[House Report 118-600]
[From the U.S. Government Publishing Office]


118th Congress    }                                       {    Report
                        HOUSE OF REPRESENTATIVES
 2d Session       }                                       {    118-600

======================================================================



 
             VIETNAM VETERANS LIVER FLUKE CANCER STUDY ACT

                                _______
                                

 July 22, 2024.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

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

                              R E P O R T

                             together with

                             MINORITY VIEWS

                        [To accompany H.R. 4424]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 4424) to direct the Secretary of Veterans 
Affairs to study and report on the prevalence of 
cholangiocarcinoma in veterans who served in the Vietnam 
theater of operations during the Vietnam era, and for other 
purposes, having considered the same, reports favorably thereon 
with an amendment and recommends that the bill as amended do 
pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     3
Hearings.........................................................     4
Subcommittee Consideration.......................................     4
Committee Consideration..........................................     4
Committee Votes..................................................     5
Committee Correspondence.........................................
Committee Oversight Findings.....................................     5
Statement of General Performance Goals and Objectives............     5
Earmarks and Tax and Tariff Benefits.............................     5
Committee Cost Estimate..........................................     5
Budget Authority and Congressional Budget Office Estimate........     5
Federal Mandates Statement.......................................     8
Advisory Committee Statement.....................................     8
Applicability to Legislative Branch..............................     8
Statement on Duplication of Federal Programs.....................     8
Section-by-Section Analysis of the Legislation...................     8
Changes in Existing Law Made by the Bill, as Reported............     9
Minority Views...................................................    16

    The amendment is as follows:
    Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Vietnam Veterans Liver Fluke Cancer 
Study Act''.

SEC. 2. STUDY ON THE PREVALENCE OF CHOLANGIOCARCINOMA IN VETERANS WHO 
                    SERVED IN THE VIETNAM THEATER OF OPERATIONS DURING 
                    THE VIETNAM ERA.

  (a) Epidemiological Study.--Not later than 120 days after the date of 
enactment of this Act, the Secretary of Veterans Affairs, in 
consultation with the Director of the Centers for Disease Control and 
Prevention of the Department of Health and Human Services, shall 
commence an epidemiological study on the prevalence of 
cholangiocarcinoma in covered veterans of the Vietnam era, using data 
from the Veterans Affairs Central Cancer Registry and the National 
Program of Cancer Registries. The study shall--
          (1) identify the rate of incidence of cholangiocarcinoma in 
        covered veterans of the Vietnam era and in residents of the 
        United States, from the beginning of the Vietnam era to the 
        date of enactment of this Act; and
          (2) for each of the groups specified in paragraph (1), 
        identify the percentage of individuals with cholangiocarcinoma 
        by various demographic characteristics, including by age, 
        gender, race, ethnicity, and the geographic location of the 
        patient at the time of diagnosis.
  (b) Report to Congress.--Not later than one year after the completion 
of the study under subsection (a), the Secretary shall submit to 
Congress a report containing--
          (1) the results of the study under subsection (a); and
          (2) recommendations for administrative or legislative actions 
        required to address issues identified in the study under 
        subsection (a).
  (c) Continued Tracking of Cholangiocarcinoma in Covered Veterans of 
the Vietnam Era.--The Secretary shall track the prevalence of 
cholangiocarcinoma in covered veterans of the Vietnam era using the 
Veterans Affairs Central Cancer Registry, and provide such information 
to Congress as required under subsection (d).
  (d) Follow-Up Reports.--The Secretary shall periodically submit to 
the Congress an updated report under subsection (b), as determined by 
the Secretary.
  (e) Definitions.--In this section:
          (1) The term ``Secretary'' means the Secretary of Veterans 
        Affairs.
          (2) The term ``Vietnam era'' has the meaning given such term 
        in section 101 of title 38, United States Code.
          (3) The term ``covered veterans of the Vietnam era'' means 
        veterans who served in the Vietnam theater of operations during 
        the Vietnam era.

SEC. 3. MODIFICATION OF CERTAIN HOUSING LOAN FEES.

  The loan fee table in section 3729(b)(2) of title 38, United States 
Code, is amended by striking ``November 15, 2031'' each place it 
appears and inserting ``November 29, 2031''.

                          Purpose and Summary

    Page H.R. 4424, the ``Vietnam Veterans Liver Fluke Cancer 
Study Act,'' was introduced by Representative Nick LaLota of 
New York on June 30, 2023. H.R. 4424, as amended, would require 
the U.S. Department of Veterans Affairs (VA), in consultation 
with the Center for Disease Control, to begin an 
epidemiological study on the prevalence of bile duct cancer in 
Vietnam era veterans using data from the VA Central Cancer 
Registry and the National Program of Cancer Registries. This 
bill would also require the Secretary to periodically submit 
updated reports to Congress.

                  Background and Need for Legislation


Section 1. Short Title

    This Act may be cited as the ``Vietnam Veterans Liver Fluke 
Cancer Study Act.''

Section 2. Study on the Prevalence of Cholangiocarcinoma in Veterans 
        Who Served in the Vietnam Theater of Operations During the 
        Vietnam Era

    Liver fluke is a form of flatworm parasite that can infect 
the bile ducks and liver of people through the consumption of 
certain undercooked fish in Southeast Asia. The infection 
caused by liver flukes can cause irritation and scarring that 
can lead to bile duct cancer, also known as cholangiocarcinoma. 
In 2018, the Northport VA Medical Center in New York conducted 
a study on the prevalence of liver fluke in a group of 50 
veterans from the Vietnam era. This study indicated that 24% of 
Vietnam veterans who ate undercooked fish while deployed tested 
positive or borderline positive for prior worm infection. 
Initial reports and reviews on the study highlight the need for 
more research on liver fluke and the development of standard 
treatment procedures for veterans who have it.
    Bile duct cancer is a relatively rare form of cancer in the 
United States, with roughly 8,000 documented cases each year. 
However, it is more common in Southeast Asia, where many 
Vietnam era veterans were deployed during the November 1, 1955, 
to May 7, 1975, timeframe. Bile duct cancer has other 
documented causes in aging populations, thus the study required 
in this bill would assist researchers and Congress in 
determining if the cancer is a result of military deployment in 
Southeast Asia or general aging.
    This section would study whether bile duct cancer 
disproportionately effects Vietnam War veterans, by studying 
its prevalence in those veterans in comparison to the general 
population. This information could be used by VA to determine 
whether bile duct cancer among Vietnam War veterans, should be 
considered presumptively service connected.
    The mandated study in this section and subsequent report to 
Congress aim to inform policy decisions, highlighting a 
commitment to veteran welfare and the importance of evidence-
based decision making. The Committee believes that this section 
could be a crucial step towards ensuring Vietnam veterans 
receive care that they deserve. Particularly after facing poor 
treatment in the form of anti-Vietnam War protests, and bias, 
it is imperative that conditions which uniquely impact Vietnam 
veterans, are studied with the same veracity as conditions 
impacting more recent veteran populations.

Section 3. Modification of Certain Housing Loan Fees

    Currently, veterans who take advantage of the VA Home Loan 
Program pay a small fee that is included in their monthly 
mortgage payment. This section would cover the costs of the 
other section of this bill by extending the current rates for 
VA home loan funding fees by two weeks to November 29, 2031. 
Extending the funding fee increases a veteran's monthly cost by 
about $5 on top of the monthly mortgage. Disabled veterans do 
not pay the funding fee and would not be affected by this 
extension of the home loan fees. The Committee believes this 
short-term extension of current funding fee rates is a 
reasonable way to cover the costs associated with the other 
sections of this bill.

                                Hearings

    On March 21, 2024, the Health Subcommittee held a 
legislative hearing on H.R. 4424. The following witnesses 
testified:
          The Honorable Chairman Mike Bost, U.S. House of 
        Representatives, 12th Congressional District, Illinois; 
        The Honorable Chris Deluzio, U.S. House of 
        Representatives, 17th Congressional District, 
        Pennsylvania; The Honorable Jack Bergman, U.S. House of 
        Representatives, 1st Congressional District, Michigan; 
        The Honorable Greg Murphy, U.S. House of 
        Representatives, 3rd Congressional District, North 
        Carolina; The Honorable Derrick Van Orden, U.S. House 
        of Representatives, 3rd Congressional District, 
        Wisconsin; The Honorable Nick LaLota, U.S. House of 
        Representatives, 1st Congressional District, New York; 
        The Honorable Debbie Dingell, U.S. House of 
        Representatives, 6th Congressional District, Michigan; 
        The Honorable Lauren Underwood, U.S. House of 
        Representatives, 14th Congressional District, Illinois; 
        Dr. Ajit Pai, Executive Director, Office of 
        Rehabilitation and Prosthetics Services, Veterans 
        Health Administration; Dr. Michael Brenna, Executive 
        Director, Office of Construction and Facilities 
        Management, Veterans Affairs; Dr. Wendy Tenhula, Deputy 
        Chief Research and Development Officer, Office of 
        Research and Development, Veterans Health 
        Administration; Dr. David Perry, Chief Officer, 
        Workforce Management and Consulting, Veterans Health 
        Administration; Mr. Jon Retzer, Assistant National 
        Legislative Director, Disabled Americans Veterans; Mr. 
        Roscoe Butler, Senior Health Policy Advisor, Paralyzed 
        Veterans of America; Ms. Brittany Elliot, Veteran 
        (USMC), Advocate; Ms. Melissa Bryant, Chair, Board of 
        Directors, Minority Veterans of America.
    The following individuals and organizations submitted 
statements for the record:
          Wounded Warrior Project, Treat Now, Superior 
        Ambulance.

                       Subcommittee Consideration

    On April 16, 2024, the Health subcommittee met in an open 
markup session, a quorum being present, and ordered H.R. 4424 
to be reported favorably to the Full Committee by voice vote.

                        Committee Consideration

    On May 1, 2024, the Full Committee met in open markup 
session, a quorum being present, and ordered H.R. 4424, as 
amended, be reported favorably to the House of Representatives 
by voice vote.
    An amendment in the nature of a substitute offered by 
Chairman Bost of Illinois made a change to include an offset by 
extending the home loan fee offset. The amendment in the nature 
of substitute was approved by voice vote.
    A motion by Ranking Member Takano of California to report 
H.R. 4424, as amended, favorably to the House of 
Representatives was agreed to by voice vote.

                            Committee Votes

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives, no recorded votes were taken with 
ordering H.R. 4424, as amended, to the House.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives of H.R. 4424, as amended, are to study the 
prevalence of cholangiocarcinoma in Vietnam era veterans and 
report back to Congress.

                  Earmarks and Tax and Tariff Benefits

    H.R. 4424, as amended, does not contain any Congressional 
earmarks, limited tax benefits, or limited tariff benefits as 
defined in clause 9 of rule XXI of the Rules of the House of 
Representatives.

                        Committee Cost Estimate

    [The Committee adopts as its own the cost estimate of H.R. 
4424, as amended, prepared by the Director of the Congressional 
Budget Office.]\1\
---------------------------------------------------------------------------
    \1\Formal score forthcoming. CBO is hoping to get us the score soon 
after this week's NDAA amendment process.
---------------------------------------------------------------------------

     Budget Authority and 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. 4424, as amended, provided by the 
Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974:]\2\

    \2\Waiting on formal score. 

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    The bill would:
           Require the Department of Veterans Affairs 
        (VA) to conduct a study on prevalence of 
        cholangiocarcinoma (cancer of the bile ducts that has 
        been linked to liver flukes)
           Increase the fees that VA charges borrowers 
        for home loan guarantees
    Estimated budgetary effects would mainly stem from:
           Conducting a study on the prevalence of 
        cholangiocarcinoma
           Increasing the fees charged by VA for home 
        loan guarantees

    Bill summary: H.R. 4424 would require the Department of 
Veterans Affairs (VA) to conduct a study on the prevalence of 
cholangiocarcinoma (cancer of the bile ducts that has been 
linked to liver flukes) among veterans who served during the 
Vietnam era. The bill would also increase the fees that VA 
charges borrowers for its home loan guarantees.
    Estimated federal cost: The estimated budgetary effects of 
H.R. 4424 are shown in Table 1. The costs of the legislation 
fall within budget function 700 (veterans benefits and 
services).


                                                   TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF H.R. 4424
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                          By fiscal year, millions of dollars--
                                                               -----------------------------------------------------------------------------------------
                                                                2024  2025  2026  2027  2028  2029  2030  2031   2032   2033  2034  2024-2029  2024-2034
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                         INCREASES IN SPENDING SUBJECT TO APPROPRIATION ESTIMATED AUTHORIZATION
 
Estimated Authorization.......................................     *     1     *     1     *     1     *     1       *     1     *       3            5
Estimated Outlays.............................................     *     1     *     1     *     1     *     1       *     1     *       3            5
 
                                        INCREASES OR DECREASES (-) IN DIRECT SPENDING ESTIMATED BUDGET AUTHORITY
 
Estimated Budget Authority....................................     *     *     *     *     1     *     *     *     -22     1     *       1          -20
Estimated Outlays.............................................     *     *     *     *     1     *     *     *     -22     1     *       1          -20
--------------------------------------------------------------------------------------------------------------------------------------------------------
* = between zero and $500,000.

    Basis of estimate: For this estimate, CBO assumes that H.R. 
4424 will be enacted in fiscal year 2024.
    Provisions that affect spending subject to appropriation 
and direct spending: Section 2 of the bill would require VA to 
conduct a study on the prevalence of cholangiocarcinoma in 
veterans from the Vietnam era and to continue to monitor 
prevalence rates and periodically update that study. The 
department is completing a study on the prevalence of 
cholangiocarcinoma among Vietnam veterans. Based on information 
from VA on the current staffing and support costs for that 
study, CBO estimates the staffing and support costs required to 
monitor prevalence rates and update the study would average 
about $600,000 per year, and total about $7 million over the 
2024-2034 period.
    CBO expects that some of the costs of implementing the bill 
would be paid from the Toxic Exposures Fund (TEF) established 
by Public Law 117-168, the Honoring our PACT Act. The TEF is a 
mandatory appropriation that VA uses to pay for health care, 
disability claims processing, medical research, and IT 
modernization that benefit veterans who were exposed to 
environmental hazards.
    Additional spending from the TEF would occur if legislation 
increases the costs of similar activities that benefit veterans 
with such exposure. CBO estimates that 18 percent of such 
additional costs would be paid from the fund in 2025, growing 
to 31 percent in 2034 as costs for those activities increase 
over time. Those percentages are based on the amount of 
formerly discretionary appropriations that CBO projects will be 
provided through the mandatory appropriation as specified in 
the Honoring our PACT Act. CBO estimates that over the 2024-
2034 period, implementing section 2 would increase spending 
subject to appropriation by $5 million and direct spending by 
$2 million.
    Direct spending: The discussion above in ``Provisions that 
affect spending subject to appropriation and direct spending'' 
describe provisions that would increase direct spending from 
the Toxic Exposures Fund under H.R. 4424. The bill also would 
increase fees paid for VA home loan guarantees, which would 
decrease direct spending. In total, the bill would decrease 
direct spending by $20 million over the 2024-2034 period.
    H.R. 4424 would increase the fees that VA charges borrowers 
for its loan guarantees. VA provides loan guarantees to lenders 
that allow eligible borrowers to obtain better loan terms--such 
as lower interest rates or smaller down payments--to purchase, 
construct, improve, or refinance a home. VA typically pays 
lenders up to 25 percent of the outstanding mortgage balance if 
a borrower's home is foreclosed upon. Those payments, net of 
fees paid by borrowers and recoveries by lenders, constitute 
the subsidy cost for the loan guarantees.\1\ That subsidy cost 
is reflected in the budget as direct spending.
---------------------------------------------------------------------------
    \1\Under the Federal Credit Reform Act of 1990, the subsidy cost of 
a loan guarantee is the net present value of estimated payments by the 
government to cover defaults and delinquencies, interest subsidies, or 
other expenses offset by any payments to the government, including 
origination or other fees, penalties, and recoveries on defaulted 
loans. Such subsidy costs are calculated by discounting those expected 
cash flows using the rate on Treasury securities of comparable 
maturity. The resulting estimated subsidy costs are recorded in the 
budget when the loans are disbursed or modified. A positive subsidy 
indicates that the loan results in net outlays from the Treasury; a 
negative subsidy indicates that the loan results in net receipts to the 
Treasury.
---------------------------------------------------------------------------
    Under current law, the rates for most of the fees that 
borrowers pay to VA for loans guaranteed after November 15, 
2031, will drop from a weighted average of about 2.3 percent to 
about 1.2 percent of the loan amount. The bill would extend the 
higher rates through November 29, 2031, thereby reducing the 
subsidy cost of loans guaranteed during that period. Using its 
forecast of loan volume based on data provided by VA, CBO 
estimates that extending the higher rates would decrease direct 
spending by $22 million over the 2024-2034 period.
    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 Table 1.
    Increase in long-term net direct spending and deficits: CBO 
estimates that enacting H.R. 4424 would not increase net direct 
spending by more than $2.5 billion in any of the four 
consecutive 10-year periods beginning in 2035.
    CBO estimates that enacting H.R. 4424 would not increase 
on-budget deficits by more than $5 billion in any of the four 
consecutive 10-year periods beginning in 2035.
    Mandates: The bill contains no intergovernmental or 
private-sector mandates as defined in the Unfunded Mandates 
Reform Act.
    Estimate prepared by: Federal costs: Matt Schmit (for 
veterans health care); Paul B.A. Holland (for home loans). 
Mandates: Brandon Lever.
    Estimate reviewed by: David Newman, Chief, Defense, 
International Affairs, and Veterans' Affairs Cost Estimates 
Unit; Kathleen FitzGerald, Chief, Public and Private Mandates 
Unit; Christina Hawley Anthony, Deputy Director of Budget 
Analysis.
    Estimate approved by: Phillip L. Swagel, Director, 
Congressional Budget Office.

                       Federal Mandates Statement

    [Section 423 of the Congressional Budget and Impoundment 
Control Act (as amended by Section 101(a)(2) of the Unfunded 
Mandate Reform Act, P.L. 104-4), is inapplicable to H.R. 4424, 
as amended.]\3\
---------------------------------------------------------------------------
    \3\Will confirm once receive formal score.
---------------------------------------------------------------------------

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
4424, as amended.

                  Applicability to Legislative Branch

    The Committee finds that H.R. 4424, as amended, does not 
relate to the terms and conditions of employment or access to 
public services or accommodation 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. 4424, as amended, establishes or reauthorizes a program 
of the Federal Government known to be duplicative of another 
Federal program, a program that was included in any report from 
the Government Accountability Office to Congress pursuant to 
section 21 of Public Law 111-139, or a program related to a 
program identified in the most recent Catalog of Federal 
Domestic Assistance.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    Section 1 would establish the short title as the ``Vietnam 
Veterans Liver Fluke Cancer Study Act.''

Section 2. Study on the prevalence of cholangiocarcinoma in veterans 
        who served in the Vietnam theater of operations during the 
        Vietnam era

    Section 2 would require the Secretary, in consultation with 
the Director of the Centers for Disease Control, to conduct an 
epidemiological study on the prevalence of cholangiocarcinoma 
in covered veterans of the Vietnam era using data from the 
Veterans Affairs Central Cancer Registry and the National 
Program of Cancer Registries. This section would require the 
Secretary to submit a report to Congress not later than one 
year after the conclusion of the study, which would include the 
result of the study and any recommendations for administrative 
or legislative actions. This section would require the 
Secretary to track the prevalence of cholangiocarcinoma in 
covered Vietnam era veterans. The section would define 
``Secretary,'' ``Vietnam era,'' and ``covered veterans of the 
Vietnam era.''

Section 3. Modification of certain housing loan fees

    Section three of the bill would provide funding for these 
programs included in the bill by extending current rates for VA 
home loan funding fees as established in section 3729 of title 
38, U.S.C. from November 15, 2031, to November 29, 2031.

         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, existing law in which no change 
is proposed is shown in roman):

         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 III--READJUSTMENT AND RELATED BENEFITS

           *       *       *       *       *       *       *


CHAPTER 37--HOUSING AND SMALL BUSINESS LOANS

           *       *       *       *       *       *       *


SUBCHAPTER III--ADMINISTRATIVE PROVISIONS

           *       *       *       *       *       *       *


Sec. 3729. Loan fee

  (a) Requirement of Fee.--(1) Except as provided in subsection 
(c), a fee shall be collected from each person obtaining a 
housing loan guaranteed, insured, or made under this chapter, 
and each person assuming a loan to which section 3714 of this 
title applies. No such loan may be guaranteed, insured, made, 
or assumed until the fee payable under this section has been 
remitted to the Secretary.
  (2) The fee may be included in the loan and paid from the 
proceeds thereof.
  (b) Determination of Fee.--(1) The amount of the fee shall be 
determined from the loan fee table in paragraph (2). The fee is 
expressed as a percentage of the total amount of the loan 
guaranteed, insured, or made, or, in the case of a loan 
assumption, the unpaid principal balance of the loan on the 
date of the transfer of the property.
  (2) The loan fee table referred to in paragraph (1) is as 
follows:


 
----------------------------------------------------------------------------------------------------------------
             Type of loan                Active duty  veteran          Reservist              Other obligor
----------------------------------------------------------------------------------------------------------------
(A)(i) Initial loan described in       2.15                     2.40                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other initial loan described in
 section 3710(a) other than with 5-
 down or 10-down (closed on or after
 October 1, 2004, and before January
 1, 2020).
(A)(ii) Initial loan described in      2.30                     2.30                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other initial loan described in
 section 3710(a) other than with 5-
 down or 10-down (closed on or after
 January 1, 2020, and before April 7,
 2023).
(A)(iii) Initial loan described in     2.15                     2.15                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other initial loan described in
 section 3710(a) other than with 5-
 down or 10-down (closed on or after
 April 7, 2023, and before November
 [15] 29, 2031).
(A)(iv) Initial loan described in      1.40                     1.40                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other initial loan described in
 section 3710(a) other than with 5-
 down or 10-down (closed on or after
 November [15] 29, 2031).
(B)(i) Subsequent loan described in    3.30                     3.30                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other subsequent loan described
 in section 3710(a) (closed on or
 after October 1, 2004, and before
 January 1, 2020).
(B)(ii) Subsequent loan described in   3.60                     3.60                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other subsequent loan described
 in section 3710(a) (closed on or
 after January 1, 2020, and before
 April 7, 2023).
(B)(iii) Subsequent loan described in  3.30                     3.30                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other subsequent loan described
 in section 3710(a) (closed on or
 after April 7, 2023, and before
 November [15] 29, 2031).
(B)(iv) Subsequent loan described in   1.25                     1.25                     NA
 section 3710(a) to purchase or
 construct a dwelling with 0-down, or
 any other subsequent loan described
 in section 3710(a) (closed on or
 after November [15] 29, 2031).
(C)(i) Loan described in section       1.50                     1.75                     NA
 3710(a) to purchase or construct a
 dwelling with 5-down (closed before
 January 1, 2020).
(C)(ii) Loan described in section      1.65                     1.65                     NA
 3710(a) to purchase or construct a
 dwelling with 5-down (closed on or
 after January 1, 2020, and before
 April 7, 2023).
(C)(iii) Loan described in section     1.50                     1.50                     NA
 3710(a) to purchase or construct a
 dwelling with 5-down (closed on or
 after April 7, 2023, and before
 November [15] 29, 2031).
(C)(iv) Loan described in section      0.75                     0.75                     NA
 3710(a) to purchase or construct a
 dwelling with 5-down (closed on or
 after November [15] 29, 2031).
(D)(i) Loan described in section       1.25                     1.50                     NA
 3710(a) to purchase or construct a
 dwelling with 10-down (closed before
 January 1, 2020).
(D)(ii) Loan described in section      1.40                     1.40                     NA
 3710(a) to purchase or construct a
 dwelling with 10-down (closed on or
 after January 1, 2020, and before
 April 7, 2023).
(D)(iii) Loan described in section     1.25                     1.25                     NA
 3710(a) to purchase or construct a
 dwelling with 10-down (closed on or
 after April 7, 2023, and before
 November [15] 29, 2031).
(D)(iv) Loan described in section      0.50                     0.50                     NA
 3710(a) to purchase or construct a
 dwelling with 10-down (closed on or
 after November [15] 29, 2031).
(E) Interest rate reduction            0.50                     0.50                     NA
 refinancing loan.
(F) Direct loan under section 3711...  1.00                     1.00                     NA
(G) Manufactured home loan under       1.00                     1.00                     NA
 section 3712 (other than an interest
 rate reduction refinancing loan).
(H) Loan to Native American veteran    1.25                     1.25                     NA
 under section 3762 (other than an
 interest rate reduction refinancing
 loan).
(I) Loan assumption under section      0.50                     0.50                     0.50
 3714.
(J) Loan under section 3733(a).......  2.25                     2.25                     2.25.
----------------------------------------------------------------------------------------------------------------

  (3) Any reference to a section in the ``Type of loan'' column 
in the loan fee table in paragraph (2) refers to a section of 
this title.
  (4) For the purposes of paragraph (2):
          (A) The term ``active duty veteran'' means any 
        veteran eligible for the benefits of this chapter other 
        than a Reservist.
          (B) The term ``Reservist'' means a veteran described 
        in section 3701(b)(5)(A) of this title who is eligible 
        under section 3702(a)(2)(E) of this title.
          (C) The term ``other obligor'' means a person who is 
        not a veteran, as defined in section 101 of this title 
        or other provision of this chapter.
          (D)(i) The term ``initial loan'' means a loan to a 
        veteran guaranteed under section 3710 or made under 
        section 3711 of this title if the veteran has never 
        obtained a loan guaranteed under section 3710 or made 
        under section 3711 of this title.
          (ii) If a veteran has obtained a loan guaranteed 
        under section 3710 or made under section 3711 of this 
        title and the dwelling securing such loan was 
        substantially damaged or destroyed by a major disaster 
        declared by the President under section 401 of the 
        Robert T. Stafford Disaster Relief and Emergency 
        Assistance Act (42 U.S.C. 5170), the Secretary shall 
        treat as an initial loan, as defined in clause (i), the 
        next loan the Secretary guarantees or makes to such 
        veteran under section 3710 or 3711, respectively, if--
                  (I) such loan is guaranteed or made before 
                the date that is three years after the date on 
                which the dwelling was substantially damaged or 
                destroyed; and
                  (II) such loan is only for repairs or 
                construction of the dwelling, as determined by 
                the Secretary.
          (E) The term ``subsequent loan'' means a loan to a 
        veteran, other than an interest rate reduction 
        refinancing loan, guaranteed under section 3710 or made 
        under section 3711 of this title that is not an initial 
        loan.
          (F) The term ``interest rate reduction refinancing 
        loan'' means a loan described in section 3710(a)(8), 
        3710(a)(9)(B)(i), 3710(a)(11), 3712(a)(1)(F), or 
        3762(h) of this title.
          (G) The term ``0-down'' means a downpayment, if any, 
        of less than 5 percent of the total purchase price or 
        construction cost of the dwelling.
          (H) The term ``5-down'' means a downpayment of at 
        least 5 percent or more, but less than 10 percent, of 
        the total purchase price or construction cost of the 
        dwelling.
          (I) The term ``10-down'' means a downpayment of 10 
        percent or more of the total purchase price or 
        construction cost of the dwelling.
  (c) Waiver of Fee.--(1) A fee may not be collected under this 
section from a veteran who is receiving compensation (or who, 
but for the receipt of retirement pay or active service pay, 
would be entitled to receive compensation), from a surviving 
spouse of any veteran (including a person who died in the 
active military, naval, air, or space service) who died from a 
service-connected disability, or from a member of the Armed 
Forces who is serving on active duty and who provides, on or 
before the date of loan closing, evidence of having been 
awarded the Purple Heart.
  (2)(A) A veteran described in subparagraph (B) shall be 
treated as receiving compensation for purposes of this 
subsection as of the date of the rating described in such 
subparagraph without regard to whether an effective date of the 
award of compensation is established as of that date.
  (B) A veteran described in this subparagraph is a veteran who 
is rated eligible to receive compensation--
          (i) as the result of a pre-discharge disability 
        examination and rating; or
          (ii) based on a pre-discharge review of existing 
        medical evidence (including service medical and 
        treatment records) that results in the issuance of a 
        memorandum rating.

           *       *       *       *       *       *       *


                             MINORITY VIEWS

    Liver fluke is a serious parasitic infection that is a 
well-recognized risk factor for the development of bile duct 
cancer. H.R. 4424, Vietnam Veterans Liver Fluke Cancer Study 
Act, would require VA, in consultation with the Centers for 
Disease Control and Prevention, to commence an epidemiological 
study on the prevalence of bile duct cancer in veterans who 
served in the Vietnam War versus their non-veteran U.S. 
resident counterparts. VA would be required to submit a report 
with the results of the study broken out by age, gender, race, 
ethnicity and geographic location.
    While Democratic Members are supportive of robust and 
thorough research about the diseases veterans may have been 
exposed to as part of their service, we believe VA raised valid 
concerns in its written testimony at the Health Subcommittee's 
legislative hearing on H.R. 4424. Specifically, VA believes 
that the bill as written may be duplicative of past and ongoing 
VA research efforts and may not advance understanding of the 
link between liver fluke and cancer mortality rates, given the 
study's required structure, which focuses on prevalence rather 
than mortality. Furthermore, VA questioned whether the study 
required by this legislation could be carried out successfully, 
given a lack of reliable data.
    In testimony provided at the Subcommittee on Health's 
legislative hearing on March 21, 2024, the Department of 
Veterans' Affairs stated:

          Given VA's observations with existing studies, the 
        bill's requirements would not be as useful to the 
        agency as VA's current efforts at this time. Any 
        additional epidemiological study would face significant 
        hurdles in counting cases because of the lack of 
        available and comprehensive health care data (such as 
        cancer diagnoses and risk factors) on the entire 
        population of Vietnam-era Veterans over the years since 
        the war, whereas VA has conducted this mortality study 
        by compiling a roster of all Vietnam Veterans along 
        with a database of their death dates and causes.

    Given VA's concerns, Democratic members have concerns about 
using the results of any study that does not follow the 
structure that VA outlined in its testimony to guide 
conclusions about cancer causation links and presumptive 
coverage decisions.

                                               Mark Takano,
                                                    Ranking Member.

                                  [all]