[House Report 113-247] [From the U.S. Government Publishing Office] 113th Congress Report HOUSE OF REPRESENTATIVES 1st Session 113-247 ====================================================================== TINNITUS RESEARCH AND TREATMENT ACT OF 2013 _______ October 22, 2013.--Committed to the Committee of the Whole House on the State of the Union and ordered to be printed _______ Mr. Miller of Florida, from the Committee on Veterans' Affairs, submitted the following R E P O R T [To accompany H.R. 1443] [Including cost estimate of the Congressional Budget Office] The Committee on Veterans' Affairs, to whom was referred the bill (H.R. 1443) to direct the Secretary of Veterans Affairs to recognize tinnitus as a mandatory condition for research and treatment by the Department of Veterans Affairs, and for other purposes, having considered the same, report favorably thereon with an amendment and recommend that the bill as amended do pass. CONTENTS Page Purpose and Summary.............................................. 2 Background and Need for Legislation.............................. 2 Hearings......................................................... 3 Subcommittee Consideration....................................... 4 Committee Consideration.......................................... 4 Committee Votes.................................................. 4 Committee Oversight Findings..................................... 5 Statement of General Performance Goals and Objectives............ 5 New Budget Authority, Entitlement Authority, and Tax Expenditures 5 Earmarks and Tax and Tariff Benefits............................. 5 Committee Cost Estimate.......................................... 5 Congressional Budget Office Estimate............................. 5 Federal Mandates Statement....................................... 6 Advisory Committee Statement..................................... 6 Statement of Constitutional Authority............................ 6 Applicability to Legislative Branch.............................. 6 Statement on Duplication of Federal Programs..................... 7 Disclosure of Directed Rulemaking................................ 7 Section-by-Section Analysis of the Legislation................... 7 Changes in Existing Law Made by the Bill as Reported............. 8 The amendment is as follows: Strike all after the enacting clause and insert the following: SECTION 1. SHORT TITLE. This Act may be cited as the ``Tinnitus Research and Treatment Act of 2013''. SEC. 2. FINDINGS. Congress makes the following findings: (1) Since 2006, the most prevalent service-connected disability for which veterans have received compensation under the laws administered by the Secretary of Veterans Affairs has been tinnitus. (2) The number of veterans receiving such compensation for tinnitus has risen each year since 2006, increasing the number and cost of the compensation claims paid by the Secretary. (3) A growing body of peer reviewed literature indicates a direct connection between traumatic brain injury, post traumatic stress disorder, and tinnitus. (4) An analysis of data collected by the Department of Veterans Affairs concluded that total amount of disability compensation paid for tinnitus by the Department of Veterans Affairs in 2012 was $1,500,000,000. (5) Based on projected rates of growth, the amount of disability compensation payable to veterans for tinnitus is expected to exceed $3,000,000,000 in 2017. SEC. 3. RECOGNITION AND TREATMENT OF TINNITUS AT DEPARTMENT OF VETERANS AFFAIRS AUDITORY CENTERS OF EXCELLENCE. The Secretary of Veterans Affairs shall recognize tinnitus as a condition for research and treatment by the Department of Veterans Affairs Auditory Centers of Excellence. SEC. 4. RESEARCH ON PREVENTION AND TREATMENT OF TINNITUS. (a) In General.--The Secretary of Veterans Affairs shall recognize the need to enhance the research and treatment of tinnitus and to ensure the allocation of appropriate resources directed at the research and enhanced treatment of tinnitus conducted by the Auditory Centers of Excellence of the Department of Veterans Affairs, commensurate with peer-review protocols. Such research shall include-- (1) an assessment of the efficacy of multidisciplinary tinnitus treatment modalities on different subsets of patients; (2) studies on the underlying etiology of tinnitus in veteran populations that occur as a result of different causal factors, including blast-related tinnitus where there is no measurable hearing loss versus other forms of noise-induced tinnitus where there is hearing loss; and (3) a study of the underlying mechanisms between hearing loss and tinnitus, including cases in which one or the other condition is present, but not both. (b) Relationship to Other Authorities.--Nothing in this section shall be construed as interfering with the discretion of the Secretary of Veterans Affairs to conduct research in accordance with peer-review protocols in order to ensure the quality and transparency of the research. SEC. 5. INTERDEPARTMENTAL COOPERATION. The Secretary of Veterans Affairs shall ensure the cooperation of the Department of Veterans Affairs with the Hearing Center of Excellence established by the Department of Defense to further research on tinnitus. PURPOSE AND SUMMARY H.R. 1443, the Tinnitus Research and Treatment Act of 2013, was introduced by Representative Michael H. Michaud of Maine, Ranking Member of the Committee on Veterans' Affairs, on April 9, 2013. H.R. 1443, as amended, would: require the Department of Veterans Affairs (VA) to recognize the need to enhance the research and treatment of tinnitus; require VA to ensure the allocation of the appropriate resources directed at the research and treatment of tinnitus conducted by the VA Auditory Centers of Excellence, commensurate with peer-review protocols; and, require VA to ensure cooperation with the Hearing Center of Excellence established by the Department of Defense (DOD) to further research on tinnitus. BACKGROUND AND NEED FOR LEGISLATION Tinnitus is the experience or sensation of hearing sound when no external sound is present. It is often characterized by a persistent ringing in the ears and can range from merely distracting to wholly debilitating, depending on the severity of the condition. While noise overexposure either from a single impulse noise or cumulative exposure to noise is still the number one cause of tinnitus, it can also develop as a result of a head or neck injury. Further, a growing body of research has directly linked tinnitus as a co-morbid condition to both traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD), indicating that tinnitus represents a larger problem than hearing loss in the blast-exposed population. Tinnitus is one of the top five reported complaints from veterans of all eras of service and is particularly prevalent among veterans of Iraq and Afghanistan. Since 2006, the number of service-connected disability claims for tinnitus has risen at a rate of 15 percent each year, making it the most frequent service-connected disability. To care for these veterans, VA audiology clinics provide a Progressive Tinnitus Management (PTM) program. According to VA, ``[t]he focus of PTM is to teach patients how to manage their reactions to tinnitus.'' The PTM program encompasses five hierarchical tiers: triage; audiologic evaluation; group education; interdisciplinary evaluation; and, individualized support. Services offered to veterans with tinnitus through the PTM program include: hearing aids, group educational counseling, individual counseling, drug therapy, sound-based therapy, cognitive behavioral therapy, and relaxation techniques. Tinnitus-related research and educational resources are provided through the National Center for Rehabilitative Auditory Research (NCRAR), a VA Rehabilitation Research and Development Center of Excellence that is located on the campus of the Portland VA medical center. The NCRAR collaborates with the VA Audiology Program to develop and evaluate the PTM program at VA medical centers. VA also conducts research related to tinnitus in collaboration with DOD through the Defense Center of Excellence for Hearing Loss and Auditory System Injuries, which was mandated by section 721 of Public Law 110-417 (122 Stat. 4356, 4506), the Duncan Hunter National Defense Authorization Act for Fiscal Year 2009. VA's total investment in tinnitus-related research totals approximately $1.2 million, about one-tenth of the total national research dollars devoted to tinnitus. While recognizing VA's efforts both within the Department and in collaboration with DOD, the Committee is concerned with the increasing number of veterans who report experiencing tinnitus and the amount of VA research dollars dedicated to understanding, treating, and preventing it. Further, the Committee believes that greater knowledge of tinnitus could lead to more effective treatments for veterans and a better understanding of the link between tinnitus and both TBI and PTSD. H.R. 1443, as amended, would address the Committee's concerns by requiring VA to conduct further research regarding this condition. HEARINGS On July 9, 2013, the Subcommittee on Health conducted a legislative hearing on various bills introduced during the 113th Congress, including Draft Legislation, the Long-Term Care Veterans Choice Act; H.R. 1443; H.R. 1612; H.R. 1702; and, H.R. 2065. The following witnesses testified: The Honorable Mike Rogers of Alabama; the Honorable David McKinley of West Virginia; Jacob Gadd, the Deputy Director for Health Care for the Veterans Affairs and Rehabilitation Commission of the American Legion; Susan E. Shore, Ph.D., the Chair of the Scientific Advisory Committee for the American Tinnitus Association; Adrian Atizado, the Assistant National Legislative Director for the Disabled American Veterans; Robert Drexler, Member of the Board of Directors for the International Code Council, Raymond C. Kelley, Director of the National Legislative Service for the Veterans of Foreign Wars; and Robert L. Jesse, M.D., Ph.D., the Principal Deputy Under Secretary for Health for the Veterans Health Administration of the U.S. Department of Veterans Affairs, accompanied by Susan Blauert, the Deputy Assistant General Counsel for the U.S. Department of Veterans Affairs. Statements for the record were submitted by the following: The Honorable Ron Barber of Arizona; the Iraq and Afghanistan Veterans of America; Tuskegee University; the National Association of State Fire Marshals; the National Coalition for Homeless Veterans; the Paralyzed Veterans of America; the Vietnam Veterans of America; and the Wounded Warrior Project. SUBCOMMITTEE CONSIDERATION On July 23, 2013, the Subcommittee on Health met in open session, a quorum being present, and favorably forwarded to the full Committee H.R. 1443, as amended, by voice vote. During consideration of H.R. 1443, the following amendment was considered and agreed to by voice vote: An amendment offered by Ms. Brownley of California that would: strike any reference to ``mandatory'' research; require VA to recognize the need to enhance the research and treatment of tinnitus; and specify that nothing in this legislation shall be construed as interfering with VA's existing research peer- review protocols. COMMITTEE CONSIDERATION On August 1, 2013, the full Committee met in an open markup session, a quorum being present and ordered H.R. 1443, as amended, reported favorably to the House of Representatives by voice vote. COMMITTEE VOTES Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list the record votes on the motion to report the legislation and amendments thereto. There were no record votes taken on amendments or in connection with ordering H.R. 1443, as amended, reported to the House. A motion by Ranking Member Michael H. Michaud of Maine to report H.R. 1443, as amended, favorably to the House of Representatives was agreed to by voice vote. COMMITTEE OVERSIGHT FINDINGS In compliance with clause 3(c)(1) of rule XIII and clause (2)(b)(1) of rule X of the Rules of the House of Representatives, the Committee's oversight findings and recommendations are reflected in the descriptive portions of this report. STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES In accordance with clause 3(c)(4) of rule XIII of the Rules of the House of Representatives, the Committee's performance goals and objectives are reflected in the descriptive portions of this report. NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX EXPENDITURES In compliance with clause 3(c)(2) of rule XIII of the Rules of the House of Representatives, the Committee adopts as its own the estimate of new budget authority, entitlement authority, or tax expenditures or revenues contained in the cost estimate prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974. EARMARKS AND TAX AND TARIFF BENEFITS H.R. 1443, as amended, does not contain any congressional earmarks, limited tax benefits, or limited tariff benefits as defined in clause 9 of rule XXI of the Rules of the House of Representatives. COMMITTEE COST ESTIMATE The Committee adopts as its own the cost estimate on H.R. 1443 prepared by the Director of the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974. CONGRESSIONAL BUDGET OFFICE COST ESTIMATE Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House of Representatives, the following is the cost estimate for H.R. 1443, as amended, provided by the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974: U.S. Congress, Congressional Budget Office, Washington, DC, August 8, 2013. Hon. Jeff Miller, Chairman, Committee on Veterans' Affairs, House of Representatives, Washington, DC. Dear Mr. Chairman: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 1443, the Tinnitus Research and Treatment Act of 2013. If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is Ann E. Futrell. Sincerely, Douglas W. Elmendorf. Enclosure. H.R. 1443--Tinnitus Research and Treatment Act of 2013 H.R. 1443 would require the Department of Veterans Affairs (VA) to treat tinnitus as a condition for research and treatment at VA Auditory Centers of Excellence. Tinnitus, the medical term for the sensation of hearing sound when no external sound is present, is the most common disability among veterans and may be caused by exposure to loud sounds during military service. The VA already provides tinnitus treatment at all its audiology clinics. Furthermore, VA's National Center for Rehabilitation Auditory Research (NCRAR) at the Portland VA Medical Center conducts research and provides educational resources for tinnitus. NCRAR has several research projects currently under way on tinnitus (for example, the Clinical Trial of Transcranial Magnetic Stimulation for Relief of Tinnitus, Telephone Tinnitus Education for Patients with TBI, and Multi- Site Evaluation of Progressive Tinnitus Management). Additionally, the VA Research Enhancement Award Program at Mountain Home Veterans Affairs Medical Center in Tennessee is conducting tinnitus-related research projects. VA is currently collaborating with the Department of Defense Hearing Center of Excellence in maintaining a joint registry, providing treatment and conducting research for tinnitus. Since this bill would codify VA's current practices regarding tinnitus, CBO estimates that implementing H.R. 1443 would have no significant cost over the 2014-2018 period. Enacting this bill would not affect direct spending or revenues; therefore, pay-as-you-go procedures do not apply. H.R. 1443 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act and would impose no costs on state, local, or tribal governments. The CBO staff contact for this estimate is Ann E. Futrell. The estimate was approved by Peter H. Fontaine, Assistant Director for Budget Analysis. FEDERAL MANDATES STATEMENT The Committee adopts as its own the estimate of federal mandates regarding H.R. 1443, as amended, prepared by the Director of the Congressional Budget Office pursuant to Section 423 of the Unfunded Mandates Reform Act. ADVISORY COMMITTEE STATEMENT H.R. 1443, as amended, creates no advisory committees within the meaning of section 5(b) of the Federal Advisory Committee Act. CONSTITUTIONAL AUTHORITY STATEMENT Pursuant to Article I, section 8 of the United States Constitution, the reported bill is authorized by Congress' power to ``provide for the common Defense and general Welfare of the United States.'' APPLICABILITY TO LEGISLATIVE BRANCH The Committee finds that the legislation does not relate to the terms and conditions of employment or access to public services or accommodations within the meaning of the Congressional Accountability Act Sec. 102(b)(3), 2 U.S.C. Sec. 24 (1995). STATEMENT ON DUPLICATION OF FEDERAL PROGRAMS Pursuant to section 3(j) of H. Res. 5, 113th Cong. (2013), the Committee finds that no provision of H.R. 1443, as amended, establishes or reauthorizes a program of the Federal Government known to be duplicative of another Federal program, a program that was included in any report from the Government Accountability Office to Congress pursuant to section 21 of Public Law 111-139, or a program related to a program identified in the most recent Catalog of Federal Domestic Assistance. DISCLOSURE OF DIRECTED RULEMAKING Pursuant to section 3(k) of H. Res. 5, 113th Cong. (2013), the Committee estimates that H.R. 1443, as amended, does not require any directed rule makings. SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION Section 1. Short title Section 1 of the bill would provide the short title of H.R. 1443, as amended, as the ``Tinnitus Research and Treatment Act of 2013.'' Section 2. Findings Section 2 of the bill would make a number of findings related to tinnitus. Section 3. Recognition and treatment of tinnitus at Department of Veterans Affairs Auditory Centers of Excellence Section 3 of the bill would require VA to recognize tinnitus as a condition for research and treatment by the VA Auditory Centers of Excellence. Section 4. Research on prevention and treatment of tinnitus Section 4(a) of the bill would require the Secretary of Veterans Affairs to recognize the need to enhance the research and treatment of tinnitus and to ensure the allocation of appropriate resources directed at the research and enhanced treatment of tinnitus conducted by the VA Auditory Centers of Excellence, commensurate with peer review protocols. Section 4(a)(1) of the bill would require such research to include an assessment of the efficacy of multidisciplinary tinnitus treatment modalities on different subsets of patients. Section 4(a)(2) of the bill would require such research to include studies on the underlying etiology of tinnitus in veteran populations that occur as a result of different causal factors, including blast-related tinnitus that does not result in hearing loss and other forms of noise-induced tinnitus that does result in hearing loss. Section 4(a)(3) of the bill would require such research to include a study of the underlying mechanisms between hearing loss and tinnitus, including cases in which only one such condition is present. Section 4(b) of the bill would require that nothing in the bill be construed as interfering with VA's discretion to conduct research in accordance with peer-review protocols in order to ensure the quality and transparency of the research. Section 5. Interdepartmental cooperation Section 5 of the bill would require VA to ensure cooperation with the Hearing Center of Excellence established by DOD to further research on tinnitus. CHANGES IN EXISTING LAW MADE BY THE BILL AS REPORTED H.R. 1443, as amended, would not make any amendments to existing law.