[House Report 105-626]
[From the U.S. Government Publishing Office]



105th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES

 2d Session                                                     105-626
_______________________________________________________________________


 
     PERSIAN GULF WAR VETERANS HEALTH CARE AND RESEARCH ACT OF 1998

_______________________________________________________________________


 July 15, 1998.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

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

                              R E P O R T

                        [To accompany H.R. 3980]

      [Including cost estimate of the Congressional Budget Office]

  The Committee on Veterans' Affairs, to whom was referred the 
bill (H.R. 3980) to amend title 38, United States Code, to 
extend the authority for the Secretary of Veterans Affairs to 
treat illnesses of Persian Gulf War veterans, to provide 
authority to treat illnesses of veterans which may be 
attributable to future combat service, and to revise the 
process for determining priorities for research relative to the 
health consequences of service in the Persian Gulf War, and for 
other purposes, having considered the same, reports favorably 
thereon with an amendment and recommends that the bill as 
amended do pass.

  The amendment is as follows:
  Strike out all after the enacting clause and insert in lieu 
thereof the following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Persian Gulf War Veterans Health Care 
and Research Act of 1998''.

SEC. 2. HEALTH CARE FOR VETERANS OF WAR.

  (a) Authority To Provide Priority Care.--Section 1710(e) of title 38, 
United States Code, is amended--
          (1) by adding at the end of paragraph (1) the following new 
        subparagraph:
  ``(D) Subject to paragraphs (2) and (3), a veteran who served on 
active duty in a theater of combat operations (as determined by the 
Secretary in consultation with the Secretary of Defense) during a 
period of war after the Vietnam era, or in combat 
against a hostile force during a period of hostilities (as defined in 
section 1712A(a)(2)(B) of this title) after the date of the enactment 
of this subparagraph, is eligible for hospital care, medical services, 
and nursing home care under subsection (a)(2)(F) for any illness, 
notwithstanding that there is insufficient medical evidence to conclude 
that such condition is attributable to such service.'';
          (2) in paragraph (2)(B), by inserting ``or (1)(D)'' after 
        ``paragraph (1)(C)'';
          (3) in paragraph (3)--
                  (A) by striking out ``and'' at the end of 
                subparagraph (A);
                  (B) by striking out ``December 31, 1998.'' in 
                subparagraph (B) and inserting in lieu thereof 
                ``December 31, 2001; and''; and
                  (C) by adding at the end the following new 
                subparagraph:
          ``(C) in the case of care for a veteran described in 
        paragraph (1)(D), after a period of five years beginning on the 
        date of the veteran's discharge or release from active 
        military, naval, or air service.''; and
          (4) by adding at the end the following new paragraph:
  ``(5) When the Secretary first provides care for veterans using the 
authority provided in paragraph (1)(D), the Secretary shall submit to 
Congress a report on the experience under that authority. The report 
shall cover the period of the first three years during which that 
authority is used and shall be submitted not later than nine months 
after the end of that three-year period. The Secretary shall include in 
the report any recommendations of the Secretary for extension of that 
authority.''.
  (b) Enrollment Priority.--Section 1705(a)(4) of such title is 
amended--
          (1) by striking out ``and'' after ``permanently housebound'' 
        and inserting in lieu thereof a comma; and
          (2) by inserting ``, and veterans described in subparagraph 
        (F) of section 1710(a)(2) of this title'' after ``disabled''.

 SEC. 3. NATIONAL CENTER FOR THE STUDY OF WAR-RELATED ILLNESSES.

  (a) In General.--(1) Chapter 73 of title 38, United States Code, is 
amended by inserting after section 7322 the following new section:

``Sec. 7323. National Center for the Study of War-Related Illnesses

  ``(a) Establishment.--The Secretary, acting through the Under 
Secretary for Health, shall establish and operate in the Veterans 
Health Administration a National Center for the Study of War-Related 
Illnesses (hereinafter in this section referred to as the `Center'). 
The Center shall, as appropriate, coordinate its activities with those 
of the National Center on Post-Traumatic-Stress Disorder established 
pursuant to section 110(c) of the Veterans' Health Care Act of 1984 
(Public Law 98-528).
  ``(b) Purposes.--The purposes of the Center shall be to promote 
improvement of clinical, research, and educational activities of the 
Veterans Health Administration with respect to war-related illnesses, 
including medically unexplained illnesses.
  ``(c) Functions.--In carrying out the purposes of the Center, the 
Under Secretary shall ensure that the Center--
          ``(1) promotes the training of health care and related 
        personnel in, and research into, the causes, mechanisms, and 
        treatment of war-related illnesses;
          ``(2) serves as a resource center for, and promotes and seeks 
        to coordinate the exchange of information regarding, research 
        and training activities carried out by the Department, the 
        Department of Defense, and other Federal and non-Federal 
        entities; and
          ``(3) coordinates with the Department of Defense and other 
        interested Federal departments and agencies in the conduct of 
        research, training, and treatment and the dissemination of 
        information pertaining to war-related illnesses.
  ``(d) Staff.--The Under Secretary shall ensure that the staff of the 
Center has an appropriate range and breadth of expertise so as to 
enable the Center to bring an interdisciplinary approach to the study 
and treatment of war-related illnesses.
  ``(e) Coordination Between Departments.--(1) In order to ensure 
needed coordination between the Department and the Department of 
Defense in carrying out the mission of the Center, the officials 
identified in subparagraphs (A) and (B) of section 8111(b)(2) of this 
title shall--
          ``(A) meet regularly to review pertinent policies, 
        procedures, and practices of their respective departments 
        relating to such coordination and to identify actions that 
        could be taken to change policies, procedures, and practices to 
        improve such coordination; and
          ``(B) take all appropriate steps to carry out those actions 
        identified under paragraph (1).
  ``(2) The Secretary and the Secretary of Defense shall submit to the 
appropriate committees of Congress an annual joint report, not later 
than April 1 each year, on the activities under paragraph (1) during 
the preceding year.''.
  (2) The table of sections at the beginning of such chapter is amended 
by inserting after the item relating to section 7322 the following new 
item:

``7323. National Center for the Study of War-Related Illnesses.''.
  (b) Effective Date.--The National Center for the Study of War-Related 
Illnesses required to be established by section 7323 of title 38, 
United States Code, as added by subsection (a), shall be established 
not later than October 1, 1999.

SEC. 4. ASSESSMENT OF EFFECTIVENESS OF CARE OF PERSIAN GULF WAR 
                    VETERANS.

  (a) Assessment by National Academy of Sciences.--Not later than 
November 1, 1998, the Secretary of Veterans Affairs shall enter into a 
contract with the National Academy of Sciences for the conduct of a 
review of a methodology which could be used by the Department of 
Veterans Affairs for determining the efficacy of treatments furnished 
to, and health outcomes (to include functional status) of, Persian Gulf 
War veterans who have been treated for illnesses which may be 
associated with their service in the Persian Gulf War.
  (b) Action on Report.--Not later than 180 days after receiving the 
final report of the National Academy of Sciences under subsection (a), 
the Secretary shall--
          (1) if scientifically feasible, develop an appropriate 
        mechanism to monitor and study the effectiveness of treatments 
        furnished to, and health outcomes of, Persian Gulf War veterans 
        who suffer from diagnosed and undiagnosed illnesses which may 
        be associated with their service in the Persian Gulf War; and
          (2) submit to the Committees on Veterans' Affairs of the 
        Senate and House of Representatives a report on the 
        implementation of this subsection.

SEC. 5. CONTRACT FOR INDEPENDENT RECOMMENDATIONS ON RESEARCH AND FOR 
                    DEVELOPMENT OF CURRICULUM ON CARE OF PERSIAN GULF 
                    WAR VETERANS.

  Section 706 of the Persian Gulf War Veterans' Health Status Act 
(title VII of Public Law 102-585; 38 U.S.C. 527 note) is amended by 
adding at the end thereof the following new subsection:
  ``(d) Research Review and Development of Medical Education 
Curriculum.--(1) In order to further understanding of the health 
consequences of military service in the Persian Gulf theater of 
operations and of new research findings with implications for improving 
the provision of care for veterans of such service, the Secretary of 
Veterans Affairs and the Secretary of Defense shall seek to enter into 
an agreement with the National Academy of Sciences under which the 
Institute of Medicine of the Academy would--
          ``(A) develop a curriculum pertaining to the care and 
        treatment of veterans of such service who have ill-defined or 
        undiagnosed illnesses for use in the continuing medical 
        education of both general and specialty physicians who provide 
        care for such veterans; and
          ``(B) periodically review and provide recommendations 
        regarding the research plans and research strategies of the 
        Departments relating to the health consequences of military 
        service in the Persian Gulf theater of operations during the 
        Persian Gulf War, including recommendations that the Academy 
        considers appropriate for additional scientific studies to 
        resolve areas of continuing scientific uncertainty relating to 
        the health consequences of any aspects of such military 
        service.
  ``(2) Not later than six months after the Institute of Medicine 
provides the Secretaries the curriculum developed under paragraph (1), 
the Secretaries shall provide for the conduct of continuing education 
programs using the curriculum developed under paragraph (1). Such 
programs shall include instruction which seeks to emphasize use of 
appropriate protocols of diagnosis, referral, and treatment of such 
veterans.''.

SEC. 6. REVISION TO PROCESS FOR DETERMINING PRIORITIES FOR HEALTH-
                    RELATED RESEARCH ON THE PERSIAN GULF WAR.

  Section 707 of the Persian Gulf War Veterans' Health Status Act 
(title VII of Public Law 102-585; 38 U.S.C. 527 note) is amended by 
striking out subsection (b) and inserting in lieu thereof the 
following:
  ``(b) Public Advisory Committee.--Not later than January 1, 1999, the 
head of the department or agency designated under subsection (a) shall 
establish an advisory committee consisting of members of the general 
public, to include Persian Gulf War veterans and representatives of 
such veterans, to provide advice to the head of that department or 
agency on proposed research studies, research plans, or research 
strategies relating to the health consequences of military service in 
the Persian Gulf theater of operations during the Persian Gulf War. The 
department or agency head shall consult with such advisory committee on 
a regular basis.
  ``(c) Reports.--(1) Not later than March 1 of each year, the head of 
the department or agency designated under subsection (a) shall submit 
to the Committees on Veterans' Affairs of the Senate and House of 
Representatives a report on--
          ``(A) the status and results of all such research activities 
        undertaken by the executive branch during the previous year;
          ``(B) research priorities identified during that year; and
          ``(C) recommendations of the public advisory committee 
        established under subsection (b) that were not adopted during 
        that year and the reasons for not adopting each such 
        recommendation.
  ``(2)(A) Not later than 120 days after submission of the 
epidemiological research study conducted by the Department of Veterans 
Affairs entitled `VA National Survey of Persian Gulf Veterans--Phase 
III', the head of the department or agency designated under subsection 
(a) shall submit to the congressional committees specified in paragraph 
(1) a report on the findings under that study.
  ``(B) With respect to any findings of that study which identify 
scientific evidence of a greater relative risk of illness or illnesses 
in family members of veterans who served in the Persian Gulf War 
theater of operations than in family members of veterans who did not so 
serve, the head of the department or agency designated under subsection 
(a) shall seek to ensure that appropriate research studies are designed 
to follow up on such findings.
  ``(d) Public Availability of Research Findings.--The head of the 
department or agency designated under subsection (a) shall ensure that 
the findings of all research conducted by or for the executive branch 
relating to the health consequences of military service in the Persian 
Gulf theater of operations during the Persian Gulf War (including 
information pertinent to improving provision of care for veterans of 
such service) are made available to the public through peer-reviewed 
medical journals, the Internet World Wide Web, and other appropriate 
media.''.

SEC. 7. DESIGNATION OF DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER IN 
                    ASPINWALL, PENNSYLVANIA.

  The Department of Veterans Affairs medical center in Aspinwall, 
Pennsylvania, is hereby designated as the ``H. John Heinz III 
Department of Veterans Affairs Medical Center''. Any reference to that 
medical center in any law, regulation, map, document, record, or other 
paper of the United States shall be considered to be a reference to the 
``H. John Heinz III Department of Veterans Affairs Medical Center''.

SEC. 8. DESIGNATION OF DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER IN 
                    GAINESVILLE, FLORIDA.

  The Department of Veterans Affairs medical center in Gainesville, 
Florida, is hereby designated as the ``Malcom Randall Department of 
Veterans Affairs Medical Center''. Any reference to that medical center 
in any law, regulation, map, document, record, or other paper of the 
United States shall be considered to be a reference to the ``Malcom 
Randall Department of Veterans Affairs Medical Center''.

                              Introduction

    On February 5, 1998, the Committee on Veterans' Affairs 
held a hearing to receive updates on research, investigations 
and programs involving Persian Gulf War veterans' illnesses. 
Those testifying at that hearing included Dr. Arthur Caplan, a 
member of the Presidential Advisory Committee on Gulf War 
Veterans' Illnesses; Dr. Donald Mattison, Chairman of the 
Institute of Medicine's Board of Health Promotion and Disease 
Prevention, accompanied by Dr. Dan G. Blazer, Chairman of the 
Institute of Medicine's Committee on the Comprehensive Clinical 
Evaluation Program; Dr. Kenneth W. Kizer, the VA's Under 
Secretary for Health; Dr. Bernard Rostker, Special Assistant to 
the Deputy Secretary of Defense for Gulf War Illnesses; and Dr. 
Donna Heivilin, Director of Planning and Reporting at the U.S. 
General Accounting Office's National Security and International 
Affairs Division, accompanied by Dr. Kwai Chan, the Division's 
Director of Special Studies and Evaluation.
    On April 23, 1998, the Subcommittee on Health received 
testimony on draft legislation to extend and expand VA's 
authority to treat Persian Gulf War veterans, to provide 
authority to treat illnesses of veterans which may be 
attributable to future combat service, and to establish a 
center for study of war-related illnesses. Among those 
testifying at that hearing were Dr. Thomas Garthwaite, the VA's 
Deputy Under Secretary for Health, who was accompanied by Dr. 
Frances Murphy, Director of the VA's Environmental Agents 
Service; Captain Craig Hyams, M.D., U.S.N., head of the 
Infectious Diseases Threat Assessment Division of the Naval 
Medical Research Institute; Dr. Richard Miller, Director of the 
Medical Follow-Up Agency of the Institute of Medicine; and Mr. 
Matthew Puglisi, Assistant Director for Gulf War Veterans of 
the National Veterans Affairs and Rehabilitation Commission, 
The American Legion.
    H.R. 3980, legislation incorporating provisions of the 
draft legislation discussed on April 23rd, was introduced on 
June 3, 1998.
    On June 4, 1998, the Subcommittee on Health met and ordered 
H.R. 3980, the Persian Gulf War Veterans Health Care and 
Research Act, and two other bills that would rename Department 
of Veterans Affairs medical centers, reported favorably to the 
full Committee by unanimous voice vote.
    The full Committee met on June 24, 1998 and ordered H.R. 
3980, as amended, reported favorably to the House by unanimous 
voice vote.

                      Summary of the Reported Bill

    H.R. 3980, as amended, would:

     1. LEstablish authority for VA to provide priority health 
care to treat illnesses that may be attributable to a veteran's 
service in combat during any period of war after the Vietnam 
War or during any other future period of hostilities 
(notwithstanding that there is insufficient medical evidence to 
conclude that such illnesses are attributable to such service). 
Treatment would be available under this special authority for a 
period of five years after such veteran's discharge from 
service. VA would be required to report to Congress on the 
first three years' use of that authority and on any 
recommendations to extend it;

     2. LExtend the VA's special authority to provide care to 
Persian Gulf veterans through December 31, 2001;

     3. LElevate the level of priority for access to VA health 
care to be afforded to Persian Gulf veterans (as well as 
Vietnam veterans and others eligible for care by virtue of 
exposure to a toxic substance, radiation, or environmental 
hazards), and to assign veterans made eligible for care under 
this bill that same high priority;

     4. LRequire VA to establish a multi-disciplinary National 
Center for the Study of War-Related Illnesses to carry out and 
foster research, education and improved clinical care of war-
related illnesses;

     5. LRequire VA (a) to enter into an agreement with the 
National Academy of Sciences to determine whether there is a 
methodology by which VA could determine the efficacy of 
treatments provided Persian Gulf War veterans for illnesses 
which may be associated with their Persian Gulf War service; 
and (b) if scientifically feasible, develop a mechanism to 
monitor and study the effectiveness of such treatments and 
health outcomes;

     6. LRequire VA and DoD to enter into an agreement with the 
National Academy of Sciences to (a) develop a curriculum (to 
take account of new research findings relating to care of 
veterans with illnesses that may be associated with Persian 
Gulf War service) for use in continuing education of VA and DoD 
physicians; and (b) periodically review and provide 
recommendations regarding the Departments' research plans 
relating to Persian Gulf illnesses;

     7. LRequire establishment of a public advisory committee 
(to include Persian Gulf War veterans and their 
representatives) to provide advice to the (VA-DOD-HHS) Persian 
Gulf War Veterans Coordinating Board on proposed research 
studies, plans, and strategies relating to Gulf War vets 
illnesses;

     8. LRequire the Persian Gulf War Veterans Coordinating 
Board to include in its annual report to Congress any new 
research priorities it has established and those 
recommendations made by the new public advisory committee which 
were not adopted (along with the reasons for non-adoption);

     9. LRequire, in the event VA's ongoing survey of Persian 
Gulf War veterans identifies scientific evidence of a greater 
relative risk of illness in families of Persian Gulf War 
veterans than in families of non-deployed vets, the Gulf War 
Coordinating Board to ensure that appropriate studies are 
designed to follow up on such findings;

    10. LRequire publication on the World Wide Web (and 
elsewhere) of the findings of all Persian Gulf War research 
conducted by or for the Government; and

    11. LDesignate the Aspinwall, PA VA Medical Center as the 
``H. John Heinz III Department of Veterans Affairs Medical 
Center'' and the Gainesville, FL VA Medical Center as the 
``Malcom Randall Department of Veterans Affairs Medical 
Center''.

                       Background and Discussion

    The House Veterans' Affairs Committee has conducted ongoing 
oversight since concerns regarding health problems among 
Persian Gulf War veterans were first voiced in 1991. The 
Committee has held sixteen hearings, and initiated the passage 
of unprecedented legislation, to address health care problems 
experienced by Persian Gulf veterans and risk factors 
associated with such service.

                     Treating War-Related Illnesses

    Although Congress has done much to address these problems, 
this Committee is concerned that Congress both continue to 
tackle unresolved questions regarding Persian Gulf veterans' 
health problems, and that it apply lessons learned from the 
Persian Gulf experience to assist veterans who may deploy 
overseas in the future. Earlier this year, for example, the 
country faced anew the possibility of committing our armed 
forces to military intervention in Iraq in response to its 
leader's breach of United Nations' weapons inspection 
agreements. With the potential for renewed combat operations in 
the Persian Gulf theater, some questioned what provision would 
be made for treating such future combatants for possible war-
related illnesses. At the same time, chronic health problems 
still afflict many veterans of Gulf service seven years ago. 
Awareness of this nagging problem heightens the importance of 
Congress addressing the ``sunset'' this December 31st of the 
special health-care authority provided these veterans in law.
    That law was first enacted in 1993, some two years after 
the cessation of Persian Gulf hostilities. With that enactment, 
Congress sought to ensure that Persian Gulf veterans could get 
access to needed VA health care for health problems which may 
have had their origin in service. In doing so, it sought to 
free these veterans of any need, for health care purposes, of 
having to obtain an adjudication of service-connection or of 
having to satisfy a financial need test to establish 
eligibility. Congress enacted a special eligibility provision 
relatively soon after becoming aware of the scope of the 
problem affecting these veterans. Subsequent hearings on 
Persian Gulf veterans' health care, however, have highlighted 
the importance of early intervention in treating the kind of 
unexplained health problems experienced by many Persian Gulf 
War veterans. The lack of even earlier treatment avenues as 
well as some clinicians' lack of understanding of these often 
complex illnesses may, in many cases, have played a role in 
acute health care problems of Persian Gulf War veterans 
becoming chronic.
    Our hearing record provides powerful support for the view 
that early, effective treatment is important not only in 
understanding the Persian Gulf War experience, but as a model 
for intervention for veterans of any future combat operations. 
Each of our wars has been unique. Yet medical literature 
suggests that war has had a similar effect on combatants 
serving more than a century apart. Testifying before the 
Subcommittee on Health, Dr. Craig Hyams described his peer-
reviewed study of the medical literature of our country's 
wartime experience, where he found that ``poorly understood war 
syndromes have recurred at least since the Civil War . . . . 
These syndromes have been characterized by similar symptoms 
(fatigue, shortness of breath, headache, sleep disturbance, 
forgetfulness, and impaired concentration).'' Another recent 
study on World War II veterans suggests a strong link between 
participation in combat and both subsequent decline in physical 
health and early death. In essence, medical literature provides 
considerable evidence that the combat experience is a 
significant risk factor in the development of subsequent 
illness, and that early treatment of war-related illness is 
important in avoiding chronic illness.
    The implications of these findings underscore the 
importance both of increasing understanding of war-related 
illnesses generally, and of ensuring that the Department of 
Veterans Affairs is better prepared to treat veterans of future 
wars or military combat. To that end, on April 23rd, the 
Subcommittee on Health heard testimony on draft legislation 
which sought to foster those objectives. The draft bill 
proposed the establishment of a special eligibility provision 
to ensure VA care of veterans of future combat deployments; 
creation of a national center on war-related illnesses; 
extension of VA's special authority for care of Persian Gulf 
War veterans; and elevation of the priority for care assigned 
those and other veterans.

           National Center for Study of War-Related Illnesses

    Witnesses at that session expressed strong support for the 
concept of VA's establishing a national center for the study of 
war-related illnesses. The Director of the Medical Follow-up 
Agency at the National Academy of Sciences, Dr. Richard Miller, 
characterized the proposed center as ``an excellent and long 
overdue effort to elucidate the causes of a major portion of 
veteran illnesses.'' Miller testified that a ``center organized 
around the phenomenon of war-related illnesses, rather than a 
single discipline or disease, can bring together the 
appropriate mix of expertise and foster appropriate 
collaborations.'' He expressed the view that such a center 
should fund studies of the causes of war-related illness, and 
described as ``essential'' epidemiologic studies of risk 
factors for developing war-related illness with the goal of 
preventing them or at least ameliorating their effects. 
Attesting to the benefit of such a center, Miller also stated 
that, ``The lack of a ready answer to the cause of these 
illnesses exhibited by Persian Gulf veterans suggests the need 
to look at the problem in new ways. He advised that such a 
center could have major implications for health care generally 
``since it is clear that medically unexplained illnesses are by 
no means limited to veteran populations.''
    Echoing the broad support for establishing such a center, 
VA's Deputy Under Secretary for Health, Dr. Thomas Garthwaite, 
cited such a center as one that would ``enhance our ability to 
create a comprehensive program for post-war clinical care, 
medical education, health risk communication and research . . . 
. We believe a Center such as the one proposed has the 
potential to significantly enhance the medical community's 
ability to address the needs of future wartime veterans.''
    As several witnesses testified, such a center should be 
multi-disciplinary, and active partnership and collaboration 
with the Department of Defense are essential. The Committee 
recognizes that VA cannot mount such an effort alone. As 
described by one expert, Dr. Matthew Friedman, Director of the 
National Center for Post-Traumatic Stress Disorder, ``the best 
chance for prevention, early detection, and rapid treatment of 
war-related illnesses is while men and women are still in 
uniform. To defer proactive medical strategies until after 
completion of military service is to wait much too long.'' Such 
a center must, for example, become a repository of deployment 
health and environmental surveillance data. To achieve the 
greatest effectiveness, VA and DoD must coordinate closely to 
ensure timely transfer of such DoD data, which is critical to 
the conduct of future research.
    While requiring that a center employ an interdisciplinary 
approach to the study of war-related illnesses, the reported 
bill vests discretion in the VA regarding the structure of such 
center. There is no requirement, for example, that such a 
``center'' be located in a single site. Its establishment could 
conceivably involve recruiting experts in all key medical 
specialties from VA medical centers across the country and 
linking them to create a ``virtual center''. That ``structure'' 
could conceivably change over time with incorporation of new 
researchers for time-limited periods. Appropriately designed, 
such a center offers the promise of reducing the risk for war-
related illnesses and increasing the likelihood of success in 
treating veterans of future combat service, according to the 
witnesses testifying on this concept.
    The reported bill would call for the establishment of such 
a center, as envisioned in the draft bill. The reported measure 
also incorporates each of the other provisions of the draft 
bill, to include authorizing VA to treat illnesses that may be 
attributable to a veteran's service in combat during any period 
of war after the Vietnam War or after service in any future 
period of hostilities (notwithstanding that there is 
insufficient medical evidence to conclude that such illnesses 
are attributable to such service). That important measure would 
ensure that medical care is available to veterans of future 
military conflicts at the earliest time, and obviate any need 
for Congress to act after each such conflict.

           Improving Care Furnished to Persian Gulf Veterans

    While key elements of the reported bill offer the promise 
of improved VA care for veterans of future combat deployments, 
its provisions also reflect ongoing concern regarding provision 
of needed care to Persian Gulf veterans.
    To that end, the reported bill would extend through 2001 
VA's special treatment authority for Persian Gulf War veterans. 
To ensure that the promise of ``priority health care'' is not 
compromised, the reported bill would also elevate the 
``enrollment priority'' afforded these veterans under section 
1705 of title 38, United States Code.
    The Committee recognizes that health care issues for 
Persian Gulf veterans are not simply issues of access. In 
oversight hearings on Persian Gulf illnesses last year, the 
Subcommittee on Health found that VA had given very little 
priority to designing programs aimed specifically at treating 
Persian Gulf veterans or at helping them manage their symptoms. 
The Committee also found that VA's record of follow-up 
treatment after providing these veterans a registry examination 
appeared uneven from facility to facility, with many instances 
of veterans ``falling through the cracks'' and little evidence 
that complex cases are being managed. Lack of understanding of 
the illnesses reported by Persian Gulf veterans and lack of 
tools available to medicine to resolve the array of their 
symptoms has certainly fueled the perception in many veterans 
that VA health care professionals lack empathy for their 
conditions, and many veterans appear to believe that the 
treatment they receive suffers as a result.
    Following the Subcommittee's hearings last year, VA has 
taken steps to foster the establishment of specialized 
treatment programs for the care of Persian Gulf veterans and to 
provide better case-management for veterans with complex health 
problems.
    There remain questions, however, regarding the 
effectiveness of VA care and the need to ensure that physicians 
who treat these veterans understand their health care problems. 
In a June 23, 1997 report on Gulf War Illnesses (GAO/NSIAD-97-
163), the General Accounting Office found, in pertinent part, 
that ``although efforts have been made to diagnose veterans' 
problems and care has been provided to many eligible veterans, 
neither DOD nor VA has systematically attempted to determine 
whether ill Gulf War veterans are any better or worse today 
than when they were first examined.'' GAO's recommendation that 
the Departments develop and implement a plan, to include the 
establishment of a centralized database, to monitor the 
clinical progress of veterans in order to identify appropriate 
and effective treatments, provoked a sharp debate. VA, for 
example, responded that GAO's recommendation ``fails to address 
the inherent problems involved in monitoring health outcomes in 
the absence of a single, well-defined illness....If the purpose 
of establishing a centralized database is to monitor the 
clinical progress of veterans, the question must be asked: 
Progress for what medical condition? How is clinical progress 
to be measured? Against what scientific standard should the 
clinical outcomes of Gulf War veterans be compared?''
    The Committee does not presume to propose answers to these 
rhetorical questions. But it does believe the underlying GAO 
concern--that the effectiveness of care afforded Persian Gulf 
veterans should be monitored, if possible--is meritorious. 
Accordingly, the reported bill would require VA to enter into a 
contract with the National Academy of Sciences under which the 
Academy would seek to develop a methodology to determine the 
efficacy of treatments furnished to, and health outcomes 
(including functional status) of, veterans who have been 
treated for illnesses which may be linked to their Persian Gulf 
service. (The Committee envisions that, to the extent possible, 
such outcome measures would include improvements in 
interpersonal relationships; involvement in productive 
activity, including employment; and improvement in perceptions 
of health status.) If the Academy determines and reports to VA 
that such a task is scientifically feasible, the reported bill 
would require VA to mount such a study. The reported bill is 
intentionally silent as to the means or scope of such an 
undertaking and has intentionally not required that VA 
establish a national database.
    While this measure provides important assurance that long 
unresolved concerns about assessing care delivery can be 
bridged, the reported bill also recognizes that VA care is only 
as good as the caregiver's knowledge about and sensitivity to 
his or her patients and their health problems. Given the 
critical role of education in providing that understanding, the 
reported bill would also require VA to contract with the 
National Academy of Sciences to develop a curriculum for use in 
the continuing medical education of physicians who provide care 
to these veterans. The Committee envisions that VA will sponsor 
educational programs for generalist and specialist physicians 
to further their understanding of the health consequences of 
service in the Gulf and of any pertinent new research findings 
which may have implications for improving their care.
                                Research

    Numerous scientific and oversight entities have reviewed 
the body of Federally sponsored research and research plans 
related to the health consequences of military service in the 
Persian Gulf War. Among those scientific reviews, the Institute 
of Medicine was charged under Public Law 102-585 to make 
recommendations as to whether there is a sound, scientific 
basis for an epidemiologic study or studies of the health 
consequences of service in the Persian Gulf War and the nature 
of the study or studies. In its October 1996 report, the IOM 
recommended further studies to identify risk factors for 
stress-related psychiatric disorders; continued follow-up of 
the mental health of deployed veterans; and continued 
monitoring of the mortality experience of Persian Gulf 
veterans.
    In a December 31, 1996 report, the Presidential Advisory 
Committee on Gulf War Veterans' Illnesses concluded that the 
government's research portfolio was appropriately weighted 
toward epidemiological studies and studies on stress-related 
disorders. To close gaps in current knowledge, the advisory 
committee recommended additional research on: (1) long-term 
health effects of low-level exposures to chemical warfare 
agents; (2) the synergistic effects of pyridostigmine bromide, 
a chemical warfare agent pretreatment, with other Gulf War risk 
factors; and (3) more emphasis on basic and applied research on 
the body's physical response to stress. In a follow-up report 
issued on October 31, 1997, the advisory committee noted that 
the government ``has made commendable progress'' in 
implementing its prior recommendations, and ``particularly 
commend[ed] the government for its new initiatives targeted on 
health effects of low-level exposure to CW [chemical warfare] 
agents. As noted in the Final Report, `the amount of data from 
either human or animal research on low-level exposures [to CW 
agents] is minimal,' but we believe the planned research may 
address any uncertainties and inconclusiveness identified in 
our December 1996 report.''
    While it is noteworthy that independent scientific reviews 
have helped shape the government's research agenda, that agenda 
has not been free from controversy. In its June 1997 report on 
Gulf War Illnesses, the General Accounting Office criticized 
the federal research effort as lacking a ``coherent approach'' 
and as having been too slow to begin. GAO questioned the 
emphasis federal departments have given epidemiological 
research rather than research on diagnosis, treatment and 
prevention of Gulf War illnesses. GAO also contrasted what it 
viewed as extensive funding devoted to the role of stress in 
veterans' illnesses, while ``basic toxicological questions 
regarding the substances to which they were exposed remain 
unanswered.''
    While the VA and DoD as well as the Presidential advisory 
committee disagreed with some of the conclusions in this GAO 
report, others have cited the report in criticizing the Federal 
Persian Gulf research program. Such critics have proposed 
changes ranging from establishing an independent body to review 
the Federal research program to structural changes aimed at 
vesting Persian Gulf research decision-making authority in an 
entity other than VA or DoD. The Committee is mindful of the 
Presidential advisory committee's assessment that the 
Government's research agenda is on sound footing but that an 
independent advisory role would lend credibility to future 
research activities. This perspective attempts to be responsive 
to the many ill Persian Gulf veterans, who are frustrated that 
research has not provided sought-after answers and who may have 
lost confidence in the Departments managing that research.
    The Committee attaches significance to veterans' concerns 
and to the importance of restoring veterans' confidence that 
Persian Gulf research will be relevant, vigorous, and 
responsive. The reported bill would address these concerns 
directly. It would provide both for independent expert 
oversight of the Federal research program relating to Gulf War 
illnesses and a complementary mechanism for ``consumer'' 
participation in such research agenda-setting.
    The reported bill would effectively carry out the 
recommendation that Congress provide for independent oversight. 
It would do so by requiring VA and DoD to enter into a contract 
with the National Academy of Sciences under which the Academy's 
Institute of Medicine would periodically review and provide 
recommendations to the Departments on their plans and 
strategies for research relating to the health consequences of 
Persian Gulf War service. Such review would involve both 
assessing and making recommendations on the Departments' 
research plans as well as recommendations on additional 
research avenues which the Departments should consider.
    The reported bill would also provide for the establishment 
of a public advisory committee which would be tasked to provide 
advice--on a regular basis--on plans and strategies for 
research relating to the health consequences of Persian Gulf 
War service, and on proposed avenues for future research. In 
carrying out that role, the Committee would report to the 
secretary of the department designated to chair the Research 
Working Group (currently the Department of Veterans Affairs). 
In providing for the establishment of such an advisory 
committee, the Committee is seeking to restore confidence and 
trust, and to help create a constructive dialogue between 
Government scientists and veterans. It is hoped that that 
process can help achieve consensus on sound directions that 
research on Persian Gulf illnesses should take. Thus, the 
reported bill envisions a committee which would have a 
meaningful consultative role in helping shape a research agenda 
and a membership which would include Persian Gulf veterans and 
representatives of such veterans. It is hoped that as a public 
advisory body, such committee would be reasonably balanced, to 
include women and minority participation.
    The reported bill would not alter the role or structure of 
the Persian Gulf Veterans Coordinating Board which was 
established to ensure coordination among the respective 
agencies; nor would it directly change the role or structure of 
the Research Working Group (established under section 707 of 
Public Law 102-585) within that coordinating entity. It is 
hoped, however, that new avenues of communication under the 
reported bill would yield a stronger, more responsive research 
effort.

                      Renaming VA Medical Centers

    Finally, the reported bill would change the designation of 
two of the Department's medical centers.The Department of 
Veterans Affairs Medical Center in Aspinwall, Pennsylvania 
would be renamed for the late Senator H. John Heinz.
    Senator Heinz made a priority of ensuring that the federal 
government maintained its commitment to our veterans. As a 
native of southeastern Pennsylvania, an area with a high rate 
of participation in our armed forces, the Senator recognized 
the important role that VA facilities have for years played in 
these communities, and also that VA benefits and services have 
played in improving the lives of countless families. His 
commitment to Pennsylvania's veterans and his recognition of 
the critical need for VA health care services in Pittsburgh led 
to the construction of the VA medical center's Aspinwall 
facility. It is fitting that, in recognition of his work for 
Pennsylvania's veterans and in acknowledgment of his tragic 
death in 1991, the Aspinwall VA facility be designated the H. 
John Heinz III Veterans Affairs Medical Center. H.R. 2775, a 
bill to so redesignate that facility, was endorsed by the major 
veterans organizations in the State and was co-sponsored by the 
entire Pennsylvania congressional delegation.
    The reported bill would also change the name of the 
Gainesville, Florida VA Medical Center in honor of its former 
director, Malcom Randall, who stepped down after a 31-year 
stewardship of that facility. A veteran of naval service in the 
Pacific in World War II, Randall has had a distinguished 59-
year career of Federal service. Randall's contributions as an 
administrator, teacher, and community leader have been widely 
recognized and honored. The VA has given him its two highest 
awards, the Meritorious Service Award and the Exceptional 
Service Award. He himself has given much of his life to the 
service of veterans and to bringing innovation and excellence 
to the medical center which, fittingly, would bear his name. 
H.R. 3336, a bill to redesignate that center as the Malcom 
Randall Department of Veterans Affairs Medical Center, received 
the endorsement of the major veterans organizations in Florida, 
and was co-sponsored by the entire Florida congressional 
delegation.

                      Section-By-Section Analysis

    Section 1 would name the Act as the ``Persian Gulf War 
Veterans Health Care and Research Act of 1998''.
    Section 2(a) would--
        (1) Lamend section 1710(e)(1) by adding a new 
        subparagraph (D) which would provide eligibility for VA 
        care for any illness to a veteran who served on active 
        duty in a theater of combat operations during a period 
        of war after the Vietnam era, or in combat against a 
        hostile force during a period of hostilities after the 
        date of enactment of this provision (notwithstanding 
        insufficient evidence to conclude that the condition is 
        attributable to such service);

        (2) Lamend section 1710(e)(2)(B) to provide that VA may 
        not furnish care to such a veteran for a condition that 
        is found to have resulted from a cause other than that 
        combat service.

        (3) Lamend section 1710(e)(3) by adding a new 
        subparagraph (C) to provide that in the case of a 
        veteran of such combat service, care may be furnished 
        for up to five years following the veteran's discharge 
        or release from service, and providing in the case of a 
        veteran eligible for care based on service in the 
        Persian Gulf War, that care may be furnished through 
        December 31, 2001;

        (4) Lamend section 1710(e) by adding a new paragraph 
        (5) to provide that the Secretary of Veterans Affairs 
        is to report to Congress within three years of first 
        providing care under new section 1710(e)(1)(D) on the 
        experience under that authority and any recommendations 
        for extending that authority.

    Section 2(b) would amend section 1705(a)(4) of title 38, 
U.S. Code, to elevate the priority (from level 6 to level 4 of 
the priority list)--for purposes of enrollment for VA health 
care--assigned those veterans eligible for VA care based on 
Persian Gulf War service, presumed exposure to herbicides 
during the Vietnam War, and exposure to ionizing radiation. It 
would assign the same priority to veterans of combat service 
under new section 1710(e)(1)(D).
    Section 3(a) would amend chapter 73 of title 38, U.S. Code, 
to add a new section 7323 calling for the Secretary of Veterans 
Affairs to establish and operate a National Center for the 
Study of War-Related Illnesses to promote improvement of VA's 
clinical, research and educational activities with respect to 
war-related illnesses. The center is to promote training in, 
and research into, the causes and treatment of war-related 
illnesses, and to coordinate with the Department of Defense and 
other Federal agencies in the conduct of research, training, 
treatment, and dissemination of findings.
    Section 3(b) would require the center to be established not 
later than October 1, 1999.
    Section 4(a) would require the Secretary of Veterans 
Affairs to enter into a contract with the National Academy of 
Sciences not later than November 1, 1998, under which the 
Academy would develop a methodology for determining the 
efficacy of treatments furnished to, and the health outcomes 
of, Persian Gulf War veterans who have been treated for 
illnesses which may be associated with that war service.
    Section 4(b) would require the Secretary, not later than 
180 days after receiving the final National Academy report, to 
develop an appropriate mechanism, if scientifically feasible, 
to monitor and study the effectiveness of such treatments and 
outcomes, and to report to the Congress on the steps taken in 
response to the Academy's report.
    Section 5 would require the Secretaries of Defense and 
Veterans Affairs to attempt to contract with the Academy (1) 
for the development of a curriculum for use in continuing 
medical education of both general and specialty physicians who 
provide care to veterans who have ill-defined or undiagnosed 
illnesses, and (2) to periodically review and provide 
recommendations regarding the research plans and strategies of 
the Federal government relating to the health consequences of 
service in the Persian Gulf War, including recommendations for 
additional scientific studies. The section would require the 
Secretaries to provide for the conduct of continuing education 
programs using the curriculum developed by the Academy.
    Section 6 would amend section 707 of the Persian Gulf War 
Veterans' Health Status Act (title VII of Public Law 102-585) 
by striking subsection (b) and adding provisions calling for--
        (1) Lestablishment of a public advisory committee to 
        provide advice to the lead Federal agency on proposed 
        research studies, research plans or research strategies 
        relating to the health consequences of Persian Gulf War 
        service;

        (2) Lannual reporting to Congress on the status of all 
        such research activity during the previous year, 
        research priorities that have been identified, and 
        those recommendations of the public advisory committee 
        which were not adopted and the reasons for not adopting 
        each such recommendation;

        (3) Lsubmission of a report to Congress on the findings 
        of the research study entitled ``VA National Survey of 
        Persian Gulf Veterans--Phase III'';

        (4) Ldevelopment of appropriate research studies to 
        follow up on any findings of the National Survey study 
        which identify scientific evidence of a greater 
        relative risk of illness or illnesses in family members 
        of veterans who served in the Persian Gulf War theater 
        of operations than in family members who did not so 
        serve;

        (5) Lpublication--through peer-reviewed medical 
        journals, the Internet, and other appropriate media--of 
        the findings of all research conducted by or for the 
        Federal government relating to the health consequences 
        of Persian Gulf War service.

    Section 7 would designate the VA Medical Center in 
Aspinwall, PA as the ``H. John Heinz III Department of Veterans 
Affairs Medical Center''.
    Section 8 would designate the VA Medical Center in 
Gainesville, FL as the ``Malcom Randall Department of Veterans 
Affairs Medical Center''.

                           Oversight Findings

    The Committee on Government Reform and Oversight issued a 
report entitled ``Gulf War Veterans' Illnesses: VA,DOD Continue 
to Resist Strong Evidence Linking Toxic Causes to Chronic 
Health Effects'' on November, 7, 1997.

               Congressional Budget Office Cost Estimate

    The following letter was received from the Congressional 
Budget Office concerning the cost of the reported bill:

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, July 6, 1998.
Hon. Bob Stump,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office (CBO) 
has prepared the enclosed cost estimate for H.R. 3980, the 
Persian Gulf War Veterans Health Care and Research Act of 1998.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Shawn Bishop, 
who can be reached at 226-2840.
            Sincerely,
                                           June E. O'Neill,
                                                           Director

    Enclosure

               congressional budget office cost estimate

 H.R. 3980--Persian Gulf War Veterans Health Care and Research Act of 
                                  1998

As ordered reported hy the House Committee on Veterans' Affairs on June 
                                24, 1998

    Summary. --H.R. 3980 would temporarily extend the 
eligibility of certain veterans of the Persian Gulf War for 
priority medical care from the Department of Veterans Affairs 
(VA). It would also extend similar benefits to certain veterans 
of future wars or hostilities. H.R. 3980 would require VA to 
contract with the National Academy of Sciences (NAS) for 
several studies relating to the care and treatment of Persian 
Gulf veterans and the health consequences of service in the 
Persian Gulf War. CBO estimates that these provisions would 
result in outlays of $76 million in 1999 and $369 million over 
the 1999-2003 period, assuming appropriation of the necessary 
amounts.
    Because the bill would not affect direct spending or 
receipts, pay-as-you-go procedures would not apply. The bill 
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 impact of H.R. 3980 over the 1999-2003 period is 
shown in the following table. The costs of this legislation 
would fall within budget function 700 (veterans affairs).


                           Table 1. Budgetary Impact of H.R.3980 as ordered reported by the House Veterans' Affairs Committee                           
                                                        [By fiscal year, in millions of dollars]                                                        
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           1998             1999             2000             2001             2002             2003    
--------------------------------------------------------------------------------------------------------------------------------------------------------
Spending Under Current Law for Veterans' Medical                                                                                                        
 Care                                                                                                                                                   
  Estimated authorization level 1.................         17,739           17,739           17,739           17,739           17,739           17,739  
  Estimated outlays...............................         17,615           18,122           17,763           17,739           17,739           17,739  
Proposed Changes                                                                                                                                        
  Eligibility for Priority Care                                                                                                                         
    Estimated authorization Level.................              0               74              101              105               27                0  
    Estimated outlays.............................              0               66               98              104               35                4  
  National Center for the Study of War-Related                                                                                                          
   Illnesses                                                                                                                                            
    Estimated authorization level.................              0                8               13               12               13               13  
    Estimated outlays.............................              0                7               13               12               13               13  
  Studies by the National Academy of Sciences                                                                                                           
    Estimated authorization Level.................              0                3                0                1                0                1  
    Estimated outlays.............................              0                3                0                1                0                1  
                                                   -----------------------------------------------------------------------------------------------------
  Subtotal-Proposed Changes                                                                                                                             
    Estimated authorization Level.................              0               85              115              118               40               14  
    Estimated outlays.............................              0               76              111              117               48               17  
                                                                                                                                                        
Total Spending Under H.R. 3980 for Veterans'                                                                                                            
 Medical Care                                                                                                                                           
  Estimated authorization level 1.................         17,739           17,824           17,854           17,857           17,779           17,753  
  Estimated outlays...............................         17,615           18,198           17,874           17,856           17,787           17,756  
                                                   =====================================================================================================
--------------------------------------------------------------------------------------------------------------------------------------------------------
NOTE: Details may not add to totals because of rounding.                                                                                                
                                                                                                                                                        
1 The 1998 level is the amount appropriated for that year. The current law amounts for 1999-2003 assume that appropriations remain at the 1998 leveL If 
  they are adjusted far inflatian, the base amounts would rise by about $600 million a year, but the estimated changes would remain as shown.           


    Eligibility for Priority Care.--Under current law, veterans 
with compensable service-connected disabilities or income below 
a certain threshold have priority status for VA medical care. 
In addition, current law grants all veterans who served in the 
Southwest Asia theater during the Persian Gulf War (PGW) 
priority status for medical care until December 31, 1998. 
Section 2 would extend eligibility for priority care to these 
PGW veterans until December 31, 2001. (Eligibility based on 
disability and income would remain part of permanent law.)
    CBO estimates that the cost of extending priority care 
under this bill would be $66 million in 1999 and $306 million 
over the three-year extension, assuming appropriation of the 
necessary amounts. CBO estimates that about 136,000 PGW 
veterans would seek priority medical care annually under this 
bill. This estimate is based on the number of PGW veterans who 
received outpatient care from the VA through April 30, 1998, 
according to an analysis of VA's Patient Treatment File. But 
many of these veterans would already be eligible for priority-
level care based on service-connected disabilities or income. 
CBO assumes that 40 percent would qualify for priority care for 
those reasons, based on the proportion of PGW patients that VA 
treated in 1996 who met those conditions. We estimate that the 
other 60 percent--roughly 80,000 veterans per year--would 
receive additional care costing about $1,300 per person each 
year.
    In addition, section 2 would grant priority status for five 
years after the date of military discharge to veterans who 
served in theater during future wars or in combat during future 
periods of hostilities. As with Persian Gulf veterans, those 
veterans would be eligible for priority care for any illness, 
notwithstanding insufficient medical evidence linking such 
illness to military service. This estimate does not include any 
medical costs that may result from this provision because CBO 
cannot predict future wars and conflicts.

    National Center for the Study of War-Related Illnesses.--
Section 3 would require the Veterans Health Administration 
(VHA) to establish a National Center for the Study of War-
Related Illnesses. CBO estimates the new center would cost $7 
million in 1999 and $58 million over the 1999-2003 period. This 
estimate assumes the new center would operate like the VA's 
Geriatric Research, Education, and Clinical Center (GRECC) 
because it would have a similar mission--coordinating clinical, 
research, and educational activities of the VA. Although GRECC 
operates at 26 sites now, it began with eight sites when it was 
established in 1975. This estimate assumes the new center would 
operate four sites in 1999 and eight sites in 2000 and 
thereafter. CBO assumes that its more limited focus would not 
require the new center to expand beyond eight sites. The 
estimate assumes start-up costs of about $1 million at each 
site and annual recurring costs of about $1.5 million per site, 
comparable to GRECC's costs.

    Studies by the National Academy of Sciences.--Sections 4 
and 5 would require VA to contract with the National Academy of 
Sciences (NAS) for three studies related to Persian Gulf War 
veterans. The first study would be directed toward developing a 
methodology that VA could use to assess treatments provided to 
Persian Gulf War veterans. The second study would develop a 
curriculum for the care and treatment of Persian Gulf Veterans 
who have undiagnosed illnesses. The third study would provide 
periodic review of and recommendations for federally funded 
research on the health consequences of service in the Persian 
Gulf theater. CBO assumes the third study would entail a report 
from NAS every two years beginning in 1999. CBO estimates the 
three studies would cost a total of $3 million in 1999 and $5 
million over the 1999-2003 period.

    Pay-as-you-go considerations. --None.

    Intergovernmental and private-sector impact. --The bill 
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: Shawn Bishop
          Impact on state, local, and tribal governments: Marc 
        Nicole (225-3220)
          Impact on the Private Sector: Rachel Schmidt (226-
        2910)

    Estimate approved by:
          Robert A. Sunshine, Deputy Assistant Director for 
        Budget Analysis

                     Inflationary Impact Statement

    The enactment of the reported bill would have no 
inflationary impact.

                            Department Views

    The Department testified at an April 23, 1998 hearing on a 
draft bill which was subsequently incorporated into H.R. 3980, 
and expressed strong support for the concepts proposed in that 
measure.

                  Applicability to Legislative Branch

    The reported bill would not be applicable to the 
legislative branch under the Congressional Accountability Act, 
Public Law 104-1, because it would apply only to certain 
Department of Veterans Affairs programs and activities.

                     Statement of Federal Mandates

    The reported bill would not establish a federal mandate 
under the Unfunded Mandates Reform Act, Public Law 104-4.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the U.S. Constitution, 
the reported bill would be authorized by Congress' power to 
``provide for the common Defence and general Welfare of the 
United States.''

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3 of rule XIII of the Rules of the 
House of Representatives, changes in existing law made by the 
bill, as reported, are shown as follows (existing law proposed 
to be omitted is enclosed in black brackets, new matter is 
printed in italics, existing law in which no change is proposed 
is shown in roman):

                      TITLE 38, UNITED STATES CODE



           *       *       *       *       *       *       *
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE

           *       *       *       *       *       *       *


SUBCHAPTER I--GENERAL

           *       *       *       *       *       *       *


Sec. 1705. Management of health care: patient enrollment system

  (a) In managing the provision of hospital care and medical 
services under section 1710(a) of this title, the Secretary, in 
accordance with regulations the Secretary shall prescribe, 
shall establish and operate a system of annual patient 
enrollment. The Secretary shall manage the enrollment of 
veterans in accordance with the following priorities, in the 
order listed:
          (1) * * *

           *       *       *       *       *       *       *

          (4) Veterans who are in receipt of increased pension 
        based on a need of regular aid and attendance or by 
        reason of being permanently housebound [and], other 
        veterans who are catastrophically disabled, and 
        veterans described in subparagraph (F) of section 
        1710(a)(2) of this title.

           *       *       *       *       *       *       *


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

Sec. 1710. Eligibility for hospital, nursing home, and domiciliary care

  (a) * * *

           *       *       *       *       *       *       *

  (e)(1)(A) * * *

           *       *       *       *       *       *       *

  (D) Subject to paragraphs (2) and (3), a veteran who served 
on active duty in a theater of combat operations (as determined 
by the Secretary in consultation with the Secretary of Defense) 
during a period of war after the Vietnam era, or in combat 
against a hostile force during a period of hostilities (as 
defined in section 1712A(a)(2)(B) of this title) after the date 
of the enactment of this subparagraph, is eligible for hospital 
care, medical services, and nursing home care under subsection 
(a)(2)(F) for any illness, notwithstanding that there is 
insufficient medical evidence to conclude that such condition 
is attributable to such service.
  (2)(A) * * *
  (B) In the case of a veteran described in paragraph (1)(C) or 
(1)(D), hospital care, medical services, and nursing home care 
may not be provided under subsection (a)(2)(F) with respect to 
a disability that is found, in accordance with guidelines 
issued by the Under Secretary for Health, to have resulted from 
a cause other than the service described in that paragraph.
  (3) Hospital care, medical services, and nursing home care 
may not be provided under or by virtue of subsection 
(a)(2)(F)--
          (A) in the case of care for a veteran described in 
        paragraph (1)(A), after December 31, 2002; [and]
          (B) in the case of care for a veteran described in 
        paragraph (1)(C), after [December 31, 1998.] December 
        31, 2001; and
          (C) in the case of care for a veteran described in 
        paragraph (1)(D), after a period of five years 
        beginning on the date of the veteran's discharge or 
        release from active military, naval, or air service.

           *       *       *       *       *       *       *

  (5) When the Secretary first provides care for veterans using 
the authority provided in paragraph (1)(D), the Secretary shall 
submit to Congress a report on the experience under that 
authority. The report shall cover the period of the first three 
years during which that authority is used and shall be 
submitted not later than nine months after the end of that 
three-year period. The Secretary shall include in the report 
any recommendations of the Secretary for extension of that 
authority.

           *       *       *       *       *       *       *


 CHAPTER 73--VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS

                       subchapter i--organization

Sec.
     * * * * * * *

           subchapter ii--general authority and administration

7311.    Quality assurance.
     * * * * * * *
7323.    National Center for the Study of War-Related Illnesses.
     * * * * * * *

Sec. 7323. National Center for the Study of War-Related Illnesses

  (a) Establishment.--The Secretary, acting through the Under 
Secretary for Health, shall establish and operate in the 
Veterans Health Administration a National Center for the Study 
of War-Related Illnesses (hereinafter in this section referred 
to as the ``Center''). The Center shall, as appropriate, 
coordinate its activities with those of the National Center on 
Post-Traumatic-Stress Disorder established pursuant to section 
110(c) of the Veterans' Health Care Act of 1984 (Public Law 98-
528).
  (b) Purposes.--The purposes of the Center shall be to promote 
improvement of clinical, research, and educational activities 
of the Veterans Health Administration with respect to war-
related illnesses, including medically unexplained illnesses.
  (c) Functions.--In carrying out the purposes of the Center, 
the Under Secretary shall ensure that the Center--
          (1) promotes the training of health care and related 
        personnel in, and research into, the causes, 
        mechanisms, and treatment of war-related illnesses;
          (2) serves as a resource center for, and promotes and 
        seeks to coordinate the exchange of information 
        regarding, research and training activities carried out 
        by the Department, the Department of Defense, and other 
        Federal and non-Federal entities; and
          (3) coordinates with the Department of Defense and 
        other interested Federal departments and agencies in 
        the conduct of research, training, and treatment and 
        the dissemination of information pertaining to war-
        related illnesses.
  (d) Staff.--The Under Secretary shall ensure that the staff 
of the Center has an appropriate range and breadth of expertise 
so as to enable the Center to bring an interdisciplinary 
approach to the study and treatment of war-related illnesses.
  (e) Coordination Between Departments.--(1) In order to ensure 
needed coordination between the Department and the Department 
of Defense in carrying out the mission of the Center, the 
officials identified in subparagraphs (A) and (B) of section 
8111(b)(2) of this title shall--
          (A) meet regularly to review pertinent policies, 
        procedures, and practices of their respective 
        departments relating to such coordination and to 
        identify actions that could be taken to change 
        policies, procedures, and practices to improve such 
        coordination; and
          (B) take all appropriate steps to carry out those 
        actions identified under paragraph (1).
  (2) The Secretary and the Secretary of Defense shall submit 
to the appropriate committees of Congress an annual joint 
report, not later than April 1 each year, on the activities 
under paragraph (1) during the preceding year.
                              ----------                              


              PERSIAN GULF WAR VETERANS' HEALTH STATUS ACT

          TITLE VII--PERSIAN GULF WAR VETERANS' HEALTH STATUS

SEC. 701. SHORT TITLE.

  This title may be cited as the ``Persian Gulf War Veterans' 
Health Status Act''.

           *       *       *       *       *       *       *


SEC. 706. AGREEMENT WITH NATIONAL ACADEMY OF SCIENCES FOR REVIEW OF 
                    HEALTH CONSEQUENCES OF SERVICE DURING THE PERSIAN 
                    GULF WAR.

  (a) * * *

           *       *       *       *       *       *       *

  (d) Research Review and Development of Medical Education 
Curriculum.--(1) In order to further understanding of the 
health consequences of military service in the Persian Gulf 
theater of operations and of new research findings with 
implications for improving the provision of care for veterans 
of such service, the Secretary of Veterans Affairs and the 
Secretary of Defense shall seek to enter into an agreement with 
the National Academy of Sciences under which the Institute of 
Medicine of the Academy would--
          (A) develop a curriculum pertaining to the care and 
        treatment of veterans of such service who have ill-
        defined or undiagnosed illnesses for use in the 
        continuing medical education of both general and 
        specialty physicians who provide care for such 
        veterans; and
          (B) periodically review and provide recommendations 
        regarding the research plans and research strategies of 
        the Departments relating to the health consequences of 
        military service in the Persian Gulf theater of 
        operations during the Persian Gulf War, including 
        recommendations that the Academy considers appropriate 
        for additional scientific studies to resolve areas of 
        continuing scientific uncertainty relating to the 
        health consequences of any aspects of such military 
        service.
  (2) Not later than six months after the Institute of Medicine 
provides the Secretaries the curriculum developed under 
paragraph (1), the Secretaries shall provide for the conduct of 
continuing education programs using the curriculum developed 
under paragraph (1). Such programs shall include instruction 
which seeks to emphasize use of appropriate protocols of 
diagnosis, referral, and treatment of such veterans.

SEC. 707. COORDINATION OF GOVERNMENT ACTIVITIES ON HEALTH-RELATED 
                    RESEARCH ON THE PERSIAN GULF WAR.

  (a) * * *
  [(b) Report.--Not later than March 1 of each year, the head 
of the department or agency designated under subsection (a) 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report on the status and 
results of all such research activities undertaken by or the 
Executive Branch of the Federal Government during the previous 
year.]
  (b) Public Advisory Committee.--Not later than January 1, 
1999, the head of the department or agency designated under 
subsection (a) shall establish an advisory committee consisting 
of members of the general public, to include Persian Gulf War 
veterans and representatives of such veterans, to provide 
advice to the head of that department or agency on proposed 
research studies, research plans, or research strategies 
relating to the health consequences of military service in the 
Persian Gulf theater of operations during the Persian Gulf War. 
The department or agency head shall consult with such advisory 
committee on a regular basis.
  (c) Reports.--(1) Not later than March 1 of each year, the 
head of the department or agency designated under subsection 
(a) shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report on--
          (A) the status and results of all such research 
        activities undertaken by the executive branch during 
        the previous year;
          (B) research priorities identified during that year; 
        and
          (C) recommendations of the public advisory committee 
        established under subsection (b) that were not adopted 
        during that year and the reasons for not adopting each 
        such recommendation.
  (2)(A) Not later than 120 days after submission of the 
epidemiological research study conducted by the Department of 
Veterans Affairs entitled ``VA National Survey of Persian Gulf 
Veterans--Phase III'', the head of the department or agency 
designated under subsection (a) shall submit to the 
congressional committees specified in paragraph (1) a report on 
the findings under that study.
  (B) With respect to any findings of that study which identify 
scientific evidence of a greater relative risk of illness or 
illnesses in family members of veterans who served in the 
Persian Gulf War theater of operations than in family members 
of veterans who did not so serve, the head of the department or 
agency designated under subsection (a) shall seek to ensure 
that appropriate research studies are designed to follow up on 
such findings.
  (d) Public Availability of Research Findings.--The head of 
the department or agency designated under subsection (a) shall 
ensure that the findings of all research conducted by or for 
the executive branch relating to the health consequences of 
military service in the Persian Gulf theater of operations 
during the Persian Gulf War (including information pertinent to 
improving provision of care for veterans of such service) are 
made available to the public through peer-reviewed medical 
journals, the Internet World Wide Web, and other appropriate 
media.

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