(iii) the cost to the Department of Veterans Affairs of the pilot program. (B) An analysis of the effectiveness of the services provided to veterans under the pilot program.

(C) The recommendations of the Secretary for means of improving the pilot program, and an estimate of the cost to the Department of implementing such recommendations.

(D) An assessment of the desirability of expanding the type or nature of services provided under the pilot program in light of plans for the provision of health care services by the Department under national health care reform.

(E) An assessment of the extent to which the provision of services under the pilot program impairs the operational or administrative independence of the readjustment counseling centers at which such services are provided.

(F) An assessment of the effect of the location of the centers on the effectiveness for the Department and for veterans of the services provided under the pilot program.

(G) Such other information as the Secretary considers appropriate.

(2) The Secretary shall submit the report not later than 18 months after the date of the enactment of this Act.

(e) DEFINITIONS.-For the purposes of this section

(1) The term "Department of Veterans Affairs general health-care facility" has the meaning given such term in section 1712A(i)(2) of title 38, United States Code.

(2) The term "eligible veteran" means any veteran eligible for outpatient services under paragraph (1), (2), or (3) of section 1712(a) of such title.

(3) The term "readjustment counseling center" has the same meaning given the term "center" in section 1712A(i)(1) of such title.

INTRODUCTION

On July 14, 1993, Committee member Daniel K. Akaka introduced S. 1226, the proposed "Readjustment Counseling Service Amendments of 1993. Joining later as cosponsors were Committee member Thomas A. Daschle and Senators Daniel K. Inouye and Paul Wellstone.

As introduced, S. 1226 would have: (1) established the Readjustment Counseling Service (RCS) as a statutory organization within the Department of Veterans Affairs (VA), required congressional notification of any proposed changes to the administrative and organizational structure of RCS, and required that a specific operating budget be identified in the VA budget submission to Congress; (2) raised the Director of RCS to the level of Assistant Chief Medical Director and established certain qualifications for the position; (3) expanded eligibility for RCS services to all veterans, regardless of period of service, and provided eligibility for bereavement counseling to the family members of those who died on active duty; (4) codified existing administrative requirements pertaining to the confidentiality of RCS patient records; (5) established the Advisory Committee on Veteran Readjustment Counseling as a permanent body; (6) required VA to submit to the Senate and House of Representatives Committees on Veterans' Affairs a plan to expand the Vietnam Veteran Resource Center (VVRC) program to all Vet Centers; and, (7) established a pilot program under which a range of primary health care services would be provided at selected Vet Centers.

At an August 3, 1993, hearing, the Committee received testimony on S. 1226, along with other legislation. Testimony on the bill was received from Hershel Gober, Deputy Secretary of Veterans Affairs, accompanied by various VA Central Office officials, and from a number of RCS program personnel from field offices and stations. In addition, the Committee heard testimony from representatives

of The American Legion, the Disabled American Veterans, the Paralyzed Veterans of America, and the Veterans of Foreign Wars. The Committee also received written testimony from AMVETS and the Vietnam Veterans of America.

After reviewing the testimony from the hearing, the Committee met in open session on October 28, 1993, and on November 3, 1993, to discuss S. 1226. During the later meeting, the Committee agreed by voice vote to report the Committee Print of S. 1226 derived from the bill as introduced, with revisions proposed by Senators Akaka, Rockefeller, and Murkowski.

SUMMARY OF S. 1226 AS REPORTED

S. 1226 as reported (hereinafter referred to as the "Committee bill") contains freestanding provisions and amendments to title 38, United States Code, that would:

1. Codify the organizational structure of the Readjustment Counseling Service as it existed on January 1, 1993; require the Secretary of Veterans Affairs to submit to the Senate and House Committees on Veterans' Affairs a report containing a full and complete statement of any proposed changes to that organizational structure at least 60 days prior to implementation; and require that funding for RCS and for oversight activities of the service (including funds for the Advisory Committee on Veteran Readjustment Counseling) be identified in the VA's annual budget submission.

2. Raise the position of Director of RCS to Assistant Chief Medical Director (ACMD) of RCS and establish minimum requirements for the position.

3. Expand eligibility for RCS services, now limited to Vietnamera veterans and veterans of post-Vietnam conflicts, to all combat veterans, including veterans of World War II and the Korean War; authorize services to all noncombat veterans on a resource-available basis; establish eligibility for bereavement counseling for the family members (defined as a veteran's parents, spouse, and children) of those killed in a theater of combat; and authorize counseling for the families of those killed other than in combat while serving on active duty or as a result of a condition incurred in or aggravated by such service.

4. Establish as a statutory body the present administratively established Advisory Committee on the Readjustment of Vietnam and Other War Veterans, rename it the Advisory Committee on the Readjustment of Veterans, and set forth general composition requirements for the committee; require the committee to provide annual written reports on activities pertinent to readjustment counseling; and direct the Secretary of Veterans Affairs to forward the reports of the committee, with appropriate comments, to the Senate and House Committees on Veterans' Affairs.

5. Require the Secretary of Veterans Affairs to submit a plan to the Senate and House Committees on Veterans' Affairs for the expansion of the Vietnam Veteran Resource Center program to all Vet Centers.

6. Require the Secretary of Veterans Affairs to report to the Senate and House Committees on Veterans' Affairs on the feasibility and desirability of the collocation of Vet Centers and VA outpatient clinics.

7. Establish a two-year pilot program under which a minimum of 1/2 full-time employee equivalent (FTEE) would be assigned to provide basic ambulatory health care services and health care screening for veterans at not less than 10 Vet Centers, selected to reflect geographic, economic, social, and ethnic differences, and require the Secretary to report to the Senate and House Committees on Veterans' Affairs six months prior to the conclusion of the pilot program.

Background

DISCUSSION

Veterans readjustment counseling centers, more popularly known as Vet Centers, were established by VA in 1979 after legislation created eligibility for VA to furnish readjustment counseling services to Vietnam-era veterans. Under the administrative aegis of the Readjustment Counseling Service (RCS), these community-based facilities were established so that veterans could obtain assistance without the institutional bureaucracy of medical centers or regional offices. The centers' informal atmosphere and autonomy were intended to make them attractive to veterans who, for a variety of reasons, were reluctant to seek assistance provided through traditional VA facilities, such as medical centers, outpatient clinics, and benefits offices.

In the 14 years since the Vet Center program was first established, more than 1.4 million veterans have availed themselves of Vet Center services. The number of Vet Centers has steadily increased since that time-from 87 to 201-and they now operate in all 50 states, Guam, Puerto Rico, and the Virgin Islands. In 1990, Congress expanded eligibility beyond the original Vietnam-era population to include the veterans of post-Vietnam conflicts, such as Lebanon, Grenada, Panama, and the Persian Gulf.

While the primary goal of the Vet Center program remains the provision of psychological counseling to assist veterans in readjusting to civilian life, it has also been active in other areas. For example, Vet Centers have taken a leading role in addressing post-traumatic stress disorder (PTSD), a syndrome associated with extraordinary psychological and emotional trauma. Vet Centers also assist veterans who are homeless, victims of natural disasters and inservice sexual trauma, suicidal, physically disabled, members of ethnic or racial minority groups, or have substance abuse problems. Where Vet Center counselors have been unable to assist veterans directly, they have been helpful in identifying, and providing access to, appropriate services offered elsewhere within VA or in the community.

The Committee bill attempts to ensure the program remains viable and responsive to the needs of veterans.

ORGANIZATION OF THE READJUSTMENT COUNSELING SERVICE IN THE DEPARTMENT OF VETERANS AFFAIRS

Committee bill

Section 2 of the Committee bill proposes to freeze the administrative structure of the RCS as of January 1, 1993, and establish a specific line item in the budget for RCS. These changes would pro

vide VA with the latitude to make modifications to the structure and organization, but only after providing the House and Senate Committees on Veterans' Affairs with a 60-day notice.

The Committee believes that these provisions will discourage attempts to curtail the operational independence of Vet Centers, while giving VA the administrative flexibility it needs to respond to changing circumstances.

Unlike the staffs of other clinical services which report to the local hospital chiefs of staff, each Vet Center is accountable directly to the Readjustment Counseling Service (RCS) at VA Central Office, through seven area offices or regions. Thus, Vet Centers enjoy significant independence from local medical centers and regional offices.

Numerous VA reports support this structure, including a May 1991 report, "A Program Evaluation of the Department of Veterans Affairs Post Traumatic Stress Disorder (PTSD) Programs," which recommended that the current structure be retained.

Endorsing the program's community-based mission, Congress enacted legislation (section 107 of P.L. 100-322) barring relocation or closure of any Vet Center without appropriate congressional notification and review.

The Committee remains concerned that the program may become vulnerable to future efforts to limit its autonomy. The Committee believes that section 2 of the Committee bill will provide Vet Centers with institutional stability and independence.

At the August 3 hearing, VA initially opposed this provision on the grounds that the Department had no plans to change the organizational or administrative structure of RCS. However, under questioning from the Committee, Deputy Secretary Gober admitted that VA could not guarantee that attempts to restrict RCS's autonomy would not be revived under future administrations. In view of this, the Deputy Secretary indicated that the Department

provision.

was not prepared to fall on our sword over this

RCS Director Dr. Arthur S. Blank expressed the view that a direct relationship existed between RCS's organizational structure and the quality of Vet Center staffing and services.

RCS team leaders and regional managers who testified at the hearing strongly supported codifying the current organizational structure of RCS. Referring to previous proposals to place Vet Centers under the administrative control of hospital chiefs of staff, RCS Regional Manager and Chief Clinical Manager-West, Dr. Alphonso Batres, asserted that

* * * the ability to be innovative and to be flexible would be greatly reduced, and I think the kinds of things that make the Vet Centers special would be lost.

Team Leader Dr. Bill Weitz added,

** * RCS team leaders, who are not used to those kinds of turf battles in hospital settings, would not fare well in terms of budget and manpower and program initiatives and creativities, and it would stifle and be a way to destroy the heart and soul of the Vet Center program.

RCS Regional Manager Dr. Susan Angell concluded that:

one of the biggest losses that we would have under a chief of staff would be the dedication that we have to hiring combat veterans to do the very work with other combat veterans that we have now, and I don't think there would be as great an effort in providing a good match to the community with a good match in the counselors, both ethnically and experientially. I think that would be a tremendous loss.

The veterans service organizations generally expressed support for section 2. The American Legion called the attempt to codify RCS as a statutory agency "a great step forward." This sentiment was echoed by virtually all of the other veterans service organizations who testified at the August 3 hearing.

DIRECTOR OF THE READJUSTMENT COUNSELING SERVICE

Section 3 of the bill would raise the position of Director of RCS to the level of Assistant Chief Medical Director (ACMD), increase the number of statutorily mandated ACMDs from eight to nine, and establish certain standards and qualifications for the position. The Director of RCS is responsible for managing a service consisting of approximately 850 employees, 201 Vet Centers, seven regional offices, and a budget of more than $56 million. Each year, Vet Centers accommodate approximately 800,000 client visits. The unique readjustment counseling services and mental health programs that the Director administers are integral to VA's mission and vital to the health care of veterans.

In spite of these responsibilities, the Director remains at a lower salary and administrative level than the heads of other clinical services (e.g., hospital services, ambulatory care, nursing, geriatrics and extended care, dentistry, environmental medicine, and public health), none of whom, unlike the Director, directly manage individual field units. While the Director now reports directly to the Associate Deputy Chief Medical Director for Clinical Programs, as do other service chiefs, the Director of RCS is alone among his peers in not holding the rank of ACMD.

The Committee believes that raising the Director of RCS to ACMD level will enhance the status of the service.

Section 3 also would amend the academic and experience requirements for the Director position, specifically opening the job to psychologists, social workers, and other health professionals, and requiring at least three years of clinical experience and two years of administrative experience within RCS or a comparable mental health counseling service. By this provision, the Committee hopes to encourage the selection of a Director from within the service or, at the very least, from a wide variety of appropriate clinical fields. At the August 3 hearing, VA expressed no objection to section 3 of the bill as introduced. However, VA stated that since all current ACMD slots had been allocated, an additional position would have to be authorized if VA were to fulfill the intent of the provision.