[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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \6\https://law.yale.edu/sites/default/files/area/clinic/
2021.02.11_-_nvlsp_white_paper_-_clean.pdf.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.

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

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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.

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PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

           *       *       *       *       *       *       *


 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

     * * * * * * *
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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