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[Senate Report 114-34]
[From the U.S. Government Publishing Office]


114th Congress  }                                              { Report
                               SENATE
 1st Session    }                                              { 114-34
                                
 ======================================================================



 
                   CLAY HUNT SUICIDE PREVENTION FOR 
                         AMERICAN VETERANS ACT

                                _______
                                

                 April 23, 2015.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                        [To accompany H.R. 203]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (H.R. 203), to 
amend title 38, United States Code (hereinafter, ``U.S.C.''), 
to provide for the conduct of annual evaluations of mental 
health care and suicide prevention programs of the Department 
of Veterans Affairs (hereinafter, ``VA'' or ``the 
Department''), to require a pilot program on loan repayment for 
psychiatrists who agree to serve in the Veterans Health 
Administration (hereinafter, ``VHA'') of the Department, and 
for other purposes, having considered the same, reports 
favorably thereon without amendment and recommends that the 
bill do pass.

                              Introduction

    On January 7, 2015, Representative Timothy Walz introduced 
H.R. 203, to provide for the conduct of annual evaluations of 
mental health care and suicide prevention programs of the 
Department, to require a pilot program on loan repayment for 
psychiatrists who agree to serve in VHA of the Department, and 
for other purposes. Representatives Courtney, Duckworth, Esty, 
Kirkpatrick, Miller (FL), Murphy (PA), O'Rourke, Rush, Scott 
(GA), Slaughter, and Smith (NJ) were original cosponsors. 
Representatives Bonamici, Brown (FL), Bustos, Cicilline, 
Cleaver, Costello, Cramer, Fitzpatrick, Foster, Garamendi, 
Gibson, Israel, Kline, Kuster, Lujan, Lujan Grisham, Murphy 
(FL), Nolan, Paulsen, Peters, Peterson, Pingree, Quigley, 
Sinema, Walters, Welch, Wenstrup, and Young (IN) were later 
added as cosponsors.
    On January 12, 2015, the House of Representatives suspended 
the rules and passed H.R. 203 by a vote of 403-0. On January 
13, 2015, Senator McCain introduced S. 167, the Clay Hunt 
Suicide Prevention for American Veterans Act. Senators 
Blumenthal, Blunt, Boozman, Brown, Burr, Casey, Donnelly, 
Durbin, Flake, Gillibrand, Hirono, Klobuchar, Manchin, 
Menendez, Moran, Murkowski, Murray, Sanders, Sullivan, and 
Tester were original cosponsors. On January 13, 2015, the bill 
was referred to the Committee. Senators Ayotte, Baldwin, 
Bennet, Boxer, Cantwell, Capito, Cardin, Collins, Coons, 
Cornyn, Daines, Feinstein, Franken, Grassley, Heitkamp, Heller, 
Hoeven, Inhofe, Johnson, King, Kirk, Markey, Murphy, Nelson, 
Peters, Reed, Schumer, Sessions, Shaheen, Stabenow, Tillis, and 
Wyden were later added as cosponsors.

                           Committee Meeting

    On January 21, 2015, the Committee met to consider 
H.R. 203. The bill was ordered to be reported favorably without 
amendment.

                    Summary of H.R. 203 as Reported

    H.R. 203, as reported (hereinafter, ``the Committee 
bill''), would provide for the conduct of annual evaluations of 
mental health care and suicide prevention programs of VA, 
require a pilot program on loan repayment for psychiatrists who 
agree to serve in VHA, and serve other purposes.
    Section 1 provides a short title of, the ``Clay Hunt 
Suicide Prevention for American Veterans Act'' or the ``Clay 
Hunt SAV Act.''
    Section 2 would require VA to obtain an independent third 
party evaluation of VA's mental health care and suicide 
prevention programs to include: (1) use of metrics that are 
common and useful for mental health and suicide prevention 
practitioners; (2) identifying the most effective programs; (3) 
identifying the cost-effectiveness of each program; and (4) 
proposing best practices. The first report will be due no later 
than December 1, 2018, and subsequent reports will be required 
annually thereafter; two interim reports cataloging and 
reporting data on existing programs will be required.
    Section 3 would require VA to publish an interactive Web 
site designed to serve as a centralized source of information 
regarding all VA mental health services.
    Section 4 would require VA to establish a pilot program to 
repay education loans relating to psychiatric medicine for no 
less than ten individuals on the condition that they agree to 
serve no less than 2 years of obligated service within VA.
    Section 5 would require VA to establish a pilot program in 
no less than five Veterans Integrated Service Networks 
(hereinafter, ``VISNs'') to assist veterans transitioning from 
active duty to veteran status and to improve veteran access to 
mental health services with community cooperation.
    Section 6 would authorize VA to collaborate with non-profit 
mental health organizations to: (1) improve the efficiency and 
effectiveness of suicide prevention efforts; (2) assist non-
profit mental health organizations through VA expertise; and 
(3) jointly carry out suicide prevention efforts.
    Section 7 would extend an additional 1 year of eligibility 
for VA health care services for certain combat veterans who 
have not enrolled and whose 5-year combat eligibility period 
recently expired.
    Section 8 stipulates that no additional funds are 
authorized to be appropriated to carry out this Act.

                       Background and Discussion

    Background. The number of veterans using VA mental health 
care treatment has risen from about 900,000 in 2006 to more 
than 1.4 million in 2013 and is expected to increase as 
servicemembers exit the military and enter the VA health care 
system. VA has attributed this increase to the improved 
screening, awareness, and understanding of post traumatic 
stress disorder (hereinafter, ``PTSD'') and other common mental 
health conditions. In testimony submitted for the Committee's 
November 19, 2014, hearing on Mental Health and Suicide Among 
Veterans, Dr. Harold Kudler, Chief Mental Health Consultant for 
VHA, noted the Department ``anticipate(s) that VA's 
requirements for providing mental health care will continue to 
grow for a decade or more after current operational missions 
have come to an end.''
    Mental health diagnoses of veterans range from mild 
depression to severe PTSD, requiring an equally broad range of 
treatment options. According to statistics from VA, since 2002, 
more than 1.7 million servicemembers have left active duty and 
become eligible for VA care. Fifty-eight percent of those 
individuals have sought care from VA and, of those, 55 percent 
have been either diagnosed provisionally or confirmed with a 
mental health condition.
    Additionally, different veterans with the same diagnosis 
may respond differently to the same treatment. The most severe 
cases of PTSD are frequently treated with intensive therapies 
at VA medical centers. Less severe cases can be treated at Vet 
Centers, which often appeal to veterans because of their 
welcoming, home-like nature. Certain veterans respond better to 
one-on-one therapies, while others respond well to group 
environments. Community Based Outpatient Clinics (hereinafter, 
``CBOC'') play an important role in telehealth delivery by 
connecting rural veterans to psychiatry services from the 
medical center.
    In an effort to meet the needs of veterans, VA began 
offering expanded access to mental health services through 
extended evening and weekend clinic hours at larger VA medical 
centers. Moreover, VA began offering same day appointments at 
some VA medical centers and services are available to veterans 
in an emergency situation. Another important change has been 
the inclusion of mental health professionals into primary care 
delivery through VA's Patient Aligned Care Teams. This improves 
the screening process to recognize and treat those veterans who 
present in their primary care location.
    VA clinicians are now trained in--and utilizing--a variety 
of evidence-based therapies, including Cognitive Behavioral 
Therapy and Prolonged Exposure Therapy. The use of these 
therapies helps ensure veterans throughout the country are 
receiving the high-quality care most likely to assist them in 
the treatment and recovery of a broad spectrum of mental health 
diagnoses. However, VA must do a better job tracking 
utilization of these services to ensure clinicians are using 
them appropriately and to make sure they are being used across 
VHA.
    Despite these changes to VA's mental health program, 
difficulties still exist. Over the last few years, the 
Committee has heard from stakeholders about several ongoing 
concerns, which will be discussed below in further detail.

                                SUICIDE

    Tragically, over the past year, it is estimated this nation 
has lost, on average, twenty-two veterans a day to suicide. 
While much of the attention has been focused on the youngest 
cohort of veterans returning from the wars in Iraq and 
Afghanistan, it is reported to be the older cohort of veterans 
who are committing suicide at higher rates. VA's Suicide Data 
Report 2012 found more than 69 percent of veteran suicides are 
among those age 50 years or older.
    Among the youngest cohort of VHA users, the largest 
increase in suicide rates has been among males under 30, 
especially those between 18-25 years of age, according to VA's 
2014 Suicide Data Report Update. This report also highlighted 
an increase in the suicide rate in female VHA users since the 
start of the wars in Iraq and Afghanistan. It is important to 
note, however, that the increase seen in this population is 
comparable to the increases among non-veteran women in the 
United States.

                        ACCESS AND SCOPE OF CARE

    The events at the Phoenix VA Health Care System in 2014 
underscored VA's inability to provide timely access to medical 
services, including mental health appointments. Concerns about 
the Department's scheduling practices had been raised by the 
VA's Office of Inspector General (hereinafter, ``VAOIG'') and 
the Government Accountability Office as early as the 1990s. In 
fact, in April 2012, the VAOIG released a report entitled 
Review of Veterans' Access to Mental Health Care, which showed 
VA was not meeting benchmarks for timely access to mental 
health care services. Some veterans were waiting as long as 60 
days for an evaluation.
    In her written testimony for the Committee hearing entitled 
VA Mental Health Care: Ensuring Timely Access to High-Quality 
Care on March 20, 2013, Kim Ruocco, National Director of 
Suicide Postvention Programs, Tragedy Assistance Program for 
Survivors, provided several examples of veterans who struggled 
to get timely access to treatment. She also discussed the 
challenges of navigating the system:

          At some point, the veteran may decide to go to the VA 
        because he or she is struggling and needs help. Often 
        this happens after a long battle and the 
        servicemember's life is already falling apart and he or 
        she is very sick. The servicemember then contacts the 
        VA looking for help with his or her symptoms, whether 
        it is addiction, anxiety, depression, uncontrollable 
        outbursts of rage, etc. This is a critical time for the 
        veteran . . . . Very often the veteran's suffering is 
        complicated with combinations of physical and emotional 
        pain including issues like traumatic brain injury, 
        post-traumatic stress, depression, moral injury, and 
        survivor guilt. These issues become the veteran's own 
        personal barriers to care. In this population we see 
        avoidance, anxiety and trouble concentrating. Symptoms 
        like panic attacks, flashbacks and hyper-vigilance 
        among this population of veterans are often described 
        to us by our surviving families.
          These symptoms run counterintutitive to navigating a 
        complex system of paperwork, crowded waiting rooms, 
        extended wait times for appointments, referrals and 
        disability ratings. The veteran enters the system 
        tentatively with trepidation and some fear. The veteran 
        is barely holding on. The veteran may feel like people 
        do not understand him and that the public does not 
        appreciate what he or she has sacrificed for this 
        country . . . . When the veteran asks for help, he or 
        she is desperate, and may be thinking of killing 
        himself or herself because he or she is losing hope 
        that things will get better. This is the composite 
        profile of the veteran who dies by suicide, who 
        initially approaches the VA for help.

    During the Committee's November 19, 2014, hearing, Susan 
Selke, Clay Hunt's mother, testified that her son exclusively 
used VA for his medical care after leaving the Marine Corps. 
She went on to note:

          Clay constantly voiced concerns about the care he was 
        receiving, both in terms of the challenges he faced 
        with scheduling appointments as well as the treatment 
        he was receiving for PTS, which consisted primarily of 
        medication . . . . Clay used to say, ``I am a guinea 
        pig for drugs.''

    Mrs. Selke also recalled a conversation she had with her 
son 2 weeks before his death:

          Clay had only two appointments in January and 
        February 2011, and neither was with a psychiatrist. It 
        was not until March 15 that Clay was finally able to 
        see a psychiatrist at the Houston VA medical center. 
        But after the appointment, Clay called me on his way 
        home and said, ``Mom, I can't go back there. The VA is 
        way too stressful and not a place I can go. I will have 
        to find a Vet Center or something.''

    Ensuring VA is providing veterans with the types of mental 
health care they want is paramount. In testimony before the 
House Committee on Veterans' Affairs on July 10, 2014, Warren 
Goldstein, Assistant Director for Traumatic Brain Injury and 
PTSD programs in the National Veterans Affairs and 
Rehabilitation Commission of The American Legion, discussed the 
findings of a survey conducted by the organization, which found 
more than half of the 3,100 veterans surveyed did not believe 
their symptoms improved as a result of psychotherapy or 
medication prescribed at VA. Furthermore, nearly a third of 
veterans actually terminated their treatment before it 
concluded. They cited reasons like stigma, travel burden, side 
effects, and frustration with the lack of progress that drove 
veterans to discontinue treatment before the end of the 
treatment cycle.

                           STAFFING SHORTAGES

    Presenting testimony on behalf of the American Federation 
of Government Employees (hereinafter, ``AFGE''), AFL-CIO, and 
the AFGE National VA Council, Michelle Williams, Ph.D., a 
coordinator of PTSD Services and Evidence Based Psychotherapy 
at the Wilmington VA Medical Center, recounted numerous stories 
about staffing issues related to mental health providers during 
the November 30, 2011, hearing on VA Mental Health Care: 
Addressing Wait Times and Access to Care. In one instance, a 
psychiatrist in a general mental health clinic stated he felt 
like ``staffing levels [would] `never catch up' with the 
growing demand for services and that at his medical center, 
trying to keep up with patients' needs [is] like `a finger in 
the dike'.'' Another psychologist at a CBOC noted she was 
overbooked every day, as she was the only mental health 
provider at that facility. She found herself handling 
individual and group appointments, walk-ins, and call-ins, as 
well as some compensation and pension examinations. This 
provider had a caseload of more than 200 patients, many of whom 
were considered high-risk patients.
    In an effort to address staffing shortages, on August 31, 
2012, President Obama signed an Executive Order directing VA to 
hire 1,600 more mental health professionals. Despite these 
additions, the Committee continued to hear concerns about 
shortages of mental health professionals across the country. As 
a result, recruitment and retention of medical professionals at 
VA became a focus during the 113th Congress as events at 
Phoenix and other VA facilities came to light during the summer 
of 2014. The Veterans Access, Choice, and Accountability Act of 
2014 (hereinafter, ``VACAA'') sought to increase the number of 
graduate medical education residency slots by up to 1,500 over 
a 5-year period, with an emphasis on those pursuing primary 
care, mental health, and other specialties the Secretary deems 
appropriate; gave priority to the five medical occupations the 
VAOIG has identified as having the largest staffing shortages; 
and increased the maximum amount of money available to eligible 
VA health care professionals in their Education Debt Reduction 
Program.
    However, given the extent of the national shortage of 
mental health care professionals across the United States, VA 
must continue to enhance its ability to recruit and retain 
staff. Rural and highly rural parts of the country face the 
largest burden.
    In the months following VACAA's implementation, the 
Committee heard from Dr. Elspeth Cameron Ritchie, Chief 
Clinical Officer, District of Columbia Department of Mental 
Health and Member of the Committee on the Assessment of Ongoing 
Efforts in the Treatment of Posttraumatic Stress Disorder, 
Institute Of Medicine, The National Academies, during the 
Committee's November 19, 2014, hearing on Mental Health and 
Suicide Among Veterans. She stated:

          [The Department of Defense] and VA have substantially 
        increased their mental health staffing--both direct 
        care and purchased care. However, staffing increases do 
        not appear to have kept pace with the demand for PTSD 
        services. Staffing shortages can result in clinicians 
        not having sufficient time to provide evidence-based 
        psychotherapies readily and with fidelity. The lack of 
        time to deliver psychotherapy with fidelity is 
        reflected in the fact that in 2013 only 53 percent of 
        [Operation Enduring Freedom (hereinafter, ``OEF'')] and 
        [Operation Iraqi Freedom (hereinafter, ``OIF'')] 
        veterans who had a primary diagnosis of PTSD and sought 
        care in the VA received the recommended eight sessions 
        within 14 weeks.

    In an effort to better meet the needs of veterans with 
mental health conditions, as a part of the President's 2012 
Executive Order to hire additional mental health staff, VA 
announced some of those slots would be used to hire peer 
support specialists. Within the last 2 years, VA has been able 
to hire 900 peer support specialists and apprentices to be 
incorporated into VA's mental health programs. These peer 
support specialists are uniquely positioned to relate to 
veterans and can serve on the front line of support for those 
veterans who are hesitant to seek care. VA has announced that 
it will start piloting the expansion of peer support to 
veterans in primary care settings. The pilot is expected to 
place one to two peer specialists in 25 primary care sites 
across the country.
    The Committee has heard from multiple witnesses over the 
years about the value of peer support. For example, in his 
written testimony to the Committee on November 30, 2011, John 
Roberts, the Executive Vice President of Mental Health and 
Family Services for the Wounded Warrior Project (hereinafter, 
``WWP'') drew attention to this when he discussed the findings 
of a survey of WWP alumni. He stated that ``nearly 30 percent 
identified talking with another OEF/OIF veteran as the most 
effective resource in coping with stress--the highest response 
rate of all the resources cited, including VA care (24 
percent), medication (15 percent) and talking with non-military 
family or friend (8 percent).''

                             OVERMEDICATION

    The effect of combat does not end when veterans return from 
the battlefield. For many servicemembers returning home from 
war, chronic pain is part of daily life. VA's latest health 
care utilization report notes musculoskeletal ailments--like 
joint, neck, and back disorders--are the most frequent 
conditions diagnosed among post-9/11 veterans. A common symptom 
of these ailments is chronic pain. In fact, VA's own statistics 
from the Office of Health Service Research & Development show 
50 percent of male veterans treated by VHA suffer from chronic 
pain and among female veterans the prevalence may be higher. As 
noted earlier in this report, 55 percent of the 58 percent of 
post-9/11 veterans seeking care at VA have a mental health 
diagnosis. Treating the invisible wounds of war can be 
challenging and often requires veterans to take multiple 
medications in order to help these individuals live fuller 
lives. However, these drugs come with significant risk if not 
properly monitored. In response to numerous stories in the 
media highlighting the problem of overmedication as it relates 
to servicemembers and veterans, especially in regards to 
opioids, the Committee held a hearing on the subject on April 
30, 2014.
    Recognizing both the need for these medications in order to 
properly treat veterans as well as the risks associated with 
their misuse, VA has taken steps to address this issue. One of 
the Department's most recent efforts is the Opioid Safety 
Initiative (hereinafter, ``OSI''). Started in October 2013 in 
Minneapolis, Minnesota, with a goal of reducing dependency on 
opioid use, this initiative includes a team approach that 
educates veterans and provides patient monitoring with 
feedback. This program also helps ensure access to, and 
encourages the use of, Complementary and Alternative Medicine 
therapies for its participants. In written testimony to the 
Committee on April 30, 2014, Dr. Robert Petzel, Under Secretary 
for Health at VHA, noted that, as a result of implementing the 
OSI, ``Minneapolis has seen a nearly 70 percent decrease in 
high-dose opioid prescribing for chronic non-cancer pain 
patients.'' Given the positive results seen in Minnesota, VA 
decided to implement this initiative nationwide.
    VA has also begun a program known as the Academic Detailing 
Service to identify and disseminate best practices for 
evidence-based mental health treatments. It also seeks to 
improve treatment outcomes while reducing reliance on high-dose 
medications to treat chronic mental health conditions. This 
initiative was initially piloted in VISNs 21 and 22. Following 
its success, VISNs 3, 12, 17, 19, and 23 are preparing to 
implement the program as well.
    While these efforts to reduce the use of opioids at VA are 
commendable, more remains to be done. A recent Administrative 
Closure by the VAOIG for alleged inappropriate prescribing 
practices of opioids at the VA Medical Center in Tomah, 
Wisconsin, has raised new concerns about the overuse of opioids 
at VA.

                                OUTREACH

    The Committee has heard regularly from witnesses and 
constituents that VA's outreach efforts are inadequate. Many 
have discussed the difficulties of not only navigating the 
system but also knowing what services are available. In an 
effort to address some of these concerns, the Committee held a 
hearing entitled Call to Action: VA Outreach and Community 
Partnerships on April 23, 2013. During the hearing, it was 
highlighted that from fiscal year (hereinafter, ``FY'') 2009 
through 2013, VA spent a total of $83.7 million on its outreach 
efforts, yet a 2010 survey found 60 percent of veterans knew 
``very little'' or ``nothing at all'' about their VA benefits, 
including access to health care.
    One of the main reasons a veteran may be reluctant to seek 
mental health treatment is the stigma surrounding such 
treatment. In his written testimony for the Committee on April 
23, 2013, Eric Weingarter, the Managing Director of the 
Survival and Veterans program at the Robin Hood Foundation 
observed:

          Many individuals fear that seeking mental health 
        services will jeopardize their career, community 
        standing or both. Others are reluctant to expose their 
        vulnerabilities to providers who may also be Armed 
        Forces personnel themselves, given the military's 
        emphasis on strength, confidence, and bravery. And some 
        veterans have found the settings or providers they used 
        especially bureaucratic or unsatisfactory in other 
        ways, and would pursue a different option if available.

    A similar sentiment was expressed by Lieutenant Colonel 
(hereinafter, ``LTC'') Kenny Allred, U.S. Army (Ret.), Chair of 
the Veterans and Military Council of the National Alliance on 
Mental Illness (hereinafter, ``NAMI''), in written testimony 
provided to the Committee on March 20, 2013, for its hearing 
about mental health wait times. LTC Allred stated:

        ``NAMI believes that the key to reducing stigma and 
        strengthening suicide prevention is a change in the way 
        we approach these problems. It is absolutely 
        unacceptable to be applying the resources we have over 
        the last 10 years and to see suicides grow at a rate of 
        twenty-percent among veterans from eighteen to twenty-
        two a day. Many of these suicides are occurring among 
        those who have never been in combat. In 2012, suicide 
        deaths among soldiers were higher than combat deaths.''

He also stressed the need for ``addressing the health and 
mental health care needs of National Guard and Reservists who 
are not considered `veterans' despite their service. These 
individuals have frequently experienced the same challenges and 
trauma as those in the more traditional branches of the 
military.''

                            EXPANDED ACCESS

    Under current law, section 1710(e) of title 38, U.S.C., 
combat veterans are eligible to enroll in the VA health care 
system up to 5 years post discharge. During such time, veterans 
are eligible for enrollment in Priority Group 6. Those who 
receive a service-connected disability rating are reassigned to 
the highest applicable health care priority group. At the end 
of the 5-year period, all others are moved to Priority Group 7 
or 8, depending on income level. Veterans in health care 
Priority Groups 7 and 8 generally pay copayments for treatments 
and medications.
    VA reports nearly 1 million of the 1.6 million veterans, 
discharged from active duty since 2002, have received VA health 
care services. Furthermore, OEF/OIF/Operation New Dawn veterans 
constitute 9 percent of the 6.3 million individuals who 
received VA health care during FY 2012.\1\
---------------------------------------------------------------------------
    \1\Epidemiology Program, Veterans Health Administration, Dep't of 
Veterans Affairs, Analysis of VA Health Care Utilization among 
Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and 
Operation New Dawn (OND) Veterans 5 (2013).
---------------------------------------------------------------------------
    Based on anecdotes and research, it has been suggested the 
5-year period under current law may be inadequate. A 2012 study 
found the median time for initiation of mental health 
outpatient care was 4.1 years for veterans. The time between 
first mental health outpatient clinic care and initiation of 
minimally adequate care was 2 years longer for male veterans 
than for female veterans (8.02 and 5.98 years, respectively, 
p<.001), thus supporting the need for a 1-year extension of 
combat veterans health care.\2\
---------------------------------------------------------------------------
    \2\Maguen, S., Madden, E., Cohen, B. E., Bertenthal, D., & Seal, K. 
H. ``Time to Treatment Among Veterans of Conflicts in Iraq and 
Afghanistan with Psychiatric Diagnosis'' Psychiatric Services 63 (12) 
1206-1212.
---------------------------------------------------------------------------
    In his testimony before the Committee on November 19, 2014, 
to support an earlier version of the Clay Hunt SAV Act, Senator 
Walsh reiterated this sentiment when he discussed delayed onset 
PTSD. He noted:

          According to the National Comorbidity Survey, only 7 
        percent of people with PTSD seek treatment within 1 
        year of their initial trauma event. The average time it 
        takes to seek treatment is well beyond the current 5-
        year combat eligibility period. Several major studies 
        have also shown that between 16 and 20 percent of 
        combat troops with mental illness suffered from delayed 
        onset PTSD, the symptoms of which may not appear for 
        several years.

    Committee Bill. The Committee bill would provide for annual 
evaluations of mental health care and suicide prevention 
programs of VA. The Committee bill would direct VA to publish 
on their Web site the mental health services available at VA. 
The Committee bill would establish a pilot program on loan 
repayment for psychiatrists who agree to serve in VHA. The 
Committee bill would improve access to mental health services 
of transitioning servicemembers. The Committee bill would 
provide for collaboration between VHA and non-profit mental 
health providers. The Committee bill would extend for 1 
additional year the period of eligibility of certain combat 
veterans for enrollment in VHA for health care. Specifically, 
the changes made by each section of the bill are outlined 
below.
    Section 2(a) of the bill would amend chapter 17 of title 
38, U.S.C., to provide for annual independent third-party 
evaluations of VA's mental health and suicide prevention 
programs. This section would also provide for VA to submit to 
the Senate Committee on Veterans' Affairs and the House 
Committee on Veterans' Affairs the most recent evaluation and 
any recommendations VA considers appropriate.
    The Committee intends that the required ``evaluation[s] of 
the mental health care and suicide prevention programs'' 
described in this provision will include a review of opioid 
prescription trends by doctors in the VA system. The review of 
opioid prescription practices shall include, but not be limited 
to: (1) an evaluation of VA opioid prescription patterns of 
take-home opioids, including frequency of written prescriptions 
for opioids, amount of opioids prescribed, and medications 
(type and amount) that are concurrently prescribed with opioids 
to patients; (2) an evaluation of VA dispensing patterns, 
including data on early refill requests and how often those 
early refill requests are granted; (3) a description of both 
the prevalence of VA patients who filled any take-home opioid 
prescriptions at a VA facility in the given fiscal year and 
those patients' baseline characteristics; (4) an assessment on 
whether VA facilities are adequately following VA/Department of 
Defense Clinical Practice Guidelines for Management of Opioid 
Therapy for Chronic Pain screening and monitoring guidelines 
for patients prescribed opioids; and (5) an assessment of VA 
patterns for prescribing opioid treatment for patients 
suffering from mental health disorders.
    Section 2(b) of the bill would direct VA to submit interim 
reports on VA's mental health and suicide prevention programs 
to the Senate Committee on Veterans' Affairs and the House 
Committee on Veterans' Affairs.
    Section 3(a) of the bill would direct VA to publish on the 
Internet information regarding all of the mental health 
services provided by VA.
    Section 3(b) of the bill describes the elements VA must 
include on the Web site directed to be built under section 
3(a), which includes the mental health care services available 
to veterans, contact information of each social work office and 
mental health clinic, and a list of mental health staff 
supporting these offices.
    Section 3(c) of the bill would direct VA to update the 
information on the Web site directed to be built under section 
3(a) at least every 90 days.
    Section 3(d) of the bill would direct VA to ensure that 
outreach directed under section 1720F(i) of title 38, U.S.C., 
regarding VA's outreach of the comprehensive suicide prevention 
program includes information about the Web site directed to be 
built under section 3(a).
    Section 4(a) of the bill would require VA to establish a 
pilot program to provide for the repayment of educational loans 
of certain psychiatrists.
    Section 4(b) of the bill would establish those eligible for 
the pilot program would be psychiatrists licensed or eligible 
to practice medicine at VA or in their final year of a 
residency program leading to a specialty in psychiatry, if they 
demonstrate a commitment to a long-term career at VHA. Section 
4(b) would also prohibit an individual who is participating in 
any other Federal government educational loan repayment program 
from participating in this pilot program.
    Section 4(c) of the bill would limit the participation of 
this program to not less than ten individuals.
    Section 4(d) of the bill would create, for those 
participating in the pilot program, an obligatory period of 
service of 2 or more years at VA.
    Section 4(e) of the bill outlines that the loan repayment 
may consist of the principal, interest, and related expenses 
and limits the amount paid to $30,000 for each year of 
obligated service.
    Section 4(f) of the bill would provide that an individual 
who does not satisfy the period of obligatory service under 
section 4(d) would be liable to repay to the United States the 
amount that had been paid on behalf of the individual, reduced 
proportionally based on the service completed.
    Section 4(g) of the bill directs VA to submit to the Senate 
Committee on Veterans' Affairs and the House Committee on 
Veterans' Affairs an initial report 2 years after the pilot 
program commences and a final report 90 days after it ends.
    Section 4(h) of the bill directs VA to prescribe 
regulations to carry out this section.
    Section 4(i) of the bill would terminate the pilot program 
3 years after the date on which it commences.
    Section 5(a) of the bill would require VA to create a pilot 
program to improve access to mental health services for 
transitioning servicemembers with mental health conditions.
    Section 5(b) of the bill would limit the locations of the 
pilot program created under section 5(a) to not less than five 
Veterans Integrated Service Networks with a large population of 
veterans who have served in the National Guard or reserves or 
with a large population of veterans transitioning back to 
Veterans Integrated Service Networks with large established 
veterans' populations.
    Section 5(c) of the bill describes the functions of the 
pilot program established by section 5(a). The program would 
include a community oriented veteran peer support program and a 
community outreach team for one VA medical center in each of 
the participating VISNs.
    Section 5(d) of the bill directs VA to submit to the Senate 
Committee on Veterans' Affairs and the House Committee on 
Veterans' Affairs an initial report 18 months after the pilot 
program starts and a final report not later than 90 days before 
the pilot program ends.
    Section 5(e) of the bill stipulates that section 5 will not 
be construed as authorizing VA to hire additional employees to 
carry out this section.
    Section 5(f) of the bill would terminate this pilot program 
3 years after it commences.
    Section 6(a) of the bill authorizes VA to collaborate with 
non-profit mental health organizations to improve efficiency 
and effectiveness of VA's suicide prevention programs; assist 
the non-profits through the use of the expertise of VA 
employees; and jointly carry out suicide prevention efforts.
    Section 6(b) of the bill directs VA, if VA engages any non-
profits for that purpose, to collaborate with those non-profit 
mental health organizations to share best practices and 
exchange training sessions.
    Section 6(c) of the bill directs VA to designate a Director 
of Suicide Prevention Coordination to implement this section.
    Section 7 of the bill would, for certain combat veterans 
whose period of eligibility under section 1710(e)(3) of title 
38, U.S.C., has expired, extend for 1 additional year 
eligibility for health care at VHA.
    Section 8 of the bill stipulates that no new appropriations 
shall be used to carry out this Act. It is the Committee's 
intent that VA use funding otherwise made available for mental 
health and suicide prevention programs.

                      Committee Bill Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the Congressional Budget Office 
(hereinafter, ``CBO''), estimates that enactment of the 
Committee bill would, relative to current law, cost $24 million 
over the 2015-2020 period, subject to appropriation of the 
necessary amounts, but would not affect direct spending or 
revenues. Enactment of the Committee bill would not affect the 
budget of state, local, or tribal governments.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                               Congressional Budget Office,
                                  Washington, DC, January 28, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 203, the Clay Hunt 
Suicide Prevention for American Veterans Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell.
            Sincerely,
                                      Douglas W. Elmendorf,
                                                          Director.

  Enclosure.

H.R. 203--Clay Hunt Suicide Prevention for American Veterans Act

    Summary: H.R. 203 would require the Department of Veterans 
Affairs (VA) to have programs for mental health care and 
suicide prevention evaluated annually. The bill also would 
extend the period of eligibility for health care for combat 
veterans and establish pilot programs for community outreach 
and repayment of education loans. In total, CBO estimates that 
implementing the bill would cost $24 million over the 2015-2020 
period, subject to appropriation of the necessary amounts.
    Pay-as-you-go procedures do not apply to this legislation 
because it would not affect direct spending or revenues.
    H.R. 203 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would not affect the budgets of state, local, or tribal 
governments.
    Estimated cost to the Federal Government: The estimated 
budgetary effect of H.R. 203 is shown in the following table. 
The costs of this legislation fall within budget function 700 
(veterans benefits and services).
    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted early in calendar year 2015, that 
the necessary amounts will be appropriated for each year, and 
that outlays will follow historical spending patterns for 
similar and existing programs.

----------------------------------------------------------------------------------------------------------------
                                                                   By fiscal year, in millions of dollars--
                                                            ----------------------------------------------------
                                                              2015   2016   2017   2018   2019   2020  2015-2020
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION
 
Evaluations of Mental Health Care and Suicide Prevention
 Programs
    Estimated Authorization Level..........................      0      0      0      2      2      2         6
    Estimated Outlays......................................      0      0      0      2      2      2         6
Web site on Mental Health Care Services
    Estimated Authorization Level..........................      *      *      *      *      *      *         1
    Estimated Outlays......................................      *      *      *      *      *      *         1
Pilot Program for Repayment of Education Loans for Certain
 Psychiatrists
    Estimated Authorization Level..........................      *      1      1      1      0      0         3
    Estimated Outlays......................................      *      1      1      1      *      0         3
Pilot Program on Community Outreach
    Estimated Authorization Level..........................      1      2      2      2      0      0         7
    Estimated Outlays......................................      1      2      2      2      *      0         7
Collaborative Efforts to Prevent Suicide
    Estimated Authorization Level..........................      *      *      *      *      *      *         1
    Estimated Outlays......................................      *      *      *      *      *      *         1
Extension of Enhanced Eligibility for Certain Veterans
    Estimated Authorization Level..........................      1      1      1      1      1      1         7
    Estimated Outlays......................................      1      1      1      1      1      1         7
                                                            ----------------------------------------------------
    Total Changes
        Estimated Authorization Level......................      3      4      5      6      3      3        24
        Estimated Outlays..................................      3      4      5      6      3      3        24
----------------------------------------------------------------------------------------------------------------
Note: Components may not sum to totals because of rounding; * = less than $500,000.

    CBO estimates that implementing H.R. 203 would have a 
discretionary cost of $24 million over the 2015-2020 period, 
assuming appropriation of the estimated amounts.

Evaluations of Mental Health Care and Suicide Prevention Programs

    Section 2 would require VA to have an independent entity 
conduct annual evaluations of the mental health care and 
suicide prevention programs at the department. In 2013, VA 
entered into a 4-year contract with an independent entity for 
$7.7 million to perform a comprehensive assessment of VA's 
mental health care system. That study will be completed at the 
end of fiscal year 2017. CBO assumes that assessment will 
address the requirements of this provision through 2017. As a 
result, we assume no additional cost from 2015 through 2017. 
Based on the costs of that assessment and adjusting for 
inflation, CBO estimates that section 2 would cost $6 million 
over the 2018-2020 period for ongoing evaluations, assuming 
appropriation of the necessary amounts.

Web site on Mental Health Care Services

    Section 3 would require VA to publish, at a centralized 
location on the Internet, up-to-date information for each 
Veteran Integrated Service Network (a regional VA health care 
system). That information would have to include the following 
items:

     Name and contact information of VA social work 
offices,
     Locations of VA mental health clinics, and
     Contact information of VA practitioners of mental 
health care.

    We assume that VA would provide this information on their 
existing mental health care Web site. Based on previous efforts 
by VA to compile and publish information online, we estimate 
upfront costs in 2015 for information technology to revise the 
mental health care Web site and compile the data would total 
less than $500,000. Thereafter, VA would be required to update 
the online material at least four times each year. Over the 
2015-2020 period, CBO estimates the total cost of this 
provision would be $1 million, assuming availability of 
discretionary funds.

Pilot Program for Repayment of Education Loans for Certain 
        Psychiatrists

    Section 4 would require VA to carry out a 3-year pilot 
program to repay the education loans of certain psychiatrists. 
Eligible psychiatrists would include those who are licensed as 
well as those in their last year of residency who agree to work 
at VA for a certain period of time. The department would be 
required to select at least 10 individuals each year for this 
pilot program, and to repay up to $30,000 per individual for 
every year of obligated service.
    For this estimate, CBO assumes that VA would completely 
repay the loans of 10 individuals in each year of the pilot 
program, and that half of the participants would be newly 
licensed psychiatrists and half would be established 
psychiatrists. Based on information from the National Center 
for Education Statistics and the Association of American 
Medical Colleges, we estimate that newly licensed and 
established psychiatrists would have average education loan 
debts of $120,000 and $50,000, respectively, in 2015. After 
factoring in the growth in costs for higher education, CBO 
estimates that implementing the pilot program would cost $3 
million over the 2015-2020 period, assuming appropriation of 
the necessary amounts.

Pilot Program on Community Outreach

    Section 5 would require VA to conduct a 3-year pilot 
program to assist veterans who recently left active-duty 
service in accessing mental health services offered by the 
department. The program would operate peer support networks and 
outreach programs at the local level in five regions of the VA 
health care system. To carry out this program, we estimate that 
VA would hire five peer support specialists at an annual salary 
of $60,000 each, five clinical support staff (certified mental 
health professionals) at a salary of $120,000 each, and a total 
of 10 support staff for the community outreach teams at a 
salary of $60,000 each. After including benefits and taking 
account of inflation, CBO estimates that implementing this 
provision would increase costs for salary and benefits by $6 
million over the 2015-2020 period.
    Section 5 also would require VA to hold an annual mental 
health summit during the 3-year period of the pilot program. 
After factoring in costs for transportation, hotel 
accommodations, food, and conference space, CBO estimates 
discretionary costs of roughly $200,000 each year for the 
annual summit. In total, CBO estimates that implementing 
section 5 would cost $7 million over the 2015-2020 period, 
assuming appropriation of the necessary amounts.

Collaborative Efforts to Prevent Suicide

    Section 6 would authorize VA to collaborate with nonprofit 
organizations that provide mental health services. This section 
also would require VA to appoint a Director of Suicide 
Prevention Coordination to manage the collaborative efforts. 
According to VA, such collaboration is already ongoing. As a 
result, we estimate that the only additional cost would be for 
hiring a new director. Assuming a salary level of GS-15, CBO 
estimates those costs would total $1 million over the 2015-2020 
period.

Extension of Enhanced Eligibility for Certain Veterans

    Section 7 would extend--for 1 year after the date of 
enactment of H.R. 203--the period of enhanced enrollment in the 
VA health care system for certain veterans. Under current law, 
veterans who served after 2003 have up to 5 years after being 
discharged from the military to enroll in the VA health care 
system with enhanced priority (priority group 6).\1\ This 
section would extend that window by 1 year for veterans who 
separated from active-duty service between January 1, 2009, and 
January 1, 2011.
---------------------------------------------------------------------------
    \1\Enrollment in the VA health care system is based on eight 
priority groups. The highest priority group consists of veterans who 
have the most severe service-connected disabilities (priority groups 1-
3); the lowest priority group consists of higher-income veterans who 
have no compensable service-connected disabilities (priority groups 7-
8). Section 7 would allow certain veterans to enroll under priority 
group 6, which makes veterans eligible for lower copayments when they 
receive services.
---------------------------------------------------------------------------
    Based on data from VA on historical participation rates, 
CBO estimates that about 4,600 veterans would take advantage of 
the extended period of enhanced enrollment. This number does 
not include veterans who would qualify for higher priority 
groups (1 through 5). Using income data from the U.S. Census 
Bureau, we estimate that 3,200 of those veterans (or 70 
percent) would have qualified and enrolled for VA health 
benefits under the income criteria of the lowest priority 
groups (priority groups 7 and 8). For those veterans, during 
the 1-year period of enhanced eligibility, we estimate an 
annual difference in VA health care costs per enrollee of $200. 
After the enhanced eligibility expires, we assume VA would 
shift those veterans to the lower priority groups that they 
would have otherwise enrolled in--therefore resulting in no 
additional costs in those years.
    We expect that the remaining 1,400 veterans would not be 
eligible to enroll in the VA health care system under current 
law. For those veterans we estimate average annual costs of 
$1,000 per enrollee, during the 1-year period of enhanced 
eligibility. After that period, we assume VA would shift those 
veterans to the lower priority groups--with average annual 
costs of about $800 per enrollee.
    In total, CBO estimates that implementing this section 
would cost $7 million over the 2015-2019 period, assuming 
appropriation of the necessary amounts.
    Pay-As-You-Go Considerations: None.
    Intergovernmental and private-sector impact: H.R. 203 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would not affect the budgets of state, 
local, or tribal governments.
    Estimate prepared by: Federal Costs: Ann E. Futrell; Impact 
on State, Local, and Tribal Governments: Jon Sperl; Impact on 
the Private Sector: Paige Piper-Bach.
    Estimate approved by: Theresa Gullo, Deputy Assistant 
Director for Budget Analysis.

                      Regulatory Impact Statement

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

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7(b) of rule XXVI of the 
Standing Rules of the Senate, the following is a tabulation of 
votes cast in person or by proxy by Members of the Committee on 
Veterans' Affairs at its January 21, 2015, meeting.

 
----------------------------------------------------------------------------------------------------------------
                Yeas                                 Senator                                 Nays
----------------------------------------------------------------------------------------------------------------
                                 X   Mr. Moran
                                 X   Mr. Boozman
                                 X   Mr. Heller
                                 X   Mr. Cassidy
                                 X   Mr. Rounds
                                 X   Mr. Tillis
                                 X   Mr. Sullivan
                                 X   Mr. Blumenthal
                      X (by proxy)   Mrs. Murray
                      X (by proxy)   Mr. Sanders
                                 X   Mr. Brown
                      X (by proxy)   Mr. Tester
                                 X   Mr. Hirono
                                 X   Mr. Manchin
                                 X   Mr. Isakson, Chairman
----------------------------------------------------------------------------------------------------------------
15                                   TALLY                                                                    0
----------------------------------------------------------------------------------------------------------------

                             Agency Report

    On March 23, 2015, Robert A. McDonald, Secretary, U.S. 
Department of Veterans Affairs, provided views on H.R. 203, 
among other issues. An excerpt from the Department views is 
reprinted below:

                         The Secretary of Veterans Affairs,
                                    Washington, DC, March 23, 2015.
Hon. Johnny Isakson,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: I am pleased to provide the Department 
of Veteran Affairs views on H.R. 203, the Clay Hunt Suicide 
Prevention for American Veterans Act, also referred to as the 
Clay Hunt SAV Act. As you know, the President signed the bill 
into law on February 12, 2015, and in his remarks at the 
signing expressed in detail the Administration's support for 
the bill and the critical importance of the areas touched on by 
H.R. 203.
    Mental health care and suicide prevention are among VA's 
highest priorities. Veterans who need help must receive that 
help when and where they need it. VA supports the Clay Hunt SAV 
Act and believes this bill complements VA's on-going multi-
faceted efforts to improving mental health care for our 
Nation's Veterans. These efforts include our implementation of 
the President's Executive Actions announced this summer, which 
focused on improving the transition from Department of Defense 
to VA for servicemembers with mental health needs, improving 
mental health peer support, and promoting mental health 
awareness and training.
    We are committed to excellence in mental health treatment 
through regular program monitoring and working with staff to 
make program improvements. VA's mental health program not only 
addresses medical treatment, but also encompasses training, 
research, support services for Veterans and their families, 
partnerships with community organizations, expanded 
eligibility, hiring efforts, technology advances, and 
innovative communications strategies to reduce negative 
perceptions of seeking mental health care.
    VA has seen improvements in our mental health program, but 
we know that there is more work to be done so that Veterans can 
reach out for help and connect with services. We appreciate the 
steps Congress has taken to support this goal through the 
passage of the Clay Hunt SAV Act.
    In the 113th Congress, VA testified before the House 
Veterans' Affairs Health Subcommittee on November 19, 2014 
regarding the introduced version of the Clay Hunt SAV Act, H.R. 
5059. H.R. 203 includes many but not all of the provisions of 
H.R. 5059 in substantially similar form--specifically sections 
1, 2, 4, 6, and 9 of H.R. 5059 as introduced. Enclosed please 
find for reference relevant testimony excerpts from that 
hearing. VA's detailed views on these provisions as provided 
then are unchanged.
    Thank you for your continued support of our Nation's 
Veterans.
            Sincerely,
                                         Robert A. McDonald

  Enclosure.

                               Enclosure

    Excerpts from Testimony Regarding H.R. 5059 (113th 
Congress) as introduced, delivered before the House Veterans' 
Affairs Health Subcommittee on November 19, 2014:

           *       *       *       *       *       *       *


              H.R. 5059, CLAY HUNT SUICIDE PREVENTION FOR 
                         AMERICAN VETERANS ACT

    Mental health care and suicide prevention are among VA's 
highest priorities, and we appreciate that the Congress 
continues to raise awareness of these important issues. VA 
agrees with many of the goals of the bill, and as expressed 
below, existing efforts of the Department are aligned with 
those goals. VA would welcome discussion with the Committee to 
examine how some provisions could be adjusted to complement 
VA's ongoing multi-faceted efforts.
    Turning to the specifics of the bill, Section 2 of H.R. 
5059 would require VA and DOD to each have an independent third 
party conduct annual evaluations of the mental health care and 
suicide prevention programs that are carried out by the 
respective Departments.
    VA supports the intent of this provision to further suicide 
prevention but has recommendations to improve its effectiveness 
to combat Veteran suicide, including addressing issues where 
there is duplication of robust activity that is ongoing at VA.
    VA does not believe that requiring an additional ongoing 
evaluation effort is necessary for its mental health and 
suicide prevention programs, as they are regularly reviewed by 
external accrediting bodies including the Joint Commission and 
Commission on Accreditation of Rehabilitation Facilities (CARF) 
as well as many internal review processes. In addition, VA 
already has robust evaluation efforts focused on mental health 
care and suicide prevention. For example, in prior years the 
Congress mandated programs such as the North East Program 
Evaluation Center (NEPEC), Serious Mental Illness Treatment, 
Resource and Evaluation Center (SMITREC), and the Program 
Evaluation Resource Center (PERC). These internal resources 
allow for timely reports from subject matter experts in 
evaluation who are familiar with the complexities of using and 
analyzing VA's administrative data. Additionally, VA complies 
with current the Congressionally-mandated reporting 
requirements, which include posting of information online, 
pursuant to Public Law 112-239 (FY 2013 NDAA), section 726. 
Section 726 requirements overlap with some of the areas 
mentioned in section 2 of the proposed bill to report on the 
annual evaluation of VA mental health programs to the Congress 
and the public. Section 726 calls for the establishment of a 
contract with the National Academy of Sciences (NAS) to conduct 
an assessment and provide an analysis and recommendations on 
the state of VA mental health services. VA has actually already 
embarked on such a project with NAS that is closely aligned 
with this requirement. For suicide prevention, VA has been 
increasing our understanding of suicide among Veterans by 
developing data sharing agreements with all 50 U.S. states and 
several U.S. territories. The initial VA Suicide Data Report 
issued in February 2013 was the first effort to analyze these 
more complete and timely data points and provide a more 
comprehensive understanding of Veteran suicide to inform VA's 
suicide prevention efforts. The February 2013 report contained 
data and analysis from 21 states.
    In an effort to understand the picture of Veteran suicide 
more completely, VA has advanced development of a VA/DOD 
Suicide Data Repository (SDR). The January 2014 update to the 
VA Suicide Data Report is the first analysis using the SDR 
information. This update also incorporates more recent data 
from the National Death Index and provides information about 
suicide rates, which the initial VA Suicide Data Report issued 
in February 2013, did not.
    VA does support, with some modification, the bill's 
requirement for review of the Department's suicide prevention 
programs, and looks forward to discussion of this important 
element of the bill. A Joint VA/DOD Clinical Practice Guideline 
(CPG) for the Assessment and Management of Patients at Risk for 
Suicide was released in 2013. VA recommends that a one-time 
evaluation of the suicide prevention program be conducted to 
support implementation of these guidelines. VA believes it can 
benefit from a one-time, targeted evaluation of this effort.
    [Testimony regarding Section 3 omitted]
    VA supports the intent of section 4. This section would 
require VA to: (1) provide Veterans information regarding all 
of the mental health care services available in the VISN where 
the Veteran is seeking such services, including the name and 
contact of each social work office, mental health clinic, and a 
list of appropriate staff; (2) update the information every 90 
days; and (3) include information about the Web site in 
outreach efforts.
    This requirement generally aligns with the goals and 
efforts currently underway for ensuring that Veterans can 
easily locate information about VA mental health services on 
the Internet. Each VISN and facility maintains their own Web 
site. National policy could be reviewed and updated to meet the 
requirements of this section, ensuring that appropriate 
information on mental health services is available and updated 
on those Web sites. VA recommends conducting an assessment of 
available tools for locating information about mental health 
services, including seeking input from Veterans in order to 
determine the most useful framework through which VA can 
provide such information. This requirement should also be 
considered in the context of the Secretary's goal of creating 
one phone number and one Web site for all VA services. VA would 
welcome discussion with the Committee on how the goals of this 
section can be furthered.
    [Testimony regarding Section 5 omitted]
    Section 6 would establish a pilot program for the repayment 
of educational loans for mental health professionals. VA 
supports the aims of section 6, but we believe the recent 
enactment of significant changes to VA's education-debt 
repayment programs (in section 302 of Public Law 113-146 and 
section 408 of Public Law 113-175) make some parts of section 6 
obsolete. We would welcome discussion of this provision with 
the Committee in light of these developments.
    [Testimony regarding Section 7-8 omitted]
    Section 9 of H.R. 5059 would require VA to establish a 
pilot program focused on assisting Veterans transitioning from 
active duty. The pilot program would be established in at least 
5 VISNs and would establish a community-oriented peer support 
network and a community outreach team for each medical center 
in those VISNs.
    VA fully supports the intent of this section but views it 
as duplicative and redundant with work that is already being 
done in every VISN throughout the country. With regard to peer 
support, VHA has a very robust peer support program that 
includes outreach and community integration as a major focus. 
There are at least 3 peer specialists for every VA medical 
center and 2 for each ``very large'' Community Based Outpatient 
Clinic (CBOC) and a total of 973 peer specialists nationwide. 
As required by Public Law 110-387, VA has established training 
guidelines and has instituted a training program that results 
in certification of peer specialists. VA has a very active 
national network that includes a peer specialist and a mental 
health professional from each VISN. These individuals provide 
linkages to the peer support network throughout the country and 
mentorship to peer specialists in each VISN. VA's peer support 
teams interact a great deal with community Veterans' 
organizations and mental health organizations via the mental 
health summits that occur at each medical center as well as 
other activities.
    In 2013, VA implemented a national requirement for each 
medical facility to host a mental health community summit 
annually. During the summits each facility invites community 
providers in their area to begin new partnerships or strengthen 
existing partnerships based on Veteran and family needs in 
their geographic location. In 2014, each facility selected a 
community mental health point of contact to provide ready 
access to information about VA eligibility and available 
clinical services, ensure warm handoffs at critical points of 
transition between systems of care, and provide an ongoing 
liaison between VA and community partners. VA created an online 
map containing the name and contact information for all 
facility POCs by state. http://www.mentalhealth.va.gov/
communityPOC.asp
    Costs associated with the provisions of H.R. 5059 cannot be 
provided at this time.

           *       *       *       *       *       *       *


                        Changes in Existing Law

    In compliance with paragraph 12 of rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
H.R. 203 are shown as follows (existing law proposed to be 
omitted is enclosed in black brackets, new matter is printed in 
italic, and existing law in which no change is proposed is 
shown in roman).

Title 38. Veterans' Benefits

           *       *       *       *       *       *       *


Part II. General Benefits

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


SEC.

                         SUBCHAPTER I. GENERAL

1701. DEFINITIONS.

           *       *       *       *       *       *       *


1709A. TELECONSULTATION.

1709B. EVALUATIONS OF MENTAL HEALTH CARE AND SUICIDE PREVENTION 
                    PROGRAMS.

SUBCHAPTER II. HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL 
TREATMENT

           *       *       *       *       *       *       *


Subchapter I. General

           *       *       *       *       *       *       *


1709B. EVALUATIONS OF MENTAL HEALTH CARE AND SUICIDE PREVENTION 
                    PROGRAMS

    (a) Evaluations.--(1) Not less frequently than once during 
each period specified in paragraph (3), the Secretary shall 
provide for the conduct of an evaluation of the mental health 
care and suicide prevention programs carried out under the laws 
administered by the Secretary.
    (2) Each evaluation conducted under paragraph (1) shall--
          (A) use metrics that are common among and useful for 
        practitioners in the field of mental health care and 
        suicide prevention;
          (B) identify the most effective mental health care 
        and suicide prevention programs conducted by the 
        Secretary, including such programs conducted at a 
        Center of Excellence;
          (C) identify the cost-effectiveness of each program 
        identified under subparagraph (B);
          (D) measure the satisfaction of patients with respect 
        to the care provided under each such program; and
          (E) propose best practices for caring for individuals 
        who suffer from mental health disorders or are at risk 
        of suicide, including such practices conducted or 
        suggested by other departments or agencies of the 
        Federal Government, including the Substance Abuse and 
        Mental Health Services Administration of the Department 
        of Health and Human Services.
    (3) The periods specified in this paragraph are the 
following:
          (A) The period beginning on the date on which the 
        Secretary awards the contract under paragraph (4) and 
        ending on September 30, 2018.
          (B) Each fiscal year beginning on or after October 1, 
        2018.
    (4) Not later than 180 days after the date of the enactment 
of this section, the Secretary shall seek to enter into a 
contract with an independent third party unaffiliated with the 
Department of Veterans Affairs to conduct evaluations under 
paragraph (1).
    (5) The independent third party that is awarded the 
contract under paragraph (4) shall submit to the Secretary each 
evaluation conducted under paragraph (1).
    (b) Annual Submission.--Not later than December 1, 2018, 
and each year thereafter, the Secretary shall submit to the 
Committee on Veterans' Affairs of the Senate and the Committee 
on Veterans' Affairs of the House of Representatives a report 
that contains the following:
          (1) The most recent evaluations submitted to the 
        Secretary under subsection (a)(5) that the Secretary 
        has not previously submitted to such Committees.
          (2) Any recommendations the Secretary considers 
        appropriate.

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

SEC. 1710. ELIGIBILITY FOR HOSPITAL, NURSING HOME, AND DOMICILIARY CARE

           *       *       *       *       *       *       *


    (e)(1) * * *

           *       *       *       *       *       *       *

    [(3) Hospital care, medical services, and nursing home care 
may not be provided under or by virtue of subsection (a)(2)(F) 
in the case of care for a veteran described in paragraph (1)(D) 
who--
          [(A) is discharged or released from the active 
        military, naval, or air service after the date that is 
        five years before the date of the enactment of the 
        National Defense Authorization Act for Fiscal Year 
        2008, after a period of five years beginning on the 
        date of such discharge or release; or
          [(B) is so discharged or released more than five 
        years before the date of the enactment of that Act and 
        who did not enroll in the patient enrollment system 
        under section 1705 of this title before such date, 
        after a period of three years beginning on the date of 
        the enactment of that Act.]
    (3) In the case of care for a veteran described in 
paragraph (1)(D), hospital care, medical services, and nursing 
home care may be provided under or by virtue of subsection 
(a)(2)(F) only during the following periods:
          (A) Except as provided by subparagraph (B), with 
        respect to a veteran described in paragraph (1)(D) who 
        is discharged or released from the active military, 
        naval, or air service after January 27, 2003, the five-
        year period beginning on the date of such discharge or 
        release.
          (B) With respect to a veteran described in paragraph 
        (1)(D) who is discharged or released from the active 
        military, naval, or air service after January 1, 2009, 
        and before January 1, 2011, but did not enroll to 
        receive such hospital care, medical services, or 
        nursing home care pursuant to such paragraph during the 
        five-year period described in subparagraph (A), the 
        one-year period beginning on the date of the enactment 
        of the Clay Hunt Suicide Prevention for American 
        Veterans Act.
          (C) With respect to a veteran described in paragraph 
        (1)(D) who is discharged or released from the active 
        military, naval, or air service on or before January 
        27, 2003, and did not enroll in the patient enrollment 
        system under section 1705 of this title on or before 
        such date, the three-year period beginning on January 
        27, 2008.

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