[House Report 117-249]
[From the U.S. Government Publishing Office]
Union Calendar No. 179
117th Congress} { Report 117-249
2d Session } HOUSE OF REPRESENTATIVES { Part 1
======================================================================
HONORING OUR PROMISE TO ADDRESS COMPREHENSIVE TOXICS ACT OF 2021
_______
February 22, 2022.--Committed to the Committee of the Whole House on
the State of the Union and ordered to be printed
_______
Mr. Takano, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
together with
MINORITY VIEWS
[To accompany H.R. 3967]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 3967) to improve health care and benefits for
veterans exposed to toxic substances, and for other purposes,
having considered the same, reports favorably thereon without
amendment and recommends that the bill do pass.
The Committee on Veterans' Affairs, to which was referred
the bill (H.R. 3967) to improve health care and benefits for
veterans exposed to toxic substances, and for other purposes,
having considered the same, report favorably thereon and
recommend that the bill do pass.
CONTENTS
Page
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 2
Hearings......................................................... 12
Subcommittee Consideration....................................... 13
Committee Consideration.......................................... 13
Committee Votes.................................................. 13
Section-by-Section Description................................... 14
Congressional Budget Office Cost Estimate........................ 21
Committee Oversight Findings..................................... 42
Constitutional Authority Statement............................... 42
Earmark Statement................................................ 42
Federal Mandates Statement....................................... 42
Advisory Committee Statement..................................... 42
Performance Goals................................................ 42
Supplemental, Additional, Dissenting, and Minority Views......... 42
Applicability to Legislative Branch.............................. 46
Statement on Duplication of Federal Programs..................... 46
Ramseyer Submission.............................................. 46
Purpose and Summary
H.R. 3967, the ``Honoring Our Promise to Address
Comprehensive Toxics Act of 2021'' or ``Honoring our PACT
Act'', was introduced by Representative Mark Takano, Chairman
of the House Committee on Veterans' Affairs, on June 17, 2021.
H.R. 3967 would increase access to health care for toxic
exposed veterans as defined in the bill, create new procedures
for the Department of Veterans Affairs (VA) to follow when
establishing new presumptions for toxic exposure, improve data
collection by VA, and presume exposures and create presumptions
of service-connection for several cohorts of veterans, such as
those exposed to airborne hazards/burn pits, radiation and
Agent Orange. The bill also authorizes VA to conduct additional
research studies and requires VA to develop an outreach program
and standardized training on toxic exposure. H.R. 3967
incorporates, in whole or in part, text of the following 15
bills: H.R. 2368 introduced by Representative Elaine Luria of
Virginia on April 5, 2021; H.R. 2372 introduced by
Representative Raul Ruiz of California on April 5, 2021; H.R.
2436 introduced by Elissa Slotkin of Michigan on April 8, 2021;
H.R. 2607 introduced by Representative David Trone of Maryland
on April 15, 2021; H.R. 1355 introduced by Representative
Stephen Lynch of Massachusetts on February 25, 2021; H.R. 1585
introduced by Representative Grace Meng of New York on March 3,
2021; H.R. 1972 introduced by Representative Josh Harder of
California on March 17, 2021; H.R. 2127 introduced by
Representative Mike Bost of Illinois on March 23, 2021; H.R.
2268 introduced by Representative Bruce Westerman of Arkansas
on March 26, 2021; H.R. 2269 introduced by Representative Bruce
Westerman of Arkansas on March 26, 2021; H.R. 2580 introduced
by Representative Jahana Hayes of Connecticut on April 15,
2021; H.R. 2569 introduced by Representative Cartwright of
Pennsylvania on April 15, 2021; H.R. 2742 introduced by
Representative Chris Pappas of New Hampshire on April 21, 2021;
H.R. 2825 introduced by Representative Tonko of New York on
April 23, 2021; and H.R. 3368 introduced by Representative
Michael San Nicolas of Guam on May 20, 2021.
Background and Need for Legislation
Whether it is airborne hazards from burn pits and other
sources while serving abroad, contaminated water at military
bases from toxins such as per- and polyfluoroalkyl substances
(PFAS), or radiation from atomic testing and cleanups--each
passing day more and more veterans speak out about their
exposure to environmental hazards and toxic substances during
military service.
As Rose Marie Martinez, Sc.D., from the National Academies
of Science, Engineering, and Medicine explained, ``each
conflict seems to have a particular exposure that is considered
the hallmark of service in that era.'' For Vietnam, it was the
herbicide defoliants, specifically Agent Orange. For the 1990-
91 Persian Gulf War, it was the smoke from burning oil well
fires. Finally, for post-9/11 operations, it was the use of
burn pits for open air waste burning. Toxic exposure from these
substances can lead to a myriad of complicated health effects
from cancers and respiratory infections to unexplained chronic-
multi symptom illnesses and birth defects.
In general, VA presumes that certain disabilities were
caused by military service because of the unique circumstances
of a specific veteran's deployment or location of service. Once
there is enough scientific evidence, certain illnesses and
conditions tied to a specific geographic region or toxic
exposure work through VA's process and are eventually added to
the presumption list. If a presumed condition is diagnosed in a
veteran in a certain group, they can then be awarded disability
compensation--and access to critical VA care and benefits for
their service-connected disability. However, VA does not always
take timely action to identify and implement new presumptions.
For example, a National Academies of Sciences, Engineering, and
Medicine (NASEM) 2016 report on Agent Orange indicated there
was a sufficient association with exposure to Agent Orange and
hypertension. This condition has yet to be added to the list of
presumptive disabilities by VA.
H.R. 3967 seeks to streamline VA's current process to
provide faster decisions and transparency for veterans and
other stakeholders. The new process outlines timeframes for
action and creates a framework that the Secretary must follow
when reviewing possible toxic exposures for presumption of
service-connection. As it stands, the burden of proof in many
instances rests on each individual veteran--forcing them to
provide evidence that they were exposed to a toxic substance
during their service and have an illness as a result. Over
230,000 veterans have joined VA's Airborne Hazards and Open
Burn Pit Registry, which documents self-reported health
impacts, but because of VA's process, some veterans wonder
whether it's worth adding their name at all. This leaves many
veterans--regardless of the severity of their illness--without
the care and services they need to overcome illnesses resulting
from their toxic exposure.
In the past, Congress has granted special eligibility for
health care to certain veterans possibly exposed to toxic
substances and environmental hazards under special treatment
authorities, but this does not cover all toxic exposed
veterans. For instance, Congress addressed the health concerns
of Vietnam-era veterans in 1981, with the passage of the
Veterans' Health Care, Training, and Small Business Loan Act
(P.L. 97-72), but many veterans who served and were exposed
were not covered. Additional action followed to include the
Blue Water Navy Vietnam Veterans Act, passed in the 116th
Congress, which was a massive step to ensure those remaining
veterans exposed to Agent Orange during their service are cared
for, but this took more than 40 years. While this was a
historic win for impacted veterans, it addresses only one
cohort of veterans exposed to toxic substances.
H.R. 3967, the Honoring Our PACT Act of 2021, seeks to
address the remaining groups of toxic exposed veterans still
waiting for recognition by VA, as well as future generations.
It recognizes toxic exposure as a cost of war. The bill would
establish expanded health care eligibility to all toxic exposed
veterans based on participation in a toxic exposure risk
activity as defined in the bill. It provides coverage for
veterans exposed to burn pits and airborne hazards while
deployed beyond the five-year limit currently in place for
those returning from combat theaters. The bill would also
create presumptive service-connection for a list of illnesses
for veterans potentially exposed to airborne hazards while
conducting military operations or while stationed at specific
overseas locations. The bill also modifies existing
presumptions for radiation and Agent Orange exposure by
expanding the list of locations and dates for which exposure is
conceded and by adding additional diseases to the list of
presumptive disabilities, such as hypertension for herbicide
exposed veterans.
The bill also addresses another obstacle for toxic exposed
veterans, which is the lack of scientific evidence available to
support new presumptions. The Honoring Our PACT Act of 2021
requests several new studies, while also authorizing VA to
commission necessary research to support decision-making on
current and emerging toxic exposures.
H.R. 3967 recognizes toxic exposure as a cost of war and
not only restores veterans' trust in VA, but also reassures
future generations that should they answer the call to serve,
VA will always be there to care for them.
TITLE I--EXPANSION OF HEALTH CARE ELIGIBILITY FOR TOXIC EXPOSED
VETERANS
Veterans speaking out about exposure to environmental
hazards and other toxic substances during military service and
resulting health conditions need help now, not later. Over
230,000 veterans have joined VA's Airborne Hazards and Open
Burn Pit Registry, which documents self-reported health
impacts. Health impacts vary from unexplained chronic multi-
symptom illnesses to cancers, birth defects, infertility, and
respiratory conditions.
Title I of the Honoring our PACT Act authorizes access to
health care for ALL toxic-exposed veterans. This is to ensure
no veteran goes without the care and benefits they need to
improve their quality of life. Section 103 of Title I also
specifically provides access for the approximately 3.5 million
veterans who may have been exposed to burn pits and airborne
hazards while serving overseas. General eligibility is based on
participation in a toxic exposure risk activity, which includes
activities identified in the Department of Defense's (DoD) new
exposure record keeping system, the Individual Longitudinal
Exposure Record (ILER), as well as activities identified by the
VA Secretary. The ILER is a web-based application that provides
DoD and VA the ability to link an individual to exposures to
improve the efficiency, effectiveness, and quality of health
care. ILER will create a complete record of a service member's
occupational and environmental health exposures over the course
of the service member's career by linking individuals to known
exposure events and incidents and compiling the exposure
history to distill and report the relevant data and information
(i.e. handling, diagnosis, action thresholds, etc.). ILER will
provide DoD and VA clinicians, claims adjudicators, and
benefits advisors the actionable data required to improve the
care provided to service members and veterans.
To ensure VA has adequate time to assess resourcing needs
and establish plans to address what will likely be an increase
in healthcare enrollment, the bill provides an 18-month
implementation period and requires the Secretary to conduct a
resource assessment and submit a report to Congress within 180
days of enactment of the bill. This provision is taken from
Representative Luria's ``COVENANT Act''. By providing the
agency with time to assess the impact of this authorization, we
can ensure minimal disruption to current care and services to
veterans already enrolled and using VA's healthcare system.
While a maximum period of 18 months is allowed before the
healthcare access provisions become effective, it is this
Committee's intent that the VA Secretary will effectuate
healthcare access for impacted veterans as quickly as possible.
The Secretary must also provide the committees of jurisdiction
a report every 90 days on where the agency is with implementing
these sections of the bill.
TITLE II--TOXIC EXPOSURE PRESUMPTION PROCESS
Title II provides for a new decision-making framework for
VA to establish new presumptions for service-connection based
on toxic exposures. The new decision process includes a Formal
Advisory Committee, an Independent Science Review Board, and a
Working Group. An explanation of the entities and activities
involved in the decision process outlined in Title II is
provided below:
Establishes a Formal Advisory Committee made up of nine
members, with five appointed by the Secretary and four
appointed by Congress. The Committee reviews data on potential
toxic exposures and determines whether to commission additional
research, advance a nomination to the Science Review Board, or
recommend Secretarial action to expand a presumption.
Establishes an Independent Science Review Board with
members and terms determined by the Secretary. Members must be
selected from the general public from among individuals who are
distinguished in the fields of medicine, biological sciences,
or health administration. The Board reviews available research
and determines (1) likelihood of association, and (2) impact of
service. The Board prepares reports and submits to the Working
Group, Committee, and Congress.
Codifies the Toxic Exposure Working Group, which is
comprised of VA employees. The Working Group evaluates the
Board's conclusions and makes recommendations to the Secretary
to establish a presumption-of-service-connection.
Requires the Secretary to respond to the Working Group's
recommendations within 60 days and determine whether to
establish or modify a presumption. The Secretary's decision,
reasoning, and sources for decision must be publicly reported.
When establishing a presumption, the Secretary would be
required to issue final regulations within 180 days of issuing
proposed regulations. The above provisions are taken from
Representative Trone's ``FASTER Presumptions Act''.
Section 203 addresses reevaluation of claims for
compensation involving presumptions of service-connection. This
section requires that whenever a new presumption of service-
connection is established, the Secretary would be required to
conduct outreach to veterans who previously filed claims and
were denied for a condition that falls under the new
presumption. For previously denied claims that are approved,
the Secretary must provide an effective date as though the
presumption was in effect on the date of the previously denied
claim. This section would apply to the newly established
presumptions included in Title IV of the bill.
It is not this Committee's intent to require automatic re-
adjudication of previously denied claims. However, this bill
does require that if a veteran wishes to reapply for a
previously denied benefit based on a newly established
presumption, VA will assign the earliest effective date
possible, as though the presumption was in place at the time of
the previously denied claim.
TITLE III--IMPROVING THE ESTABLISHMENT OF SERVICE CONNECTION FOR TOXIC
EXPOSED VETERANS
Title III requires the Secretary to consider the ILER of a
veteran when adjudicating a toxic exposure claim. Provisions of
Title III are provided below:
Establishes a concession of exposure for veterans exposed
to airborne hazards and burn pits. This concession of exposure
to certain substances is for the purpose of establishing a
direct service-connection in a disability compensation claim.
Eligibility is based on locations and dates of service. This
provision is taken from Representative Luria's bill, the
``COVENANT Act''.
Requires that VA provide an exam and medical opinion
related to toxic exposure claims where the veteran has evidence
of a disability and participation in a toxic exposure risk
activity. This provision is taken from Representative Slotkin's
bill, the ``Veterans Burn Pits Exposure Recognition Act of
2021''.
TITLE IV--PRESUMPTIONS OF SERVICE-CONNECTION
Title IV of the bill includes a presumption of service-
connection for the several cohorts of veterans previously
excluded, and who have been fighting for years to be recognized
as toxic-exposed veterans.
Section 406 of Title IV creates a presumption of service-
connection for 23 conditions which include respiratory
conditions and cancers for the approximately 3.5 million
veterans who were exposed to burn pits and other airborne
hazards. This provision is taken from Representative Ruiz's
``Presumptive Benefits for War Fighters Exposed to Burn Pits
and Other Toxins Act'', and Representative Luria's ``COVENANT
Act''.
Both DoD and VA acknowledge that service members who were
exposed to airborne hazards, such as open burn pit smoke, while
serving may be at risk for short- and long-term health issues.
After deployment to locations with open burn pits and other
pollution sources, service members have returned with a range
of mild to serious respiratory illnesses. VA notes that in
Iraq, Afghanistan, and other areas of the Southwest Asia
theater of military operations, open-air combustion of trash
and other waste in burn pits was a common practice. The DoD
closed out most burn pits and is planning to close the
remainder; however, its use has left a lasting impact on the
service members who were exposed to them. Whether noted by the
Environmental Protection Agency or other government entities,
it is widely accepted that the burning of waste and garbage can
have a significantly negative impact on not just the
environment but human health. This is acknowledged though the
laws that prevent burning of waste and the regulations that
surround exposure and handling of toxic substances.
As many as 3.5 million service members were exposed to
toxic substances through DoD's use of burn pits. At least 230
pits were utilized in Iraq and Afghanistan, with the largest of
these burn pits located at the Balad Air Base in Iraq. During
its operation, it comprised 10 acres of burning trash, 24 hours
a day, 365 days a year. VA's Airborne Hazards and Open Burn Pit
Registry website shows that more than 230,000 veterans and
service members have submitted their information to the
registry, many of which are suffering and dying from illnesses
such as lung diseases, cancers, and other respiratory
illnesses. VA established this registry in 2014, to collect
data on exposed veterans and help VA better understand the
potential health effects of exposure to airborne hazards during
military service.
To support a claim for benefits, per VA's website and
current law, a veteran must submit evidence of (1) a current
physical or mental disability from a medical professional or
layperson (someone who is not a trained professional), (2) an
event, injury, or disease that happened during active-duty
service (which is the case for exposure to airborne hazards),
and (3) a link, usually provided by a medical professional,
between the veteran's current disability and the event, injury,
or disease that happened during service. The onus is on the
veteran in most cases to prove their case of exposure, unless
there is a presumption in place. Presumptions can establish
that anyone who served in a specific location was more than
likely exposed to a specific toxic substance and can also
establish a link between that exposure and certain
disabilities. The application of a presumption removes the
burden from the veteran to submit evidence to establish this
link. Section 406 removes this burden from veterans for the 23
conditions related to airborne hazards. VA has already
initiated action to recognize three of the conditions as
presumptive to particulate matter (PM) exposure while serving
abroad: asthma, rhinitis, and sinusitis.
VA reviewed several studies conducted by NASEM that
examined the possible contribution of air pollution to adverse
health effects among U.S. military personnel who served in the
Middle East to include their dependents. The National Research
Council (NRC) of NASEM independently reviewed DoD's final
report in ``Review of the Department of Defense Enhanced
Particulate Matter Surveillance Program (EPMSP) Report'' in
2010. The NRC committee highlighted that the EPMSP was one of
the first large-scale efforts to characterize PM exposure in
deployed military personnel. In VA's interim final rule\1\ on
PM presumptions that was published on August 5, 2021, VA noted
that:
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\1\https://www.federalregister.gov/documents/2021/08/05/2021-16693/
presumptive-service-connection-for-respiratory-conditions-due-to-
exposure-to-particulate-matter#: :text=The%20De-
partment%20of%20Veterans%20Affairs%20%28VA%29%20is%20issuing,association
%20with%20presumed%20exposures%20to%20fine%2C%20particulate%20matter.
. . . the NRC committee found that the EPMSP results
clearly documented that deployed Service Members
deployed in the Middle East ``are exposed to high
concentrations of PM and that the particle composition
varies considerably over time and space.'' Further, the
NRC Report committee concluded that ``it is indeed
plausible that exposure to ambient pollution in the
Middle East theater is associated with adverse health
outcomes.'' The health outcomes noted may occur both
during service (acute) as well as manifest years after
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exposure (chronic).
The Committee's review of available scientific evidence and
reports, including VA's own assessments related to PM, supports
recognition of the 23 respiratory conditions and cancers
included in this section of the bill as a starting point for
this group of toxic-exposed veterans.
Section 404 of Title IV creates a presumption of service-
connection for approximately 490,000 Agent Orange-exposed
veterans suffering from hypertension and Monoclonal gammopathy
of undetermined significance (MGUS). This provision is taken
from Representative Harder's bill, the ``Fair Care for Vietnam
Veterans Act of 2021''. A NASEM report on Agent Orange,
published on November 15, 2018, reported there was ``sufficient
evidence of an association'' between Hypertension and Agent
Orange exposure. This places hypertension in the highest
category of an association; however, VA failed to add these
conditions to the list of presumptive conditions associated
with Agent Orange. Vietnam veterans have waited decades for
scientific support and now have that, but they are still
waiting for the benefits they deserve due to VA's unwillingness
to take decisive action. Section 404 of Title IV seeks to
remedy this by adding these conditions to the presumptive list
through legislation.
Section 401 of Title IV provides coverage for the
approximately 6,000 radiation-exposed veterans who were
assigned to clean nuclear testing sites in Enewetak Atoll in
the Marshall Islands during the late 1970s. This provision is
taken from Representative Meng's bill, the ``Mark Takai Atomic
Veterans Healthcare Parity Act of 2021.'' Enewetak Atoll was
the site of more than 40 nuclear tests between 1946 and 1958.
The service members who participated in its nuclear cleanup
between 1977 and 1980 suffer from high rates of cancers due to
their exposure to radiation and nuclear waste but are currently
unable to receive the same treatments and service-related
disability presumptions that other ``radiation-exposed
veterans'' receive.
As said by Representative Meng, ``These veterans served our
nation with honor and distinction. It is long past time that we
address the failure of our system to help them.''
Representative Meng's bill has the support of over 11 different
veteran advocacy groups. The National Association of Atomic
Veterans National Commander Keith Kiefer in a statement of
support noted that ``Despite contamination of the islands with
Plutonium, Strontium, Cesium and other toxic materials from
years of testing 43 atomic bombs, the veterans did not have
proper PPG (Personal Protective Gear) or monitoring during
removal and transportation of approximately 110,000 cubic yards
contaminated soil, these bureaucracies continue to deny any
exposure and proper care associated with that.'' He also noted
that of all the veterans who participated in this project, they
have found about only 10 percent alive with most of the
survivors having cancer(s) and at least one suffers with six
unique cancers. With many of these veterans having already
passed, Congress cannot continue to delay benefits that would
improve the quality of life for this group of toxic-exposed
veterans.
Section 402 of Title IV provides coverage for the
approximately 1,600 radiation-exposed veterans who responded to
the 1966 nuclear accident in Palomares, Spain. This provision
is taken from Representative Hayes's bill the ``Palomares
Veterans Act of 2021''. In January 1966, a U.S. Air Force
aircraft transporting four nuclear weapons and a refueling
tanker aircraft collided over Palomares, Spain, while
attempting inflight refueling. The four weapons were released
in the collision, and two of the weapons were destroyed upon
impact from the detonation of conventional explosives present
in the weapons. The damage to these weapons released plutonium,
highly enriched uranium, and certain other radioactive
materials, but did not involve a nuclear detonation. Many of
the airmen who responded to the accident report being given
little to no protective clothing and were not instructed on the
potential consequences of exposure to such dangerous
substances. They were ordered to clear contaminated crops,
shovel tainted soil into burn pits, and consume the local water
and food--placing them in direct contact with large amounts of
plutonium. Based on declassified reports from the Atomic Energy
Commission, there were more than 3 billion micrograms of
plutonium released into the air as a result of the accident.
This level of exposure raises major concerns of toxic exposure
in Palomares veterans.
Veterans who participated in the cleanup are speaking out
about health conditions such as cancer that they feel is
directly due to their exposure to radioactive materials during
the cleanup. Many of these veterans have filed disability
claims with VA and received denials as VA does not include the
Palomares cleanup incident as a ``radiation risk activity''
within its current regulations. This is due in main part to
VA's reliance on questionable dosing estimates providing by the
Air Force. A physicist, Frank von Hippel, challenged the Air
Force's dosing estimate methods in a publication titled History
of Dose, Risk, and Compensation Assessments for US Veterans of
the 1966 Plutonium Cleanup in Palomares, Spain\2\ in December
2019. The U.S. Air Force has continued to examine radiological
exposures associated with this incident and issued a recent
report, U.S. Air Force Safety Center, Topical Issues for
Assessment of Dose to Palomares Accident Recovery Workers
(1966),\3\ on July 7, 2020.
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\2\https://journals.lww.com/health-physics/Fulltext/2019/12000/
History_of_Dose,_Risk,_and_ Compensation.13.aspx.
\3\https://urldefense.proofpoint.com/v2/url?u=https-
3A_www.safety.af.mil_Portals_71_docu- ments_Weapons_Palomares-2520Dose-
2520Assessment-2520Rpt-25207-2520Jul-25202020.pdf-3Fver-3D2020-2D08-
2D05-2D113936-2D200&d=DwMFAg&c=L93KkjKsAC98uTvC4KvQDdT
DRzAeWDDRmG6S3YXllH0&r=vyDR8HjB88IX8YJD94iTOsWUsbQNJXaiQpXgvLmUlAY&m=
Dsawq2jZCKeEgnm8LgEFH4n1exySABZ-
EdzXINb8ypI&s=n5fJ3X2t6lFvYewy_JCmx49Z668Ls UVTCq0sH1MF3BA&e=.
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Air Force dosing estimates have also been challenged by
veterans and advocacy groups in a class action suit led by one
participant, Victor Skaar. In Skaar v. Wilkie,\4\ the Court of
Appeals for Veterans Claims issued a decision in December 2020,
that found that VA had not fulfilled its legal responsibility
to determine whether the method it uses to assess Palomares
veterans' radiation exposure is scientifically sound. Victor
Skaar, the lead appellant, argued that VA unjustifiably
excluded Palomares from the list of ``radiation-risk
activities,'' and used unsound scientific methodologies to deny
his disability benefits claim as well as many others. Section
402 of Title IV seeks to remedy these errors and establish a
presumption for the remaining Palomares veterans and their
dependents.
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\4\http://uscourts.cavc.gov/documents/SkaarVB_17-2574%20(12-17-
20).pdf.
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Section 403 of Title IV provides coverage for Agent Orange-
exposed veterans who served in Thailand, Laos, and Cambodia.
This provision is taken from Representative Cartwright's bill
the ``Veterans Agent Orange Exposure Equity Act''. VA currently
requires veterans with service in Thailand, Laos, and Cambodia
to carry the burden of proving they were exposed to Agent
Orange during the Vietnam War. VA currently reviews service-
connected disability claims from this group of veterans on a
case-by-case basis and adds additional restrictions on where
and in what military occupation a veteran must have served in
Thailand to receive benefits. VA's current process arbitrarily
disqualifies many veterans from receiving the benefits they
have earned and need.
Veterans should not have to bear the burden of proving
their case when VA and DoD have evidence that supports exposure
to herbicides for veterans in Thailand, Laos, and Cambodia. The
DoD and VA have acknowledged that Agent Orange was stored,
tested, and used outside of the Republic of Vietnam, and
included these locations in a public facing list on VA's
website. Section 403 of Title IV uses the dates and locations
identified by DoD to provide a presumption of exposure for this
cohort of veterans.
Also included in this section is coverage for veterans who
served in Guam, American Samoa, and Johnston Island. The number
of impacted veterans is difficult to gauge; however, based on
counts from advocacy groups, the number is approximately
50,000. A Government Accountability Office (GAO) report
released in November 2018, titled Agent Orange: Action Needed
to Improve Accuracy and Communication of Information on Testing
and Storage Locations\5\ (GAO-19-24), reported that the DoD
record keeping on at least one vessel carrying Agent Orange
ported in Guam was deficient with many of the records lost or
destroyed, and the records that do exist do not indicate what
cargo was unloaded or remained on board. Further,
identification of Agent Orange testing and storage sites
outside of Vietnam was deficient, and some of the commercial
herbicides that VA conceded were used in Guam contained 2,4-D;
2,4,5-T, or both. The provisions of the ``Agent Orange Act of
1991,'' apply to all herbicides containing 2,4-D or dioxin used
in support of combat operations in Vietnam, and can therefore
be inclusive of those used in Guam.
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\5\https://www.gao.gov/assets/gao-19-24.pdf.
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Using VA's legal standard, the Veterans Legal Services
Clinic of the Jerome N. Frank Legal Services Organization at
the Yale Law school examined widely available evidence and
determined that it is ``as likely as not'' that service members
who served on Guam were exposed to toxic herbicides containing
dioxin. This comprehensive study, titled NVLSP And VLSC White
Paper Confirming That Veterans Who Served in Guam from 1958-
1980 Were Likely Exposed to Dioxin-Containing Herbicide Agents
Including Agent Orange,\6\ issued in May 2020, and updated on
February 12, 2021, ``includes official government documents
describing widespread practices of herbicide spraying,
mishandling, and improper disposal prior to the enactment of
federal hazardous waste regulations enacted in 1976.'' Over the
course of three decades, soil testing conducted by the U.S.
Environmental Protection Agency and the Guam Environmental
Protection Agency have revealed herbicide and dioxin pollution
in locations throughout the island where veterans have noted
toxic chemicals were sprayed. Very recent soil samples tested
in 2018, and repeated in 2019, detected 2,4-D and 2,4,5-T as
well as the toxic TCDD byproduct.
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\6\https://law.yale.edu/sites/default/files/area/clinic/
2021.02.11_-_nvlsp_white_paper_-_clean.pdf.
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As with the other cohorts of veterans addressed in this
title, reasonable doubt should be given to these veterans who
continue to report about their exposures to toxic substances
during service. This section intends to accomplish that by
providing a presumption of Agent Orange exposure for veterans
with qualifying service in Guam, American Samoa, and Johnston
Island.
Section 405 of Title IV seeks to makes improvements to the
Gulf War Illness presumption process by extending VA's
authority to grant benefits for Gulf War Illness and
eliminating the sunset date currently in place for veteran
eligibility.
TITLE V--RESEARCH MATTERS
Title V designates VA as the coordinating authority for all
research activities conducted by the federal government on the
health consequences of military toxic exposures and requires VA
to develop a Toxic Exposure Research Strategic Plan to ensure
that the government's research activities related to military
toxic exposure are collaborative, transparent, and highly
coordinated. VA must provide a report to Congress within one
year of the date of enactment. Additional elements of Title V
delineate the following:
Requires collection of clinical data for use in toxic
exposure research. This provision is taken from Representative
Bost's ``Toxic Exposure in the American Military Act''.
Requires three separate studies on veterans who served in
Southwest Asia and other locations, covering mortality,
toxicology, and epidemiology. This provision is taken from
Representative Trone's ``FASTER Presumptions Act''.
Requires an epidemiological study on the health trends of
all Post 9/11 veterans, and a study on the incidence of cancers
among veterans.
Directs VA to conduct a study on the feasibility of
providing Civilian Health and Medical Program of the Department
of Veterans Affairs (CHAMPVA) benefits to dependents of
veterans for healthcare costs related to toxic exposures
experienced on DoD-maintained facilities.
TITLE VI--IMPROVEMENT OF RESOURCES AND TRAINING REGARDING TOXIC EXPOSED
VETERANS
Title VI has the following provisions regarding resource
allocation and training opportunities:
Requires VA to publish a list of the benefits and
healthcare resources available to veterans and survivors
related to toxic exposure. This provision is taken from
Representative Bost's ``Toxic Exposure in the American Military
Act''.
Directs VA to incorporate a toxic exposure questionnaire
during primary care appointments. This provision is taken from
Representative Bost's ``Toxic Exposure in the American Military
Act''.
Requires improved standardized training for VA claims
processors, as well as health care personnel conducting
examinations to assist in the accurate adjudication of toxic
exposure claims. This provision is taken from Representative
Luria's ``COVENANT Act'' and Representative Trone's ``FASTER
Presumptions Act''.
TITLE VII--REGISTRIES, RECORDS, AND OTHER MATTERS
Title VII includes the following provisions related to
record keeping:
Requires VA to establish a Fort McClellan Health Registry
and provide the option of a health examination and consultation
to any veteran who was stationed at Fort McClellan. This Title
also requires VA to do appropriate outreach to veterans listed
in the registry about options, new research, and the
consequences of toxic substance exposure. This provision is
taken from Representative Tonko's ``Fort McClellan Health
Registry Act''.
Directs VA to establish a registry for current or past
members of the Armed Forces who may have been exposed to PFAS
due to the environmental release of aqueous film-forming foam
at a military installation or other DoD location. This
provision is taken from Representative Pappas's ``PFAS Registry
Act of 2021''.
Requires DoD to review the ILER periodically to determine
whether additional exposures should be added, based on
geography, occupation, and timeframe of service.
Requires an independent study on the ILER to assess the
quality of location and exposure data and determine whether a
member of the Armed Forces can be reasonably assured that any
toxic exposure they experienced during service will be
reflected in their records.
Requires the Secretary of Defense and the Secretary of
Veterans Affairs to allow for service members and veterans to
correct their military records as they pertain to toxic
exposures.
Hearings
On May 5, 2021, the full Committee conducted a legislative
hearing on various bills introduced during the 117th Congress.
Many of these bills were incorporated into H.R. 3967. The
following witnesses testified: The Honorable Mike Bost, U.S.
House of Representatives, 12th Congressional District of
Illinois; The Honorable Elaine Luria, U.S. House of
Representatives, 2nd Congressional District of Virginia; The
Honorable Troy Nehls, U.S. House of Representatives, 22nd
Congressional District of Texas; The Honorable Chris Pappas,
U.S. House of Representatives, 1st Congressional District of
New Hampshire; The Honorable Elissa Slotkin, U.S. House of
Representatives, 8th Congressional District of Michigan; The
Honorable Raul Ruiz, U.S. House of Representatives, 36th
Congressional District of California; The Honorable Bruce
Westerman, U.S. House of Representatives, 4th Congressional
District of Arkansas; The Honorable Stephen Lynch, U.S. House
of Representatives, 8th Congressional District of
Massachusetts; The Honorable Lee Zeldin, U.S. House of
Representatives, 1st Congressional District of New York; The
Honorable Paul Tonko, U.S. House of Representatives, 20th
Congressional District of New York; The Honorable Matt
Cartwright, U.S. House of Representatives, 8th Congressional
District of Pennsylvania; The Honorable Jahana Hayes, U.S.
House of Representatives, 5th Congressional District of
Connecticut; The Honorable Gregory Murphy, U.S. House of
Representatives, 3rd Congressional District of North Carolina;
Mr. Ronald Burke, Deputy Under Secretary for Policy and
Oversight, Veterans Benefits Administration; accompanied by Ms.
Beth Murphy, Executive Director for Compensation Service,
Veterans Benefits Administration, and Dr. Patricia Hastings,
Chief Consultant, Post Deployment Health Service, Veterans
Health Administration; Dr. Karl Kelsey, Professor of
Epidemiology, Pathology and Laboratory Medicine, Brown
University, National Academies of Sciences, Engineering, and
Medicine; Aleksandr Morosky, Government Affairs Specialist,
Wounded Warrior Project; Travis Horr, Director, Government
Affairs, Iraq and Afghanistan Veterans of America; Shane L.
Liermann, Deputy National Legislative Director for Benefits,
Disabled American Veterans; Kristina Keenan, Associate
Director, Disability Assistance and Memorial Affairs, Veterans
of Foreign Wars; and Jim Price, Veteran and Advocate.
Subcommittee Consideration
H.R. 3967 was not considered before the Subcommittee on
Disability Assistance and Memorial Affairs.
Committee Consideration
On June 24, 2021, the full Committee met in an open markup
session, a quorum being present, to consider H.R. 3967. An
amendment in the nature of a substitute was offered by
Representative Mike Bost of Illinois. The amendment was not
agreed to in a recorded vote. The Committee ordered that H.R.
3967 as introduced be ordered favorably reported to the House
of Representatives.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the recorded
votes on the motion to report the legislation and amendments
thereto. Representative Bost offered an Amendment in the Nature
of a Substitute. The results of the record vote on an amendment
or motion to transmit, together with the names of those voting
for and against, are printed below.
Veterans' Affairs Committee record vote No. 2
Amendment by Representative Bost to H.R. 3967 in the Nature
of a Substitute, replacing the text of the bill with a
feasibility and advisability study of the underlying bill as
introduced. Defeated: 14-10. The vote was as follows:
----------------------------------------------------------------------------------------------------------------
Majority Members Vote Minority Members Vote
----------------------------------------------------------------------------------------------------------------
Mr. Takano...................................... Nay Mr. Bost.......................... Aye
Ms. Brownley.................................... Nay Ms. Radewagen..................... ............
Mr. Lamb........................................ Nay Mr. Bergman....................... Aye
Mr. Levin....................................... Nay Mr. Banks......................... Aye
Mr. Pappas...................................... ............ Mr. Roy........................... ............
Ms. Luria....................................... Nay Mr. Murphy........................ Aye
Mr. Mrvan....................................... Nay Mr. Mann.......................... Aye
Mr. Sablan...................................... ............ Mr. Moore......................... Aye
Ms. Underwood................................... Nay Ms. Mace.......................... Aye
Mr. Allred...................................... Nay Mr. Cawthorn...................... ............
Ms. Frankel..................................... Nay Mr. Nehls......................... Aye
Mr. Brown....................................... Nay Mr. Rosendale..................... Aye
Ms. Slotkin..................................... Nay Ms. Miller-Meeks.................. Aye
Mr. Trone....................................... Nay
Ms. Kaptur...................................... ............
Mr. Ruiz........................................ Nay
Mr. Gallego..................................... Nay
----------------------------------------------------------------------------------------------------------------
Veterans' Affairs Committee record vote No. 3
Representative Luria requested a record vote on the motion
to transmit the bill to the House of Representative. Affirmed:
14-11. The vote was as follows:
----------------------------------------------------------------------------------------------------------------
Majority Members Vote Minority Members Vote
----------------------------------------------------------------------------------------------------------------
Mr. Takano...................................... Aye Mr. Bost.......................... Nay
Ms. Brownley.................................... ............ Ms. Radewagen..................... ............
Mr. Lamb........................................ Aye Mr. Bergman....................... ............
Mr. Levin....................................... ............ Mr. Banks......................... Nay
Mr. Pappas...................................... Aye Mr. Roy........................... ............
Ms. Luria....................................... ............ Mr. Murphy........................ Nay
Mr. Mrvan....................................... Aye Mr. Mann.......................... ............
Mr. Sablan...................................... ............ Mr. Moore......................... Nay
Ms. Underwood................................... ............ Ms. Mace.......................... ............
Mr. Allred...................................... ............ Mr. Cawthorn...................... Nay
Ms. Frankel..................................... Aye Mr. Nehls......................... ............
Mr. Brown....................................... ............ Mr. Rosendale..................... Nay
Ms. Slotkin..................................... Aye Ms. Miller-Meeks.................. Nay
Mr. Trone....................................... ............
Ms. Kaptur...................................... ............
Mr. Ruiz........................................ ............
Mr. Gallego..................................... Aye
----------------------------------------------------------------------------------------------------------------
Section-by-Section Description
Section 1: Short Title; References to Title 38, United States Code;
Table of Contents
This section includes a table of contents and specifies
that this Act may be cited as the ``Honoring our Promise to
Address Comprehensive Toxics Act of 2021'' or the ``Honoring
our PACT Act of 2021''.
TITLE I--EXPANSION OF HEALTH CARE FOR TOXIC EXPOSED VETERANS
Section 101: Short title
Section 101 would establish the ``Conceding Our Veterans'
Exposures Now and Necessitating Training Act'' or the
``COVENANT Act'' as the short title of Title I of the Act.
Section 102: Definitions relating to toxic exposed veterans
Section 102(a) amends section 1710(a)(2)(F) to clarify the
section applies to ``toxic exposed veterans''.
Section 102(b) defines ``toxic exposure'' and defines
``toxic exposed veterans'' as a veteran described in section
1710(e)(1) of title 38 United States Code. This section
includes Vietnam-era herbicide-exposed veterans, radiation-
exposed veterans, veterans with requisite service during the
Persian Gulf War, certain veterans who served on active duty in
a theater of combat operations, Shipboard Hazard and Defense
(SHAD) testing participants, certain Camp Lejeune veterans, and
any veterans who participated in a toxic exposure risk
activity.
Section 102(c) defines ``toxic exposure risk activity'' as
any risk of exposure recorded in the Individual Longitudinal
Exposure Record (ILER), which documents exposures to toxic
substances or that the Secretary determines qualifies for
purposes of this subsection. Additionally, the Secretary of VA
has the authority to make their own determination that a
veteran participated in a toxic exposure risk activity when the
ILER does not contain the appropriate data.
Section 103: Expansion of health care for specific categories of toxic
exposed veterans
Section 103(a) authorizes access to health care for all
toxic-exposed veterans, inclusive of those exposed to burn pits
and airborne hazards. Eligibility is based on participation in
a toxic exposure risk activity, which includes activities
identified in the ILER as well as activities identified by the
VA Secretary. This covers any illness a covered veteran wishes
to seek care for and gives Priority Group 6 level access which
covers the cost of care.
Section 103(b) requires the Secretary to complete a
resource assessment and report on the Department's ability to
implement this section within 180 days after enactment and
every 90 days thereafter until the effective date found in
section 103(c) is effective.
Section 103(c) provides an effective date for the
amendments made in this section that would be either the date
the Secretary certifies through a report to Congress that the
Department has the resources and personnel necessary to
implement the amendment or the date that is 18 months after
enactment of the Act, whichever is earlier.
TITLE II--TOXIC EXPOSURE PRESUMPTION PROCESS
Section 201: Short Title
Section 201 would establish the ``Fairly Assessing Service-
related Toxic Exposure Residuals Presumptions Act'' or the
``FASTER Presumptions Act'' as the short title of Title II of
the Act.
Section 202: Improvements to ability of Department of Veterans Affairs
to establish presumptions of service-connection based on toxic
exposure
Section 202(a) provides new procedures that VA must follow
to establish new presumptions for service-connection based on
toxic exposures. The new review process includes a Formal
Advisory Committee, an Independent Science Review Board, and a
Working Group.
This section defines the term ``illness'' as used in this
section as a disease or other condition affecting the health of
an individual.
This section establishes a Formal Advisory Committee on
Toxic Exposure made up of nine members, with five appointed by
the Secretary and four appointed by Congress in a bipartisan
manner. Each member will serve a two-year term.
The Committee reviews data on potential toxic exposures and
determines whether to commission additional research, advance a
nomination to the Science Review Board, or recommend
Secretarial action to expand a presumption. The Committee would
fall under the Federal Advisory Committee Act except this would
be a permanent committee not subject to the two-year renewal
requirement. This section also requires annual reports to the
Committees on Veterans' Affairs of the Senate and House of
Representatives by the Formal Advisory Committee.
This section establishes a Science Review Board with
members and terms determined by the Secretary in collaboration
with the National Academies of Sciences, Engineering and
Medicine. Members must be selected from the general public from
among individuals who are distinguished in the fields of
medicine, biological sciences, or health administration.
Members cannot concurrently serve on the Committee. The Board
would evaluate research nominated by the Committee and
determines the strength of association between toxic exposure
and an illness. The Board reviews available research and
determines (1) likelihood of association, and (2) impact of
service. The Board prepares reports and submits to the VA
Working Group, Committee and Congress.
This section establishes that if evidence for association
is either ``sufficient'' or ``equipoise and above'' (i.e. more
likely than not), then the Board shall calculate the
probability of association for an individual. If the evidence
for association is ``below equipoise,'' then the Board may
choose to gather additional data or request additional
research.
This section establishes a Working Group comprised of VA
employees. The Working Group evaluates the Board's conclusions
on toxic exposure cases and makes recommendations to the
Secretary regarding whether to establish a presumption-of-
service-connection. A report outlining the recommendations made
by the Working Group would also be submitted to Congress.
This section requires the Secretary to respond to any
recommendations made by the Working Group within 60 days. If
the Secretary proposes new presumptions in response, the
Secretary must then issue final regulations within 180 days of
the proposed regulation. Should the Secretary decide against
adding a new presumption, VA must publish this decision in the
Federal Register with information relating to this decision
within 90 days.
This section requires the Secretary to maintain benefits
for veterans and survivors in receipt of compensation when the
Secretary removes a presumption of service-connection for which
the award of benefits was established.
Section 202(b) provides conforming amendments which require
the Secretary to ensure any determination made on or after the
date of enactment of this Act regarding a presumption of
service-connection is made pursuant to the procedures outlined
in this section.
Section 203: Reevaluation of claims for compensation involving
presumptions of service-connection
This section requires that when a regulation or Federal
court decision establishes or modifies a presumption of
service-connection, the Secretary must identify all claims for
compensation that were previously received and denied. The
Secretary must conduct outreach to this group of individuals
and if a claim is received from this group and then granted,
establish an effective date as if the new presumption was in
effect at the time of the prior claim.
This section also requires the Secretary to provide public
notice of the ability of veterans to reapply for benefits when
applicable.
TITLE III--IMPROVING THE ESTABLISHMENT OF SERVICE CONNECTION PROCESS
FOR TOXIC EXPOSED VETERANS
Section 301: Short title
This title may be cited as the ``Veterans Burn Pits
Exposure Recognition Act''.
Section 302: Presumptions of toxic exposure
This section directs the Secretary to consider any entry in
the Individual Longitudinal Exposure Record (ILER) that
qualifies as a toxic exposure risk activity as a presumption of
exposure for a claim for service-connection. If the ILER record
does not contain the necessary information, the VA should
consider the totality of the circumstances of the veteran's
service before making a decision.
This section establishes a presumption of exposure to a
list of substances, chemicals and hazards such as particulate
matter, volatile organic compounds and dioxins, for veterans
who served in certain locations. It also allows the Secretary
to add or remove from the list of substances in collaboration
with DoD.
Section 303: Medical nexus examinations for toxic exposure risk
activities
This section requires VA provide medical examinations and
medical opinions for any veteran who submits a claim for a
service-connected disability relating to toxic exposure with
evidence of a disability and participation in a toxic exposure
risk activity. An examination with an opinion would be
sufficient or, if necessary, a separate examination and medical
opinion.
TITLE IV--PRESUMPTIONS OF SERVICE CONNECTION
Section 401: Treatment of veterans who participated in the cleanup of
Enewetak Atoll as radiation-exposed veterans for purposes of
presumption of service-connection of certain disabilities by
Department of Veterans Affairs
This section may be cited as the ``Mark Takai Atomic
Veterans Healthcare Parity Act''.
This section designates veterans who participated in the
radioactive cleanup of Enewetak Atoll from January 1977 to
December 1980 as radiation-exposed veterans who are eligible
for the presumption of service-connection for associated
diseases.
Section 402: Treatment of veterans who participated in nuclear response
near Palomares, Spain, as radiation-exposed veterans for
purposes of presumption of service-connection of certain
disabilities by Department of Veterans Affairs
This section may be cited as the ``Palomares Veterans
Act''.
This section designates veterans who participated in the
cleanup of the crashed nuclear weapon carrying B-52 off the
coast of Palomares, Spain in the 1960s as radiation-exposed
veterans who are eligible for the presumption of service-
connection for associated diseases.
Section 403: Presumptions of service-connection for diseases associated
with exposures to certain herbicide agents for veterans who
served in certain locations
This section may be cited as the ``Veterans Agent Orange
Exposure Equity Act''.
This section expands the locations for which a presumption
of service-connection is warranted based on exposure to
herbicides such as Agent Orange. The expanded list of locations
includes veterans who meet the following criteria:
Service in Thailand at any United States or
Royal Thai base during the period beginning on January
9, 1962, and ending on June 30, 1976;
Service in Laos during the period beginning
on December 1, 1965, and ending on September 30, 1969;
Service in Cambodia at Mimot or Krek, Kompon
Cham Province during the period beginning on April 16,
1969, and ending on April 30, 1969; or
Service in Guam or American Samoa, or in the
territorial waters thereof, during the period beginning
on January 9, 1962, and ending on July 31, 1980, or
served on Johnston Atoll or on a ship that called at
Johnston Atoll during the period beginning on January
1, 1972, and ending on September 30, 1977.
This section defines the term ``Vietnam-era herbicide-
exposed veteran'' for purposes of healthcare eligibility.
Section 404: Addition of additional diseases associated with exposure
to certain herbicide agents for which there is a presumption of
service-connection for veterans who served in certain locations
This section may be cited as the ``Fair Care for Vietnam
Veterans Act''.
This section adds hypertension and monoclonal gammopathy of
undetermined significance (MGUS) to the list of presumptive
disabilities associated with exposure to herbicide agents such
as Agent Orange.
Section 405: Improving compensation for disabilities occurring in
Persian Gulf War veterans
This section removes the end dates for Gulf War Illness
disability eligibility and requires VA staff to enact a
Disability Benefits Questionnaire (DBQ) specifically to ensure
that Gulf War veterans are screened for Gulf War Illness with a
mandated report to Congress on this implementation annually. It
also modifies eligibility criteria by allowing a covered
illness to become manifest to any degree at any time after
service.
Section 406: Presumption of service-connection for certain diseases
associated with exposure to burn pits and other toxins
This section may be cited as the ``Presumptive Benefits for
War Fighters Exposed to Burn Pits and Other Toxins Act''.
This section creates a presumption of service-connection
for more than 20 illnesses for veterans exposed to airborne
hazards and burn pits based on the location and dates of their
service. The illnesses include respiratory conditions and 11
types of cancer. This includes respiratory cancers of any type
such as lung cancer and reproductive cancers of any type such
as breast cancer or ovarian cancer.
This section grants the Secretary authority to add to the
list pursuant to regulations established under Title II of this
bill.
TITLE V--RESEARCH MATTERS
Section 501: Coordination by Department of Veterans Affairs of toxic
exposure research
This section designates VA as the official coordinating
authority for military toxic exposure-related studies and
research performed by the federal government. It requires the
creation of a Toxic Exposure Research Strategic Plan to
organize and sort toxic exposure-related research at different
federal agencies.
This section requires the Secretary to submit an annual
report to Congress on the implementation of the Toxic Exposure
Research Strategic Plan.
Section 502: Data collection, analysis, and report on treatment of
veterans for illnesses related to toxic exposure
This section requires the Secretary of VA to collect,
compile, and coordinate medical data for veterans receiving
health care to further identify potential links between
illnesses, military history, and toxic exposure.
This section requires the Secretary to submit to the
Committee on Veterans' Affairs in the Senate and House of
Representatives an annual report outlining these efforts.
Section 503: Studies related to veterans who served in Southwest Asia
and certain other locations
This section requires that VA performs a mortality study,
an epidemiological study, and a toxicology study to assess the
health trends of veterans who served in Southwest Asia during
the War on Terror and report these findings back to Congress
within 180 days.
Section 504: Study on health trends of post 9/11 veterans
This section requires an epidemiological study on the
health trends of all Post 9/11 veterans and requires that a
report on the study be sent to Congress not later than two
years after enactment of the Act.
Section 505: Study on cancer rates among veterans
This section requires a study on the incidence of cancers
among veterans and requires that a report on the study be sent
to Congress not later than two years after enactment of the
Act.
Section 506: Study on feasibility and advisability of furnishing
hospital care and medical services to dependents of veterans
who participated in toxic exposure risk activities
This section directs VA to conduct a study on the
feasibility of providing Civilian Health and Medical Program of
the Department of Veterans Affairs (CHAMPVA) benefits to
dependents of veterans for healthcare costs related to toxic
exposures experienced on military bases and other DoD-
maintained facilities.
This section defines ``qualifying dependent'' and requires
that a report on the study be sent to Congress not later than
two years after enactment of the Act.
TITLE VI--IMPROVEMENT OF RESOURCES AND TRAINING REGARDING TOXIC EXPOSED
VETERANS
Section 601: Short title; Definitions
This title may be cited as the ``Toxic Exposure in the
American Military Act'' or the ``TEAM Act''.
This section states the terms ``active military, naval, or
air service'', ``toxic exposure'', and ``toxic exposed
veteran'' have the meanings given those terms in section 101 of
title 38, United States Code.
Section 602: Publication of list of resources of Department of Veterans
Affairs for Toxic Exposure Veterans and outreach program for
such veterans and caregivers and survivors of such veterans
This section requires VA to publish a list of the benefits
and healthcare resources available to veterans and survivors
related to toxic exposures on an annual basis.
This section requires the Secretary to develop, with input
from the community, an informative outreach program for
veterans concerning illness that may be related to toxic
exposure and available benefits.
Section 603: Incorporation of toxic exposure questionnaire during
primary care appointments
This section directs VA to incorporate a toxic exposure
questionnaire during primary care appointments to improve
understanding by the Department of toxic exposures of veterans
while serving in the Armed Forces. The questions must be
determined with input from medical professionals.
Section 604: Training for personnel of the Department of Veterans
Affairs with respect to toxic exposure veterans
This section requires training on toxic exposure for
healthcare personnel.
This section also requires improved standardized training
for VA benefit personnel, such as claims processors and health
care personnel conducting examinations, to assist in the
accurate adjudication of toxic exposure claims.
This section requires VA conduct quarterly, randomized
reviews of the quality of claims adjudication of claims
relating to toxic exposure.
TITLE VII--REGISTRIES, RECORDS, AND OTHER MATTERS
Section 701: Registry of individuals exposed to per- and
polyfluoroalkyl substances on military installations
This section requires the Secretary, within one year of
enactment, create and maintain a registry of individual's who
may have been exposed to per- and polyfluoroalkyl substances
(PFAS).
This section requires the Secretary submit a report to
Congress on the status of data collection and any
recommendations on addressing the needs of veterans exposed to
PFAS within 2 years with a follow-up report due in 5 years.
Section 702: Fort McClellan Health Registry
This section requires the VA to establish a Fort McClellan
Health Registry and provide the option of a health examination
and consultation to any veteran who was stationed at Fort
McClellan during a specific timeframe. It also requires VA to
do appropriate outreach to veterans listed in the registry
about their options, new research, and the consequences of
toxic substance exposure.
Section 703: Independent study on Individual Longitudinal Exposure
Record
This section requires DoD to enter into a contract with an
independent research entity to conduct a study on the ILER to
assess the quality of location and exposure data and determine
whether a member of the Armed Forces can be reasonably assured
that any toxic exposure they experienced during service will be
reflected in their records.
Section 704: Biannual report on Individual Longitudinal Exposure Record
This section requires DoD to review the ILER periodically
to determine whether additional exposures should be added,
based on geography, occupation, and timeframe of service. It
also requires periodic reports to Congress.
Section 705: Correction by members of the Armed Forces of exposure
records
Requires the Secretary of Defense and the Secretary of
Veterans Affairs to allow for service members and veterans to
correct their military records as they pertain to toxic
exposures.
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. 3967 provided by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974:
According to the Congressional Budget Office estimate, H.R.
3967 would increase direct spending by $281.5 billion and
increase spending subject to appropriation by $146.8 billion
over the 2022-2031 period. (We receive this from CBO--check the
Floor Action folder for the report).
U.S. Congress,
Congressional Budget Office,
Washington, DC, December 7, 2021.
Hon. Mark Takano,
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. 3967, the Honoring
our PACT Act of 2021.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Logan Smith.
Sincerely,
Phillip L. Swagel,
Director.
Enclosure.
The bill would
Increase disability compensation and expand
health care services for a larger group of veterans who
were exposed to toxic substances or served in certain
locations during their military service
Increase the number of veterans without
service-connected disabilities who can receive health
care from the Department of Veterans Affairs
Require several studies and reports on
veterans' toxic exposures during military service
Estimated budgetary effects would mainly stem from
Increased disability compensation and
increased health care costs for certain veterans
Operating costs and administrative costs for
processing disability compensation claims and
implementing the bill's other provisions
Areas of significant uncertainty include
Estimating the number of veterans affected
by the bill and the changes in their disability ratings
Anticipating the number and prevalence of
disabilities presumed to be connected to military
service
Estimating the number of veterans who would
receive additional health care
Bill summary: H.R. 3967 would increase disability
compensation and health care benefits administered by the
Department of Veterans Affairs (VA) for veterans who have been
exposed to toxic substances, materials, or environments during
military service. In the future, veterans who developed
conditions linked to toxic exposure also would receive those
benefits. Survivors of veterans whose disabilities were caused
by toxic exposure would receive additional compensation and
access to health care under the bill. Veterans and survivors
who had previously been denied compensation for certain
conditions would receive retroactive payments. H.R. 3967 also
would increase access to other VA benefits, including education
assistance and home loan guarantees for some of those veterans
and their dependents. Finally, the bill would require VA to
conduct studies, prepare reports, and conduct outreach. In
total, CBO estimates, enacting H.R. 3967 would increase direct
spending by $282 billion and increase spending subject to
appropriation by $147 billion over the 2022-2031 period.
Estimated Federal cost: The estimated budgetary effects of
H.R. 3967 are shown in Table 1 (all tables are at the end of
this estimate). The costs of the legislation fall within budget
function 700 (veterans' benefits and services).
Basis of estimate: For this estimate, CBO assumes that the
estimated amounts will be appropriated each year, that outlays
will follow historical spending patterns for affected programs,
and that H.R. 3967 will be enacted in fiscal year 2022. Most
provisions would take effect upon enactment.
Direct spending: The bill would make several changes to
VA's benefit programs that affect direct spending.
Disability Compensation. VA ordinarily compensates veterans
who have disabilities or diseases that have been determined on
the basis of military medical records and physical examinations
to be connected to military service. Disabilities are rated by
severity; higher ratings make veterans eligible to receive more
compensation.
Under H.R. 3967, VA would be required to presume that
veterans with certain medical conditions developed them as a
result of exposure to toxic substances during military service.
Some veterans who have disabilities and who served in locations
specified in the bill also would receive disability
compensation and access to the VA health care system. The bill
also would require VA to reevaluate any previously denied
claims for disability compensation whenever a new presumption
is established. That requirement would apply to any presumption
that a disability or condition is service-connected that would
be established by the bill, and future presumptions established
by VA.
CBO analyzed the bill's provisions to determine the types
of conditions or disabilities that would be presumed to have
been caused by military service. CBO used prevalence rates for
those conditions obtained from sources such as the Centers for
Disease Control and Prevention to estimate the number of
veterans who would be likely to have those conditions. CBO used
data on age ranges and periods of service to estimate both the
percentage of veterans currently receiving compensation (who
thus would be likely to receive increased compensation) and the
percentage who would receive compensation for the first time
under H.R. 3967. Using information from VA, CBO estimated how
many potentially eligible veterans would apply for compensation
and projected when veterans would begin to receive new or
increased disability compensation. To estimate caseloads and
benefit amounts that would arise from the requirement to
reevaluate previously denied claims, CBO used information from
VA on such denials, information on how long ago, on average,
those claims were denied, and on the severity of the condition
being established. Finally, CBO accounted for mortality among
the affected group when estimating how many veterans would
continue to receive compensation under the bill over the 2022-
2031 period. CBO used the estimated number of veteran deaths to
determine how many new survivors of deceased veterans would
receive compensation under the bill.
According to CBO's baseline budget projections, 5.4 million
veterans--or 30 percent of the nation's nearly 19 million
veterans--will receive disability compensation in fiscal year
2022. CBO projects that number will rise, reaching 6.1 million
in 2031. Using information from VA, the Department of Defense,
and medical and scientific organizations, CBO estimates that
about 100,000 additional veterans would begin receiving
compensation in 2022 under the bill. By 2031, almost 2 million
more veterans would receive disability compensation, relative
to current law. That figure represents an increase of 32
percent over CBO's baseline projection for 2031.
Under the bill, veterans who currently have or will have
service-connected disabilities would be determined to have
additional disabilities and thus would receive additional
compensation. CBO estimates that 200,000 veterans who already
get disability compensation would receive increased amounts in
2022, and that 1.6 million would receive increased compensation
by 2031. Some veterans who receive a new disability rating
under one provision of H.R. 3967 may receive additional
compensation under other provisions. Thus, the total number of
veterans affected by the bill is less than the sum of veterans
who would newly receive compensation and those who would
receive additional compensation.
CBO estimates that under the bill about 17,000 additional
survivors of totally disabled veterans or veterans who die from
service-connected disabilities caused by toxic exposure would
receive survivor compensation in 2022; the number of such
survivors would increase to 110,000 by 2031.
CBO estimates that VA would pay retroactive benefits to 1.2
million veterans whose claims were denied, and to about 70,000
survivors of deceased veterans. CBO expects those payments to
be made within five years of a new presumption's establishment.
Disability and survivor compensation is paid from mandatory
appropriations; as a result, enacting H.R. 3967 would increase
direct spending. In total, higher disability compensation would
increase direct spending by $279.6 billion over the 2022-2031
period, CBO estimates (see Table 1).
Other Mandatory Benefits. Under current law, veterans who
receive disability compensation also may be eligible for
readjustment benefits from VA, including educational
assistance, job training, and independent-living services for
veterans who have service-connected disabilities that limit or
prevent them from working. Education assistance benefits also
are available to dependents of veterans who are permanently and
totally disabled and to survivors of those who have died as a
result of a service-connected disability. Additionally,
eligible borrowers who obtain a VA-guaranteed home loan are
exempted from paying fees for the guarantee if they have a
service-connected disability or if they are the spouse of a
veteran who dies as a result of such a disability. Using
information from VA about trends for those programs and average
costs for benefits, CBO estimates that those mandatory benefits
under the bill would cost $1.8 billion over the 2022-2031
period.
Spending subject to appropriation: Implementing H.R. 3967
would increase spending for VA health care and for the
operating costs of processing disability claims, training
staff, conducting studies, and preparing reports. Spending for
those activities is discretionary and would be subject to
appropriation of the estimated amounts.
Health Care. Under current law, eligible veterans who
enroll in VA's health care system are assigned to priority
groups primarily on the basis of whether they have one or more
service-connected disabilities and on the severity of those
disabilities. Veterans without service-connected disabilities
also can receive health care from VA, depending on their income
and other benefits they receive. Assignment to a priority group
affects access to health care and is used to determine out-of-
pocket costs. Veterans with service-connected disabilities
receive the highest priority for medical treatment. In general,
VA's costs to provide care are higher for veterans in higher
priority groups. Veterans in those priority groups pay less out
of pocket--or pay nothing at all. Some also can receive
additional benefits, such as transportation subsidies for
medical appointments. Veterans in the highest priority groups
are more likely than those in lower groups to enroll in and use
VA health benefits and services.
The bill would provide health care benefits to veterans who
were exposed to toxic substances during their service even if
they do not have a service-connected disability as a result of
that exposure. Some veterans would become newly eligible for
care in the VA system, and others who will be eligible for care
under current law would be moved to a higher priority group.
Some veterans would be determined to have a service-connected
disability that would place them in a higher priority group.
CBO expects that veterans who became newly eligible or were
moved into a higher priority group would receive more care from
VA.
Using information from VA, CBO estimated the number of the
affected veterans in two categories. The first consists of
veterans who would newly enroll in the VA health care system;
the other group consists of veterans who enroll and receive
health care from VA under current law. CBO made additional
population adjustments over the 10-year period to those cohorts
on the basis of such factors as Medicare eligibility, expected
mortality, and changes in the projected demand for VA health
care. On the basis of information from VA on average costs of
care by priority group, CBO estimated the average costs of
additional care and applied that to the affected populations.
CBO expects that reliance on VA health care among veterans
affected by H.R. 3967 would increase gradually and that the
full cost of care would phase in over a period of several
years.
Survivors of veterans with service-connected disabilities
caused by toxic exposure are eligible to enroll in the Civilian
Health and Medical Program of the Department of Veterans
Affairs (CHAMPVA), a health insurance plan. To determine the
incremental cost for new CHAMPVA beneficiaries, CBO used
mortality rates to estimate the number of deaths among veterans
who would be determined to have service-connected disabilities
under the bill.
CBO anticipates that under current law, almost 9 million of
the nation's roughly 19 million veterans will be enrolled in
VA's health care system in fiscal year 2022. H.R. 3967 would
increase that number by about 1.4 million over the next 10
years because of new eligibility or placement in a higher
priority group. By 2031, CBO estimates, the bill would increase
the total number of veterans receiving VA health care by 15
percent.
CBO also estimates that some veterans who are enrolled or
will enroll in the VA health care system under current law
would be moved to a higher priority group under the bill. On
the basis of data on participation rates in the VA health care
system, CBO estimates that each year, on average, 740,000 of
those veterans would be placed in a higher priority group and
continue to receive additional care over 2022-2031 period.
About 12,000 additional survivors of veterans with service-
connected disabilities would use CHAMPVA benefits in 2022; that
number would increase to about 79,000 new beneficiaries by
2031.
CBO estimates that total spending for VA health care would
increase by $136.1 billion over the 2022-2031 period, assuming
appropriation of the estimated amounts.
Operating Costs. CBO estimates that the department would
require significant resources to implement the bill. VA would
require additional staff and resources, including information
technology resources, to process millions of claims for
disability compensation. Other provisions of the bill would
require VA to study veterans' toxic exposures, train staff, and
produce reports. In total, satisfying those requirements would
cost $10.8 billion over the 2022-2031 period, CBO estimates.
Components of the bill: CBO estimated the costs of H.R.
3967 in nine components. Some affect each of the four cost
categories described above. Other components affect one or two
of those categories. This estimate accounts for interactions
among the bill's components.
TITLE I. EXPANSION OF HEALTH CARE FOR TOXIC EXPOSURE VETERANS
Title I would expand eligibility for VA health care to
veterans who had service-connected environmental exposures to
toxic substances, chemicals, or airborne hazards, or who
participated in activities during their military service that
carried a risk of exposure, regardless of whether they have a
service-connected disability.
Veterans who participated in an activity or were in
locations that result in an entry in the Individual
Longitudinal Exposure Record would qualify under the bill as
having been exposed. (That record is used by VA and the
Department of Defense to track service members' potential
environmental exposures to toxic substances.) The Secretary of
Veterans Affairs also would have the authority to identify
other qualifying exposures.
CBO expects that under title I, 50 percent of the veteran
population not previously eligible for VA health care would
become eligible; many of those veterans eventually would enroll
in the VA health care system. CBO also expects that the bill
would change eligibility for 50 percent of veterans who will be
eligible under current law to enroll in a lower priority group
(for veterans with high household income). Those veterans would
become eligible for a higher priority group (and for free care
or reduced copayments) for certain types of care.
Some veterans who would become newly eligible under title I
would subsequently be placed in a higher priority group after
receiving a new disability rating under title II, III, or IV.
The health care costs for those veterans are accounted for
under title I until the time they would be expected to receive
the new rating. At that point, the higher costs for their care
are accounted for in the estimate for the other title.
CBO estimates that under H.R. 3967, about 69,000 veterans
would newly enroll in the VA health care system in 2022; by
2026, that number would increase to 896,000. By 2031, the size
of the group would fall to 260,000 as some veterans qualify for
health care under other provisions of the bill. Some of the
decline arises from a projected 15 percent reduction projected
in the number of living veterans over the next decade. On the
basis of health care costs for current enrollees, CBO estimates
that, on average, newly enrolled veterans would receive $7,400
in VA health care each year.
CBO estimates that in 2022, about 837,000 veterans who are
enrolled or will enroll in VA health care under current law
would be eligible for a higher priority group under title I of
the bill. By 2031, that number would decline to 140,000
veterans as some veterans become eligible for a higher priority
group because they receive a disability rating as a result of
other provisions of the bill. Some of the decline is caused by
the projected reduction in the number of living veterans. On
average, those veterans would receive about $900 more in health
care per year because their use of health care would increase
and their copayments would be lower.
After accounting for the gradual enrollment of new
beneficiaries and additional health care cost of current
beneficiaries, CBO estimates that health care costs under title
I would total $41.4 billion over the 2022-2031 period, (see
Table 2). Such spending would be subject to appropriation.
TITLE II. TOXIC EXPOSURE PRESUMPTION PROCESS
Title II would establish a new process for determining
whether a medical condition or disability is attributable to a
veteran's service-connected exposure to a toxic substance or
activity. Under title II, a committee composed of members
appointed by the Congress, including health experts and at
least one representative from a veterans' service organization,
would recommend that a board of experts study certain exposures
to toxic substances to determine whether a link could be found
to a medical condition or disability. The findings would be
presented to VA, which could use the information to determine
whether to presume that the disability is service-connected. VA
would have 60 days from receiving a recommendation to make a
determination. If the department determines that a presumption
of service connection is warranted, it would have to issue
final regulations to implement the decision within 180 days.
Similar processes have been used for other toxic
exposures--notably for conditions associated with exposure to
Agent Orange. CBO anticipates that under title II, VA would
establish new presumptive exposures and conditions. After an
initial review and time to implement the process and conduct
the initial studies, CBO expects that starting in 2024, VA
would establish a presumption of exposure for one condition a
year.
Using the total prevalence rate of conditions associated
with exposure to Agent Orange as a basis, CBO estimated a rate
of 2 percent for each new condition and applied that rate to
the total veteran population estimated to be living in each
year, minus those already eligible for the presumption of
exposure to Agent Orange. The result was an estimated number of
veterans who could newly receive compensation or who would be
eligible for payments in addition to amounts they will receive
under current law. A new group of survivors also would receive
payments under title II. CBO also expects that H.R. 3967's
requirement that VA reevaluate previously-denied claims would
apply to title II, and that some veterans and survivors would
receive retroactive benefits related to each new condition
added. In total, CBO estimates, enacting title II would
increase direct spending by $126.9 billion over the 2022-2031
period and increase spending subject to appropriation by $40.0
billion over the same period (see Table 3).
Mandatory Spending. CBO estimates that the first
presumption of service-connected exposure established in 2024
would result in about 17,000 additional veterans receiving
compensation in that year. That number would rise in subsequent
years as more veterans receive a disability rating from that
presumption. New presumptions added in 2025 and later years
would further increase the numbers of veterans who would newly
receive disability compensation.
CBO estimates that by 2031, about 925,000 additional
veterans would be receiving compensation as a result of
additional presumptions added under title II. On average, those
veterans would receive $14,100 per year over the 2024-2031
period. About 32,000 veterans who will receive compensation
under current law would receive additional payments in 2024,
and that by 2031 that number would increase to 810,000
veterans. On average, those veterans would receive an
additional $11,900 per year. CBO further estimates that by
2031, an additional 50,000 survivors of veterans with service-
connected disabilities would receive compensation of $20,000
per year, on average.
Finally, CBO estimates that about 605,000 veterans would
receive retroactive payments of about $50,000, as a result of
the requirement to reevaluation previously denied claims.
Additionally, 43,000 survivors would receive retroactive
payments averaging about $25,000. Most of those survivors who
become eligible for compensation also would receive ongoing
payments that would average $20,000 per year over the budget
window.
All told, CBO estimates, compensation arising from the new
process would increase direct spending by $126.2 billion over
the 2022-2031 period. Of that amount, $36.7 billion would arise
from the requirement to reevaluate previously denied claims.
Other mandatory VA benefits, such as education assistance
and fee-exempt loan guarantees, would increase under title II.
As more veterans receive compensation, more of them and their
dependents would become eligible for those benefits. Other
mandatory spending would total $0.7 billion over the 2022-2031
period.
Discretionary Spending. Because more veterans would receive
disability ratings under H.R. 3967, some of those veterans and
certain dependents would be assigned to the highest priority
groups and thus become eligible to receive additional health
care benefits at no charge or with very small copayments. They
also could be eligible for transportation subsidies and for
long-term care and dental care from VA.
CBO estimates that about 9,000 additional veterans would
newly enroll in the VA health care system in 2024, and that by
2031, about 517,000 additional veterans would enroll as a
result of new eligibility or assignment to a higher priority
group for care. On the basis of health care costs for current
enrollees, on average, VA health care for those veterans would
cost $11,500 per year.
CBO estimates that in 2024, about 4,000 veterans who will
be enrolled in the VA health care system under current law
would be moved to a higher priority group. By 2031, that number
would increase to 230,000 veterans. On average, those veterans
would receive about $7,000 in additional care each year.
By 2031, an additional 36,000 survivors of disabled
veterans would use CHAMPVA benefits, at a cost of $5,000 per
year, on average, CBO estimates.
After accounting for the gradual enrollment of new
beneficiaries and additional health care costs for current
beneficiaries, CBO estimates that health care costs under title
II would total $35.4 billion over the 2022-2031 period. VA also
would need additional resources to implement the new
presumption process. Using information from VA, CBO estimates
that the operating costs for implementation and for processing
disability claims would total $4.7 billion over the 2022-2031
period.
TITLE III. IMPROVING THE ESTABLISHMENT OF SERVICE CONNECTION PROCESS
FOR TOXIC EXPOSED VETERANS
Title III would require VA to presume that veterans have
had service-connected exposures if the Individual Longitudinal
Exposure Record indicates evidence of an exposure, or if they
served in a location or under an assignment that would make
exposure likely. Veterans who served in certain locations also
would be presumed to have been exposed to substances listed in
the bill. CBO estimates that title III would increase direct
spending by $46.3 billion over the 2022-2031 period and
increase spending subject to appropriation by $21.9 billion
over the same period (see Table 4).
Mandatory Spending. To estimate the number of veterans who
would newly receive disability compensation under title III,
CBO used information from VA, including information on the
number of claims VA denied for service-connected disabilities
associated with exposure to toxic substances.
CBO estimates that by 2031, 6 percent more veterans would
receive compensation than under current law, and 4 percent more
would have their disability ratings increased.
Another 19,000 veterans would receive compensation in 2022;
that number would rise to 352,000 by 2031. Those veterans would
receive, on average, $13,800 per year in compensation payments
over the 2022-2031 period. In 2022, 8,000 veterans who will
receive compensation under current law would receive additional
compensation under title III. By 2031, that number would reach
255,000. On average, those veterans would receive $11,700 in
additional compensation over the 2022-2031 period. By 2031, an
additional 16,000 survivors of disabled veterans would receive
annual compensation of $20,000, on average.
About 93,000 veterans would receive retroactive payments
for previously denied claims averaging $50,000, and about 6,000
survivors would receive retroactive payments averaging $25,000.
CBO expects that those retroactive payments would be made over
the 2022-2026 period. Most of the survivors who get retroactive
compensation also would receive ongoing payments that would
average $20,000 per year over the budget window.
In total, CBO estimates, compensation payments would
increase direct spending by $45.7 billion over the 2022-2031
period. Of that amount, $5.6 billion would arise from the
requirement to reevaluate previously denied claims.
Spending for other mandatory VA benefits, such as education
assistance and fee-exempt loan guarantees, also would increase
under title III. As more veterans receive compensation, more of
them and their dependents would become eligible for those
benefits. CBO estimates that those other mandatory costs would
total $0.6 billion over the 2022-2031 period.
Discretionary Spending. More veterans would receive
disability ratings under H.R. 3967 and some of them would be
assigned to the highest priority group. As a result, they would
be eligible either for free health care or for reduced
copayments and for additional benefits, including
transportation subsidies and access to long-term care and
dental care from VA. Some dependents also would be newly
eligible for certain health care benefits.
CBO estimates that under title III, about 10,000 additional
veterans would newly enroll in the VA health care system in
2022, and that by 2031, about 197,000 additional veterans would
enroll as a result of new eligibility or assignment to a higher
priority group. Using health care costs for current enrollees,
those veterans would receive, on average, an estimated $13,500
in health care from VA each year.
CBO expects that in 2022, about 5,000 veterans who will be
enrolled in the VA health care system under current law would
be placed in a higher priority group under title III. By 2031,
that number would increase to 87,000 veterans. On average,
those veterans would receive about $8,800 in additional care
each year.
CBO estimates that by 2031, an additional 12,000 survivors
of disabled veterans would use CHAMPVA benefits at a cost of
$5,000, on average, per year.
After accounting for the gradual enrollment of new
beneficiaries and additional health care costs for current
beneficiaries, CBO estimates that health care costs under title
III would total $20.6 billion over the 2022-2031 period.
VA would require additional resources to process disability
claims under title III. Using information from VA, CBO
estimates that those increased costs would total $1.3 billion
over the 2022-2031 period.
TITLE IV. EXPANSION OF PRESUMPTIONS OF SERVICE CONNECTION FOR FORGOTTEN
VETERANS
H.R. 3967 would establish presumptions of exposure for
veterans who served in several locations listed in the bill.
Section 401. Enewetak Atoll. Section 401 would establish a
presumption of exposure for service members who participated in
the cleanup of nuclear materials at Enewetak Atoll in the
Pacific Ocean, a location where the United States conducted
nuclear tests. Veterans who served at Enewetak Atoll between
1977 and 1980 who later developed certain cancers would receive
disability compensation under this section and would be
eligible for additional VA health care. CBO estimates that
under section 401, about 500 veterans and survivors of deceased
veterans would receive compensation and about 300 would receive
increased health care from VA. Using information from VA on
previously denied claims, CBO estimates 14 veterans would
receive retroactive payments. In total, section 401 would
increase direct spending by $116 million and increase spending
subject to appropriation by $34 million over the 2022-2031
period (see Table 5).
Section 402. Palomares. Section 402 would establish a
presumption of service connection for veterans who participated
in the cleanup of a nuclear incident in Palomares, Spain,
between January 1966 and March 1967 following an incident in
1966, when several U.S. nuclear weapons were released after two
planes collided. Service members who participated in the
response and cleanup who later developed certain cancers would
receive disability compensation under this section and become
eligible for additional VA health care. CBO estimates that
under section 402 about 150 veterans and survivors of deceased
veterans would receive compensation and about 100 would receive
increased health care from VA. Using information from VA on
previously denied claims, CBO estimates three veterans would
receive retroactive payments. In total, section 402 would
increase direct spending by $29 million and increase spending
subject to appropriation by $8 million over the 2022-2031
period (see Table 6).
Section 403. Agent Orange. Under current law, veterans who
served in the Republic of Vietnam or its territorial seas
between January 1962 and May 1975 are eligible for a
presumption of exposure to the herbicide Agent Orange, which VA
presumes caused several medical conditions and disabilities.
Section 403 would include veterans who served in Thailand,
Laos, Cambodia, Guam, American Samoa, and Johnston Atoll during
periods specified in the bill as service members who would be
presumed to have been exposed to Agent Orange. CBO expects that
those veterans would receive retroactive payments for
previously denied Veterans who served in those locations also
would be eligible for compensation for conditions added by
section 404, as described below. Section 403 would expand
eligibility for certain veterans for increased VA health care,
regardless of whether the veteran had a condition associated
with exposure to Agent Orange. CBO estimates that under section
403, about 50,000 veterans and survivors of deceased veterans
would receive compensation and about 20,000 would receive
increased health care from VA. Of those beneficiaries, 18,000
veterans and 2,000 survivors would receive payments for
previously denied claims. In total, section 403 would increase
direct spending by $6.9 billion and increase spending subject
to appropriation by $2.8 billion over the 2022-2031 period (see
Table 7).
Section 404. Hypertension. Section 404 would include
exposure to Agent Orange as a presumptive cause of hypertension
and of monoclonal gammopathy of an undetermined significance.
Veterans who served in Vietnam or its territorial seas during
the Vietnam War would be compensated if they have either
condition. Using information from the Centers for Disease
Control and Prevention concerning prevalence, CBO estimates
that about 600,000 of the 1.6 million living veterans who
served in Vietnam or its offshore waters who currently receive
disability compensation have hypertension and would be eligible
for increased compensation. However, CBO estimates that only
about half of the veterans with hypertension would receive
increased payments because not all diagnoses are considered
severe enough to warrant additional compensation. Under section
404 those eligible beneficiaries would receive annual payments
of $8,300, on average, over the 2022-2031 period.
CBO also estimates that about 51,000 veterans would newly
receive disability compensation in 2022 under section 404; by
2031, that number would reach 464,000 veterans. The payments
would depend on the severity of the diagnosis, but on average
would total $2,500 per year. By 2031, an additional 26,000
survivors of disabled veterans would receive annual
compensation of $20,000, on average.
Veterans of the Vietnam War are eligible for retroactive
payments for conditions that are later determined to be related
to exposure to Agent Orange. Using information from VA on
previous denials of disability claims related to hypertension
among that group, CBO estimates that VA would provide
retroactive payments averaging $13,500 to about 229,000
veterans and would pay an average of $100,000 to about 13,000
survivors of deceased veterans.
In total, CBO estimates, section 404 would increase direct
spending by $37.4 billion over the 2022-2031 period.
Some veterans who newly receive disability compensation
also would receive more health care from VA. CBO estimates that
about 21,000 additional veterans would newly enroll in the VA
health care system in 2022, and by 2031, about 197,000
additional veterans would enroll as a result of new eligibility
or assignment to a higher priority group for care. On average,
those veterans would receive about $11,000 in additional care
each year. In 2022, about 12,000 veterans who are enrolled or
will enroll in the VA health care system under current law
would be moved to a higher priority group. By 2031, that number
would increase to 115,000 veterans. Those veterans would
receive an average of $2,300 in additional health care each
year. CBO also estimates that by 2031, an additional 19,000
survivors of disabled veterans would use CHAMPVA benefits at an
annual cost of $5,000, on average.
After accounting for the gradual enrollment of new
beneficiaries and additional health care costs for current
beneficiaries, health care costs under section 404 would total
$18.4 billion over the 2022-2031 period. Processing disability
claims would cost $3.1 billion. In total, CBO estimates,
section 404 would increase spending subject to appropriation by
$21.5 billion over the 2022-2031 period (see Table 8).
Section 405. Persian Gulf War Veterans. Under current law,
veterans who served in Southwest Asia are eligible for a
presumption that certain conditions, including several
infectious diseases, were caused by military service as long as
their symptoms appear by December 31, 2026. Section 405 would
eliminate that deadline. By doing so, the bill would increase
the number of veterans receiving compensation, relative to
current law. Further, under section 405, those conditions would
be presumed to have been cause by military service for veterans
who served in Afghanistan, Israel, Egypt, Turkey, Syria, and
Jordan. CBO estimates that about 23,000 veterans and survivors
of deceased veterans would receive compensation and about 9,000
would receive increased health care from VA. In total, section
405 would increase direct spending by about $750 million and
increase spending subject to appropriation by $370 million over
the 2022-2031 period (see Table 9).
Section 406. Burn Pits. Under section 406, veterans who
served in Afghanistan, Iraq, and other locations during
designated periods would be presumed to have been exposed to
toxic substances emitted from the open-air combustion of waste
in burn pits. The section would require VA to provide
compensation to veterans who have any of 24 listed conditions.
On August 2, 2021, VA issued a regulation specifying that
it assumes that asthma, sinusitis, and rhinitis are connected
to exposure to burn pits among that group of veterans. As a
result, under current law, veterans who served in one of those
places and develop one or more of those conditions within 10
years of completing service will be eligible for a presumption
that a condition is service-connected. CBO anticipates that
other veterans with those three conditions that manifest more
than 10 years after discharge would receive compensation under
section 406.
Development of any of the other 21 conditions listed in
section 406 would be presumed to be service related for
eligible veterans. CBO estimates that by 2031, about 192,000
veterans would receive a new rating under the bill. Those
veterans would receive an average payment of $15,500 per year.
About 235,000 veterans would receive additional compensation
averaging $14,000 per year, and 14,000 survivors of deceased
veterans would receive compensation averaging $20,000 per year.
Using information from VA on the number of veterans who served
in eligible locations and whose disability claims for
conditions listed in section 406 have been previously denied,
CBO estimates about 268,000 veterans and about 5,500 survivors
would receive retroactive payments at an average of $50,000 and
$160,000, respectively. CBO expects that those retroactive
payments would be made over the 2022-2024 period.
CBO estimates about 165,000 veterans and survivors of
deceased veterans would receive increased health care from VA
under section 406.
CBO also estimates that spending for other mandatory
benefits such as education assistance and fee-exempt loan
guarantees would increase. In total, section 406 would increase
direct spending for compensation and other mandatory benefits
by $63.1 billion, of which $15.7 billion would arise from the
requirement to reevaluate previously denied claims. It also
would increase spending subject to appropriation by $18.8
billion over the 2022-2031 period (see Table 10).
Uncertainty: Mandatory spending under H.R. 3967 will depend
on the number of veterans who receive new or increased
disability compensation. CBO's estimate is highly contingent on
VA's implementation of the bill, particularly the new processes
specified in title II.
For this estimate, CBO anticipates that one new service-
connected condition would be added each year. Under a similar
process implemented under the Agent Orange Act, VA did not add
a new condition every year, but in some years it added more
than one. Title II concerns exposure to any substance that is
deemed toxic, whereas the Agent Orange process considered
exposure only to specific herbicides. If more or fewer
conditions are established under the bill than CBO anticipates,
the number of affected veterans could be higher or lower than
estimated by CBO.
Additionally, this estimate is sensitive to the prevalence
of conditions that are presumed to be caused by military
service. If common conditions such as hypertension are added,
costs could be higher than CBO estimates. Alternatively, if
only rare conditions are added under H.R. 3967, costs could be
lower.
The estimated costs of title III also are subject to
considerable uncertainty, particularly regarding how VA would
evaluate entries in the Individual Longitudinal Exposure Record
when determining whether a disability is connected to military
service. It is difficult to anticipate how much weight VA will
give to such entries in adjudicating disability claims. CBO
estimates that by 2031, the presumption that certain veterans
were exposed to toxic substances would increase the number
receiving disability compensation by about 6 percent and that
about 4 percent of veterans who will receive compensation under
current law will see an increase in compensation.
CBO estimates that under current law almost 40 percent of
veterans will receive disability compensation; under the bill,
that proportion would increase to roughly half of all veterans.
If the number rose by more than CBO estimates (such that more
than 50 percent of veterans have service-connected disabilities
identified as a result of the bill), costs could be higher than
CBO estimates. Alternatively, if fewer than 600,000 veterans--
according to CBO's estimate--are affected under title III,
costs would be lower.
The number of veterans and survivors who receive payments
for previously denied claims is also subject to uncertainty.
CBO used information on previously denied claims for
disabilities connected to exposure to Agent Orange and to burn
pits to estimate the number veterans who would receive
retroactive payments for claims related to those exposures. CBO
used similar rates and amounts to estimate the cost of
reevaluting claims that would arise under other sections of the
bill. If those factors are higher or lower than those estimated
here, costs would differ.
Other factors, such as the amount of compensation veterans
receive, also could differ from the amounts CBO estimates.
Changes in those inputs also would affect costs but to a much
smaller degree than would differences in the size of the
affected population.
The health care costs under H.R. 3967 would depend largely
on the number of veterans who would be newly eligible and
assigned to a higher priority group as a result of the bill's
definition of toxic exposure. CBO estimates that under the bill
roughly 7 million veterans could be newly eligible for VA
health care or could be moved to a higher priority group. CBO
also estimates that 50 percent of those veterans would meet one
of the broad criteria for eligibility under title I such as
having an entry in the Individual Longitudinal Exposure Record.
If a smaller percentage of veterans became eligible, costs
would be lower. Conversely, if the percentage was larger, costs
would increase.
Previous CBO estimate: On October 26, 2021, CBO transmitted
a cost estimate for S. 3003, the Comprehensive and Overdue
Support for Troops of War Act of 2021, as reported by the
Senate Committee on Veterans' Affairs on October 19, 2021. CBO
estimated that bill would increase direct spending by $225
billion over the 2022-2031 period, and increase spending
subject to appropriation by $188 billion over the same period.
Many provisions of that bill are similar or identical to
provisions in H.R. 3967. However H.R. 3967 would require VA to
reevaluate previously denied claims for compensation, which
increases the costs for most sections of the bill compared to
S. 3003. The estimated cost of title III in H.R. 3967 is lower
than the cost of S. 3003 because the former bill does not
require VA to give weight to lay statements about toxic
exposure when evaluating disability claims. CBO also reduced
discretionary costs for the estimate of title I in H.R. 3967
compared to S. 3003. CBO estimates that fewer veterans would
become eligible for health care from VA under H.R. 3967 because
the bill does not explicitly expand eligibility for health care
benefits to veterans with exposure to open burn pits or to
veterans who have been awarded certain service medals, whereas
S. 3003 includes those additional provisions for eligibility.
After CBO completed its estimate of S. 3003, VA announced
an extension of the period in which veterans who served in the
Persian Gulf and have certain illnesses could apply for that
presumption of service connection. The period was extended from
December 31, 2021, to December 1, 2026. As a result of this
rulemaking, CBO's estimate of Section 405 in S. 3003 would be
reduced from a $1 billion increase in direct spending and an
increase of $600 million in spending subject to appropriation,
to an estimate of $284 million and $171 million, respectively.
Pay-As-You-Go considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget-reporting and enforcement
procedures for legislation affecting direct spending or
revenues. The net changes in outlays that are subject to those
pay-as-you-go procedures are shown in the direct spending
section of Table 1.
Increase in Long-Term Deficits: CBO estimates that enacting
the COST of War Act would increase on-budget deficits by more
than $5 billion in each of the four consecutive 10-year periods
beginning in 2032.
Mandates: None.
Estimate prepared by: Logan Smith (disability
compensation), Etaf Khan (Veterans Administration health care),
Paul B.A. Holland (other mandatory benefits).
Estimate reviewed by: David Newman, Chief, Defense,
International Affairs, and Veterans' Affairs Cost Estimates
Unit; Leo Lex, Deputy Director of Budget Analysis; Theresa
Gullo, Director of Budget Analysis.
TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF H.R. 3967, HONORING OUR PACT ACT OF 2021
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, billions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation...................................... 10.1 14.1 19.6 17.3 23.2 27.1 32.6 38.8 45.3 51.5 84.4 279.6
Other Mandatory Benefits.......................... * * 0.1 0.2 0.2 0.2 0.3 0.2 0.3 0.3 0.6 1.8
Total Direct Spending......................... 10.1 14.2 19.7 17.5 23.4 27.3 32.8 39.0 45.6 51.8 84.9 281.5
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... 0.8 3.2 6.5 10.2 14.2 15.9 17.9 20.7 23.9 27.5 34.9 140.7
Estimated Outlays............................. 0.7 2.9 6.1 9.7 13.5 15.4 17.5 20.1 23.3 26.8 32.9 136.1
Operating Costs:
Estimated Authorization....................... 1.1 1.4 1.4 .8 1.0 1.0 1.0 1.1 1.1 1.1 5.7 11.0
Estimated Outlays............................. .9 1.3 1.4 .9 1.0 1.0 1.0 1.1 1.1 1.1 5.5 10.8
Total Discretionary Spending:
Estimated Authorization....................... 1.9 4.6 8.0 11.0 15.2 16.8 18.9 21.7 25.0 28.6 40.6 151.6
Estimated Outlays............................. 1.6 4.2 7.5 10.6 14.5 16.4 18.5 21.2 24.4 27.9 38.4 146.8
Memorandum
Cumulative Beneficiaries, Thousands of People
Disability Compensation:b
New Ratings................................... 100 334 587 774 977 1,182 1,373 1,585 1,785 1,965 n.a. n.a.
Increased Ratings............................. 200 374 555 645 789 940 1,095 1,264 1,443 1,608 n.a. n.a.
Survivors of Deceased Veterans................ 17 22 32 42 53 62 73 84 97 110 n.a. n.a.
Health Care:
New Enrollees................................. 118 478 844 1,133 1,371 1,357 1,342 1,329 1,315 1,297 n.a. n.a.
Current Enrollees............................. 861 833 806 778 752 726 701 676 652 628 n.a. n.a.
Survivors of Deceased Veterans................ 12 16 23 30 37 45 52 61 70 79 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * = between zero and $50 million.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 2.--TITLE I, EXPANSION OF HEALTH CARE FOR TOXIC EXPOSURE VETERANS
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, billions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... 0.6 2.4 4.2 5.8 7.0 6.3 5.5 4.5 3.5 2.5 19.9 42.1
Estimated Outlays............................. 0.5 2.1 3.9 5.5 6.8 6.3 5.5 4.6 3.6 2.6 18.8 41.4
Memorandum
Cumulative Beneficiaries, Thousands of People
Health Care:
New Enrollee.................................. 69 319 566 764 896 771 647 513 383 260 n.a. n.a.
Current Enrollee.............................. 837 751 661 587 510 433 360 282 209 140 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * = between zero and $50 million.
TABLE 3.--TITLE II, TOXIC EXPOSURE PRESUMPTION PROCESS
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, billions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation...................................... 0 0 2.3 5.5 10.0 13.5 17.4 21.5 25.8 30.2 17.8 126.2
Other Mandatory Benefits.......................... 0 0 * * * 0.1 0.1 0.1 0.2 0.2 0.1 0.7
Total Direct Spending......................... 0 0 2.3 5.5 10.0 13.6 17.5 21.7 26.0 30.3 17.9 126.9
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... 0 0 0.1 0.4 1.0 2.3 4.2 6.7 9.6 12.8 1.5 37.2
Estimated Outlays............................. 0 0 0.1 0.3 1.0 2.2 4.0 6.4 9.2 12.3 1.3 35.4
Operating Costs:
Estimated Authorization....................... * * 0.2 0.4 0.6 0.7 0.7 0.7 0.8 0.8 1.2 4.8
Estimated Outlays............................. * * 0.1 0.3 0.6 0.6 0.7 0.7 0.8 0.8 1.0 4.7
Total Discretionary Spending:
Estimated Authorization...................... * * 0.2 0.7 1.7 3.0 5.0 7.5 10.4 13.6 2.6 42.0
Estimated Outlays............................. * * 0.2 0.7 1.5 2.8 4.7 7.1 9.9 13.1 2.4 40.0
Memorandum
Cumulative Beneficiaries, Thousands of People
Disability Compensation:b
New Ratings................................... 0 0 17 76 184 323 474 629 779 925 n.a. n.a.
Increased Ratings............................. 0 0 32 98 210 326 444 564 686 810 n.a. n.a.
Survivors of Deceased Veterans................ 0 0 5 11 17 23 29 36 43 50 n.a. n.a.
Health Care:
New Enrollees................................. 0 0 9 41 101 177 262 349 434 517 n.a. n.a.
Current Enrollees............................. 0 0 4 19 46 80 118 156 194 230 n.a. n.a.
Survivors of Deceased Veterans................ 0 0 4 8 12 16 21 26 31 36 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * = between zero and $50 million.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 4.--TITLE III, IMPROVING THE ESTABLISHMENT OF SERVICE CONNECTION PROCESS FOR TOXIC EXPOSED VETERANS
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, billions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation...................................... 0.8 2.0 2.8 3.5 4.3 4.0 5.0 6.4 7.9 9.0 13.4 45.7
Other Mandatory Benefits.......................... * * * 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.2 0.6
Total Direct Spending......................... 0.8 2.0 2.8 3.5 4.4 4.1 5.1 6.5 8.0 9.1 13.6 46.3
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... 0.1 0.2 0.6 1.0 1.5 2.1 2.7 3.5 4.4 5.4 3.4 21.5
Estimated Outlays............................. 0.1 0.2 0.5 0.9 1.5 2.0 2.6 3.4 4.3 5.2 3.2 20.6
Operating Costs:
Estimated Authorization....................... 0.1 0.1 0.1 0.1 0.2 0.1 0.1 0.2 0.2 0.1 0.6 1.3
Estimated Outlays............................. * 0.1 0.1 0.1 0.1 0.1 0.1 0.2 0.2 0.1 0.5 1.3
Total Discretionary Spending:
Estimated Authorization....................... 0.1 0.4 0.7 1.1 1.7 2.2 2.8 3.7 4.6 5.5 4.0 22.8
Estimated Outlays............................. 0.1 0.3 0.7 1.1 1.6 2.1 2.7 3.5 4.4 5.4 3.7 21.9
Memorandum
Cumulative Beneficiaries, Thousands of People
Disability Compensation:b
New Ratings................................... 19 57 96 112 149 185 220 273 319 352 n.a. n.a.
Increased Ratings............................. 8 26 45 60 84 108 135 174 222 255 n.a. n.a.
Survivors of Deceased Veterans................ 1 2 4 6 8 9 11 12 14 16 n.a. n.a.
Health Care:
New Enrollees................................. 10 31 53 61 81 101 121 151 178 197 n.a. n.a.
Current Enrollees............................. 5 14 24 28 37 46 55 68 79 87 n.a. n.a.
Survivors of Deceased Veterans................ ** 2 3 4 6 7 8 9 10 12 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * = between zero and $50 million; ** = fewer than 500 beneficiaries.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 5.--SECTION 401, ENEWETAK ATOLL
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, millions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation...................................... 4 10 9 12 12 13 13 13 15 15 47 116
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... * 1 2 3 4 4 5 5 5 6 10 35
Estimated Outlays............................. * 1 2 3 4 4 5 5 5 5 10 34
Memorandum
Cumulative Beneficiaries
Disability Compensation:b
New Ratings................................... 53 165 230 239 248 254 260 264 266 267 n.a. n.a.
Increased Ratings............................. 18 55 77 80 83 85 87 88 89 89 n.a. n.a.
Survivors of Deceased Veterans................ 28 89 125 132 138 145 151 157 163 168 n.a. n.a.
Health Care:
New Enrollees................................. 28 90 125 131 136 140 143 147 148 149 n.a. n.a.
Current Enrollees............................. 13 40 57 59 61 63 65 65 66 66 n.a. n.a.
Survivors of Deceased Veterans................ 20 64 90 95 100 104 109 113 117 121 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * between zero and $500,000.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 6.--SECTION 402, PALOMARES
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, millions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation...................................... 1 2 3 3 3 3 3 3 4 4 12 29
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... * * 1 1 1 1 1 1 1 1 3 8
Estimated Outlays............................. * * 1 1 1 1 1 1 1 1 3 8
Memorandum
Cumulative Beneficiaries
Disability Compensation:b
New Ratings................................... 18 53 70 68 65 62 59 56 52 48 n.a. n.a.
Increased Ratings............................. 6 18 23 23 22 21 20 19 17 16 n.a. n.a.
Survivors of Deceased Veterans................ 15 47 64 66 67 68 69 70 70 70 n.a. n.a.
Health Care:
New Enrollees................................. 10 29 38 37 36 34 33 31 29 26 n.a. n.a.
Current Enrollees............................. 4 13 17 17 16 16 15 14 13 12 n.a. n.a.
Survivors of Deceased Veterans................ 11 34 46 47 48 49 50 50 50 50 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * between zero and $500,000.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 7.--SECTION 403, AGENT ORANGE
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, billions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation...................................... 0.6 0.7 1.0 0.6 0.6 0.7 0.7 0.7 0.7 0.7 3.5 6.9
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... * * 0.1 0.2 0.3 0.4 0.4 0.4 0.4 0.4 0.7 2.7
Estimated Outlays............................. * * 0.1 0.2 0.3 0.4 0.4 0.4 0.4 0.4 0.6 2.6
Operating Costs:
Estimated Authorization....................... * * * * * * * * * * .2 .2
Estimated Outlays............................. * * * * * * * * * * .2 .2
Total Discretionary Spending:
Estimated Authorization....................... 0.1 0.1 0.1 0.2 0.3 0.4 0.4 0.4 0.4 0.4 0.8 2.8
Estimated Outlays............................. * 0.1 0.1 0.2 0.3 0.4 0.4 0.4 0.4 0.4 0.8 2.8
Memorandum
Cumulative Beneficiaries, Thousands of People
Disability Compensation:b
New Ratings................................... 2 9 16 21 23 24 24 23 23 23 n.a. n.a.
Increased Ratings............................. 7 14 24 24 23 23 23 22 22 22 n.a. n.a.
Survivors of Deceased Veterans................ 2 2 2 2 2 2 2 3 3 3 n.a. n.a.
Health Care:
New Enrollees................................. 1 5 9 11 13 13 13 13 13 13 n.a. n.a.
Current Enrollees............................. 1 2 4 5 6 6 6 6 6 6 n.a. n.a.
Survivors of Deceased Veterans................ 2 2 2 2 2 2 2 2 2 2 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * between zero and $50 million.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 8.--SECTION 404, HYPERTENSION
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, billions of dollars--
-----------------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation...................................... 2.9 3.8 4.6 3.4 3.5 3.7 3.7 3.8 3.9 4.0 18.2 37.4
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization....................... * 0.2 0.8 1.6 2.4 2.6 2.7 2.8 2.9 3.0 4.9 19.0
Estimated Outlays............................. * 0.2 0.7 1.4 2.3 2.6 2.7 2.8 2.9 3.0 4.6 18.4
Operating Costs:
Estimated Authorization....................... 0.8 0.8 0.7 0.2 0.2 0.1 0.1 0.1 0.1 0.1 2.7 3.1
Estimated Outlays............................. 0.6 0.8 0.7 0.3 0.2 0.1 0.1 0.1 0.1 0.1 2.6 3.1
Total Discretionary Spending:
Estimated Authorization....................... 0.8 1.0 1.5 1.8 2.6 2.7 2.8 2.9 3.0 3.1 7.6 22.1
Estimated Outlays............................. 0.6 0.9 1.4 1.8 2.5 2.7 2.8 2.8 2.9 3.0 7.2 21.5
Memorandum
Cumulative Beneficiaries, Thousands of People
Disability Compensation:b
New Ratings................................... 51 178 329 427 473 492 486 479 472 464 n.a. n.a.
Increased Ratings............................. 151 224 297 294 291 289 285 282 278 274 n.a. n.a.
Survivors of Deceased Veterans................ 13 13 14 15 17 18 20 22 24 26 n.a. n.a.
Health Care:
New Enrollees................................. 21 74 137 179 199 207 205 203 200 197 n.a. n.a.
Current Enrollees............................. 12 44 81 105 117 122 121 119 117 115 n.a. n.a.
Survivors of Deceased Veterans................ 9 10 10 11 12 13 14 16 17 19 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * between zero and $50 million.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 9.--SECTION 405, PERSIAN GULF WAR VETERANS
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, millions of dollars--
-------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation................................................ 33 40 47 30 38 61 86 112 139 167 188 753
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization................................. * 2 6 13 22 34 50 67 86 106 43 386
Estimated Outlays....................................... * 2 6 12 21 32 47 64 83 102 41 369
Memorandum
Cumulative Beneficiaries, Thousands of People
Disability Compensation:b
New Ratings............................................. 1 2 2 2 3 4 6 7 9 10 n.a. n.a.
Increased Ratings....................................... 1 1 2 3 3 5 7 9 11 13 n.a. n.a.
Survivors of Deceased Veterans.......................... ** ** ** ** ** ** ** ** ** ** n.a. n.a.
Health Care:
New Enrollees........................................... ** 1 1 1 1 2 3 4 5 6 n.a. n.a.
Current Enrollees....................................... ** ** ** 1 1 1 1 2 2 3 n.a. n.a.
Survivors of Deceased Veterans.......................... ** ** ** ** ** ** ** ** ** ** n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * = between zero and $50 million; ** = fewer than 500 beneficiaries.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
TABLE 10.--SECTION 406, BURN PITS
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, billions of dollars--
-------------------------------------------------------------------------------------------
2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2022-2026 2022-2031
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increases in Direct Spending Outlaysa
Compensation................................................ 5.7 7.6 8.8 4.3 4.7 5.2 5.7 6.3 6.8 7.4 31.2 62.6
Other Mandatory Benefits.................................... * * 0.1 0.1 0.1 0.1 * * * * 0.3 0.5
Total Direct Spending................................... 5.7 7.6 8.9 4.4 4.8 5.3 5.8 6.3 6.9 7.5 31.5 63.1
Increases in Spending Subject to Appropriation
Health Care:
Estimated Authorization................................. 0.1 0.4 0.8 1.3 1.8 2.1 2.4 2.7 2.9 3.3 4.4 17.8
Estimated Outlays....................................... 0.1 0.3 0.7 1.2 1.7 2.1 2.3 2.6 2.9 3.2 4.2 17.2
Operating Costs:
Estimated Authorization................................. 0.2 0.4 0.4 0.1 0.1 0.1 0.1 0.1 0.1 0.1 1.2 1.6
Estimated Outlays....................................... 0.2 0.4 0.4 0.2 0.1 0.1 0.1 0.1 0.1 0.1 1.2 1.6
Total Discretionary Spending:
Estimated Authorization................................. 0.3 0.8 1.2 1.4 1.9 2.2 2.5 2.7 3.0 3.3 5.6 19.4
Estimated Outlays....................................... 0.3 0.7 1.1 1.4 1.8 2.2 2.4 2.7 3.0 3.3 5.4 18.8
Memorandum
Cumulative Beneficiaries, Thousands of People
Disability Compensation:b
New Ratings............................................. 28 89 127 136 145 155 164 173 183 192 n.a. n.a.
Increased Ratings....................................... 34 109 156 167 178 189 200 212 223 235 n.a. n.a.
Survivors of Deceased Veterans.......................... 1 4 6 7 8 9 10 11 13 14 n.a. n.a.
Health Care:
New Enrollees........................................... 15 49 69 75 80 85 91 96 102 107 n.a. n.a.
Current Enrollees....................................... 7 22 31 34 36 38 41 43 45 48 n.a. n.a.
Survivors of Deceased Veterans.......................... 1 3 5 5 6 7 7 8 9 10 n.a. n.a.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Components may not sum to totals because of rounding; n.a. = not applicable; * = between zero and $50 million; ** = fewer than 500 beneficiaries.
aBudget authority equals outlays.
bThe total number of affected veterans is smaller than the sum of veterans receiving new disability ratings and those receiving increased disability
ratings.
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.
Constitutional Authority Statement
Pursuant to Article I, section 8 of the United States
Constitution, H.R. 3967 is authorized by Congress' power to
``provide for the common Defense and general Welfare of the
United States.''
Earmark Statement
H.R. 3967 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.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 3967, prepared by the Director of the
Congressional Budget Office pursuant to section 423 of the
Unfunded Mandates Reform Act.
Advisory Committee Statement
An advisory committee within the meaning of section 5(b) of
the Federal Advisory Committee Act would be created by H.R.
3967.
Performance Goals
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 to increase access to quality and
timely health care and benefits to veterans potentially and
definitively exposed to toxic substances while serving in the
uniformed services of the United States of America.
Supplemental, Additional, Dissenting, and Minority Views
Minority Views
Introduction
Toxic-exposed veterans are suffering. They are looking to
Congress, and our Committee in particular, for assistance.
Republican Members are committed to addressing the needs of
toxic-exposed veterans in a fair and fiscally sound manner.
That said, the Democratic Majority's decision to report H.R.
3967 out of Committee without basic information necessary to
evaluate the proposal was premature and unwise.
Reporting the bill was premature because the Committee
lacks basic information from the Biden Administration that is
necessary to evaluate its merits. Reporting the bill was unwise
because it is giving veterans false hope. Preliminary cost
estimates indicate that this bill may cost well over $1
trillion dollars. With no clear path to success in its current
form, reporting the bill also gave veterans an empty promise.
We disagree with the premise that the Committee needs to pass
an unworkable bill to ``be on the same footing as the Senate''
and because ``we have momentum on our side.'' The Committee
keeps the momentum going by demanding that the Biden
Administration provide Congress information it has requested to
move forward. The Committee should urge the Secretary to come
off the sideline and meaningfully participate in discussions.
Given the Administration's refusal to do so voluntarily,
Ranking Member Bost offered an amendment that would have
replaced all provisions in the underlying bill with language
requiring the Department of Veterans Affairs (VA) to submit a
study containing information necessary to evaluate the policies
set forth in H.R. 3967 within 90 days of enactment.
Specifically, the study would have mandated VA to provide
detailed information on the effect H.R. 3967 would have on the
Department's benefits and healthcare system, such as potential
increases in wait times for healthcare services and benefits
adjudications; the anticipated increase in the number of
compensation beneficiaries and VA healthcare users; cost
estimates; and the resources, staffing, infrastructure, and
information technology required to implement the bill.
Regrettably, the Democratic majority opposed this amendment.
The Committee lacks basic information necessary to evaluate
the proposals set forth in H.R. 3967. There have been no
discussions on how the Committee will pay for the potentially
$1 trillion dollar mandatory costs associated with this bill as
required by budget rules or for the expected several billions
of dollars in discretionary costs. For these reasons, as
amplified below, Republicans opposed reporting the H.R. 3967.
Analysis
Under current law, VA does not have a framework for
establishing presumptions of entitlement to service connection
for conditions linked to toxic exposure that could entitle
veterans to receive monthly disability compensation from VA.
Additionally, veterans are not eligible to seek care from VA to
treat any illnesses that may result from toxic exposures unless
they are already eligible to enroll in the VA healthcare system
under a different enrollment criteria. We have heard
heartbreaking stories from veterans and their families about
their challenges applying for VA benefits and care for
conditions they believe are linked to toxic exposures. We
believe the Department's healthcare and benefits system for
toxic-exposed veterans needs improvement to ensure that we
honor our nation's promise to the men and women who served our
country in uniform.
We appreciate the Majority's efforts to establish a
comprehensive disability decision-making framework within the
Honoring our PACT Act. We also appreciate the Majority's intent
to require VA to allow a larger population of toxic-exposed
veterans to enroll in the VA healthcare system, without the
need to establish service connection, in priority group 6.
Moreover, as a general matter, we support additional outreach
to veterans on VA services for toxic exposure; improved
training for VA medical staff, claims processors, and
disability examiners; and, further research into the health
effects of military toxic exposures. This is why Ranking Member
Bost introduced H.R. 2127, the Toxic Exposure in the American
Military (TEAM) Act, which would make similar changes to VA's
services for toxic-exposed veterans.
Nevertheless, we have concerns about the Department's
ability to implement H.R. 3967 without compromising services
for other veterans. We believe the following five points are
critical to evaluating whether H.R. 3967, or any bill with such
far-reaching implications on VA and veterans, has a viable path
to becoming law:
1. COST ESTIMATES AND IMPACT STATEMENTS FROM VA
Committee Members should understand the consequences of the
bill on veterans, taxpayers, the Department, and the Federal
government. Such information should include:
VA's views on the bill, including whether it
can be implemented, as written;
The effect on VA's benefits, healthcare, and
memorial affairs systems;
Whether the bill helps toxic-exposed
veterans;
The staffing, infrastructure, information
technology, funding, and other resources needed to
implement the bill; and,
How much the bill would cost the American
people.
On May 5, 2021, the Committee held a hearing on 15 wide-
ranging toxic exposure bills. VA was invited to provide
testimony at that hearing but declined to take a position on
any of the bills, opting instead to make general statements
about toxic exposure.\1\ On May 19, 2021, Ranking Member Bost
sent a letter to Secretary McDonough asking VA to provide views
and cost estimates for the bills that were included on the May
5, 2021 Full Committee Legislative Hearing, a majority of which
are included in the Honoring our PACT Act.
---------------------------------------------------------------------------
\1\https://docs.house.gov/meetings/VR/VR00/20210505/112559/HHRG-
117-VR00-Wstate-BurkeR-20210505.pdf.
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Ranking Member Bost renewed his request during the June 8,
2021, Full Committee hearing on VA's fiscal year (FY) 2022
budget request, and Secretary McDonough committed to providing
technical assistance and cost estimates. However, ``technical
assistance'' from the Department is not a formal statement of
the Administration's position. Therefore, VA's provision of
technical assistance does not absolve the Department's
responsibility to provide formal views.
2. RELIABLE ESTIMATES FROM THE CONGRESSIONAL BUDGET OFFICE (CBO) AND
OFFICE OF MANAGEMENT AND BUDGET (OMB) AND, IF THEY DIFFER, THE
OPPORTUNITY TO RECONCILE THEM
It is unreasonable to ask Committee Members to support
legislation, particularly legislation of this magnitude,
without a reliable estimate on the impact it would have on the
budget. We do not have that for H.R. 3967.
On June 22, 2021, CBO provided an informal estimate stating
that Title II of H.R. 3967 would make it ``easier for veterans
to receive disability compensation'' and ``even small changes
result in significant increases in program costs.'' Further,
CBO provided hypothetical, informal estimates that, if the bill
increases the number of compensation recipients by 25 percent
beginning in 2023, the bill would increase direct spending by
about $300 billion over the 2022-2031 budget window. Similarly,
if the bill increased the number of compensation recipients by
50 percent, the bill would increase direct spending by more
than $1 trillion over the 2022-2031 budget window.
CBO also anticipated additional mandatory costs in the
billions as a result of increased compensation for dependents
and increases to the average rating of all disability
recipients. According to CBO, these figures do not account for
costs associated with retroactive benefits that would be
awarded under Sec. 203.
Further, CBO estimated that discretionary spending would
increase by hundreds of billions over the 2022-2031 budget
window due to the expansion of VA healthcare beneficiaries;
changes to VA's provision of healthcare, such as higher
priority care and lower copayments; and resources needed to
process compensation claims under this bill.
When pressed by the Ranking Member to clarify their
informal estimate, CBO indicated that they needed information
from the Administration in order to provide a more reliable
accounting. Again, the Administration's refusal to provide
Congress and others with information necessary to evaluate this
proposal is a barrier to moving forward in a fiscally
responsible manner.
Moreover, CBO and OMB may provide different cost estimates
for this legislation. Therefore, CBO and OMB should both be
afforded the opportunity to estimate the costs of enacting this
legislation and reconcile any differences, which would provide
Congress and the American people with a better understanding of
how much this bill would cost and allow Congress to discuss how
it will be paid for.
3. MEANINGFUL INPUT AND ENGAGEMENT FROM THE BIDEN ADMINISTRATION
Following the markup, Ranking Member Bost led a letter to
President Biden asking him and Secretary McDonough to provide
the information his amendment would have required. The
Administration has a duty to provide input on legislation that
could cost taxpayers $1 trillion--roughly \1/6\ of his entire
budget request for FY 2022--and potentially direct resources
away from other critical programs at VA or elsewhere in the
Federal government.
4. AN AGREEMENT WITH SENATE VETERANS AFFAIRS' COMMITTEE (SVAC) CHAIRMAN
TESTER AND SVAC RANKING MEMBER MORAN ON HOW TO MOVE FORWARD
Improving the way VA serves toxic-exposed veterans is a
mutual goal between the House and Senate Veterans' Affairs
Committee. We need bipartisan, bicameral agreement on policy
and offsets to cover the cost of the bill. Without this, any
bill will fail. Toxic-exposed veterans deserve better than
that.
5. OPEN, PUBLIC DIALOGUE ON THIS ISSUE AFTER RECEIVING ALL THE ABOVE
INFORMATION WITH THE VA, VETERANS, VETERAN SERVICE ORGANIZATIONS
(VSOS), AND OTHER STAKEHOLDERS
Comprehensive toxic exposure legislation must strike a fair
balance between the needs of toxic-exposed veterans; taxpayers,
some of whom are veterans; and VA, who will be required to
implement it. Veterans, taxpayers, and other stakeholders
should be afforded an open forum, such as a roundtable or
hearing, to comment on the House and Senate agreed upon toxic
exposure legislation and provide recommendation for
improvement.
Clearly, the Minority did not have the information and
assurances necessary to responsibly vote on this bill during
the June 24, 2021, markup. We believe the study authorized in
the Ranking Member's amendment would have allowed Members on
both sides of the aisle to determine the best path forward on
this important issue. We urge the Majority to work with us to
obtain this data so that we can proceed forward in a diligent,
responsible manner.
Mike Bost,
Ranking Member.
Aumua Amata Coleman Radewagen,
Vice Ranking Member.
Jack Bergman.
Chip Roy.
Jim Banks.
Gregory F. Murphy.
Tracey Mann.
Nancy Mace.
Troy E. Nehls.
Mariannette Miller-Meeks.
Barry Moore.
Madison Cawthorn.
Matthew M. Rosendale.
Applicability to Legislative Branch
The Committee finds that H.R. 3967 does not relate to the
terms and condition of employment or access to public services
or accommodations within the meaning of section 102(b)(3) of
the Congressional Accountability Act.
Statement on Duplication of Federal Programs
Pursuant to clause 3(c)(5) of rule XIII of the Rules of the
House of Representatives, the Committee finds that no provision
of H.R. 3967 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.
Ramseyer Submission
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) 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, and existing law in which no
change is proposed is shown in roman):
TITLE 38, UNITED STATES CODE
* * * * * * *
PART I--GENERAL PROVISIONS
* * * * * * *
CHAPTER 1--GENERAL
* * * * * * *
Sec. 101. Definitions
For the purposes of this title--
(1) The terms ``Secretary'' and ``Department'' mean the
Secretary of Veterans Affairs and the Department of Veterans
Affairs, respectively.
(2) The term ``veteran'' means a person who served in the
active military, naval, air, or space service, and who was
discharged or released therefrom under conditions other than
dishonorable.
(3) The term ``surviving spouse'' means (except for purposes
of chapter 19 of this title) a person of the opposite sex who
was the spouse of a veteran at the time of the veteran's death,
and who lived with the veteran continuously from the date of
marriage to the date of the veteran's death (except where there
was a separation which was due to the misconduct of, or
procured by, the veteran without the fault of the spouse) and
who has not remarried or (in cases not involving remarriage)
has not since the death of the veteran, and after September 19,
1962, lived with another person and held himself or herself out
openly to the public to be the spouse of such other person.
(4)(A) The term ``child'' means (except for purposes of
chapter 19 of this title (other than with respect to a child
who is an insurable dependent under subparagraph (B) or (C) of
section 1965(10) of such chapter) and section 8502(b) of this
title) a person who is unmarried and--
(i) who is under the age of eighteen years;
(ii) who, before attaining the age of eighteen years,
became permanently incapable of self-support; or
(iii) who, after attaining the age of eighteen years
and until completion of education or training (but not
after attaining the age of twenty-three years), is
pursuing a course of instruction at an approved
educational institution;
and who is a legitimate child, a legally adopted child, a
stepchild who is a member of a veteran's household or was a
member at the time of the veteran's death, or an illegitimate
child but, as to the alleged father, only if acknowledged in
writing signed by him, or if he has been judicially ordered to
contribute to the child's support or has been, before his
death, judicially decreed to be the father of such child, or if
he is otherwise shown by evidence satisfactory to the Secretary
to be the father of such child. A person shall be deemed, as of
the date of death of a veteran, to be the legally adopted child
of such veteran if such person was at the time of the veteran's
death living in the veteran's household and was legally adopted
by the veteran's surviving spouse before August 26, 1961, or
within two years after the veteran's death; however, this
sentence shall not apply if at the time of the veteran's death,
such person was receiving regular contributions toward the
person's support from some individual other than the veteran or
the veteran's spouse, or from any public or private welfare
organization which furnishes services or assistance for
children. A person with respect to whom an interlocutory decree
of adoption has been issued by an appropriate adoption
authority shall be recognized thereafter as a legally adopted
child, unless and until that decree is rescinded, if the child
remains in the custody of the adopting parent or parents during
the interlocutory period. A person who has been placed for
adoption under an agreement entered into by the adopting parent
or parents with any agency authorized under law to so act shall
be recognized thereafter as a legally adopted child, unless and
until such agreement is terminated, if the child remains in the
custody of the adopting parent or parents during the period of
placement for adoption under such agreement. A person described
in clause (ii) of the first sentence of this subparagraph who
was a member of a veteran's household at the time the person
became 18 years of age and who is adopted by the veteran shall
be recognized as a legally adopted child of the veteran
regardless of the age of such person at the time of adoption.
(B) For the purposes of subparagraph (A) of this paragraph,
in the case of an adoption under the laws of any jurisdiction
other than a State (as defined in section 101(20) of this title
and including the Commonwealth of the Northern Mariana
Islands)--
(i) a person residing outside any of the States shall
not be considered to be a legally adopted child of a
veteran during the lifetime of such veteran (including
for purposes of this subparagraph a Commonwealth Army
veteran or new Philippine Scout, as defined in section
3566 of this title) unless such person--
(I) was less than eighteen years of age at
the time of adoption;
(II) is receiving one-half or more of such
person's annual support from such veteran;
(III) is not in the custody of such person's
natural parent, unless such natural parent is
such veteran's spouse; and
(IV) is residing with such veteran (or in the
case of divorce following adoption, with the
divorced spouse who is also an adoptive or
natural parent) except for periods during which
such person is residing apart from such veteran
(or such divorced spouse) for purposes of full-
time attendance at an educational institution
or during which such person or such veteran (or
such divorced spouse) is confined in a
hospital, nursing home, other health-care
facility, or other institution; and
(ii) a person shall not be considered to have been a
legally adopted child of a veteran as of the date of
such veteran's death and thereafter unless--
(I) at any time within the one-year period
immediately preceding such veteran's death,
such veteran was entitled to and was receiving
a dependent's allowance or similar monetary
benefit under this title for such person; or
(II) for a period of at least one year prior
to such veteran's death, such person met the
requirements of clause (i) of this
subparagraph.
(5) The term ``parent'' means (except for purposes of chapter
19 of this title) a father, a mother, a father through
adoption, a mother through adoption, or an individual who for a
period of not less than one year stood in the relationship of a
parent to a veteran at any time before the veteran's entry into
active military, naval, air, or space service or if two persons
stood in the relationship of a father or a mother for one year
or more, the person who last stood in the relationship of
father or mother before the veteran's last entry into active
military, naval, air, or space service.
(6) The term ``Spanish-American War'' (A) means the period
beginning on April 21, 1898, and ending on July 4, 1902, (B)
includes the Philippine Insurrection and the Boxer Rebellion,
and (C) in the case of a veteran who served with the United
States military forces engaged in hostilities in the Moro
Province, means the period beginning on April 21, 1898, and
ending on July 15, 1903.
(7) The term ``World War I'' (A) means the period beginning
on April 6, 1917, and ending on November 11, 1918, and (B) in
the case of a veteran who served with the United States
military forces in Russia, means the period beginning on April
6, 1917, and ending on April 1, 1920.
(8) The term ``World War II'' means (except for purposes of
chapters 31 and 37 of this title) the period beginning on
December 7, 1941, and ending on December 31, 1946.
(9) The term ``Korean conflict'' means the period beginning
on June 27, 1950, and ending on January 31, 1955.
(10) The term ``Armed Forces'' means the United States Army,
Navy, Marine Corps, Air Force, Space Force, and Coast Guard,
including the reserve components thereof.
(11) The term ``period of war'' means the Spanish-American
War, the Mexican border period, World War I, World War II, the
Korean conflict, the Vietnam era, the Persian Gulf War, and the
period beginning on the date of any future declaration of war
by the Congress and ending on the date prescribed by
Presidential proclamation or concurrent resolution of the
Congress.
(12) The term ``veteran of any war'' means any veteran who
served in the active military, naval, air, or space service
during a period of war.
(13) The term ``compensation'' means a monthly payment made
by the Secretary to a veteran because of service-connected
disability, or to a surviving spouse, child, or parent of a
veteran because of the service-connected death of the veteran
occurring before January 1, 1957.
(14) The term ``dependency and indemnity compensation'' means
a monthly payment made by the Secretary to a surviving spouse,
child, or parent (A) because of a service-connected death
occurring after December 31, 1956, or (B) pursuant to the
election of a surviving spouse, child, or parent, in the case
of such a death occurring before January 1, 1957.
(15) The term ``pension'' means a monthly or other periodic
payment made by the Secretary to a veteran because of service,
age, or non-service-connected disability, or to a surviving
spouse or child of a veteran because of the non-service-
connected death of the veteran.
(16) The term ``service-connected'' means, with respect to
disability or death, that such disability was incurred or
aggravated, or that the death resulted from a disability
incurred or aggravated, in line of duty in the active military,
naval, air, or space service.
(17) The term ``non-service-connected'' means, with respect
to disability or death, that such disability was not incurred
or aggravated, or that the death did not result from a
disability incurred or aggravated, in line of duty in the
active military, naval, air, or space service.
(18) The term ``discharge or release'' includes (A)
retirement from the active military, naval, air, or space
service, and (B) the satisfactory completion of the period of
active military, naval, air, or space service for which a
person was obligated at the time of entry into such service in
the case of a person who, due to enlistment or reenlistment,
was not awarded a discharge or release from such period of
service at the time of such completion thereof and who, at such
time, would otherwise have been eligible for the award of a
discharge or release under conditions other than dishonorable.
(19) The term ``State home'' means a home established by a
State (other than a possession) or Indian tribe (as defined in
section 4 of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 5304)) for veterans disabled by age,
disease, or otherwise who by reason of such disability are
incapable of earning a living. Such term also includes such a
home which furnishes nursing home care for veterans.
(20) The term ``State'' means each of the several States,
Territories, and possessions of the United States, the District
of Columbia, and the Commonwealth of Puerto Rico. For the
purpose of section 2303 and chapters 34 and 35 of this title,
such term also includes the Canal Zone.
(21) The term ``active duty'' means--
(A) full-time duty in the Armed Forces, other than
active duty for training;
(B) full-time duty (other than for training purposes)
as a commissioned officer of the Regular or Reserve
Corps of the Public Health Service (i) on or after July
29, 1945, or (ii) before that date under circumstances
affording entitlement to ``full military benefits'' or
(iii) at any time, for the purposes of chapter 13 of
this title;
(C) full-time duty as a commissioned officer in the
commissioned officer corps of the National Oceanic and
Atmospheric Administration or its predecessor
organization the Coast and Geodetic Survey (i) on or
after July 29, 1945, or (ii) before that date (I) while
on transfer to one of the Armed Forces, or (II) while,
in time of war or national emergency declared by the
President, assigned to duty on a project for one of the
Armed Forces in an area determined by the Secretary of
Defense to be of immediate military hazard, or (III) in
the Philippine Islands on December 7, 1941, and
continuously in such islands thereafter, or (iii) at
any time, for the purposes of chapter 13 of this title;
(D) service as a cadet at the United States Military,
Air Force, or Coast Guard Academy, or as a midshipman
at the United States Naval Academy; and
(E) authorized travel to or from such duty or
service.
(22) The term ``active duty for training'' means--
(A) full-time duty in the Armed Forces performed by
Reserves for training purposes;
(B) full-time duty for training purposes performed as
a commissioned officer of the Reserve Corps 1
of the Public Health Service (i) on or after July 29,
1945, or (ii) before that date under circumstances
affording entitlement to ``full military benefits'', or
(iii) at any time, for the purposes of chapter 13 of
this title;
(C) in the case of members of the Army National Guard
or Air National Guard of any State, full-time duty
under section 316, 502, 503, 504, or 505 of title 32,
or the prior corresponding provisions of law;
(D) duty performed by a member of a Senior Reserve
Officers' Training Corps program when ordered to such
duty for the purpose of training or a practice cruise
under chapter 103 of title 10 for a period of not less
than four weeks and which must be completed by the
member before the member is commissioned; and
(E) authorized travel to or from such duty.
The term does not include duty performed as a temporary member
of the Coast Guard Reserve.
(23) The term ``inactive duty training'' means--
(A) duty (other than full-time duty) prescribed for
Reserves (including commissioned officers of the
Reserve Corps 1 of the Public Health
Service) by the Secretary concerned under section 206
of title 37 or any other provision of law;
(B) special additional duties authorized for Reserves
(including commissioned officers of the Reserve Corps
of the Public Health Service) by an authority
designated by the Secretary concerned and performed by
them on a voluntary basis in connection with the
prescribed training or maintenance activities of the
units to which they are assigned; and
(C) training (other than active duty for training) by
a member of, or applicant for membership (as defined in
section 8140(g) of title 5) in, the Senior Reserve
Officers' Training Corps prescribed under chapter 103
of title 10.
In the case of a member of the Army National Guard or Air
National Guard of any State, such term means duty (other than
full-time duty) under sections 316, 502, 503, 504, or 505 of
title 32, or the prior corresponding provisions of law. Such
term does not include (i) work or study performed in connection
with correspondence courses, (ii) attendance at an educational
institution in an inactive status, or (iii) duty performed as a
temporary member of the Coast Guard Reserve.
(24) The term ``active military, naval, air, or space
service'' includes--
(A) active duty;
(B) any period of active duty for training during
which the individual concerned was disabled or died
from a disease or injury incurred or aggravated in line
of duty; and
(C) any period of inactive duty training during which
the individual concerned was disabled or died--
(i) from an injury incurred or aggravated in
line of duty; or
(ii) from an acute myocardial infarction, a
cardiac arrest, or a cerebrovascular accident
occurring during such training.
(25) The term ``Secretary concerned'' means--
(A) the Secretary of the Army, with respect to
matters concerning the Army;
(B) the Secretary of the Navy, with respect to
matters concerning the Navy or the Marine Corps;
(C) the Secretary of the Air Force, with respect to
matters concerning the Air Force or the Space Force;
(D) the Secretary of Homeland Security, with respect
to matters concerning the Coast Guard;
(E) the Secretary of Health and Human Services, with
respect to matters concerning the Public Health
Service; and
(F) the Secretary of Commerce, with respect to
matters concerning the National Oceanic and Atmospheric
Administration or its predecessor organization the
Coast and Geodetic Survey.
(26) The term ``Reserve'' means a member of a reserve
component of one of the Armed Forces.
(27) The term ``reserve component'' means, with respect to
the Armed Forces--
(A) the Army Reserve;
(B) the Navy Reserve;
(C) the Marine Corps Reserve;
(D) the Air Force Reserve;
(E) the Space Force Reserve;
(F) the Coast Guard Reserve;
(G) the Army National Guard of the United States; and
(H) the Air National Guard of the United States.
(28) The term ``nursing home care'' means the accommodation
of convalescents or other persons who are not acutely ill and
not in need of hospital care, but who require nursing care and
related medical services, if such nursing care and medical
services are prescribed by, or are performed under the general
direction of, persons duly licensed to provide such care. Such
term includes services furnished in skilled nursing care
facilities, in intermediate care facilities, and in combined
facilities. It does not include domiciliary care.
(29) The term ``Vietnam era'' means the following:
(A) The period beginning on November 1, 1955, and
ending on May 7, 1975, in the case of a veteran who
served in the Republic of Vietnam during that period.
(B) The period beginning on August 5, 1964, and
ending on May 7, 1975, in all other cases.
(30) The term ``Mexican border period'' means the period
beginning on May 9, 1916, and ending on April 5, 1917, in the
case of a veteran who during such period served in Mexico, on
the borders thereof, or in the waters adjacent thereto.
(31) The term ``spouse'' means a person of the opposite sex
who is a wife or husband.
(32) The term ``former prisoner of war'' means a person who,
while serving in the active military, naval air, or space
service, was forcibly detained or interned in line of duty--
(A) by an enemy government or its agents, or a
hostile force, during a period of war; or
(B) by a foreign government or its agents, or a
hostile force, under circumstances which the Secretary
finds to have been comparable to the circumstances
under which persons have generally been forcibly
detained or interned by enemy governments during
periods of war.
(33) The term ``Persian Gulf War'' means the period beginning
on August 2, 1990, and ending on the date thereafter prescribed
by Presidential proclamation or by law.
(34) The term ``agency of original jurisdiction'' means the
activity which entered the original determination with regard
to a claim for benefits under laws administered by the
Secretary.
(35) The term ``relevant evidence'' means evidence that tends
to prove or disprove a matter in issue.
(36) The term ``supplemental claim'' means a claim for
benefits under laws administered by the Secretary filed by a
claimant who had previously filed a claim for the same or
similar benefits on the same or similar basis.
(37) The term ``toxic exposure'' includes the following:
(A) A toxic exposure risk activity, as defined in
section 1710(e)(4) of this title.
(B) An exposure to a substance, chemical, or airborne
hazard specified in section 1119(b)(2).
(38) The term ``toxic exposed veteran'' means a veteran
described in section 1710(e)(1) of this title.
* * * * * * *
PART II--GENERAL BENEFITS
* * * * * * *
CHAPTER 11--COMPENSATION FOR SERVICE-CONNECTED DISABILITY OR DEATH
SUBCHAPTER I--GENERAL
Sec.
1101. Definitions.
* * * * * * *
SUBCHAPTER II--WARTIME DISABILITY COMPENSATION
* * * * * * *
[1116. Presumptions of service connection for diseases associated with
exposure to certain herbicide agents; presumption of exposure
for veterans who served in the Republic of Vietnam.]
1116. Presumptions of service connection for diseases associated with
exposure to certain herbicide agents; presumption of exposure
for veterans who served in certain locations.
* * * * * * *
1119. Presumptions of toxic exposure.
1120. Presumption of service connection for certain diseases associated
with exposure to burn pits and other toxins.
* * * * * * *
SUBCHAPTER VI--GENERAL COMPENSATION PROVISIONS
* * * * * * *
1164. Presumptions of service-connection for Coronavirus Disease 2019.
1165. Choice of sex of medical examiner for certain disabilities.
1167. Reevaluation of compensation determinations pursuant to changes in
presumptions of service connection.
1168. Medical nexus examinations for toxic exposure risk activities.
Subchapter VII--Research and determinations relating to presumptions of
service connection based on toxic exposure
1171. Procedures to determine presumptions of service connection based
on toxic exposure; definitions.
1172. Formal Advisory Committee on Toxic Exposure.
1173. Science Review Board.
1174. Working group on presumptions of service connection.
1175. Regulations regarding presumptions of service connection based on
toxic exposure.
1166. Specialized teams to evaluate claims involving military sexual
trauma.
* * * * * * *
SUBCHAPTER II--WARTIME DISABILITY COMPENSATION
* * * * * * *
Sec. 1112. Presumptions relating to certain diseases and disabilities
(a) For the purposes of section 1110 of this title, and
subject to the provisions of section 1113 of this title, in the
case of any veteran who served for ninety days or more during a
period of war--
(1) a chronic disease becoming manifest to a degree
of 10 percent or more within one year from the date of
separation from such service;
(2) a tropical disease, and the resultant disorders
or disease originating because of therapy, administered
in connection with such diseases, or as a preventative
thereof, becoming manifest to a degree of 10 percent or
more within one year from the date of separation from
such service, or at a time when standard or accepted
treatises indicate that the incubation period thereof
commenced during such service;
(3) active tuberculous disease developing a 10
percent degree of disability or more within three years
from the date of separation from such service;
(4) multiple sclerosis developing a 10 percent degree
of disability or more within seven years from the date
of separation from such service;
(5) Hansen's disease developing a 10 percent degree
of disability or more within three years from the date
of separation from such service;
shall be considered to have been incurred in or aggravated by
such service, notwithstanding there is no record of evidence of
such disease during the period of service.
(b)(1) For the purposes of section 1110 of this title and
subject to the provisions of section 1113 of this title, in the
case of a veteran who is a former prisoner of war--
(A) a disease specified in paragraph (2) which became
manifest to a degree of 10 percent or more after active
military, naval, air, or space service shall be
considered to have been incurred in or aggravated by
such service, notwithstanding that there is no record
of such disease during the period of service; and
(B) if the veteran was detained or interned as a
prisoner of war for not less than thirty days, a
disease specified in paragraph (3) which became
manifest to a degree of 10 percent or more after active
military, naval, air, or space service shall be
considered to have been incurred in or aggravated by
such service, notwithstanding that there is no record
of such disease during the period of service.
(2) The diseases specified in this paragraph are the
following:
(A) Psychosis.
(B) Any of the anxiety states.
(C) Dysthymic disorder (or depressive neurosis).
(D) Organic residuals of frostbite, if the Secretary
determines that the veteran was detained or interned in
climatic conditions consistent with the occurrence of
frostbite.
(E) Post-traumatic osteoarthritis.
(F) Osteoporosis, if the Secretary determines that
the veteran has post-traumatic stress disorder (PTSD).
(3) The diseases specified in this paragraph are the
following:
(A) Avitaminosis.
(B) Beriberi (including beriberi heart disease).
(C) Chronic dysentery.
(D) Helminthiasis.
(E) Malnutrition (including optic atrophy associated
with malnutrition).
(F) Pellagra.
(G) Any other nutritional deficiency.
(H) Cirrhosis of the liver.
(I) Peripheral neuropathy except where directly
related to infectious causes.
(J) Irritable bowel syndrome.
(K) Peptic ulcer disease.
(L) Atherosclerotic heart disease or hypertensive
vascular disease (including hypertensive heart disease)
and their complications (including myocardial
infarction, congestive heart failure and arrhythmia).
(M) Stroke and its complications.
(c)(1) For the purposes of section 1110 of this title, and
subject to the provisions of section 1113 of this title, a
disease specified in paragraph (2) of this subsection becoming
manifest in a radiation-exposed veteran shall be considered to
have been incurred in or aggravated during active military,
naval, air, or space service, notwithstanding that there is no
record of evidence of such disease during a period of such
service.
(2) The diseases referred to in paragraph (1) of this
subsection are the following:
(A) Leukemia (other than chronic lymphocytic
leukemia).
(B) Cancer of the thyroid.
(C) Cancer of the breast.
(D) Cancer of the pharynx.
(E) Cancer of the esophagus.
(F) Cancer of the stomach.
(G) Cancer of the small intestine.
(H) Cancer of the pancreas.
(I) Multiple myeloma.
(J) Lymphomas (except Hodgkin's disease).
(K) Cancer of the bile ducts.
(L) Cancer of the gall bladder.
(M) Primary liver cancer (except if cirrhosis or
hepatitis B is indicated).
(N) Cancer of the salivary gland.
(O) Cancer of the urinary tract.
(P) Bronchiolo-alveolar carcinoma.
(Q) Cancer of the bone.
(R) Cancer of the brain.
(S) Cancer of the colon.
(T) Cancer of the lung.
(U) Cancer of the ovary.
(3) For the purposes of this subsection:
(A) The term ``radiation-exposed veteran'' means (i)
a veteran who, while serving on active duty,
participated in a radiation-risk activity, or (ii) an
individual who, while a member of a reserve component
of the Armed Forces, participated in a radiation-risk
activity during a period of active duty for training or
inactive duty training.
(B) The term ``radiation-risk activity'' means any of
the following:
(i) Onsite participation in a test involving
the atmospheric detonation of a nuclear device
(without regard to whether the nation
conducting the test was the United States or
another nation).
(ii) The occupation of Hiroshima or Nagasaki,
Japan, by United States forces during the
period beginning on August 6, 1945, and ending
on July 1, 1946.
(iii) Internment as prisoner of war in Japan
(or service on active duty in Japan immediately
following such internment) during World War II
which (as determined by the Secretary) resulted
in an opportunity for exposure to ionizing
radiation comparable to that of veterans
described in clause (ii) of this subparagraph.
(iv) Service in a capacity which, if
performed as an employee of the Department of
Energy, would qualify the individual for
inclusion as a member of the Special Exposure
Cohort under section 3621(14) of the Energy
Employees Occupational Illness Compensation
Program Act of 2000 (42 U.S.C. 7384l(14)).
(v) Cleanup of Enewetak Atoll during the
period beginning on January 1, 1977, and ending
on December 31, 1980.
(vi) Onsite participation in the response
effort following the collision of a United
States Air Force B-52 bomber and refueling
plane that caused the release of four
thermonuclear weapons in the vicinity of
Palomares, Spain, during the period beginning
January 17, 1966, and ending March 31, 1967.
(4) A radiation-exposed veteran who receives a payment under
the provisions of the Radiation Exposure Compensation Act of
1990 (42 U.S.C. 2210 note) shall not be deprived, by reason of
the receipt of that payment, of receipt of compensation to
which that veteran is entitled by reason of paragraph (1), but
there shall be deducted from payment of such compensation the
amount of the payment under that Act.
Sec. 1113. Presumptions rebuttable
(a) Where there is affirmative evidence to the contrary, or
evidence to establish that an intercurrent injury or disease
which is a recognized cause of any of the diseases or
disabilities within the purview of section 1112, 1116, 1117,
[or 1118] 1118, or 1120 of this title, has been suffered
between the date of separation from service and the onset of
any such diseases or disabilities, or the disability is due to
the veteran's own willful misconduct, service-connection
pursuant to section 1112, 1116, [or 1118] 1118, or 1120 of this
title, or payments of compensation pursuant to section 1117 of
this title, will not be in order.
(b) Nothing in section 1112, 1116, 1117, [or 1118] 1118, or
1120 of this title, subsection (a) of this section, or section
5 of Public Law 98-542 (38 U.S.C. 1154 note) shall be construed
to prevent the granting of service-connection for any disease
or disorder otherwise shown by sound judgment to have been
incurred in or aggravated by active military, naval, air, or
space service.
* * * * * * *
Sec. 1116. Presumptions of service connection for diseases associated
with exposure to certain herbicide agents;
presumption of exposure for veterans who served in
[the Republic of Vietnam] certain locations
(a)(1) For the purposes of section 1110 of this title, and
subject to section 1113 of this title--
(A) a disease specified in paragraph (2) of this
subsection becoming manifest as specified in that
paragraph in a veteran who[, during active military,
naval, or air service, served in the Republic of
Vietnam during the period beginning on January 9, 1962,
and ending on May 7, 1975] performed covered service;
and
(B) each additional disease (if any) that (i) the
Secretary determines in regulations prescribed under
this section warrants a presumption of service-
connection by reason of having positive association
with exposure to an herbicide agent, and (ii) becomes
manifest within the period (if any) prescribed in such
regulations in a veteran who[, during active military,
naval, or air service, served in the Republic of
Vietnam during the period beginning on January 9, 1962,
and ending on May 7, 1975] performed covered service,
and while so serving was exposed to that herbicide
agent,
shall be considered to have been incurred in or aggravated by
such service, notwithstanding that there is no record of
evidence of such disease during the period of such service.
(2) The diseases referred to in paragraph (1)(A) of this
subsection are the following:
(A) Non-Hodgkin's lymphoma becoming manifest to a
degree of disability of 10 percent or more.
(B) Each soft-tissue sarcoma becoming manifest to a
degree of disability of 10 percent or more other than
osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or
mesothelioma.
(C) Chloracne or another acneform disease consistent
with chloracne becoming manifest to a degree of
disability of 10 percent or more within one year after
the last date on which the veteran [performed active
military, naval, or air service in the Republic of
Vietnam during the period beginning on January 9, 1962,
and ending on May 7, 1975] performed covered service.
(D) Hodgkin's disease becoming manifest to a degree
of disability of 10 percent or more.
(E) Porphyria cutanea tarda becoming manifest to a
degree of disability of 10 percent or more within a
year after the last date on which the veteran
[performed active military, naval, or air service in
the Republic of Vietnam during the period beginning on
January 9, 1962, and ending on May 7, 1975] performed
covered service.
(F) Respiratory cancers (cancer of the lung,
bronchus, larynx, or trachea) becoming manifest to a
degree of disability of 10 percent or more.
(G) Multiple myeloma becoming manifest to a degree of
disability of 10 percent or more.
(H) Diabetes Mellitus (Type 2).
(I) Parkinsonism.
(J) Bladder cancer.
(K) Hypothyroidism.
(L) Hypertension.
(M) Monoclonal gammopathy of undetermined
significance.
(3) For purposes of this section, the term ``herbicide
agent'' means a chemical in an herbicide used in support of the
United States and allied military operations in the Republic of
Vietnam during the period beginning on January 9, 1962, and
ending on May 7, 1975.
[(b)(1) Whenever the Secretary determines, on the basis of
sound medical and scientific evidence, that a positive
association exists between (A) the exposure of humans to an
herbicide agent, and (B) the occurrence of a disease in humans,
the Secretary shall prescribe regulations providing that a
presumption of service connection is warranted for that disease
for the purposes of this section.
[(2) In making determinations for the purpose of this
subsection, the Secretary shall take into account (A) reports
received by the Secretary from the National Academy of Sciences
under section 3 of the Agent Orange Act of 1991, and (B) all
other sound medical and scientific information and analyses
available to the Secretary. In evaluating any study for the
purpose of making such determinations, the Secretary shall take
into consideration whether the results are statistically
significant, are capable of replication, and withstand peer
review.
[(3) An association between the occurrence of a disease in
humans and exposure to an herbicide agent shall be considered
to be positive for the purposes of this section if the credible
evidence for the association is equal to or outweighs the
credible evidence against the association.
[(c)(1)(A) Not later than 60 days after the date on which the
Secretary receives a report from the National Academy of
Sciences under section 3 of the Agent Orange Act of 1991, the
Secretary shall determine whether a presumption of service
connection is warranted for each disease covered by the report.
If the Secretary determines that such a presumption is
warranted, the Secretary, not later than 60 days after making
the determination, shall issue proposed regulations setting
forth the Secretary's determination.
[(B) If the Secretary determines that a presumption of
service connection is not warranted, the Secretary, not later
than 60 days after making the determination, shall publish in
the Federal Register a notice of that determination. The notice
shall include an explanation of the scientific basis for that
determination. If the disease already is included in
regulations providing for a presumption of service connection,
the Secretary, not later than 60 days after publication of the
notice of a determination that the presumption is not
warranted, shall issue proposed regulations removing the
presumption for the disease.
[(2) Not later than 90 days after the date on which the
Secretary issues any proposed regulations under this
subsection, the Secretary shall issue final regulations. Such
regulations shall be effective on the date of issuance.
[(d) Whenever a disease is removed from regulations
prescribed under this section--
[(1) a veteran who was awarded compensation for such
disease on the basis of the presumption provided in
subsection (a) before the effective date of the removal
shall continue to be entitled to receive compensation
on that basis; and
[(2) a survivor of a veteran who was awarded
dependency and indemnity compensation for the death of
a veteran resulting from such disease on the basis of
such presumption shall continue to be entitled to
receive dependency and indemnity compensation on such
basis.
[(e) Subsections (b) through (d) shall cease to be effective
on September 30, 2015.]
(b) The Secretary shall ensure that any determination made on
or after the date of the enactment of the Honoring our Promise
to Address Comprehensive Toxics Act of 2021 regarding a
presumption of service connection based on exposure to an
herbicide agent under this section is made pursuant to
subchapter VII of this chapter, including with respect to
assessing reports received by the Secretary from the National
Academy of Sciences under section 3 of the Agent Orange Act of
1991 (Public Law 102-4).
[(f)] (c) For purposes of establishing service connection for
a disability or death resulting from exposure to a herbicide
agent, including a presumption of service-connection under this
section, a veteran who[, during active military, naval, or air
service, served in the Republic of Vietnam during the period
beginning on January 9, 1962, and ending on May 7, 1975]
performed covered service, shall be presumed to have been
exposed during such service to an herbicide agent containing
dioxin or 2,4-dichlorophenoxyacetic acid, and may be presumed
to have been exposed during such service to any other chemical
compound in an herbicide agent, unless there is affirmative
evidence to establish that the veteran was not exposed to any
such agent during that service.
(d) In this section, the term ``covered service'' means
active military, naval, or air service--
(1) performed in the Republic of Vietnam during the
period beginning on January 9, 1962, and ending on May
7, 1975;
(2) performed in Thailand at any United States or
Royal Thai base during the period beginning on January
9, 1962, and ending on June 30, 1976, without regard to
where on the base the veteran was located or what
military job specialty the veteran performed;
(3) performed in Laos during the period beginning on
December 1, 1965, and ending on September 30, 1969;
(4) performed in Cambodia at Mimot or Krek, Kampong
Cham Province during the period beginning on April 16,
1969, and ending on April 30, 1969; or
(5) performed on Guam or American Samoa, or in the
territorial waters thereof, during the period beginning
on January 9, 1962, and ending on July 31, 1980, or
served on Johnston Atoll or on a ship that called at
Johnston Atoll during the period beginning on January
1, 1972, and ending on September 30, 1977.
* * * * * * *
Sec. 1116B. Presumption of herbicide exposure for certain veterans who
served in Korea
(a) Presumption of Service-Connection.--(1) For the purposes
of section 1110 of this title, and subject to section 1113 of
this title, a disease specified in subsection (b) that becomes
manifest as specified in that subsection in a veteran described
in paragraph (2) shall be considered to have been incurred or
aggravated in the line of duty in the active military, naval,
or air service, notwithstanding that there is no record of
evidence of such disease during the period of such service.
(2) A veteran described in this paragraph is a veteran who,
during active military, naval, or air service, served in or
near the Korean Demilitarized Zone (DMZ), during the period
beginning on September 1, 1967, and ending on August 31, 1971.
(b) Diseases.--A disease specified in this subsection is--
(1) a disease specified in paragraph (2) of
subsection (a) of section 1116 of this title that
becomes manifest as specified in that paragraph; or
(2) any additional disease that--
(A) pursuant to subchapter VII of this
chapter, the Secretary determines in
regulations warrants a presumption of service-
connection by reason of having positive
association with exposure to an herbicide
agent; and
(B) becomes manifest within any period
prescribed in such regulations.
(c) Herbicide Agent.--For purposes of this section, the term
``herbicide agent'' has the meaning given such term in section
1821(d) of this title.
Sec. 1117. Compensation for disabilities occurring in Persian Gulf War
veterans
(a)(1) The Secretary may pay compensation under this
subchapter to a Persian Gulf veteran with a qualifying chronic
disability that [became manifest--] became manifest to any
degree at any time.
[(A) during service on active duty in the Armed
Forces in the Southwest Asia theater of operations
during the Persian Gulf War; or
[(B) to a degree of 10 percent or more during the
presumptive period prescribed under subsection (b).]
(2) For purposes of this subsection, the term ``qualifying
chronic disability'' means a chronic disability resulting from
any of the following (or any combination of any of the
following):
(A) An undiagnosed illness.
(B) A medically unexplained chronic multisymptom
illness (such as chronic fatigue syndrome,
fibromyalgia, and irritable bowel syndrome) that is
defined by a cluster of signs or symptoms.
(C) Any diagnosed illness that the Secretary
determines in regulations prescribed [under subsection
(d)] under subsection (c) warrants a presumption of
service-connection.
[(b) The Secretary shall prescribe by regulation the period
of time following service in the Southwest Asia theater of
operations during the Persian Gulf War that the Secretary
determines is appropriate for presumption of service connection
for purposes of this section. The Secretary's determination of
such period of time shall be made following a review of any
available credible medical or scientific evidence and the
historical treatment afforded disabilities for which
manifestation periods have been established and shall take into
account other pertinent circumstances regarding the experiences
of veterans of the Persian Gulf War.]
[(c)] (b)(1) Whenever the Secretary determines under section
1118(c) of this title that a presumption of service connection
previously established under this section is no longer
warranted--
(A) a veteran who was awarded compensation under this
section on the basis of the presumption shall continue
to be entitled to receive compensation under this
section on that basis; and
(B) a survivor of a veteran who was awarded
dependency and indemnity compensation for the death of
a veteran resulting from the disease on the basis of
the presumption before that date shall continue to be
entitled to receive dependency and indemnity
compensation on that basis.
(2) This subsection shall cease to be effective on September
30, 2011.
[(d)] (c)(1) The Secretary shall prescribe regulations to
carry out this section.
(2) Those regulations shall include the following:
(A) A description of the period and geographical area
or areas of military service in connection with which
compensation under this section may be paid.
(B) A description of the illnesses for which
compensation under this section may be paid.
(C) A description of any relevant medical
characteristic (such as a latency period) associated
with each such illness.
(d) If a Persian Gulf veteran at a medical facility of the
Department presents with any one symptom associated with Gulf
War Illness, the Secretary shall ensure that health care
personnel of the Department use a disability benefits
questionnaire, or successor questionnaire, to identify Gulf War
Illness.
(e) A disability for which compensation under this subchapter
is payable shall be considered to be service connected for
purposes of all other laws of the United States.
(f) For purposes of this section, the term ``Persian Gulf
veteran'' means a veteran who served on active duty in the
Armed Forces in the Southwest Asia theater of operations,
Afghanistan, Israel, Egypt, Turkey, Syria, or Jordan, during
the Persian Gulf War.
(g) For purposes of this section, signs or symptoms that may
be a manifestation of an undiagnosed illness or a chronic
multisymptom illness include the following:
(1) Fatigue.
(2) Unexplained rashes or other dermatological signs
or symptoms.
(3) Headache.
(4) Muscle pain.
(5) Joint pain.
(6) Neurological signs and symptoms.
(7) Neuropsychological signs or symptoms.
(8) Signs or symptoms involving the upper or lower
respiratory system.
(9) Sleep disturbances.
(10) Gastrointestinal signs or symptoms.
(11) Cardiovascular signs or symptoms.
(12) Abnormal weight loss.
(13) Menstrual disorders.
(h)(1) If the Secretary determines with respect to a medical
research project sponsored by the Department that it is
necessary for the conduct of the project that Persian Gulf
veterans in receipt of compensation under this section or
section 1118 of this title participate in the project without
the possibility of loss of service connection under either such
section, the Secretary shall provide that service connection
granted under either such section for disability of a veteran
who participated in the research project may not be terminated.
Except as provided in paragraph (2), notwithstanding any other
provision of law any grant of service-connection protected
under this subsection shall remain service-connected for
purposes of all provisions of law under this title.
(2) Paragraph (1) does not apply in a case in which--
(A) the original award of compensation or service
connection was based on fraud; or
(B) it is clearly shown from military records that
the person concerned did not have the requisite service
or character of discharge.
(3) The Secretary shall publish in the Federal Register a
list of medical research projects sponsored by the Department
for which service connection granted under this section or
section 1118 of this title may not be terminated pursuant to
paragraph (1).
(i)(1) The Secretary shall take such actions as may be
necessary to ensure that health care personnel of the
Department are appropriately trained to effectively carry out
this section.
(2) Not less frequently than once each year, the Secretary
shall submit to Congress a report on the actions taken by the
Secretary to carry out paragraph (1).
Sec. 1118. Presumptions of service connection for illnesses associated
with service in the Persian Gulf during the Persian
Gulf War
(a)(1) For purposes of section 1110 of this title, and
subject to section 1113 of this title, each illness, if any,
described in paragraph (2) shall be considered to have been
incurred in or aggravated by service referred to in that
paragraph, notwithstanding that there is no record of evidence
of such illness during the period of such service.
(2) An illness referred to in paragraph (1) is any diagnosed
or undiagnosed illness that--
(A) the Secretary determines in regulations
prescribed under this section to warrant a presumption
of service connection by reason of having a positive
association with exposure to a biological, chemical, or
other toxic agent, environmental or wartime hazard, or
preventive medicine or vaccine known or presumed to be
associated with service in the Armed Forces in the
Southwest Asia theater of operations during the Persian
Gulf War; and
(B) becomes manifest within the period, if any,
prescribed in such regulations in a veteran who served
on active duty in that theater of operations during
that war and by reason of such service was exposed to
such agent, hazard, or medicine or vaccine.
(3) For purposes of this subsection, a veteran who served on
active duty in the Southwest Asia theater of operations during
the Persian Gulf War and has an illness described in paragraph
(2) shall be presumed to have been exposed by reason of such
service to the agent, hazard, or medicine or vaccine associated
with the illness in the regulations prescribed under this
section unless there is conclusive evidence to establish that
the veteran was not exposed to the agent, hazard, or medicine
or vaccine by reason of such service.
(4) For purposes of this section, signs or symptoms that may
be a manifestation of an undiagnosed illness include the signs
and symptoms listed in section 1117(g) of this title.
[(b)(1)(A) Whenever the Secretary makes a determination
described in subparagraph (B), the Secretary shall prescribe
regulations providing that a presumption of service connection
is warranted for the illness covered by that determination for
purposes of this section.
[(B) A determination referred to in subparagraph (A) is a
determination based on sound medical and scientific evidence
that a positive association exists between--
[(i) the exposure of humans or animals to a
biological, chemical, or other toxic agent,
environmental or wartime hazard, or preventive medicine
or vaccine known or presumed to be associated with
service in the Southwest Asia theater of operations
during the Persian Gulf War; and
[(ii) the occurrence of a diagnosed or undiagnosed
illness in humans or animals.
[(2)(A) In making determinations for purposes of paragraph
(1), the Secretary shall take into account--
[(i) the reports submitted to the Secretary by the
National Academy of Sciences under section 1603 of the
Persian Gulf War Veterans Act of 1998; and
[(ii) all other sound medical and scientific
information and analyses available to the Secretary.
[(B) In evaluating any report, information, or analysis for
purposes of making such determinations, the Secretary shall
take into consideration whether the results are statistically
significant, are capable of replication, and withstand peer
review.
[(3) An association between the occurrence of an illness in
humans or animals and exposure to an agent, hazard, or medicine
or vaccine shall be considered to be positive for purposes of
this subsection if the credible evidence for the association is
equal to or outweighs the credible evidence against the
association.
[(c)(1) Not later than 60 days after the date on which the
Secretary receives a report from the National Academy of
Sciences under section 1603 of the Persian Gulf War Veterans
Act of 1998, the Secretary shall determine whether or not a
presumption of service connection is warranted for each
illness, if any, covered by the report.
[(2) If the Secretary determines under this subsection that a
presumption of service connection is warranted, the Secretary
shall, not later than 60 days after making the determination,
issue proposed regulations setting forth the Secretary's
determination.
[(3)(A) If the Secretary determines under this subsection
that a presumption of service connection is not warranted, the
Secretary shall, not later than 60 days after making the
determination, publish in the Federal Register a notice of the
determination. The notice shall include an explanation of the
scientific basis for the determination.
[(B) If an illness already presumed to be service connected
under this section is subject to a determination under
subparagraph (A), the Secretary shall, not later than 60 days
after publication of the notice under that subparagraph, issue
proposed regulations removing the presumption of service
connection for the illness.
[(4) Not later than 90 days after the date on which the
Secretary issues any proposed regulations under this
subsection, the Secretary shall issue final regulations. Such
regulations shall be effective on the date of issuance.
[(d) Whenever the presumption of service connection for an
illness under this section is removed under subsection (c)--
[(1) a veteran who was awarded compensation for the
illness on the basis of the presumption before the
effective date of the removal of the presumption shall
continue to be entitled to receive compensation on that
basis; and
[(2) a survivor of a veteran who was awarded
dependency and indemnity compensation for the death of
a veteran resulting from the illness on the basis of
the presumption before that date shall continue to be
entitled to receive dependency and indemnity
compensation on that basis.
[(e) Subsections (b) through (d) shall cease to be effective
on September 30, 2011.]
(b) The Secretary shall ensure that any determination made on
or after the date of the enactment of the Honoring our Promise
to Address Comprehensive Toxics Act of 2021 regarding a
presumption of service connection based on a toxic exposure
under this section is made pursuant to subchapter VII of this
chapter.
Sec. 1119. Presumptions of toxic exposure
(a) Consideration of Individual Longitudinal Exposure Record
Required.--If a veteran submits to the Secretary a claim for
compensation for a service-connected disability under section
1110 of this title with evidence of a disability and a toxic
exposure that occurred during active military, naval, or air
service, the Secretary shall, in adjudicating such claim,
consider--
(1) the Individual Longitudinal Exposure Record of
the veteran; and
(2) if the Individual Longitudinal Exposure Record of
the veteran does not indicate that the veteran was
subject to a toxic exposure during active military,
naval, or air service, the totality of the
circumstances of the service of the veteran.
(b) Presumption of Specific Toxic Exposure for Members who
Served in Certain Locations.--(1) The Secretary shall, for
purposes of section 1110 and chapter 17 of this title, presume
that any covered veteran was exposed to the substances,
chemicals, and hazards listed in paragraph (2) during the
service of the covered veteran specified in subsection (c)(1),
unless there is affirmative evidence to establish that the
covered veteran was not exposed to any such substances,
chemicals, or hazards in connection with such service.
(2)(A) Subject to subparagraph (B), the substances,
chemicals, and airborne hazards listed in this paragraph are as
follows:
(i) Particulate matter, including the following:
(I) PM-10.
(II) PM-2.5.
(ii) Polycyclic aromatic hydrocarbons (PAHs),
including the following:
(I) Acenaphthene.
(II) Acenaphthylene.
(III) Anthracene.
(IV) Benzo(a)anthracene.
(V) Benzo(a)pyrene.
(VI) Benzo(b)fluoranthene.
(VII) Benzo(g,h,i)perylene.
(VIII) Benzo(k)fluoranthene.
(IX) Chrysene.
(X) Dibenz(a,h)anthracene.
(XI) Fluoranthene.
(XII) Fluorene.
(XIII) Indeno(1,2,3-cd)pyrene.
(XIV) Naphthalene.
(XV) Phenanthrene.
(XVI) Pyrene.
(iii) Volatile organic compounds (VOCs), including
the following:
(I) Acetone.
(II) Acrolein.
(III) Benzene.
(IV) Carbon Disulfide.
(V) Chlorodifluoromethane.
(VI) Chloromethane.
(VII) Ethylbenzene.
(VIII) Hexachlorobutadiene.
(IX) Hexane.
(X) m/p-Xylene.
(XI) Methylene Chloride.
(XII) Pentane.
(XIII) Propylene.
(XIV) Styrene.
(XV) Toluene.
(iv) Toxic organic halogenated dioxins and furans
(dioxins), including the following:
(I) 1,2,3,4,6,7,8 HPCDD.
(II) 1,2,3,4,6,7,8 HPCDF.
(III) 1,2,3,4,7,8,9 HPCDF.
(IV) 1,2,3,4,7,8 HXCDD.
(V) 1,2,3,6,7,8 HXCDD.
(VI) 1,2,3,7,8,9 HXCDD.
(VII) 1,2,3,4,7,8 HXCDF.
(VIII) 1,2,3,6,7,8 HXCDF.
(IX) 1,2,3,7,8,9 HXCDF.
(X) 1,2,3,7,8 PECDD.
(XI) 1,2,3,7,8 PECDF.
(XII) 2,3,4,6,7,8 HXCDF.
(XIII) 2,3,4,7,8 PECDF.
(XIV) 2,3,7,8 TCDD.
(XV) 2,3,7,8 TCDF.
(XVI) Octachlorodibenzodioxin.
(XVII) Octachlorodibenzofuran.
(v) Such other substances, chemicals, and airborne
hazards as the Secretary, in collaboration with the
Secretary of Defense, may determine appropriate.
(B)(i) The Secretary may add to or remove from the list under
subparagraph (A) as the Secretary, in collaboration with the
Secretary of Defense, determines appropriate.
(ii) Beginning not later than two years after the date of the
enactment of the Honoring our Promise to Address Comprehensive
Toxics Act of 2021, and not less frequently than once every two
years thereafter, the Secretary shall submit to Congress a
report identifying any additions or removals made pursuant to
subparagraph (A) during the period covered by the report.
(c) Definitions.--In this section:
(1) The term ``covered veteran'' means any veteran
who--
(A) on or after August 2, 1990, performed
active military, naval, or air service while
assigned to a duty station in--
(i) Bahrain;
(ii) Iraq;
(iii) Kuwait;
(iv) Oman;
(v) Qatar;
(vi) Saudi Arabia;
(vii) Somalia; or
(viii) United Arab Emirates; or
(B) on or after September 11, 2001, performed
active military, naval, or air service while
assigned to a duty station in--
(i) Afghanistan;
(ii) Djibouti;
(iii) Egypt;
(iv) Jordan;
(v) Lebanon;
(vi) Syria;
(vii) Yemen;
(viii) Uzbekistan;
(ix) the Philippines; or
(x) any other country determined
relevant by the Secretary.
(2) The term ``Individual Longitudinal Exposure
Record'' includes any pilot program or other program
used by the Department of Veterans Affairs or the
Department of Defense to track how members of the Armed
Forces or veterans have been exposed to various
occupational or environmental hazards.
(3) The term ``toxic exposure risk activity'' has the
meaning given such term in section 1710(e)(4) of this
title.
Sec. 1120. Presumption of service connection for certain diseases
associated with exposure to burn pits and other
toxins
(a) Presumption of Service Connection.--For the purposes of
section 1110 of this title, and subject to section 1113 of this
title, a disease specified in subsection (b) becoming manifest
in a covered veteran shall be considered to have been incurred
in or aggravated during active military, naval, or air service,
notwithstanding that there is no record of evidence of such
disease during the period of such service.
(b) Diseases Specified.--The diseases specified in this
subsection are the following:
(1) Asthma that was diagnosed after service of the
covered veteran as specified in subsection (c).
(2) The following types of cancer:
(A) Head cancer of any type.
(B) Neck cancer of any type.
(C) Respiratory cancer of any type.
(D) Gastrointestinal cancer of any type.
(E) Reproductive cancer of any type.
(F) Lymphoma cancer of any type.
(G) Lymphomatic cancer of any type.
(H) Kidney cancer.
(I) Brain cancer.
(J) Melanoma.
(K) Pancreatic cancer.
(3) Chronic bronchitis.
(4) Chronic obstructive pulmonary disease.
(5) Constrictive bronchiolitis or obliterative
bronchiolitis.
(6) Emphysema.
(7) Granulomatous disease.
(8) Interstitial lung disease.
(9) Pleuritis.
(10) Pulmonary fibrosis.
(11) Sarcoidosis.
(12) Chronic sinusitis.
(13) Chronic rhinitis.
(14) Glioblastoma.
(15) Any other disease for which the Secretary
determines, pursuant to regulations prescribed under
subchapter VII that a presumption of service connection
is warranted based on a positive association with a
substance, chemical, or airborne hazard specified in
section 1119(b)(2) of this title.
(c) Covered Veteran Defined.--In this section, the term
``covered veteran'' has the meaning given that term in section
1119(c) of this title.
* * * * * * *
SUBCHAPTER VI--GENERAL COMPENSATION PROVISIONS
* * * * * * *
Sec. 1167. Reevaluation of compensation determinations pursuant to
changes in presumptions of service connection
(a) Reevaluation.--Except as provided in subsection (b),
whenever a law, including through a regulation or Federal court
decision, establishes or modifies a presumption of service
connection, the Secretary shall--
(1) identify all claims for compensation under this
chapter that--
(A) were submitted to the Secretary;
(B) were evaluated and denied by the
Secretary before the date on which such
provision of law went into effect; and
(C) might have been evaluated differently had
the establishment or modification been
applicable to the claim;
(2) allow for the reevaluation of such claims at the
election of the veteran; and
(3) with respect to claims approved pursuant to such
reevaluation, provide compensation under this chapter
effective as if the establishment or modification of
the presumption of service connection had been in
effect on the date of the submission of the original
claim described in paragraph (1).
(b) Outreach.--With respect to each claim identified under
subsection (a), the Secretary shall conduct outreach to inform
relevant veterans that they may elect to have a claim be
reevaluated in light of the establishment or modification of a
presumption of service connection described in such subsection.
Such outreach shall include the following:
(1) The Secretary shall publish on the internet
website of the Department a notice that such veterans
may elect to have a claim so reevaluated.
(2) The Secretary shall notify, in writing or by
electronic means, veterans service organizations of the
ability of such veterans to elect to have a claim so
reevaluated.
(c) Relation to Other Laws.--The Secretary shall carry out
subsection (a) to the degree that doing so does not conflict
with any other provision of law.
Sec. 1168. Medical nexus examinations for toxic exposure risk
activities
(a) Medical Examinations and Medical Opinions.--(1) Except as
provided in subsection (b), if a veteran submits to the
Secretary a claim for compensation for a service-connected
disability under section 1110 of this title with evidence of a
disability and evidence of participation in a toxic exposure
risk activity during active military, naval, or air service,
and such evidence is not sufficient to establish a service
connection for the disability, the Secretary shall--
(A) provide the veteran with a medical examination
under section 5103A(d) of this title; and
(B) request a medical opinion as to whether it is at
least as likely as not that there is a nexus between
the disability and the toxic exposure risk activity.
(2) When providing the Secretary with a medical opinion
requested under paragraph (1), the health care provider shall
consider the total potential exposure through all applicable
military deployments, and the synergistic, combined effect of
all applicable toxic exposure risk activities.
(b) Exception.--Subsection (a) shall not apply if the
Secretary determines there is no indication of an association
between the disability claimed by the veteran and the toxic
exposure risk activity for which the veteran submitted
evidence.
(c) Toxic Exposure Risk Activity Defined.--In this section,
the term ``toxic exposure risk activity'' has the meaning given
such term in section 1710(e)(4) of this title.
SUBCHAPTER VII--RESEARCH AND DETERMINATIONS RELATING TO PRESUMPTIONS OF
SERVICE CONNECTION BASED ON TOXIC EXPOSURE
Sec. 1171. Procedures to determine presumptions of service connection
based on toxic exposure; definitions
(a) Procedures.--The Secretary shall determine whether to
establish, or to remove, presumptions of service connection
based on toxic exposure pursuant to this subchapter, whereby--
(1) the Formal Advisory Committee on Toxic Exposure
under section 1172 of this title--
(A) provides advice to the Secretary on toxic
exposed veterans and cases in which veterans
who, during active military, naval, or air
service, may have experienced a toxic exposure
or their dependents may have experienced a
toxic exposure while the veterans were serving
in the active military, naval, or air service;
(B) provides to the Secretary recommendations
on corrections needed in the Individual
Longitudinal Exposure Record to better reflect
veterans and dependents described in
subparagraph (A); and
(C) provides to the Secretary recommendations
regarding which cases of possible toxic
exposure described in subparagraph (A) the
Science Review Board should review;
(2) the Science Review Board under section 1173 of
this title--
(A) reviews cases of possible toxic exposure
nominated by the Secretary;
(B) reviews research nominated by the
Secretary;
(C) develops recommendations for new
research; and
(D) determines the strength of evidence
supporting positive association between toxic
exposure and an illness;
(3) the Working Group under section 1174 of this
title evaluates the conclusions of the Science Review
Board and recommends to the Secretary whether to
establish or modify a presumption of service
connection; and
(4) the Secretary prescribes regulations under
section 1175 of this title.
(b) Illness Defined.--In this subchapter, the term
``illness'' includes a disease or other condition affecting the
health of an individual.
(c) Nonapplication of Sunset Requirements.--Section 14 of the
Federal Advisory Committee Act (5 U.S.C. App.) shall not apply
to an entity established under this subchapter.
Sec. 1172. Formal Advisory Committee on Toxic Exposure
(a) Establishment.--(1) There is in the Veterans Health
Administration of the Department the Formal Advisory Committee
on Toxic Exposure (in this section referred to as the
``Committee'').
(2)(A) The Committee shall be composed of nine members
appointed as follows:
(i) Five members shall be appointed by the Secretary.
(ii) One member shall be appointed by the Speaker of
the House of Representatives.
(iii) One member shall be appointed by the minority
leader of the House of Representatives.
(iv) One member shall be appointed by the majority
leader of the Senate.
(v) One member shall be appointed by the minority
leader of the Senate.
(B) The members appointed under subparagraph (A) shall meet
the following criteria:
(i) Not more than three members shall be appointed
from among individuals who are officials or employees
of the Veterans Benefits Administration or the Veterans
Health Administration.
(ii) At least one member shall be appointed from
among individuals who are officials or employees of
other departments or agencies of the Federal
Government, including the Department of Defense and the
Agency of Toxic Substances and Disease Registry of the
Centers for Disease Control and Prevention.
(iii) At least one member shall be appointed from
among individuals who are representatives of disabled
veterans.
(iv) At least one member shall be appointed from
among individuals in the private sector, State or local
government, or academia, who are experts in toxicology
and epidemiology.
(3) The Secretary shall determine the pay and allowances of
the members of the Committee, including with respect to any
additional pay and allowances for members who are officials or
employees of the Federal Government.
(4) Each member of the Committee shall be appointed for a
two-year term, and may serve not more than three successive
terms.
(5) A vacancy in the Committee shall be filled in the manner
in which the original appointment was made.
(b) Consultation.--The Secretary may consult with, and seek
the advice of, the Committee with respect to cases in which
veterans who, during active military, naval, or air service,
are suspected of having experienced a toxic exposure or
dependents of veterans who may have experienced a toxic
exposure during such service.
(c) Assessments.--(1) The Committee shall assess cases of the
toxic exposure of veterans and their dependents that occurred
during active military, naval, or air service.
(2) The assessments under paragraph (1) shall cover suspected
and known toxic exposures occurring during active military,
naval, or air service, including by identifying and evaluating
new and emerging toxic exposures that are not recognized under
existing presumptions of service connection.
(3) The Committee may conduct an assessment under paragraph
(1) in response to a person described in subsection (e)(2), by
a majority vote of the members of the Committee.
(4) The Committee shall on a periodic basis assess the
Individual Longitudinal Exposure Record to ensure the accuracy
of data collected.
(d) Research Recommendations.--(1) Following an assessment of
a case of the toxic exposure of veterans or their dependents
that occurred during active military, naval, or air service
under subsection (c), the Committee may develop a
recommendation for the Secretary regarding whether there should
be a review of the health effects related to the case of
exposure conducted by the Science Review Board established
under section 1173 of this title.
(2) Upon receipt of evidence suggesting that previous
findings regarding the periods and locations of exposure
covered by an existing presumption of service connection are no
longer supported, the Committee may nominate such evidence for
evaluation by the Working Group to modify the periods and
locations.
(e) Input.--(1) Not less than quarterly, the Committee shall
provide an opportunity for persons described in paragraph (2)
to present written or oral comments to the Committee.
(2) The persons described in this paragraph are persons who
may be affected by the actions of the Committee, including--
(A) veterans, the families of veterans, veterans
service organizations and representatives, researchers,
and other members of the general public; and
(B) departments and agencies of the Federal
Government.
(f) Reports by the Committee.--Not less frequently than once
each year, the Committee shall submit to the Secretary and the
Committees on Veterans' Affairs of the Senate and the House of
Representatives, and make publicly available, a report on--
(1) recommendations for research under subsection
(d), if any; and
(2) recommendations for such legislative or
administrative action as the Committee considers
necessary for the Committee to be more effective in
carrying out the requirements of this section.
(g) Responses by Secretary.--In response to each report
submitted under subsection (f), the Secretary shall submit to
the Secretary and the Committees on Veterans' Affairs of the
Senate and the House of Representatives, and make publicly
available, a report on--
(1) the findings and opinions of the Secretary with
respect to the report most recently submitted under
subsection (f); and
(2) whether the Secretary intends to nominate to the
Science Review Board the review recommended by the
Committee in the report, and if not, an explanation of
why, including citations and sources.
Sec. 1173. Science Review Board
(a) Establishment.--(1) There is in the Veterans Health
Administration of the Department the Science Review Board (in
this section referred to as the ``Board'').
(2)(A) The members of the Board shall be appointed by the
Secretary, in consultation with the National Academies of
Sciences, Engineering, and Medicine, from the general public
from among individuals who are distinguished in the fields of
medicine, biological sciences, or health administration.
(B) An individual may not concurrently serve on the Board and
the Formal Advisory Committee on Toxic Exposure under section
1172 of this title.
(C) The Secretary shall determine the number, terms of
service, and pay and allowances of members of the Board
appointed by the Secretary.
(b) Duties.--(1) Upon receiving a nomination for the
evaluation of research on the health effects of toxic exposures
of members of the active military, naval, or air service or
dependents of such members made by the Secretary, the Board
shall--
(A) evaluate the likelihood that a positive
association exists between an illness and a toxic
exposure while serving in the active military, naval,
or air service; and
(B) assess the toxic exposures and illnesses
identified by the Secretary and determine whether the
evidence supports a finding of a positive association
between the toxic exposure and the illness.
(2) In carrying out paragraph (1)(B), the Board shall review
all relevant data to determine the strength of evidence for a
positive association based on the following four categories:
(A) The ``sufficient'' category, where the evidence
is sufficient to conclude that a positive association
exists.
(B) The ``equipoise and above'' category, where the
evidence is sufficient to conclude that a positive
association is at least as likely as not, but not
sufficient to conclude that a positive association
exists.
(C) The ``below equipoise'' category, where the
evidence is not sufficient to conclude that a positive
association is at least as likely as not, or is not
sufficient to make a scientifically informed judgment.
(D) The ``against'' category, where the evidence
suggests the lack of a positive association.
(3)(A) With respect to an evaluation conducted under this
subsection, if the Board determines that the evidence for a
positive association is categorized as either the sufficient or
equipoise and above categories, the Board shall estimate the
size of the positive association effect among those exposed by
calculating the relative risk and exposure prevalence.
(B)(i) The Board shall use the relative risk and exposure
prevalence calculated under subparagraph (A) to estimate the
service-attributable fraction of illness in a military setting
to determine the probability of positive association for an
individual.
(ii) In calculating the service-attributable fraction of
illness, the Board shall consider the dose-response
relationships.
(4)(A) With respect to an evaluation conducted under this
subsection, if the Board determines that the evidence for a
positive association is categorized as the below equipoise
category, the Board shall develop a recommendation as to
whether additional data gathering and research are necessary.
(B) If the Board recommends additional data gathering and
research pursuant to subparagraph (A), the Secretary shall seek
to enter into an agreement with the National Academies of
Sciences, Engineering, and Medicine, or another nonprofit,
nongovernmental entity that the Secretary determines has
similar expertise and objectivity as the National Academies, to
conduct such data gathering and research.
(c) Reports.--(1) For each evaluation conducted under
subsection (b) where the Board determines that the evidence for
positive association is categorized as either the sufficient or
equipoise and above categories, the Board shall submit to the
Secretary a report identifying the evidence found to reach such
positive association determinations.
(2) In addition to submitting reports under paragraph (1),
the Board shall submit to the Secretary reports, at such times
and at such frequencies as the Board considers appropriate,
containing such recommendations as the Board may have for
additional or new research on matters relating to toxic
exposures described in subsection (b)(1).
(d) Responses From the Secretary.--(1) In response to each
report received by the Secretary under subsection (c)(1), the
Secretary shall submit to the Committees on Veterans' Affairs
of the Senate and the House of Representatives, and make
publicly available, a report on the findings and opinions of
the Secretary with respect to the report received under such
subsection.
(2) Each report submitted under paragraph (1) of this
subsection shall include, with respect to a report received
under subsection (c)(1), the following:
(A) The findings and opinions of the Secretary with
respect to the report received under subsection (c)(1).
(B) Whether the Secretary intends to nominate to the
Working Group, established under section 1174(a) of
this title, the work of the Science Review Board
covered by the report received under subsection (c)(1)
for further action, and if not, an explanation of why,
including citations and sources.
Sec. 1174. Working group on presumptions of service connection
(a) Establishment.--The Secretary shall establish a working
group (in this section referred to as the ``Working Group'')
to--
(1) evaluate--
(A) the conclusions of the Science Review
Board contained in each report submitted under
section 1173(c)(1) of this title; and
(B) evidence nominated by the Formal Advisory
Committee on Toxic Exposure under section
1172(d)(2) regarding the periods and locations
of exposure covered by an existing presumption
of service connection; and
(2) develop and submit to the Secretary a
recommendation with respect to whether--
(A) to establish a presumption of service
connection for the toxic exposure and illness
covered by the report described in subparagraph
(A) of paragraph (1); or
(B) to modify an existing presumption of
service connection described in subparagraph
(B) of such paragraph.
(b) Recommendations.--(1) In making a recommendation under
subsection (a)(2), the Working Group shall--
(A) in cases where the evidence for a positive
association is categorized as either the sufficient or
equipoise and above categories, as described in
subparagraph (A) or (B) of section 1173(b)(2) of this
title, weigh such evidence heavily in favor of
establishing a presumption of service connection;
(B) take into consideration such factors as may be
determined appropriate by the Secretary; and
(C) if the Working Group determines that additional
research, studies, or reports are appropriate before
making a final recommendation with respect to
establishing or modifying a presumption of service
connection, submit to the Secretary a description of
such appropriate additional research, studies, or
reports.
(2) At the same time as when the Working Group submits to the
Secretary a recommendation under paragraph (2) of subsection
(a) with respect to an evaluation under paragraph (1) of such
subsection, the Working Group shall submit to the Committees on
Veterans' Affairs of the Senate and the House of
Representatives a description of such recommendation.
(c) Report.--The Secretary shall periodically publish on the
internet website of the Department a report identifying any
factors for the Working Group to consider under subsection
(b)(1)(B), as determined appropriate by the Secretary.
Sec. 1175. Regulations regarding presumptions of service connection
based on toxic exposure
(a) Action Upon Working Group Recommendation.--Not later than
60 days after the date on which the Secretary receives a
recommendation to establish or modify a presumption of service
connection under section 1174(a)(2) of this title--
(1) if the Secretary determines that the presumption,
or modification, is warranted, the Secretary shall
issue proposed regulations setting forth the
presumption or revise regulations to carry out such
modification; or
(2) if the Secretary determines that the presumption,
or modification, is not warranted, the Secretary shall
publish in the Federal Register a notice of the
determination, including the reasons supporting the
determination.
(b) Final Regulation.--Not later than 180 days after the date
on which the Secretary issues any proposed regulations under
subsection (a)(1), the Secretary shall issue final regulations.
Such regulations shall be effective on the date of issuance.
(c) Removal of Presumption.--(1) The Secretary may issue
regulations to remove an illness from a presumption of service
connection previously established pursuant to a regulation
issued under subsection (b).
(2) Whenever an illness is removed from regulations pursuant
to paragraph (1), or the periods and locations of exposure
covered by a presumption of service connection are modified
under subsection (a)--
(A) a veteran who was awarded compensation for such
illness on the basis of the presumption provided under
such regulations before the effective date of the
removal or modification shall continue to be entitled
to receive compensation on that basis; and
(B) a survivor of a veteran who was awarded
dependency and indemnity compensation for the death of
a veteran resulting from such illness on the basis of
such presumption shall continue to be entitled to
receive dependency and indemnity compensation on such
basis.
* * * * * * *
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
* * * * * * *
SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL
TREATMENT
Sec. 1710. Eligibility for hospital, nursing home, and domiciliary care
(a)(1) The Secretary (subject to paragraph (4)) shall furnish
hospital care and medical services which the Secretary
determines to be needed--
(A) to any veteran for a service-connected
disability; and
(B) to any veteran who has a service-connected
disability rated at 50 percent or more.
(2) The Secretary (subject to paragraph (4)) shall furnish
hospital care and medical services, and may furnish nursing
home care, which the Secretary determines to be needed to any
veteran--
(A) who has a compensable service-connected
disability rated less than 50 percent or, with respect
to nursing home care during any period during which the
provisions of section 1710A(a) of this title are in
effect, a compensable service-connected disability
rated less than 70 percent;
(B) whose discharge or release from active military,
naval, air, or space service was for a disability that
was incurred or aggravated in the line of duty;
(C) who is in receipt of, or who, but for a
suspension pursuant to section 1151 of this title (or
both a suspension and the receipt of retired pay),
would be entitled to disability compensation, but only
to the extent that such veteran's continuing
eligibility for such care is provided for in the
judgment or settlement provided for in such section;
(D) who is a former prisoner of war, who was awarded
the medal of honor under section 7271, 8291, or 9271 of
title 10 or section 491 of title 14, or who was awarded
the Purple Heart;
(E) who is a veteran of the Mexican border period or
of World War I;
(F) [who was exposed to a toxic substance, radiation,
or other conditions, as provided in subsection (e)] in
accordance with subsection (e), who is a toxic exposed
veteran; or
(G) who is unable to defray the expenses of necessary
care as determined under section 1722(a) of this title.
(3) In the case of a veteran who is not described in
paragraphs (1) and (2), the Secretary may, to the extent
resources and facilities are available and subject to the
provisions of subsections (f) and (g), furnish hospital care,
medical services, and nursing home care which the Secretary
determines to be needed.
(4) The requirement in paragraphs (1) and (2) that the
Secretary furnish hospital care and medical services, the
requirement in section 1710A(a) of this title that the
Secretary provide nursing home care, the requirement in section
1710B of this title that the Secretary provide a program of
extended care services, and the requirement in section 1745 of
this title to provide nursing home care and prescription
medicines to veterans with service-connected disabilities in
State homes shall be effective in any fiscal year only to the
extent and in the amount provided in advance in appropriations
Acts for such purposes.
(5) During any period during which the provisions of section
1710A(a) of this title are not in effect, the Secretary may
furnish nursing home care which the Secretary determines is
needed to any veteran described in paragraph (1), with the
priority for such care on the same basis as if provided under
that paragraph.
(b)(1) The Secretary may furnish to a veteran described in
paragraph (2) of this subsection such domiciliary care as the
Secretary determines is needed for the purpose of the
furnishing of medical services to the veteran.
(2) This subsection applies in the case of the following
veterans:
(A) Any veteran whose annual income (as determined
under section 1503 of this title) does not exceed the
maximum annual rate of pension that would be applicable
to the veteran if the veteran were eligible for pension
under section 1521(d) of this title.
(B) Any veteran who the Secretary determines has no
adequate means of support.
(c) While any veteran is receiving hospital care or nursing
home care in any Department facility, the Secretary may, within
the limits of Department facilities, furnish medical services
to correct or treat any non-service-connected disability of
such veteran, in addition to treatment incident to the
disability for which such veteran is hospitalized, if the
veteran is willing, and the Secretary finds such services to be
reasonably necessary to protect the health of such veteran. The
Secretary may furnish dental services and treatment, and
related dental appliances, under this subsection for a non-
service-connected dental condition or disability of a veteran
only (1) to the extent that the Secretary determines that the
dental facilities of the Department to be used to furnish such
services, treatment, or appliances are not needed to furnish
services, treatment, or appliances for dental conditions or
disabilities described in section 1712(a) of this title, or (2)
if (A) such non-service-connected dental condition or
disability is associated with or aggravating a disability for
which such veteran is receiving hospital care, or (B) a
compelling medical reason or a dental emergency requires
furnishing dental services, treatment, or appliances (excluding
the furnishing of such services, treatment, or appliances of a
routine nature) to such veteran during the period of
hospitalization under this section.
(d) In no case may nursing home care be furnished in a
hospital not under the direct jurisdiction of the Secretary
except as provided in section 1720 of this title.
(e)(1)(A) A Vietnam-era herbicide-exposed veteran is eligible
(subject to paragraph (2)) for hospital care, medical services,
and nursing home care under subsection (a)(2)(F) for any
disability, notwithstanding that there is insufficient medical
evidence to conclude that such disability may be associated
with such exposure.
(B) A radiation-exposed veteran is eligible for hospital
care, medical services, and nursing home care under subsection
(a)(2)(F) for any disease suffered by the veteran that is--
(i) a disease listed in section 1112(c)(2) of this
title; or
(ii) any other disease for which the Secretary, based
on the advice of the Advisory Committee on
Environmental Hazards, determines that there is
credible evidence of a positive association between
occurrence of the disease in humans and exposure to
ionizing radiation.
(C) Subject to paragraph (2) of this subsection, a veteran
who served on active duty between August 2, 1990, and November
11, 1998, in the Southwest Asia theater of operations during
the Persian Gulf War is eligible for hospital care, medical
services, and nursing home care under subsection (a)(2)(F) for
any disability, notwithstanding that there is insufficient
medical evidence to conclude that such disability may be
associated with such service.
(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 Persian Gulf War, or in combat
against a hostile force during a period of hostilities after
November 11, 1998, 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.
(E) Subject to paragraph (2), a veteran who participated in a
test conducted by the Department of Defense Deseret Test Center
as part of a program for chemical and biological warfare
testing from 1962 through 1973 (including the program
designated as ``Project Shipboard Hazard and Defense (SHAD)''
and related land-based tests) 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 illness is
attributable to such testing.
(F) Subject to paragraph (2), a veteran who served on active
duty in the Armed Forces at Camp Lejeune, North Carolina, for
not fewer than 30 days during the period beginning on August 1,
1953, and ending on December 31, 1987, is eligible for hospital
care and medical services under subsection (a)(2)(F) for any of
the following illnesses or conditions, notwithstanding that
there is insufficient medical evidence to conclude that such
illnesses or conditions are attributable to such service:
(i) Esophageal cancer.
(ii) Lung cancer.
(iii) Breast cancer.
(iv) Bladder cancer.
(v) Kidney cancer.
(vi) Leukemia.
(vii) Multiple myeloma.
(viii) Myelodysplastic syndromes.
(ix) Renal toxicity.
(x) Hepatic steatosis.
(xi) Female infertility.
(xii) Miscarriage.
(xiii) Scleroderma.
(xiv) Neurobehavioral effects.
(xv) Non-Hodgkin's lymphoma.
(G) Subject to paragraph (2), a veteran who participated in a
toxic exposure risk activity while serving on active duty,
active duty for training, or inactive duty training is eligible
for hospital care, medical services, and nursing home care
under subsection (a)(2)(F) for any illness.
(H) Subject to paragraph (2), a covered veteran (as defined
in section 1119(c) of this title) is eligible for hospital
care, medical services, and nursing home care under subsection
(a)(2)(F) for any illness.
(2)(A) In the case of a veteran described in paragraph
(1)(A), hospital care, medical services, and nursing home care
may not be provided under subsection (a)(2)(F) with respect
to--
(i) a disability that is found, in accordance with
guidelines issued by the Under Secretary for Health, to
have resulted from a cause other than an exposure
described in paragraph (4)(A)(ii); or
(ii) a disease for which the National Academy of
Sciences, in a report issued in accordance with section
3 of the Agent Orange Act of 1991, has determined that
there is limited or suggestive evidence of the lack of
a positive association between occurrence of the
disease in humans and exposure to a herbicide agent.
(B) In the case of a veteran described in subparagraph (C),
(D), (E), [or (F)] (F), (G), or (H) of paragraph (1), 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 or testing] service, testing, or
activity described in such subparagraph.
(3) In the case of care for a veteran described in paragraph
(1)(D), hospital care, medical services, and nursing home care
may be provided under or by virtue of subsection (a)(2)(F) only
during the following periods:
(A) Except as provided by subparagraph (B), with
respect to a veteran described in paragraph (1)(D) who
is discharged or released from the active military,
naval, air, or space service after January 27, 2003,
the five-year period beginning on the date of such
discharge or release.
(B) With respect to a veteran described in paragraph
(1)(D) who is discharged or released from the active
military, naval, air, or space service after January 1,
2009, and before January 1, 2011, but did not enroll to
receive such hospital care, medical services, or
nursing home care pursuant to such paragraph during the
five-year period described in subparagraph (A), the
one-year period beginning on the date of the enactment
of the Clay Hunt Suicide Prevention for American
Veterans Act.
(C) With respect to a veteran described in paragraph
(1)(D) who is discharged or released from the active
military, naval, air, or space service on or before
January 27, 2003, and did not enroll in the patient
enrollment system under section 1705 of this title on
or before such date, the three-year period beginning on
January 27, 2008.
(4) For purposes of this subsection--
[(A) The term ``Vietnam-era herbicide-exposed
veteran'' means a veteran (i) who served on active duty
in the Republic of Vietnam (including offshore of such
Republic as described in section 1116A(d) of this
title) during the period beginning on January 9, 1962,
and ending on May 7, 1975, and (ii) who the Secretary
finds may have been exposed during such service to
dioxin or was exposed during such service to a toxic
substance found in a herbicide or defoliant used for
military purposes during such period.]
(A) The term ``Vietnam-era herbicide-exposed
veteran'' means a veteran who--
(i) performed covered service, as defined in
section 1116(d) of this title; or
(ii) the Secretary finds may have been
exposed during such service to dioxin or was
exposed during such service to a toxic
substance found in a herbicide or defoliant
used for military purposes during such period.
(B) The term ``radiation-exposed veteran'' has the
meaning given that term in section 1112(c)(3) of this
title.
(C) The term ``toxic exposure risk activity'' means
any activity--
(i) that requires a corresponding entry in
the Individual Longitudinal Exposure Record of
the Department for the veteran who carried out
the activity; or
(ii) that the Secretary determines qualifies
for purposes of this subsection when taking
into account what is reasonably prudent to
protect the health of veterans.
(5) When the Secretary first provides care for veterans using
the authority provided in paragraph (1)(D), the Secretary shall
establish a system for collection and analysis of information
on the general health status and health care utilization
patterns of veterans receiving care under that paragraph. Not
later than 18 months after first providing care under such
authority, the Secretary shall submit to Congress a report on
the experience under that authority. The Secretary shall
include in the report any recommendations of the Secretary for
extension of that authority.
(f)(1) The Secretary may not furnish hospital care or nursing
home care (except if such care constitutes hospice care) under
this section to a veteran who is eligible for such care under
subsection (a)(3) of this section unless the veteran agrees to
pay to the United States the applicable amount determined under
paragraph (2) or (4) of this subsection.
(2) A veteran who is furnished hospital care or nursing home
care under this section and who is required under paragraph (1)
of this subsection to agree to pay an amount to the United
States in order to be furnished such care shall be liable to
the United States for an amount equal to--
(A) the lesser of--
(i) the cost of furnishing such care, as
determined by the Secretary; or
(ii) the amount determined under paragraph
(3) of this subsection; and
(B) before September 30, 2022, an amount equal to $10
for every day the veteran receives hospital care and $5
for every day the veteran receives nursing home care.
(3)(A) In the case of hospital care furnished during any 365-
day period, the amount referred to in paragraph (2)(A)(ii) of
this subsection is--
(i) the amount of the inpatient Medicare deductible,
plus
(ii) one-half of such amount for each 90 days of care
(or fraction thereof) after the first 90 days of such
care during such 365-day period.
(B) In the case of nursing home care furnished during any
365-day period, the amount referred to in paragraph (2)(A)(ii)
of this subsection is the amount of the inpatient Medicare
deductible for each 90 days of such care (or fraction thereof)
during such 365-day period.
(C)(i) Except as provided in clause (ii) of this
subparagraph, in the case of a veteran who is admitted for
nursing home care under this section after being furnished,
during the preceding 365-day period, hospital care for which
the veteran has paid the amount of the inpatient Medicare
deductible under this subsection and who has not been furnished
90 days of hospital care in connection with such payment, the
veteran shall not incur any liability under paragraph (2) of
this subsection with respect to such nursing home care until--
(I) the veteran has been furnished, beginning with
the first day of such hospital care furnished in
connection with such payment, a total of 90 days of
hospital care and nursing home care; or
(II) the end of the 365-day period applicable to the
hospital care for which payment was made,
whichever occurs first.
(ii) In the case of a veteran who is admitted for nursing
home care under this section after being furnished, during any
365-day period, hospital care for which the veteran has paid an
amount under subparagraph (A)(ii) of this paragraph and who has
not been furnished 90 days of hospital care in connection with
such payment, the amount of the liability of the veteran under
paragraph (2) of this subsection with respect to the number of
days of such nursing home care which, when added to the number
of days of such hospital care, is 90 or less, is the difference
between the inpatient Medicare deductible and the amount paid
under such subparagraph until--
(I) the veteran has been furnished, beginning with
the first day of such hospital care furnished in
connection with such payment, a total of 90 days of
hospital care and nursing home care; or
(II) the end of the 365-day period applicable to the
hospital care for which payment was made,
whichever occurs first.
(D) In the case of a veteran who is admitted for hospital
care under this section after having been furnished, during the
preceding 365-day period, nursing home care for which the
veteran has paid the amount of the inpatient Medicare
deductible under this subsection and who has not been furnished
90 days of nursing home care in connection with such payment,
the veteran shall not incur any liability under paragraph (2)
of this subsection with respect to such hospital care until--
(i) the veteran has been furnished, beginning with
the first day of such nursing home care furnished in
connection with such payment, a total of 90 days of
nursing home care and hospital care; or
(ii) the end of the 365-day period applicable to the
nursing home care for which payment was made,
whichever occurs first.
(E) A veteran may not be required to make a payment under
this subsection for hospital care or nursing home care
furnished under this section during any 90-day period in which
the veteran is furnished medical services under paragraph (3)
of subsection (a) to the extent that such payment would cause
the total amount paid by the veteran under this subsection for
hospital care and nursing home care furnished during that
period and under subsection (g) for medical services furnished
during that period to exceed the amount of the inpatient
Medicare deductible in effect on the first day of such period.
(F) A veteran may not be required to make a payment under
this subsection or subsection (g) for any days of care in
excess of 360 days of care during any 365-calendar-day period.
(4) In the case of a veteran covered by this subsection who
is also described by section 1705(a)(7) of this title, the
amount for which the veteran shall be liable to the United
States for hospital care under this subsection shall be an
amount equal to 20 percent of the total amount for which the
veteran would otherwise be liable for such care under
subparagraphs (2)(B) and (3)(A) but for this paragraph.
(5) For the purposes of this subsection, the term ``inpatient
Medicare deductible'' means the amount of the inpatient
hospital deductible in effect under section 1813(b) of the
Social Security Act (42 U.S.C. 1395e(b)) on the first day of
the 365-day period applicable under paragraph (3) of this
subsection.
(g)(1) The Secretary may not furnish medical services (except
if such care constitutes hospice care) under subsection (a) of
this section (including home health services under section 1717
of this title) to a veteran who is eligible for hospital care
under this chapter by reason of subsection (a)(3) of this
section unless the veteran agrees to pay to the United States
in the case of each outpatient visit the applicable amount or
amounts established by the Secretary by regulation.
(2) A veteran who is furnished medical services under
subsection (a) of this section and who is required under
paragraph (1) of this subsection to agree to pay an amount to
the United States in order to be furnished such services shall
be liable to the United States, in the case of each visit in
which such services are furnished to the veteran, for an amount
which the Secretary shall establish by regulation.
(3) This subsection does not apply with respect to the
following:
(A) Home health services under section 1717 of this
title to the extent that such services are for
improvements and structural alterations.
(B) Education on the use of opioid antagonists to
reverse the effects of overdoses of specific
medications or substances.
(h) Nothing in this section requires the Secretary to furnish
care to a veteran to whom another agency of Federal, State, or
local government has a duty under law to provide care in an
institution of such government.
* * * * * * *
PART V--BOARDS, ADMINISTRATIONS, AND SERVICES
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CHAPTER 73--VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS
SUBCHAPTER I--ORGANIZATION
Sec.
7301. Functions of Veterans Health Administration: in general.
* * * * * * *
SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION
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7330D. Coordination of toxic exposure research.
* * * * * * *
SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION
* * * * * * *
Sec. 7330D. Coordination of toxic exposure research
(a) In General.--The Secretary shall coordinate all research
activities carried out or funded by the executive branch of the
Federal Government on the health consequences of toxic
exposures experienced during service in the Armed Forces.
(b) Strategic Plan.--In carrying out subsection (a), the
Secretary shall establish a strategic plan, to be known as the
Toxic Exposure Research Strategic Plan, to ensure that the
research activities specified in such subsection are
collaborative, transparent, and highly coordinated.
(c) Report.--Not later than one year after the date of the
enactment of the Honoring our Promise to Address Comprehensive
Toxics Act of 2021, and annually thereafter, the Secretary
shall submit to the Committee on Veterans' Affairs of the House
of Representatives and the Senate a report on any research
activities specified in subsection (a) carried out during the
year covered by the report.
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