIONAL CENTERS OF EXCELLENCE ON POST-TRAUMATIC STRESS DISORDER 
                    AND SUBSTANCE USE DISORDERS.

           *       *       *       *       *       *       *


7330A. NATIONAL CENTERS OF EXCELLENCE ON POST-TRAUMATIC STRESS DISORDER 
                    AND SUBSTANCE USE DISORDERS.

    (a) Establishment of Centers.--(1) The Secretary shall 
establish not less than six national centers of excellence on 
post-traumatic stress disorder and substance use disorders.
    (2) The purpose of the centers established under this 
section is to serve as Department facilities that provide 
comprehensive inpatient or residential treatment and recovery 
services for veterans diagnosed with both post-traumatic stress 
disorder and a substance use disorder.
    (b) Location.--Each center established in accordance with 
subsection (a) shall be located at a medical center of the 
Department that--
          (1) provides specialized care for veterans with post-
        traumatic stress disorder and a substance use disorder; 
        and
          (2) is geographically situated in an area with a high 
        number of veterans that have been diagnosed with both 
        post-traumatic stress disorder and substance use 
        disorder.
    (c) Process of Referral and Transition To Step Down 
Diagnosis Rehabilitation Treatment Programs.--The Secretary 
shall establish a process to refer and aid the transition of 
veterans from the national centers of excellence on post-
traumatic stress disorder and substance use disorders 
established pursuant to subsection (a) to programs that provide 
step down rehabilitation treatment for individuals with post-
traumatic stress disorder and substance use disorders.
    (d) Collaboration With the National Center for Post-
Traumatic Stress Disorder.--The centers established under this 
section shall collaborate in the research of the National 
Center for Post-Traumatic Stress Disorder.