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                                                       Calendar No. 686
105th Congress                                                   Report
                                 SENATE

 2d Session                                                     105-362
_______________________________________________________________________


 
                 PERSIAN GULF WAR VETERANS ACT OF 1998

                                _______
                                

                October 2, 1998.--Ordered to be printed

_______________________________________________________________________


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

                              R E P O R T

                         [To accompany S. 2358]

    The Committee on Veterans' Affairs, to which was referred 
the bill (S. 2358) to provide for the establishment of a 
service connection for illnesses associated with service in the 
Persian Gulf War, to extend and enhance certain health care 
authorities relating to such service, and for other purposes, 
having considered the same, reports favorably thereon with 
amendments, and recommends that the bill, as amended, do pass.

                          Committee Amendments

    The amendments are as follows:
    In the Table of Contents, strike ``TITLE I--SERVICE 
CONNECTION FOR GULF WAR ILLNESSES'' and insert in lieu thereof 
``TITLE I--SERVICE CONNECTION FOR PERSIAN GULF WAR ILLNESSES''.
    In the Table of Contents, strike ``TITLE II--EXTENSION AND 
ENHANCEMENT OF GULF WAR HEALTH CARE AUTHORITIES'' and insert in 
lieu thereof ``TITLE II--EXTENSION AND ENHANCEMENT OF PERSIAN 
GULF WAR HEALTH CARE AUTHORITIES''.
    On page 3, line 2, insert ``PERSIAN'' after ``FOR''.
    On page 10, lines 10 and 11, strike out ``sections 
103(a)(6) and 104(d)'' and insert in lieu thereof ``section 
103(a)(6)''.
    On page 13, line 2, strike out clause (vi).
    On page 13, line 3, strike out ``ionizing'' and insert in 
lieu thereof ``sources of''.
    On page 26, line 2, insert ``PERSIAN'' after ``OF''.
    Thus, the text of the bill (strike out the material in 
brackets and insert the material in italic) as reported is as 
follows:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Persian Gulf War 
Veterans Act of 1998''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:
    Sec. 1. Short title; table of contents.

       TITLE I--SERVICE CONNECTION FOR PERSIAN GULF WAR ILLNESSES

Sec. 101. Presumption of service connection for illnesses associated 
with service in the Persian Gulf during the Persian Gulf War.
Sec. 102. Agreement with National Academy of Sciences.
Sec. 103. Monitoring of health status and health care of Persian Gulf 
War veterans.
Sec. 104. Reports on recommendations for additional scientific 
research.
Sec. 105. Outreach.
Sec. 106. Definitions.

  TITLE II--EXTENSION AND ENHANCEMENT OF PERSIAN GULF WAR HEALTH CARE 
                              AUTHORITIES

Sec. 201. Extension of authority to provide health care for Persian 
Gulf War veterans.
Sec. 202. Extension and improvement of evaluation of health status of 
spouses and children of Persian Gulf War veterans.

                        TITLE III--MISCELLANEOUS

Sec. 301. Assessment of establishment of independent entity to evaluate 
post-conflict illnesses among members of the Armed Forces and health 
care provided by DoD and VA before and after deployment of such 
members.

       TITLE I--SERVICE CONNECTION FOR PERSIAN GULF WAR ILLNESSES

SEC. 101. PRESUMPTION OF SERVICE CONNECTION FOR ILLNESSES ASSOCIATED 
                    WITH SERVICE IN THE PERSIAN GULF DURING THE PERSIAN 
                    GULF WAR.

    (a) In General.--(1) Subchapter II of chapter 11 of title 38, 
United States Code, is amended by adding at the end the following:

``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 orpresumed 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.
     ``(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 102 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 102 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 Secretarys 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 10 
years after the first day of the fiscal year in which the National 
Academy of Sciences submits to the Secretary the first report under 
section 102 of the Persian Gulf War Veterans Act of 1998.''.
    (2) The table of sections at the beginning of such chapter is 
amended by inserting after the item relating to section 1117 the 
following new item:

``1118. Presumptions of service connection for illnesses associated 
with service in the Persian Gulf during the Persian Gulf War.''.

    (b) Conforming Amendments.--Section 1113 of title 38, United States 
Code, is amended--
          (1) by striking out ``or 1117'' each place it appears and 
        inserting in lieu thereof ``1117, or 1118''; and
          (2) in subsection (a), by striking out ``or 1116'' and 
        inserting in lieu thereof ``, 1116, or 1118''.
    (c) Compensation for Undiagnosed Gulf War Illnesses.--Section 1117 
of title 38, United States Code, is amended--
          (1) by redesignating subsections (c), (d), and (e) as 
        subsections (d), (e), and (f), respectively; and
          (2) by inserting after subsection (b) the following new 
        subsection (c):
    ``(c)(1) Whenever the Secretary determines under section 1118(c) of 
this title that a presumption of service connection for an undiagnosed 
illness (or combination of undiagnosed illnesses) previously 
established under this section is no longer warranted--
          ``(A) a veteran who was awarded compensation under this 
        section for such illness (or combination of illnesses) 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 10 years after 
the first day of the fiscal year in which the National Academy of 
Sciences submits to the Secretary the first report under section 102 of 
the Persian Gulf War Veterans Act of 1998.''.

SEC. 102. AGREEMENT WITH NATIONAL ACADEMY OF SCIENCES.

    (a) Purpose.--The purpose of this section is to provide for the 
National Academy of Sciences, an independent nonprofit scientific 
organization with appropriate expertise, to review and evaluate the 
available scientific evidence regarding associations between illnesses 
and exposure to toxic agents, environmental or wartime hazards, or 
preventive medicines or vaccines associated with Gulf War service.
    (b) Agreement.--The Secretary of Veterans Affairs shall seek to 
enter into an agreement with the National Academy of Sciences for the 
Academy to perform the activities covered by this section and [sections 
103(a)(6) and 104(d)] section 103(a)(6). The Secretary shall seek to 
enter into the agreement not later than two months after the date of 
enactment of this Act.
    (c) Identification of Agents and Illnesses.--(1) Under the 
agreement under subsection (b), the National Academy of Sciences 
shall--
          (A) identify the biological, chemical, or other toxic agents, 
        environmental or wartime hazards, or preventive medicines or 
        vaccines to which members of the Armed Forces who served in the 
        Southwest Asia theater of operations during the Persian Gulf 
        War may have been exposed by reason of such service; and
          (B) identify the illnesses (including diagnosed illnesses and 
        undiagnosed illnesses) that are manifest in such members.
    (2) In identifying illnesses under paragraph (1)(B), the Academy 
shall review and summarize the relevant scientific evidence regarding 
illnesses among the members described in paragraph (1)(A) and among 
other appropriate populations of individuals, including mortality, 
symptoms, and adverse reproductive health outcomes among such members 
and individuals.
    (d) Initial Consideration of Specific Agents.--(1) In identifying 
under subsection (c) the agents, hazards, or preventive medicines or 
vaccines to which members of the Armed Forces may have been exposed for 
purposes of the first report under subsection (i), the National Academy 
of Sciences shall consider, within the first six months after the date 
of enactment of this Act, the following:
          (A) The following organophosphorous pesticides:
                  (i) Chlorpyrifos.
                  (ii) Diazinon.
                  (iii) Dichlorvos.
                  (iv) Malathion.
          (B) The following carbamate pesticides:
                  (i) Proxpur.
                  (ii) Carbaryl.
                  (iii) Methomyl.
          (C) The carbamate pyridostigmine bromide used as nerve agent 
        prophylaxis.
          (D) The following chlorinated dydrocarbon and other 
        pesticides and repellents:
                  (i) Lindane.
                  (ii) Pyrethrins.
                  (iii) Permethrins.
                  (iv) Rodenticides (bait).
                  (v) Repellent (DEET).
          (E) The following low-level nerve agents and precursor 
        compounds at exposure levels below those which produce 
        immediately apparent incapacitating symptoms:
                  (i) Sarin.
                  (ii) Tabun.
          (F) The following synthetic chemical compounds:
                  (i) Mustard agents at levels below those which cause 
                immediate blistering.
                  (ii) Volatile organic compounds.
                  (iii) Hydrazine.
                  (iv) Red fuming nitric acid.
                  (v) Solvents.
                  [(vi) Uranium.]
          (G) The following [ionizing] sources of radiation:
                  (i) Depleted uranium.
                  (ii) Microwave radiation.
                  (iii) Radio frequency radiation.
          (H) The following environmental particulates and pollutants:
                  (i) Hydrogen sulfide.
                  (ii) Oil fire byproducts.
                  (iii) Diesel heater fumes.
                  (iv) Sand micro-particles.
          (I) Diseases endemic to the region (including the following):
                  (i) Leishmaniasis.
                  (ii) Sandfly fever.
                  (iii) Pathogenic escherechia coli.
                  (iv) Shigellosis.
          (J) Time compressed administration of multiple live, 
        ``attenuated'', and toxoid vaccines.
    (2) The consideration of agents, hazards, and medicines and 
vaccines under paragraph (1) shall not preclude the Academy from 
identifying other agents, hazards, or medicines or vaccines to which 
members of the Armed Forces may have been exposed for purposes of any 
report under subsection (i).
    (3) Not later than six months after the date of enactment of this 
Act, the National Academy of Science shall submit to the designated 
congressional committees a report specifying the agents, hazards, and 
medicines and vaccines considered under paragraph (1).
    (e) Determinations of Associations Between Agents and Illnesses.--
(1) For each agent, hazard, or medicine or vaccine and illness 
identified under subsection (c), the National Academy of Sciences shall 
determine, to the extent that available scientific data permit 
meaningful determinations--
          (A) whether a statistical association exists between exposure 
        to the agent, hazard, or medicine or vaccine and the illness, 
        taking into account the strength of the scientific evidence and 
        the appropriateness of the scientific methodology used to 
        detect the association;
          (B) the increased risk of the illness among human or animal 
        populations exposed to the agent, hazard, or medicine or 
        vaccine; and
          (C) whether a plausible biological mechanism or other 
        evidence of a causal relationship exists between exposure to 
        the agent, hazard, or medicine or vaccine and the illness.
    (2) The Academy shall include in its reports under subsection (i) a 
full discussion of the scientific evidence and reasoning that led to 
its conclusions under this subsection.
    (f) Review of Potential Treatment Models for Certain Illnesses.--
Under the agreement under subsection (b), the National Academy of 
Sciences shall separately review, for each chronic undiagnosed illness 
identified under subsection (c)(1)(B) and for any other chronic illness 
that the Academy determines to warrant such review, the available 
scientific data in order to identify empirically valid models of 
treatment for such illnesses which employ successful treatment 
modalities for populations with similar symptoms.
    (g) Recommendations for Additional Scientific Studies.--(1) Under 
the agreement under subsection (b), the National Academy of Sciences 
shall make any recommendations that it considers appropriate for 
additional scientific studies (including studies relating to treatment 
models) to resolve areas of continuing scientific uncertainty relating 
to the health consequences of exposure to toxic agents, environmental 
or wartime hazards, or preventive medicines or vaccines associated with 
Gulf War service.
    (2) In making recommendations for additional studies, the Academy 
shall consider the available scientific data, the value and relevance 
of the information that could result from such studies, and the cost 
and feasibility of carrying out such studies.
    (h) Subsequent Reviews.--(1) Under the agreement under subsection 
(b), the National Academy of Sciences shall conduct on a periodic and 
ongoing basis additional reviews of the evidence and data relating to 
its activities under this section.
    (2) As part of each review under this subsection, the Academy 
shall--
          (A) conduct as comprehensive a review as is practicable of 
        the evidence referred to in subsection (c) and the data 
        referred to in subsections (e), (f), and (g) that became 
        available since the last review of such evidence and data under 
        this section; and
          (B) make determinations under the subsections referred to in 
        subparagraph (A) on the basis of the results of such review and 
        all other reviews previously conducted for purposes of this 
        section.
    (i) Reports.--(1) Under the agreement under subsection (b), the 
National Academy of Sciences shall submit to the committees and 
officials referred to in paragraph (5) periodic written reports 
regarding the Academy's activities under the agreement.
    (2) The first report under paragraph (1) shall be submitted not 
later than 18 months after the date of enactment of this Act. That 
report shall include--
          (A) the determinations and discussion referred to in 
        subsection (e);
          (B) the results of the review of models of treatment under 
        subsection (f); and
          (C) any recommendations of the Academy under subsection (g).
    (3) Reports shall be submitted under this subsection at least once 
every two years, as measured from the date of the report under 
paragraph (2).
    (4) In any report under this subsection (other than the report 
under paragraph (2)), the Academy may specify an absence of meaningful 
developments in the scientific or medical community with respect to the 
activities of the Academy under this section during the 2-year period 
ending on the date of such report.
    (5) Reports under this subsection shall be submitted to the 
following:
          (A) The designated congressional committees.
          (B) The Secretary of Veterans Affairs.
          (C) The Secretary of Defense.
    (j) Sunset.--This section shall cease to be effective 10 years 
after the last day of the fiscal year in which the National Academy of 
Sciences submits the first report under subsection (i).
    (k) Alternative Contract Scientific Organization.--(1) If the 
Secretary is unable within the time period set forth in subsection (b) 
to enter into an agreement with the National Academy of Sciences for 
the purposes of this section on terms acceptable to the Secretary, the 
Secretary shall seek to enter into an agreement for purposes of this 
section with another appropriate scientific organization that is not 
part of the Government, operates as a not-for-profit entity, and has 
expertise and objectivity comparable to that of the National Academy of 
Sciences.
    (2) If the Secretary enters into an agreement with another 
organization under this subsection, any reference in this section, 
sections 103 and 104, and section 1118 of title 38, United States Code 
(as added by section 101), to the National Academy of Sciences shall be 
treated as a reference to such other organization.

SEC. 103. MONITORING OF HEALTH STATUS AND HEALTH CARE OF PERSIAN GULF 
                    WAR VETERANS.

    (a) Information Data Base.--(1) The Secretary of Veterans Affairs 
shall, in consultation with the Secretary of Defense, develop a plan 
for the establishment and operation of a single computerized 
information data base for the collection, storage, and analysis of 
information on--
          (A) the diagnosed illnesses and undiagnosed illnesses 
        suffered by current and former members of the Armed Forces who 
        served in the Southwest Asia theater of operations during the 
        Persian Gulf War; and
          (B) the health care utilization patterns of such members 
        with--
                  (i) any chronic undiagnosed illnesses; and
                  (ii) any chronic illnesses for which the National 
                Academy of Sciences has identified a valid model of 
                treatment pursuant to its review under section 102(f).
    (2) The plan shall provide for the commencement of the operation of 
the data base not later than 18 months after the date of enactment of 
this Act.
    (3) The Secretary shall ensure in the plan that the data base 
provides the capability of monitoring and analyzing information on--
          (A) the illnesses covered by paragraph (1)(A);
          (B) the health care utilization patterns referred to in 
        paragraph (1)(B); and
          (C) the changes in health status of veterans covered by 
        paragraph (1).
    (4) In order to meet the requirement under paragraph (3), the plan 
shall ensure that the data base includes the following:
          (A) Information in the Persian Gulf War Veterans Health 
        Registry established under section 702 of the Persian Gulf War 
        Veterans' Health Status Act (title VII of Public Law 102-585; 
        38 U.S.C. 527 note).
          (B) Information in the Comprehensive Clinical Evaluation 
        Program for Veterans established under section 734 of the 
        National Defense Authorization Act for Fiscal Years 1992 and 
        1993 (10 U.S.C. 1074 note).
          (C) Information derived from other examinations and treatment 
        provided by Department of Veterans Affairs health care 
        facilities to veterans who served in the Southwest Asia theater 
        of operations during the Persian Gulf War.
          (D) Information derived from other examinations and treatment 
        provided by military health care facilities to current members 
        of the Armed Forces (including members of the active components 
        and members of the reserve components) who served in that 
        theater of operations during that war.
          (E) Such other information as the Secretary of Veterans 
        Affairs and the Secretary of Defense consider appropriate.
    (5) Not later than one year after the date of enactment of this 
Act, the Secretary shall submit the plan developed under paragraph (1) 
to the following:
          (A) The designated congressional committees.
          (B) The Secretary of Veterans Affairs.
          (C) The Secretary of Defense.
          (D) The National Academy of Sciences.
    (6)(A) The agreement under section 102 shall require the evaluation 
of the plan developed under paragraph (1) by the National Academy of 
Sciences. The Academy shall complete the evaluation of the plan not 
later than 90 days after the date of its submittal to the Academy under 
paragraph (5).
    (B) Upon completion of the evaluation, the Academy shall submit a 
report on the evaluation to the committees and individuals referred to 
in paragraph (5).
    (7) Not later than 90 days after receipt of the report under 
paragraph (6), the Secretary shall--
          (A) modify the plan in light of the evaluation of the Academy 
        in the report; and
          (B) commence implementation of the plan as so modified.
    (b) Annual Report.--Not later than April 1 each year after the year 
in which operation of the data base under subsection (a) commences, the 
Secretary of Veterans Affairs and the Secretary of Defense shall 
jointly submit to the designated congressional committees a report 
containing--
          (1) with respect to the data compiled under this section 
        during the preceding year--
                  (A) an analysis of the data;
                  (B) a discussion of the types, incidences, and 
                prevalence of the illnesses identified through such 
                data;
                  (C) an explanation for the incidence and prevalence 
                of such illnesses; and
                  (D) other reasonable explanations for the incidence 
                and prevalence of such illnesses; and
          (2) with respect to the most current information received 
        under section 102(i) regarding treatment models reviewed under 
        section 102(f)--
                  (A) an analysis of the information;
                  (B) the results of any consultation between such 
                Secretaries regarding the implementation of such 
                treatment models in the health care systems of the 
                Department of Veterans Affairs and the Department of 
                Defense; and
                  (C) in the event either such Secretary determines not 
                to implement such treatment models, an explanation for 
                such determination.

SEC. 104. REPORTS ON RECOMMENDATIONS FOR ADDITIONAL SCIENTIFIC 
                    RESEARCH.

    (a) Reports.--Not later than 90 days after the date on which the 
Secretary of Veterans Affairs receives any recommendations from the 
National Academy of Sciences for additional scientific studies under 
section 102(g), the Secretary of Veterans Affairs, Secretary of 
Defense, and Secretary of Health and Human Services shall jointly 
submit to the designated congressional committees a report on such 
recommendations, including whether or not the Secretaries intend to 
carry out any recommended studies.
    (b) Elements.--In each report under subsection (a), the Secretaries 
shall--
          (1) set forth a plan for each study, if any, that the 
        Secretaries intend to carry out; or
          (2) in case of each study that the Secretaries intend not to 
        carry out, set forth a justification for the intention not to 
        carry out such study.

SEC. 105. OUTREACH.

    (a) Outreach by Secretary of Veterans Affairs.--The Secretary of 
Veterans Affairs shall, in consultation with the Secretary of Defense 
and the Secretary of Health and Human Services, carry out an ongoing 
program to provide veterans who served in the Southwest Asia theater of 
operations during the Persian Gulf War the information described in 
subsection (c).
    (b) Outreach by Secretary of Defense.--The Secretary of Defense 
shall, in consultation with the Secretary of Veterans Affairs and the 
Secretary of Health and Human Services, carry out an ongoing program to 
provide current members of the Armed Forces (including members of the 
active components and members of the reserve components) who served in 
that theater of operations during that war the information described in 
subsection (c).
    (c) Covered Information.--Information under this subsection is 
information relating to--
          (1) the health risks, if any, resulting from exposure to 
        toxic agents, environmental or wartime hazards, or preventive 
        medicines or vaccines associated with Gulf War service; and
          (2) any services or benefits available with respect to such 
        health risks.

SEC. 106. DEFINITIONS.

    In this title:
          (1) The term ``toxic agent, environmental or wartime hazard, 
        or preventive medicine or vaccine associated with Gulf War 
        service'' means a biological, chemical, or other toxic agent, 
        environmental or wartime hazard, or preventive medicine or 
        vaccine that is known or presumed to be associated with service 
        in the Armed Forces in the Southwest Asia theater of operations 
        during the Persian Gulf War, whether such association arises as 
        a result of single, repeated, or sustained exposure and whether 
        such association arises through exposure singularly or in 
        combination.
          (2) The term ``designated congressional committees'' means 
        the following:
                  (A) The Committees on Veterans' Affairs and Armed 
                Services of the Senate.
                  (B) The Committees on Veterans' Affairs and National 
                Security of the House of Representatives.
          (3) The term ``Persian Gulf War'' has the meaning given that 
        term in section 101(33) of title 38, United States Code.

  TITLE II--EXTENSION AND ENHANCEMENT OF PERSIAN GULF WAR HEALTH CARE 
                              AUTHORITIES

SEC. 201. EXTENSION OF AUTHORITY TO PROVIDE HEALTH CARE FOR PERSIAN 
                    GULF WAR VETERANS.

    Section 1710(e)(3)(B) of title 38, United States Code, is amended 
by striking out ``December 31, 1998'' and inserting in lieu thereof 
``December 31, 2001''.

SEC. 202. EXTENSION AND IMPROVEMENT OF EVALUATION OF HEALTH STATUS OF 
                    SPOUSES AND CHILDREN OF PERSIAN GULF WAR VETERANS.

    (a) Extension.--Subsection (b) of section 107 of the Persian Gulf 
War Veterans' Benefits Act (title I of Public Law 103--446; 38 U.S.C. 
1117 note) is amended by striking out ``ending on December 31, 1998.'' 
and inserting in lieu thereof ``ending on the earlier of--
          ``(1) the date of the completion of expenditure of funds 
        available for the program under subsection (c); or
          ``(2) December 31, 2001.''.
    (b) Termination of Certain Testing and Evaluation Requirements.--
Subsection (a) of that section is amended by striking out the flush 
matter following paragraph (3).
    (c) Outreach.--Subsection (g) of that section is amended--
          (1) by inserting ``(1)'' before ``The Secretary'';
          (2) by redesignating paragraphs (1) and (2) of paragraph (1), 
        as designated by paragraph (1) of this subsection, as 
        subparagraphs (A) and (B) of that paragraph; and
          (3) by adding at the end the following new paragraphs:
    ``(2) In addition to the outreach activities under paragraph (1), 
the Secretary shall also provide outreach with respect to the 
following:
          ``(A) The existence of the program under this section.
          ``(B) The purpose of the program.
          ``(C) The availability under the program of medical 
        examinations and tests, and not medical treatment.
          ``(D) The findings of any published, peer-reviewed research 
        with respect to any associations (or lack thereof) between the 
        service of veterans in the Southwest Asia theater of operations 
        and particular illnesses or disorders of their spouses or 
        children.
    ``(3) Outreach under this subsection shall be provided any veteran 
who served as a member of the Armed Forces in the Southwest Asia 
theater of operations and who--
          ``(A) seeks health care or services at medical facilities of 
        the Department of Veterans Affairs; or
          ``(B) is or seeks to be listed in the Persian Gulf War 
        Veterans Registry.''.
    (d) Enhanced Flexibility in Examinations.--That section is further 
amended--
          (1) by redesignating subsections (i) and (j) as subsections 
        (k) and (l), respectively; and
          (2) by inserting after subsection (h) the following new 
        subsection (i):
    ``(i) Enhanced Flexibility in Examinations.--In order to increase 
the number of diagnostic tests and medical examinations under the 
program under this section, the Secretary may--
          ``(1) reimburse the primary physicians of spouses and 
        children covered by that subsection for the costs of conducting 
        such tests or examinations, with such rates of reimbursement 
        not to exceed the rates paid contract entities under subsection 
        (d) for conducting tests or examinations under the program;
          ``(2) conduct such tests or examinations of spouses covered 
        by that subsection in medical facilities of the Department; and
          ``(3) in the event travel is required in order to facilitate 
        such tests or examinations by contract entities referred to in 
        paragraph (1), reimburse the spouses and children concerned for 
        the costs of such travel and of related lodging.''.
    (e) Enhanced Monitoring of Program.--That section is further 
amended by inserting after subsection (i), as amended by subsection (d) 
of this section, the following new subsection (j):
    ``(j) Enhanced Monitoring of Program.--In order to enhance 
monitoring of the program under this section, the Secretary shall 
provide for monthly reports to the Central Office of the Department on 
activities with respect to the program by elements of the Department 
and contract entities under subsection (d).''.

                        TITLE III--MISCELLANEOUS

SEC. 301. ASSESSMENT OF ESTABLISHMENT OF INDEPENDENT ENTITY TO EVALUATE 
                    POST-CONFLICT ILLNESSES AMONG MEMBERS OF THE ARMED 
                    FORCES AND HEALTH CARE PROVIDED BY DOD AND VA 
                    BEFORE AND AFTER DEPLOYMENT OF SUCH MEMBERS.

    (a) Agreement for Assessment.--The Secretary of Veterans Affairs 
shall seek to enter into an agreement with the National Academy of 
Sciences, or other appropriate independent organization, under which 
agreement the Academy shall carry out the assessment referred to in 
subsection (b).
    (b) Assessment.--(1) Under the agreement, the Academy shall assess 
the need for and feasibility of establishing an independent entity to--
          (A) evaluate and monitor interagency coordination on issues 
        relating to the post-deployment health concerns of members of 
        the Armed Forces, including coordination relating to outreach 
        and risk communication, recordkeeping, research, utilization of 
        new technologies, international cooperation and research, 
        health surveillance, and other health-related activities;
          (B) evaluate the health care (including preventive care and 
        responsive care) provided to members of the Armed Forces both 
        before and after their deployment on military operations;
          (C) monitor and direct government efforts to evaluate the 
        health of members of the Armed Forces upon their return from 
        deployment on military operations for purposes of ensuring the 
        rapid identification of any trends in diseases or injuries 
        among such members as a result of such operations;
          (D) provide and direct the provision of ongoing training of 
        health care personnel of the Department of Defense and the 
        Department of Veterans Affairs in the evaluation and treatment 
        of post-deployment diseases and health conditions, including 
        nonspecific and unexplained illnesses; and
          (E) make recommendations to the Department of Defense and the 
        Department of Veterans Affairs regarding improvements in the 
        provision of health care referred to in subparagraph (B), 
        including improvements in the monitoring and treatment of 
        members referred to in that subparagraph.
    (2) The assessment shall cover the health care provided by the 
Department of Defense and, where applicable, by the Department of 
Veterans Affairs.
    (c) Report.--(1) The agreement shall require the Academy to submit 
to the committees referred to in paragraph (3) a report on the results 
of the assessment under this section not later than one year after the 
date of enactment of this Act.
    (2) The report shall include the following:
          (A) The recommendation of the Academy as to the need for and 
        feasibility of establishing an independent entity as described 
        in subsection (b) and a justification of such recommendation.
          (B) If the Academy recommends that an entity be established, 
        the recommendations of the Academy as to--
                  (i) the organizational placement of the entity;
                  (ii) the personnel and other resources to be 
                allocated to the entity;
                  (iii) the scope and nature of the activities and 
                responsibilities of the entity; and
                  (iv) mechanisms for ensuring that any recommendations 
                of the entity are carried out by the Department of 
                Defense and the Department of Veterans Affairs.
    (3) The report shall be submitted to the following:
          (A) The Committee on Veterans' Affairs and the Committee on 
        Armed Services of the Senate.
          (B) The Committee on Veterans' Affairs and the Committee on 
        National Security of the House of Representatives.
    Amend the title so as to read: ``A Bill to provide for the 
establishment of a presumption of service-connection for illnesses 
associated with service in the Persian Gulf War, to extend and enhance 
certain health care authorities relating to such service, and for other 
purposes.''.

    Amend the title so as to read: ``To provide for the 
establishment of a presumption of service connection for 
illnesses associated with service in the Persian Gulf War, to 
extend and enhance certain health care authorities relating to 
such service, and for other purposes.''.

                              Introduction

    On January 9, 1997, the Committee held the first of a 
series of three oversight hearings on Persian Gulf War issues. 
At the January 9, 1997, hearing, the Committee received the 
testimony of the Honorable Jesse Brown, Secretary of Veterans 
Affairs; Mr. George J. Tenet, then-Acting Director, Central 
Intelligence Agency; and Joyce C. Lashof, M.D., Chairperson, 
Presidential Advisory Committee on Persian Gulf War Veterans' 
Illnesses. In addition, the Committee accepted statements and 
correspondence for the record from the Honorable John C. White, 
Deputy Secretary of Defense, and The American Legion, the 
Veterans of Foreign Wars, and the Disabled American Veterans.
    On January 29, 1997, the Committee held a second oversight 
hearing on Persian Gulf War issues, and received the testimony 
of General H. Norman Schwarzkopf, U.S. Army (Retired), and the 
Honorable Bernard D. Rostker, Special Assistant to the Deputy 
Secretary of Defense for Gulf War Illnesses. In addition, the 
Committee accepted a statement for the record from the Non 
Commissioned Officers Association of the United States of 
America.
    On April 17, 1997, the Committee held a third oversight 
hearing on Persian Gulf War issues, and received the testimony 
of General Colin L. Powell, U.S. Army (Retired), former 
Chairman, Joint Chiefs of Staff.
    On October 24, 1997, the Ranking Minority Member of the 
Committee, Senator John D. Rockefeller IV, introduced S. 1320, 
the ``Persian Gulf War Veterans Act of 1997,'' with the 
cosponsorship of Senator Tom Daschle, Committee Member Daniel 
K. Akaka, Committee Member Paul Wellstone, and Committee Member 
Patty Murray. As introduced, S. 1320 would have provided for 
the establishment of a scientific basis for VA to assess the 
nature of the association between illnesses and exposure to 
toxic agents and environmental or other wartime hazards as a 
result of service in the Persian Gulf during the Persian Gulf 
War.
    On March 17, 1998, the Committee held an additional 
oversight hearing on Persian Gulf War issues, and received the 
testimony of Mark E. Gebicke, Director, Military Affairs and 
Operations, National Security and International Affairs 
Division, General Accounting Office; the Honorable Bernard D. 
Rostker, Special Assistant to the Deputy Secretary of Defense 
for Gulf War Illnesses; the Honorable Gary Christopherson, 
Acting Assistant Secretary of Defense, Health Affairs; Rear 
Admiral Michael L. Cowan, Deputy Director for Medical 
Readiness, Joint Chiefs of Staff, J-4 (Logistics), U.S. 
Department of Defense; Randolph F. Wycoff, M.D., M.P.H., 
Associate Commissioner for Operations, Food and Drug 
Administration; and Melissa A. McDiarmid, M.D., Associate 
Professor of Medicine, University of Maryland School of 
Medicine. That hearing focused on shortcomings in chemical and 
biological warfare medical preparedness during the Persian Gulf 
War, and on Department of Defense strategies for future 
deployments.
    In addition to the above-noted hearings, the Committee held 
field hearings on Persian Gulf War issues at the following 
sites on the dates noted: Pittsburgh, Pennsylvania, January 27, 
1997; Philadelphia, Pennsylvania, February 3, 1997; 
Wormleysburg, Pennsylvania, February 7, 1997; Huntington, West 
Virginia, April 2, 1997; Wheeling, West Virginia, April 3, 
1997; Kent, Washington, August 5, 1997; and Pittsburgh, 
Pennsylvania, November 20, 1997. At those hearings, testimony 
was received from Persian Gulf War veterans and their families 
and other interested persons.
    Finally, the Committee has otherwise conducted extensive 
oversight and investigative activities on Persian Gulf War 
issues during the 105th Congress. In the spring of 1997, the 
Committee established a bipartisan Special Investigation Unit 
(SIU) on Gulf War Illnesses which undertook, over a period 
exceeding 1 year, a thorough investigation and analysis of all 
issues related to Persian Gulf War veterans' illnesses and 
health problems. See Report of the Special Investigation Unit 
on Gulf War Illnesses, S. Prt. 105-39, September 1, 1998. In 
connection with this investigation, the SIU conducted numerous 
staff briefings, site visits, and personal interviews, as 
summarized in the SIU's report.
    On July 27, 1998, Senator Rockefeller introduced S. 2358, 
the ``Persian Gulf War Veterans Act of 1998,'' with the 
cosponsorship of the Chairman of the Committee, Senator Arlen 
Specter, Senator Robert C. Byrd, Senator Daschle, Senator Max 
Cleland, Senator Kent Conrad, Senator Murray, Senator John F. 
Kerry, Senator Christopher J. Dodd, Senator Herb Kohl, Senator 
Barbara A. Mikulski, Committee Member Y. Tim Hutchinson, 
Senator Wendell H. Ford, Committee Member Strom Thurmond, 
Committee Member Ben Nighthorse Campbell, and Committee Member 
James M. Jeffords. As introduced, S. 2358 would have provided 
for the establishment of a service connection for illnesses 
associated with service in the Persian Gulf War and would have 
extended and enhanced certain health care authorities relating 
to such service.

                           Committee Meeting

    After carefully reviewing the testimony from the foregoing 
hearings and the preliminary findings of the Special 
Investigation Unit on Gulf War Illnesses, the Committee met in 
open session on July 28, 1998, and voted unanimously to report 
S. 2358, with technical amendments as itemized above.

                     Summary of S. 2358 as Reported

    S. 2358 as reported (hereinafter referred to as the 
``Committee bill'') contains freestanding provisions and 
amendments to title 38, United States Code, that would:
          1. Authorize VA to determine by regulation that 
        illnesses specified by regulation shall be considered 
        to have been incurred in or aggravated by service in 
        the Persian Gulf during the Persian Gulf War, and to 
        determine by regulation the period or periods of time 
        after service during which such illnesses must have 
        become manifest in order to be considered to have been 
        incurred in or aggravated by service in the Persian 
        Gulf during the Persian Gulf War (section 101).
          2. Require that such determinations be based on sound 
        medical and scientific evidence that a positive 
        association exists between an exposure to biological, 
        chemical, or other toxic agent, environmental or 
        wartime hazard, or preventive medicine or vaccine known 
        or presumed to be associated with Persian Gulf War 
        service and the occurrence of a diagnosed or 
        undiagnosed illness (section 101).
          3. Require VA to seek to enter into an agreement with 
        the National Academy of Sciences (NAS) (or an alternate 
        scientific organization) to provide a medical and 
        scientific basis for making such determinations of 
        associations (section 102(b)).
          4. Require that NAS (or the alternate contractor) 
        identify biological, chemical, or other toxic agents, 
        environmental or wartime hazards, or preventive 
        medicines or vaccines to which Persian Gulf War 
        veterans may have been exposed (sections 102(c) and 
        (d)).
          5. Require that NAS (or the alternate contractor) 
        identify the chronic illnesses, including diagnosed and 
        undiagnosed illnesses, that are manifest in Persian 
        Gulf War veterans (section 102(c)).
          6. Require that NAS (or the alternate contractor) 
        make determinations, as possible, concerning (1) 
        whether associations exist between illness and 
        exposures to biological, chemical, or other toxic 
        agents, environmental or wartime hazards, or preventive 
        medicines or vaccines; (2) increased risks of 
        illnesses; and (3) whether there is a plausible 
        biological mechanism or evidence exists of a causal 
        relationship between the exposures and the illnesses 
        (section 102(e)).
          7. Require that NAS (or the alternate contractor) 
        assess potential treatment models for chronic 
        undiagnosed illnesses that have affected Persian Gulf 
        War veterans (section 102(f)).
          8. Require that NAS (or the alternate contractor) 
        provide recommendations to VA for additional research 
        to resolve areas of scientific uncertainty, and require 
        that, thereafter, VA, the Department of Defense (DOD), 
        and the Department of Health and Human Services (HHS) 
        jointly submit to Congress a report on their plans, if 
        any, to carry out the recommended research (sections 
        102(g) and 104).
          9. Require that VA, in consultation with DOD, 
        establish and operate a computerized information 
        database to collect, store and analyze information on 
        Persian Gulf War veterans' chronic diagnosed and 
        undiagnosed illnesses, and their health care 
        utilization patterns, and to report to the Congress 
        annually with respect to that data (section 103).
          10. Require that VA, in consultation with DOD and 
        HHS, conduct ongoing outreach programs to provide 
        information regarding health risks, health care, and 
        related benefits to Persian Gulf War veterans (section 
        105).
          11. Extend VA's authority to provide health care to 
        Gulf War veterans through December 31, 2001 (section 
        201).
          12. Extend and improve VA's program for the health 
        examination and evaluation of the spouses and children 
        of Persian Gulf veterans (section 202).
          13. Require that VA enter into an agreement with NAS 
        (or an alternate contractor) to carry out an assessment 
        of the need for, and feasibility of, establishing an 
        independent entity to evaluate and monitor interagency 
        coordination on issues relating to post-deployment 
        health concerns of members of the Armed Forces (section 
        301).

                               Discussion

       TITLE I: SERVICE CONNECTION FOR PERSIAN GULF WAR VETERANS

Section 101. Presumption of service connection for illnesses associated 
        with service in the Persian Gulf during the Persian Gulf War

            Background
    Veterans who sustain service-connected disabilities are 
entitled to benefits administered by VA including, among other 
benefits, compensation and priority access to health care 
services. Generally,veterans may gain eligibility for such 
benefits by demonstrating a link between their disability and their 
active military, naval, or air service. To establish such a link, the 
veteran must show, generally, that his or her disability results from 
an injury or disease that was incurred coincident with service.
    Certain diagnosed diseases are presumed, as a matter of 
law, to be service-connected if they manifest under conditions 
specified by statute. For example, chronic diseases specified 
in 38 U.S.C. Sec. 1101(3) will be presumed to be incurred in 
service, and they will give rise to a designation of service 
connection, if they manifest within 1 year of the veteran's 
separation from service. Other diagnosed diseases, e.g., 
tuberculosis, multiple sclerosis, etc., will be presumed 
service connected if they manifest within other periods of 
time. See 38 U.S.C. Sec. 1112. Underlying these statutory 
presumptions is a requirement that the veteran be diagnosed 
with the disease which is the subject of the statutory 
presumption in question.
    Many Gulf War veterans have experienced disabilities 
resulting from symptoms which elude traditional diagnostic 
categories. Such veterans had been at significant disadvantage 
when they sought a designation of service connection under 
standards that require an underlying diagnosis. As a 
consequence, VA is authorized by statute to provide 
compensation to Persian Gulf War veterans who suffer chronic 
disabilities resulting from undiagnosed illnesses that manifest 
within the time period specified by VA regulation. 38 U.S.C. 
Sec. 1117. Similarly, Persian Gulf War veterans are eligible 
for VA health care services on a priority basis if VA finds, as 
it has, that Persian Gulf War veterans may have been exposed to 
toxic substances or environmental hazards. This rule applies 
even though the veteran might be not be able to establish that 
the disability in question is associated with toxic or 
environmental exposures in the Persian Gulf theater of 
operations. 38 U.S.C. Sec. 1710 (e)(1)(C).
            Committee bill
    Section 101 of the Committee bill would codify VA authority 
to presume that a diagnosed or undiagnosed illness was incurred 
in service during the Persian Gulf War, despite the absence of 
evidence that the illness manifested during service, if the 
illness becomes manifest within the time period, if any, after 
service in the Gulf specified by VA regulation and if the 
illness is one that VA determines, by regulation, is associated 
with exposure to a biological, chemical, or other toxic agent, 
environmental or wartime hazard, or preventive medicine or 
vaccine known to be, or presumed to be, associated with service 
in the Persian Gulf War. VA would be required to determine such 
associations, if any, by reference to sound medical and 
scientific evidence as identified by the National Academy of 
Sciences (or an alternative scientific organization), as 
outlined below.

Section 102. Agreement with National Academy of Sciences

            Background
    As noted above, many Persian Gulf War veterans have 
experienced serious, unexplained health problems that many 
suspect are related to service in the Gulf. Servicemembers 
were, most assuredly, exposed to many agents that may have 
adversely affected their health. That said, there does not 
appear to be any single ``Gulf War syndrome.'' Rather, Persian 
Gulf War veterans contend with many symptoms and illnesses, the 
causes of which are unexplained at this time.
    The fact that the symptoms and illnesses of many Persian 
Gulf War veterans are unexplained is not due to a lack of 
effort. In 1991, Public Law 102-190 mandated that a registry be 
maintained of servicemembers exposed to fumes from burning oil 
wells in Kuwait. That statute also required that medical 
examinations be provided, on request, to any servicemember on 
the registry. Finally, Public Law 102-190 required, in 
addition, that DOD report to the Congress the results of all 
ongoing studies to determine the health consequences of such 
exposures, and that it make recommendations for additional 
studies.
    Subsequently, it became evident that exposure to fumes from 
burning oil wells in Kuwait was not the only potential 
environmental health hazard to which Persian Gulf War veterans 
had been exposed. As a consequence, Congress expanded, in the 
Veterans Health Care Act of 1992 (Public Law 102-585), the 
Persian Gulf War Veterans Health Registry, and authorized 
health examinations, blood and urine testing, and x-rays for 
all Persian Gulf veterans who requested such services. In 
addition, the statute required that VA and DOD contract with 
NAS' Medical Follow-Up Agency (MFUA) to secure a review of 
existing medical, scientific and other information on the 
health consequences of service in the Gulf, and to determine 
whether epidemiological studies ought to be commended by VA 
and/or DOD.
    In April 1994, the National Institutes of Health held a 
workshop on the health effects of service in the Gulf War. 
Participants concluded that they were unable to obtain 
sufficient information to draw conclusions with respect to the 
causes of illnesses experienced by Gulf War veterans.
    On May 26, 1995, the President established the Presidential 
Advisory Committee on Gulf War Veterans' Illnesses (PAC). The 
PACconducted a review of all Governmental activities related to 
Gulf War illness issues, including the conducting and financing of 
research, medical treatment activities, and outreach efforts, and 
issued reports in December 1996 and October 1997 that made several 
recommendations focused on the need to better understand--and, in the 
future, prevent--veterans' post-conflict health concerns.
    In 1997, the Committee assembled a Special Investigation 
Unit (SIU) on Gulf War Illnesses which conducted a year-long 
investigation on issues relating to Persian Gulf War illnesses. 
The Report of the Special Investigation Unit on Gulf War 
Illnesses, S. Prt. 105-39, found, among other things, that 
there was insufficient evidence, as of September 1998, to prove 
or disprove that Gulf War veterans were exposed to chemical 
weapon nerve agents, or that the health effects which some Gulf 
War veterans are experiencing were caused by such an exposure. 
The SIU did find, however, that there is reliable evidence that 
chemical weapons were present at least one site, Khamisiyah, 
and that previously unknown information continues to surface on 
Iraq's chemical weapons capabilities during the Persian Gulf 
War.
    Many Persian Gulf War veterans who are suffering from 
disabilities that appear to be related to service are still not 
being compensated. There is a great need to monitor these 
veterans--and those who still may exhibit disabilities in the 
future--to define more clearly the long-term health effects of 
Gulf War service. More importantly, there is a great need to 
treat these veterans, and to determine whether treatments 
provided are resulting in positive outcomes. The Committee's 
Special Investigation Unit found that progress in this regard 
has not been satisfactory, given the time and money expended on 
research.
            Committee bill
    Section 102 of the Committee bill would require VA to 
contract with NAS (or another independent scientific 
organization if VA is unable to reach an agreement with NAS) to 
provide a scientific basis for determining the association 
between illnesses and exposures to environmental or wartime 
hazards as a result of service in the Gulf War. NAS would be 
directed to identify biological, chemical, or other toxic 
agents, environmental or wartime hazards, or other preventive 
medicines or vaccines to which members of the Armed Forces who 
served in the Southwest Asia theater of operations during the 
Gulf War may have been exposed by reason of such service. NAS 
would be directed, further, to identify the chronic illnesses, 
including diagnosed and undiagnosed illnesses, that are 
manifest in Persian Gulf War veterans. In identifying such 
illnesses, NAS would be required to review and summarize the 
relevant scientific evidence regarding chronic illnesses among 
service members and other appropriate populations, and in 
making determinations of associations between agents and 
illnesses, NAS would be required to assess statistical 
associations between exposures and illnesses and to identify 
plausible biological mechanisms or other evidence of causal 
relationships between agents and illnesses.
    NAS would be directed to begin its analysis by reviewing 
initially a list of potential agents to which Persian Gulf War 
veterans may have been exposed. The Committee's purpose in 
specifying this list is not to limit NAS' consideration of 
potential causation factors; rather, it is intended to provide 
an initial blueprint to speed up the process of providing 
compensation and health care to veterans. In addition, NAS 
would be directed to assess potential treatment models for 
chronic undiagnosed illnesses that have affected Persian Gulf 
War veterans, and to make recommendations for additional 
research.

Section 103. Monitoring of health status and health care of Persian 
        Gulf War veterans

            Background
    The United States military failed, during the Persian Gulf 
War, to collect or preserve health and operations data which, 
in retrospect, would have been highly useful in advancing our 
understanding of the health problems faced by Gulf War 
veterans. The inability to retrieve such documents greatly 
hinders VA, DOD, and independent researchers' efforts to 
establish links between conditions in the Gulf and Gulf War 
veterans' symptoms and, thus, greatly hinders efforts to 
discover, and deliver, effective medical treatment to Gulf War 
veterans. It also impedes VA's timely processing of 
compensation claims.
            Committee bill
    Section 103 of the Committee bill would require VA, in 
consultation with DOD, to develop a plan for the creation of a 
single computerized database to collect, store, and analyze 
information regarding the health status of current and former 
members of the Armed Forces who served in the Southwest Asia 
theater of operations during Persian Gulf War. First, the 
information database would collect information on chronic 
diagnosed and undiagnosed illness suffered by Persian Gulf War 
veterans. Second, it would collect information on the health 
care utilization patterns of such veterans so that the health 
status of such veterans could be continuously and uniformly 
monitored. VA and DOD would be required to report annually to 
the Congress with respect to that data collected.

Section 104. Reports on recommendations for additional scientific 
        research

            Background
    As outlined above, the legislative and executive branches 
have attempted to address the needs of Persian Gulf War 
veterans. The common activities of all groups participating in 
that effort--VA, DOD, NAS' Medical Follow-Up Agency, NIH, the 
Presidential Advisory Committee on Gulf War Veterans' 
Illnesses, and the Committee's SIU--have been to study reports 
of undiagnosed and diagnosed illnesses among Gulf War veterans, 
to examine the environmental exposures that were present in the 
Gulf, to evaluate the biological plausibility of various 
illnesses, and to review the information available on the 
incidence and prevalence of these health problems.
            Committee bill
    As outlined above, section 102 of the Committee bill would 
set into motion an NAS analysis of, among other things, 
scientific research needs and priorities. Section 104 of the 
Committee bill would require VA, DOD, and HHS to submit a 
jointly prepared report in response to NAS recommendations 
concerning such issues. The Committee believes that veterans 
would be better served if all executive branch officials having 
an interest in Persian Gulf War veterans' issues would work in 
a coordinated fashion toward a common end.

Section 105. Outreach

    Section 105 of the Committee bill would require VA and DOD 
to consult with each other, and to consult with HHS, in 
developing coordinated, and ongoing, outreach programs to 
Persian Gulf War veterans, including active duty service 
members and members of the Reserve components. Such outreach 
programs would emphasize health risks resulting from the 
exposure to toxic agents, environmental or wartime hazards, or 
preventive medicines or vaccines associated with Persian Gulf 
War service, and services and benefits available to Persian 
Gulf War veterans. The Committee believes that evolving 
information about the diagnosis and treatment of Gulf War 
illnesses, research issues, and expanding services and benefits 
for Gulf War veterans, must be readily available to concerned 
veterans. As is the case with respect to research, a 
coordinated effort toward a common end by all concerned 
executive branch agencies would, in the Committee's view, 
advance the interests of Persian Gulf War veterans.

  title ii: extension and enhancement of persian gulf war health care 
                              authorities

    Title II of the Committee bill contains an amendment to 
title 38, United States Code, and a freestanding provision to 
extend and improve certain authorities, as outlined below.

Section 201. Extension of authority to provide health care for Persian 
        Gulf War veterans

            Background
    As described in some detail above, immediately after the 
Persian Gulf War--and even to this date--many of the health 
problems that affect Persian Gulf War veterans are not well 
understood. Nonetheless, it is the Committee's judgement that 
Persian Gulf War veterans should not be denied access to VA 
health care services on a priority basis pending the evolution 
of scientific understanding of the ills that affect many 
Persian Gulf War veterans. Accordingly, under the terms of 
Public Law 103-446, veterans who may have been exposed to toxic 
substances or environmental hazards in the Southwest Asia 
theater of operations during the Persian Gulf War are eligible 
for VA health care services on a priority basis. VA authority 
to provide access to care on that basis expires on December 31, 
1998. See 38 U.S.C. Sec. 1710(e)(3)(B).
            Committee bill
    Section 201 of the Committee bill would extend VA's 
authority to provide access to health care services on a 
priority basis to veterans who may have been exposed to toxic 
substances or environmental hazards in the Southwest Asia 
theater of operations during the Persian Gulf War through 
December 31, 2001.

Section 202. Extension and improvement of evaluation of health status 
        of spouses and children of Persian Gulf War veterans

            Background
    Generally, VA provides health care services to eligible 
veterans, not to eligible veterans' family members. 
Nonetheless, VA is authorized to evaluate the health status of 
Persian Gulf War veterans' spouses and children--though VA is 
not authorized to provide health care services to such 
persons--so that veterans' families may address concerns they 
may have regarding health problems associated with the 
veteran's service in the Gulf War. This authority, which 
included a statutory directive that VA evaluate the health 
status of Persian Gulf Warveterans' spouses and children and 
which authorized $2 million to fund such evaluations, is scheduled to 
expire on December 31, 1998.
    In March 1998, the General Accounting Office (GAO) issued a 
report, VA Health Care: Persian Gulf Dependents' Medical Exam 
Program Ineffectively Carried Out, which was critical of VA's 
implementation of the above-summarized statutory directive. 
Among other things, GAO recommended: (1) that VA simplify the 
process for requesting and scheduling evaluations; (2) that VA 
offer examinations at additional locations; (3) that VA seek 
authority to reimburse participants for travel expenses; and 
(4) that VA increase its capacity to monitor the implementation 
of the program.
            Committee bill
    Section 202 of the Committee bill would extend VA's 
authority to evaluate the health status of Persian Gulf War 
veterans' spouses and children, and extend the statutory 
directive that VA evaluate the health status of Persian Gulf 
War veterans' spouses and children until the expenditure of 
funds authorized for the study or until December 31, 2001. 
Further, it would mandate improved outreach activities and 
facilitate enhanced monitoring of program activities. Finally, 
it would authorize VA to reimburse the primary physicians of 
Persian Gulf War veterans' spouses and children for conducting 
tests and evaluations in furtherance of the mandate that VA 
evaluate the health status of Persian Gulf War veterans' 
spouses and children, and authorize the reimbursement of such 
spouses' and children's travel and lodging expenses in order to 
facilitate the medical testing and evaluation of such persons. 
The Committee is determined that the statutory directive of 
section 107 of Public Law 103-446 will be carried out.

                        title iii: miscellaneous

    Title III of the Committee bill contains a freestanding 
provision requiring VA to contract for a study to determine the 
need for, and the feasibility of, establishing an independent 
entity to evaluate post-conflict illnesses among veterans and 
health care services provided to such persons by VA and DOD, as 
outlined below.

Section 301. Assessment of establishment of independent entity to 
        evaluate post-conflict illnesses among members of the armed 
        forces and health care provided by DOD and VA before and after 
        deployment of such members

            Background
    In observing many of the health problems of Persian Gulf 
War veterans, many are reminded of past difficulties in 
understanding the post-conflict health problems of veterans of 
other military deployments. For example, for many years 
following the end of the conflict in Vietnam--and, to a certain 
extent, even to this day--there has been controversy relating 
to illnesses suffered by Vietnam veterans which are deemed to 
be related to exposures to certain herbicide agents in Vietnam. 
See 38 U.S.C. Sec. 1116.
    The primary mission of the Department of Defense is to the 
defense of the Nation. VA's mission is to care for veterans 
once they have left service. Most assuredly, both agencies have 
an abiding interest in minimizing avoidable environmental risks 
and investigating post-deployment illnesses. Neither agency, 
however, is charged with such activities as its primary 
mission.
            Committee bill
    Section 301 of the Committee bill would require VA to 
secure a study from NAS (or other appropriate independent 
organization) to assess the need (if any) for, and the 
feasibility of, the establishment of an independent entity to 
do the following: evaluate and monitor interagency coordination 
of issues relating to post-deployment health concerns of 
members the Armed Forces (including agencies' risk 
communications and outreach efforts to deployed personnel, and 
their recordkeeping, research, and health surveillance 
activities); evaluate health care services provided to members 
of the Armed Forces, both before and after deployment; monitor 
and direct post-deployment health evaluations; and provide and 
direct training to DOD and VA health care providers to assist 
in the evaluation and treatment of post-deployment maladies. 
NAS would be charged, further, with providing recommendations 
with respect to the organization, placement, and 
responsibilities of such an entity--if it were to recommend the 
establishment of such an independent entity at all.

                             Cost Estimate

    In compliance with paragraph 11(a) of rule XXVI of the 
Standing Rules of the Senate, the Committee, based on 
information supplied by the Congressional Budget Office (CBO), 
estimates that the costs resulting from the enactment of the 
Committee bill, as compared to costs under current law and as 
scored against the current CBO baseline for the first 5 years 
following enactment, would be as follows: direct spending would 
not increase in fiscal year 1999, but would increase by$40 
million in fiscal years 1999-2003. The bill would not affect the 
budgets of State, local, or tribal governments.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 31, 1998.
Hon. Arlen Specter,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 2358, the Persian 
Gulf War Veterans Act of 1998.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Charles 
Riemann.
            Sincerely,
                                         June E. O'Neill, Director.
    Enclosure.

S. 2358.--Persian Gulf War Veterans Act of 1998

    Summary: S. 2358 would provide a mechanism for establishing 
a service connection for illnesses associated with service in 
the Persian Gulf War and would extend and enhance certain 
health care authorities related to such service. CBO estimates 
that enacting the bill would increase direct spending by about 
$41 million over the 1999-2003 period; in addition, it would 
increase discretionary spending by $69 million in 1999 and by 
$342 million over the five-year period, assumingappropriation 
of the necessary amounts. Because the bill would raise direct spending, 
pay-as-you-go procedures would apply.
    The bill contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would not have a significant effect on the budgets of 
state, local, or tribal governments.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 2358 is shown in the following table. 
Direct spending costs would stem from payments for disability 
compensation and dependency and indemnity compensation (DIC). 
Discretionary spending would increase due to the provision of 
medical care services, assuming appropriation of the necessary 
amounts. The costs of this bill would fall within budget 
function 700 (veterans' affairs).

                                    [By fiscal year, in millions of dollars]
----------------------------------------------------------------------------------------------------------------
                                                   1998       1999       2000       2001       2002       2003
----------------------------------------------------------------------------------------------------------------
                                             DISABILITY COMPENSATION
Spending under current law:
    Estimated budget authority................     17,115     18,271     19,296     20,784     22,193     23,587
    Estimated outlays.........................     17,039     18,164     19,252     20,741     22,158     23,554
Proposed changes:
    Estimated budget authority................          0          0          0          0         10         30
    Estimated outlays.........................          0          0          0          0         10         30
Spending under S. 2358:
    Estimated budget authority................     17,115     18,271     19,296     20,784     22,203     23,617
    Estimated Outlays.........................     17,039     18,164     19,252     20,741     22,168     23,584
                                  EVALUATION OF DEPENDENTS OF GULF WAR VETERANS
Proposed changes:
    Estimated budget authority................          0      (\1\)      (\1\)      (\1\)          0          0
    Estimated outlays.........................          0      (\1\)      (\1\)      (\1\)          0          0
                                             VETERANS' MEDICAL CARE
Spending under current law:
    Estimated authorization level \2\.........     17,739     17,739     17,739     17,739     17,739     17,739
    Estimated outlays.........................     17,615     18,122     17,763     17,739     17,739     17,739
Proposed changes:
    Estimated authorization level.............          0         77        107        109         35         16
    Estimated outlays.........................          0         69        104        108         42         19
Spending under S. 2358:
    Estimated authorization level \2\.........     17,739     17,816     17,846     17,848     17,773     17,755
    Estimated outlays.........................     17,615     18,191     17,867     17,847     17,781     17,758
                                             TOTAL PROPOSED CHANGES
Direct spending:
    Estimated budget authority................          0      (\1\)      (\1\)      (\1\)         10         30
    Estimated outlays.........................          0      (\1\)      (\1\)      (\1\)         10         30
Spending subject to appropriation:
    Estimated authorization level.............          0         77        107        109         35         16
    Estimated Outlays.........................          0         69        104        108         42         19
----------------------------------------------------------------------------------------------------------------
\1\ Less than $500,000.
\2\ The 1998 level is the amount appropriated for that year. The current law amounts for 1999-2003 assume that
  appropriations remain at the 1998 level. If they are adjusted for inflation, the base amounts would rise by
  about $600 million a year, but the estimated changes would remain as shown.

    Disability compensation: Veterans of the Persian Gulf War 
are entitled to disability compensation under the same 
conditions as other veterans, but in addition, current law 
allows VA to award benefits to Gulf War veterans suffering from 
undiagnosed illnesses. In general, a veteran is eligible for 
disability compensation if a diagnosed illness becomes manifest 
during military service or during the one-year period following 
discharge--the so-called presumptive period. Gulf War veterans 
are also eligible for the benefit if they have an undiagnosed 
illness, but in those cases the presumptive period lasts, under 
current regulations, until 2001 for illnesses that have chronic 
symptoms. Based on those criteria and others, VA pays 
disability compensation to approximately80,000 Gulf War 
veterans out of the approximately 697,000 U.S. troops deployed to the 
Persian Gulf region during Operations Desert Shield and Desert Storm.
    S. 2358 would set up a mechanism for VA to establish a list 
of illnesses that would be presumed to have a connection to 
military service for Gulf War veterans. S. 2358 would establish 
a presumption, unless there is conclusive evidence to the 
contrary, that ailing Gulf War veterans were exposed to 
approximately 30 different agents, hazards, and vaccines listed 
in the bill if VA regulations associate exposure with the 
illness. The bill would provide that whenever VA determines 
that sound medical and scientific evidence points to a positive 
association between those exposures and diagnosed or 
undiagnosed diseases, VA shall prescribe regulations presuming 
that the illness is connected to military service if it occurs 
in a veteran during a time period to be also set by 
regulations. In making those determinations, VA would be 
required to consider several factors including reports by the 
National Academy of Science (NAS) that the bill would require. 
It would also allow VA to remove existing presumptions for 
illnesses that VA determines are not warranted based on a NAS 
report. (Individuals receiving benefits based on the existing 
presumption would continue to receive them.)
    S. 2358 would require that NAS determine whether exposure 
to an item on the list has statistical association with an 
illness, the increased risk of illness due to exposure, and the 
plausibility of a biological mechanism or other evidence of a 
causal relationship. Within 18 months of the bill's enactment, 
NAS would be required to identify the hazards faced by 
individuals who served in the theater of operations during the 
war and the illnesses that are manifest in such members. In 
addition, NAS would review potential treatment models for 
certain illnesses and make recommendations for additional 
scientific studies. NAS would also be required to conduct 
ongoing reviews of the evidence and data on exposures and 
illnesses associated with service during the Persian Gulf War.
    The bill would raise spending for disability compensation 
because it would increase VA's authority to determine what 
diseases are service connected for Gulf War veterans and when 
the disease must become manifest before it would pay benefits. 
The potential costs are increased by provisions that would 
define the standards that VA would use and that, under certain 
conditions, would grant a broad presumption of exposure to the 
agents, hazards, and vaccines. The statistical standard under 
the bill could lead to benefits for veterans whose exposure 
falls short of that which might be found to cause disease. It 
is also possible that veterans could suffer those diseases from 
causes apart from their service in the Gulf War--for example, 
hazards experienced in their subsequent civilian employment--
yet be eligible for compensation under the presumed linkages 
that could be established under the bill. Much would depend on 
medical research and the length of the presumptive periods 
determined by VA.
    The budgetary impact can vary widely depending on what NAS 
and other researchers find and how VA would use its discretion. 
CBO has no basis for estimating what medical research will 
uncover regarding the health effects of the agents, hazards, 
and vaccines listed in the bill. Under current law, roughly 
80,000 veterans who do not qualify based on income or diagnosed 
disabilities come to VA for medical care because of conditions 
related to service during the Gulf War. This population 
provides some indication of how many veterans might benefit 
from the bill--at least for illnesses that occur within 10 
years. Some of these veterans might not qualify under the bill 
for disability compensation, on the other hand others who do 
not come to VA for medical care might qualify--especially 
veterans whose ailments might occur many years from now. Thus, 
based on the average benefit currently paid to other Gulf War 
veterans--about $3,500 annually--the annual costs of S. 2358 
could be $300 million dollars a year or more, depending on the 
number of ailing veterans who seek medical care from VA. 
Because of the time it would take for the medical research, 
deliberations within VA, and manifestation of some diseases, 
the full budgetary impact of the bill might not be felt for 10 
to 20 years. CBO estimates that these provisions of the bill 
would raise direct spending by about $40 million over the 1999-
2003 period.
    Evaluation of health status of dependents of Gulf War 
veterans: Section 202 would extend the Persian Gulf Spouse and 
Children Examination Program until December 31, 2001. This 
program, which expires on December 31, 1998, requires VA to 
provide diagnostic testing and health examinations, but not 
treatment, to dependents of Gulf War veterans who volunteer for 
testing in order to study the association between illnesses of 
veterans and illnesses of their family members. In addition, 
this bill would require VA to conduct specific outreach 
activities to promote the program, reimburse private-sector 
physicians who provide health examinations in accordance with 
the program, and reimburse dependents for the costs of travel.
    A recent audit by the General Accounting Office found that 
VA has spent only $150,000 of the $2 million appropriated for 
the program in the 18 months that it has been operational. This 
spending covered the costs of 871 exams.
    CBO expects that VA's spending will accelerate over the 
three-year extension period but still be less than $500,000 
annually. VA currently has another 800 exams pending or in 
process. CBO expects that demand for such exams would increase 
as a result of the changes in reimbursement policies and 
outreach activities specified in this bill.
    Veterans' medical care: As shown in the following table, 
the bill contains several provisions that would raise spending 
for veterans' medical care, assuming appropriation of the 
necessary amounts.

----------------------------------------------------------------------------------------------------------------
                                                                       1999     2000     2001     2002     2003
----------------------------------------------------------------------------------------------------------------
                                       SPENDING SUBJECT TO APPROPRIATIONS
Proposed changes
    Special eligibility for priority care (section 201):
        Estimated authorization level..............................       74      101      105       27        0
        Estimated outlays..........................................       66       98      104       35        4
    Care for new compensation recipients (section 101):
        Estimated authorization level..............................        0        0        0        4       12
        Estimated outlays..........................................        0        0        0        3       11
    Scientific evaluations by the National Academy of Sciences
     (section 102):
        Estimated authorization level..............................        1        1        1        1        1
        Estimated outlays..........................................        1        1        1        1        1
    Database development (section 103):
        Estimated authorization level..............................        1        5        3        3        3
        Estimated outlays..........................................        1        5        3        3        3
    Study of independent entity (section 301):
        Estimated authorization level..............................        1        0        0        0        0
        Estimated outlays..........................................        1        0        0        0        0
    Total:
        Estimated authorization level..............................       77      107      109       35       16
        Estimated outlays..........................................       69      104      108       42       19
----------------------------------------------------------------------------------------------------------------

    Special eligibility for priority care.--Under current law, 
veterans with compensable service-connected disabilities or 
income below a certain threshold have priority access to VA 
medical care. In addition, current law grants all veterans who 
served in the Southwest Asia theater during the Gulf War 
priority for VA care until December 31, 1998. Section 201 would 
extend eligibility for priority care to these veterans until 
December 31, 2001. (Eligibility based on disability and income 
would remain part of permanent law.)
    CBO estimates that the cost of extending priority care 
under this bill would be $66 million in 1999 and $306 million 
over the three-year extension, assuming appropriation of the 
necessary amounts. CBO estimates that about 136,000 veterans 
would seek priority medical care annually under this bill. This 
estimate is based on the number of Gulf War veterans who 
received outpatient care from the VA through April 30, 1998, 
according to an analysis of VA's Patient Treatment File. But 
many of these veterans would already be eligible for priority-
level care based on service-connected disabilities or income. 
CBO assumes that 40 percent would qualify for priority care for 
those reasons, based on the proportion of Gulf War veterans 
that VA treated in 1996 who met those conditions. We estimate 
that the other 60 percent--roughly 80,000 veterans per year--
would receive additional care costing about $1,300 per person 
each year.
    Care for new compensation recipients.--Veterans awarded 
disability compensation under S. 2358 would thereby become 
eligible for priority medical care from VA. Such eligibility 
would not begin until 2002, when compensation benefits under 
this bill are first expected to be awarded. CBO estimates that 
discretionary medical spending would increase by $3 million in 
2002 and $11 million in 2003 based on assumptions similar to 
those described above for the extension of special eligibility 
of Gulf War veterans.
    Other provisions.--Section 102 would require VA to contract 
with NAS for a review and evaluation of the available 
scientific evidence regarding associations between illnesses 
and exposures among Gulf War veterans, a review of potential 
treatment models, and additional reviews on an ongoing basis. 
CBO estimates that implementing these provisions would result 
in outlays of about $1 million a year over the 1999-2003 
period.
    Section 103 would require VA, in consultation with the 
Department of Defense (DoD), to develop a plan for the creation 
of a computerized database to collect, store, and analyze 
information on the health status and health care of Gulf War 
veterans. The plan would be reviewed by NAS within one year of 
the bill's enactment and implemented by VA thereafter. Based on 
costs of similar databases, CBO estimates that this provision 
would result in outlays of about $1 million in 1999 and about 
$15 million over the 1999-2003 period.
    Section 301 would require VA to contract with NAS for 
recommendations on the establishment of an independent entity 
that would evaluate and monitor post-conflict illnesses of 
members of the armed forces. CBO estimates that this provision 
would result in $1 million in outlays in 1999, based on costs 
of NAS studies that are similar in scope.
    Section 105 would require VA and DoD to carry out ongoing 
outreach programs to provide Gulf War veterans with information 
about the health risks associated with service and any services 
or benefits available to them. CBO estimates that this 
provision would have no significant budgetary impact because VA 
is undertaking similar activities under current law.
    Pay-as-you-go considerations: Section 252 of the Balanced 
Budget and Emergency Deficit Control Act sets up pay-as-you-go 
procedures for legislation affecting direct spending or 
receipts. The net changes in outlays and governmental receipts 
that are subject to pay-as-you-go procedures are shown in the 
following table. For the purposes of enforcing pay-as-you-go 
procedures, only the effects in the current year, the budget 
year, and the succeeding four years are counted.

                                    [By fiscal year, in millions of dollars]
----------------------------------------------------------------------------------------------------------------
                                      1998   1999   2000   2001   2002   2003   2004   2005   2006   2007   2008
----------------------------------------------------------------------------------------------------------------
Changes in outlays.................      0      0      0      0     10     30     50     70     90    110    130
Changes in receipts................   (\1\
                                         )   (\1\
                                                )   (\1\
                                                       )   (\1\
                                                              )   (\1\
                                                                     )   (\1\
                                                                            )   (\1\
                                                                                   )   (\1\
                                                                                          )   (\1\
                                                                                                 )   (\1\
                                                                                                        )   (\1\
                                                                                                               )
----------------------------------------------------------------------------------------------------------------
\1\ Not applicable.

    Intergovernmental and private-sector impact: The bill 
contains no intergovernmental or private-sector mandates as 
defined in the Unfunded Mandates Reform Act of 995 and would 
not have a significant effect on the budgets of state, local, 
or tribal governments.
    Previous CBO estimate: On July 6, 1998, CBO prepared a cost 
estimate for H.R. 3980 as ordered reported by the House 
Committee on Veterans' Affairs. Section 2 of that bill is 
similar to section 201 of S. 2358 because both sections would 
extend VA's authority to provide medical care to certain Gulf 
War veterans. The cost estimates for that provision are the 
same. H.R. 3980 would extend similar authority to VA for 
veterans of future wars or conflicts, but CBO is unable to 
estimate those costs.
    Estimate prepared by: Federal costs: Charles Riemann 
(compensation) and Shawn Bishop (health care); impact on State, 
local, and tribal governments: Marc Nicole; and impact on the 
private sector: Rachel Schmidt.
    Estimate approved by: Paul N. Van de Water, Assistant 
Director for Budget Analysis.

                      Regulatory Impact Statement

    In compliance with paragraph 11(b) of rule XXVI of the 
Standing Rules of the Senate, the Committee on Veterans' 
Affairs has made an evaluation of the regulatory impact which 
would be incurred in carrying out the Committee bill. The 
Committee finds that the Committee bill would not entail any 
significant regulation of individuals or businesses or result 
in any significant impact on the personal privacy of any 
individuals, and that the paperwork resulting from enactment 
would be minimal.

                 Tabulation of Votes Cast in Committee

    In compliance with paragraph 7 of rule XXVI of the Standing 
Rules of the Senate, the following is a tabulation of votes 
cast in person or by proxy by members of the Committee on 
Veterans' Affairs at its July 28, 1998, meeting. On that date, 
the Committee, by unanimous voice vote, ordered S. 2358, as 
amended, reported favorably to the Senate.

                              Agency Report

Letter from Hon. Donna E. Shalala, Secretary, Department of Health and 
Human Services, to Hon. Arlen Specter, Chairman, U.S. Senate Committee 
                          on Veterans' Affairs

           Department of Health and Human Services,
                                   Office of the Secretary,
                                Washington, DC, September 23, 1998.
Hon. Arlen Specter,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: We take this opportunity to inform you 
of the views of the Department of Health and Human Services 
(HHS) on S. 2358, a bill entitled the ``Persian Gulf War 
Veterans Act of 1998''.
    In summary, HHS has concerns about the bill's mechanism for 
reviewing and evaluating the available scientific evidence 
regarding associations between exposures and illnesses among 
Gulf War veterans and its ability to produce a scientifically 
credible assessment in the time frame allowed. HHS also has 
concerns about the feasibility of implementing the single 
computerized information database in the time frame allowed and 
cautions that a number of issues, including privacy issues, 
need to be carefully considered.
    The bill would create a mechanism for determining 
presumption of service connection for illnesses among Gulf War 
veterans. Illnesses found to have a positive association with 
exposures encountered during the Gulf War would be considered. 
to have been incurred in or aggravated by Gulf War service even 
absent evidence that the illness occurred during the period of 
service. An illness would be deemed to be positively associated 
with exposures even where the evidence for the association was 
merely equal to, and not greater than, the evidence against the 
association. The bill would require the Department of Veterans 
Affairs (VA) to enter into a contract with the National Academy 
of Sciences to review and evaluate the available scientific 
evidence regarding associations between exposures and 
illnesses. The Academy's first report regarding the 
determination of associations would be issued within 18 months 
after enactment of the bill.
    HHS is concerned that the bill would establish a process 
entailing a review of extremely complex questions, with 
fragmentary data, in a short time, and yielding results that 
may give the appearance of scientific conclusions where no such 
conclusions would be valid. The scientific determination of the 
association between exposure to environmental, infectious, 
chemical, and other toxic agents and adverse health effects is 
extremely complex. The health impact of such exposures depends 
on many factors including the specific agent(s), dose and 
duration of exposure, and the health of those exposed. Genetic 
variability may also increase or decrease susceptibility to 
environmental exposures. Associations determined through animal 
research may not apply to human exposures. It is also our 
understanding that there are only fragmentary data about which 
service personnel were exposed to which agents, in what 
concentrations, and over what period of time.
    Given this complexity, we believe it would be very 
difficult for the Academy to produce meaningful conclusions on 
all of the issues specified by the bill regarding the health 
impact of military service in the Gulf War, especially within 
the time frame provided in the bill. Also, we are concerned 
that the process would result in determinations that would give 
the appearance of scientific conclusions, even though the data 
would not support a conclusion with the degree of certainty 
that science normally requires.
    S. 2358 would also require the VA and the Department of 
Defense (DoD) to create a unified computerized information data 
base, within 18 months after the date of enactment of the Act, 
to document the health status of Gulf War veterans and their 
health care utilization patterns. Merger of such large data 
bases raises substantial privacy concerns. Persons who have 
access to the data base (whether properly or improperly) would 
learn much more information than they would with access to only 
one of the original data bases. It would be appropriate to 
consider who will maintain the data base, who will have access 
to the data, what uses of the data will be permitted, how the 
validity of the data will be ensured, and how the privacy of 
the data base will be protected. However, the bill makes no 
provision for such concerns.
    The bill would also require the Secretary of HHS to consult 
with the Secretaries of Veterans Affairs and Defense in their 
outreach to Gulf War veterans. HHS supports such outreach 
efforts and agrees that there is a need to improve health risk 
communication efforts for all military personnel. Current 
outreach efforts which are already coordinated among the three 
Departments are broad and comprehensive, and fulfill the intent 
of this provision of the bill. HHS has already been consulting 
with VA and DoD on health risk communication through the 
activities of the Persian Gulf Veterans Coordinating Board. 
Interagency planning for future military deployments, as 
documented in the Presidential Review Directive-5 (``A National 
Obligation: Planning for Health Preparedness for and 
Readjustment of the Military, Veterans. and Their Families 
afterFuture Deployments'') has given improved health risk 
communication a central role.
    In summary, HHS has some concerns regarding some of the 
specific components of S. 2359, and we defer to the judgment of 
VA (as expressed in VA's September 3, 1998, report to you) 
regarding the bill.
    The Office of Management and Budget has advised that there 
is no objection to the presentation of this report from the 
standpoint of the Administration's program.
            Sincerely,
                                       Donna E. Shalala, Secretary.
                              ----------                              


letter from the Department of Defense to Hon. Arlen Specter, Chairman, 
               U.S. Senate Committee on Veterans' Affairs

                             Department of Defense,
                                    General Counsel Office,
                                Washington, DC, September 16, 1998.
Hon. Arlen Specter,
Chairman, Committee on Veterans' Affairs
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: We are pleased to provide the Committee 
with the views of the Department of Defense on S. 2358, 105th 
Congress, a bill ``To provide for the establishment of a 
service-connection for illnesses associated with service in the 
Persian Gulf War, to extend and enhance certain health care 
authorities relating to such service, and for other purposes.''
    The Department of Defense supports the measure in part. In 
particular, the Department welcomes any recommendations the 
National Academy of Sciences may have on additional scientific 
studies to resolve areas of continuing scientific uncertainty 
regarding the health consequences of Gulf War service.
    The Department of Defense has considerable concerns about 
several other elements of S. 2358. In particular, the 
Department opposes section 301 which would undermine the 
authority and responsibility of the Secretary of Defense to 
support the health and safety of service men and women, 
following and during current and future force deployments. Our 
concerns about this element and our other concerns are 
contained in the attachment.
    The Office of Management and Budget advises that, from the 
standpoint of the Administration's program, there is no 
objection to the presentation of this report for the 
consideration of the committee.
            Sincerely,
                                                  Judith A. Miller.
    Attachment.

Department of Defense Comments on Provisions of S. 2358 Persian Gulf 
        War Veterans Act of 1998

    Sections 101 and 102 of the bill would call for presumption 
of service connection for any veteran from the Gulf War with 
any diagnosed or undiagnosed illness which could be in any way 
associated with or deemed caused by exposure to any of a list 
of materials which includes organophosphorous, carbamate, 
chlorinated hydrocarbon, and other pesticides and repellents, 
PB, Sarin, Tabun, low-level mustard agents, VOCs, solvents, 
Uranium ionizing and non-ionizing radiation, oil fire 
byproducts, sand, etc. as determined by a scientific panel. 
Given the comprehensive nature of the current ongoing efforts 
supporting the establishment of an objective basis for making 
the determinations regarding service connection of illnesses 
suffered by Gulf War veterans, the Department of Defense 
considers the enactment of sections 101 and 102 of S. 2358 as 
being unnecessary and without regard for current scientific 
standards of association.
    The establishment of only a ``positive association'' for a 
particular outcome does not take into account current 
scientific standards of association and cause and effect 
relationships in determining the etiology of disease, may 
require determinations based on very limited evidence, and 
fails to consider the dose-response relationship. A dose-
response relationship is critical if one were to consider 
disease outcome based on presumed exposure to the list of 
agents contained in the bill. This presumption would limit the 
ability to conduct scientific research to determine if actual 
exposures during the Gulf War resulted in adverse health 
outcomes and development of preventive measures to negate such 
exposures during future conflicts. The legislation alsoimplies 
the existence of deleterious health effects (without scientific basis) 
from the use of health-preserving vaccines.
    The overuse of animal studies in making a determination of 
``positive association'' of disease outcome in humans is 
inappropriate. Although animal studies can be used to determine 
biological plausibility that a certain health outcome has the 
potential to occur in human populations, such studies cannot be 
used to make a presumption of such an association in humans. 
The Department of Veterans Affairs has stated that human 
epidemiologic studies are often ineffective in establishing a 
``cause and effect'' determination and principles of bio-ethics 
prohibit exposing human research subjects to harmful toxins. 
Thus, it is only possible to establish ``association'' in 
epidemiologic studies. In addition, references throughout the 
section refer to a concept of undiagnosed illnesses in animal 
models, a concept currently not accepted by the scientific 
community.
    The Department of Defense defers to the judgment of the 
Department of Veterans Affairs regarding the proper scientific 
standard to be used in determining service connection of the 
illnesses suffered by Gulf War veterans.
    The Department of Defense supports the involvement of the 
National Academy of Sciences to evaluate scientific and medical 
evidence regarding health outcomes among Gulf War veterans. 
However, we do not support the inclusion for evaluation by the 
NAS of the list of specific agents contained in section 102 of 
S. 2358 and suggest that the entire list be deleted and that 
the NAS be directed to determine which exposures are relevant 
for evaluation/study. This list is inconsistent and inaccurate. 
Some agents are omitted while others are listed twice or 
inappropriately categorized; the designation of uranium as a 
``synthetic chemical compound'' is incorrect and the category 
of ionizing radiation is in error as it includes non-ionizing 
types of radiation.
    The Department of Defense is committed to an aggressive, 
coordinated, well-focused, but broadly scoped and strong Gulf 
War veterans' illnesses research program that does the 
following: furthers the fundamental understanding of the 
illnesses; provides enhanced diagnostic capabilities and 
efficacious treatment modalities for veterans; and supports the 
establishment of policies and preventive measures that minimize 
the risk of such illnesses during future military operations.
    We also are committed to ensuring that our research program 
is of the highest quality. We use competition and independent 
review for scientific merit to secure the very best research 
performers, hypotheses, and experimental designs, from all 
possible sources, including the Federal, civilian, national and 
international communities. This commitment follows an 
appreciation at all levels within the Department of Defense of 
our responsibility to achieve an optimal investment of taxpayer 
dollars, to assist our Gulf War veterans in securing diagnoses 
and treatments for their disabilities and illnesses, and to 
prevent such disabilities and illnesses as a consequence of 
future deployments.
    Our research program and findings on Gulf War veterans 
illnesses are coordinated and integrated with those of the 
Department of Veterans Affairs and Health and Human Services 
through the Research Working Group of the Persian Gulf 
Veterans' Coordinating Board.
    Section 103 of S. 2358 would require the development of a 
plan for a single computerized information database to amass 
and analyze information on diagnosed and undiagnosed illnesses 
among Gulf War veterans and submit an annual report to Congress 
on the data and the findings and analysis relating to such 
data. The Department of Defense strongly opposes these 
requirements. Such a database would duplicate ongoing efforts 
established under section 734 of the National Defense 
Authorization Act for Fiscal Years 1992 and 1993 (10 U.S.C. 
1074). Collecting data on illnesses among Gulf War veterans 
seeking care outside the Department of Defense and the 
Department of Veterans Affairs medical departments, i.e. 
private sector, is neither feasible nor desirable. Capturing 
medical data from the private sector on health outcomes and 
treatment efficacy for Gulf War veterans and their families 
would require the establishment of a national computerized 
medical record or a laborious review of dispersed medical 
records from hospitals and doctor's offices around the world. 
Even if a comprehensive medical database were established, it 
may not yield the desired information on health outcomes and 
treatment efficacy. The costs associated with such a 
requirement would be prohibitive.
    The Department of Defense in collaboration with the 
Department of Veterans Affairs has an ongoing contract with the 
National Academy of Sciences, Institute of Medicine, on how to 
best measure the health and treatment outcomes of Gulf War 
veterans. The Department of Defense looks forward to the 
recommendations from the National Academy of Sciences, 
Institute of Medicine, and feels any efforts that might 
circumvent the Academy's ongoing efforts are both premature and 
inappropriate.
    Section 104 of S. 2358 would require the Departments of 
Defense, Veterans Affairs, and Health and Human Services to 
jointly submit a report addressing in detail the 
recommendations of the National Academy of Sciences concerning 
the need for additional scientificstudies and the Departments' 
responses to those recommendations. The Department of Defense welcomes 
any recommendations the National Academy of Sciences may have on 
additional scientific studies to resolve areas of continuing scientific 
uncertainty regarding the health consequences of Gulf War service.
    Section 105 of S. 2358 would require continuation of 
ongoing outreach for Gulf War veterans. We support this 
provision, however any intent to increase and enhance current 
efforts would require that the Department of Defense dedicate 
staff above current levels.
    Section 201 of S. 2358 would end existing authority for the 
Department of Veterans Affairs to provide health care for Gulf 
War veterans. The Department of Defense supports efforts 
extending special authority to provide care for Gulf War 
veterans for any disability possibly related to their service 
in the theater of operations, rather than requiring evidence of 
particular exposures. Using data from the Comprehensive 
Clinical Evaluation Program is inappropriate from a research 
standpoint in that it is derived from a self-selected 
population and excludes the majority of Gulf War veterans.
    Section 301 of S. 2358 would require the Department of 
Veterans Affairs to assess establishment of an agreement with 
the National Academy of Sciences to evaluate the need for, and 
feasibility of establishing, an independent entity to evaluate 
and monitor interagency coordination on issues relating to the 
post-deployment health concerns of members of the Armed Forces; 
evaluate the health care provided to members of the Armed 
Forces both before and after their deployment on military 
operations; monitor and direct governmental efforts to evaluate 
the health of members of the Armed Forces upon their return 
from deployment on military operations for purposes of ensuring 
rapid identification of any trend in diseases or injuries among 
them as a result of such operations; provide and direct other 
provision of ongoing training of health care personnel of the 
Department of Defense and Department of Veterans Affairs; and 
make recommendations to the Department of Defense and 
Department of Veterans Affairs regarding improvements in 
providing health care, including improved monitoring and 
treatment of military members.
    The Department of Defense strongly opposes section 301 of 
the bill. The proposed action would seriously undermine the 
authority and responsibility of the Secretary of Defense to 
support the health and safety of service men and women, 
following and during current and future force deployments. It 
is entirely inappropriate for the National Academy of Sciences 
to be directed to make what is essentially a Federal government 
policy decision. The National Academy of Sciences consistently 
has supported the Department of Defense's response to Gulf War 
health issues, and the National Academy of Sciences' 
recommendations for program enhancements have been implemented 
as appropriate.

          Changes in Existing Law Made by S. 2358 as Reported

    In compliance with paragraph 12 of rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
the Committee bill, as reported, are shown as follows (existing 
law proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

TITLE 38, UNITED STATES CODE

           *       *       *       *       *       *       *


                       PART II--GENERAL BENEFITS

   CHAPTER 11--COMPENSATION FOR SERVICE-CONNECTED DISABILITY OR DEATH

          * * * * * * *

             Subchapter II--Wartime Disability Compensation

1110. * * *
     * * * * * * *
1118. Presumptions of service connection for illnesses associated 
          withservice in the Persian Gulf during the Persian Gulf War.
     * * * * * * *

Subchapter II--Wartime Disability Compensation

           *       *       *       *       *       *       *


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, [or 
1117] 1117, or 1118 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 [or1116], 1116, or 1118 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, [or 1117] 1117, or 1118 
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, or air 
service.

           *       *       *       *       *       *       *


Sec. 1117. Compensation for disabilities occurring in Persian Gulf War 
                    veterans

    (a) * * *

           *       *       *       *       *       *       *

    (c)(1) Whenever the Secretary determines under section 
1118(c) of this title that a presumption of service connection 
for an undiagnosed illness (or combination of undiagnosed 
illnesses) previously established under this section is no 
longer warranted--
          (A) a veteran who was awarded compensation under this 
        section for such illness (or combination of illnesses) 
        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 10 years 
after the first day of the fiscal year in which the National 
Academy of Sciences submits to the Secretary the first report 
under section 102 of the Persian Gulf War Veterans Act of 1998.
    [(c)](d)(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)] (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.
    [(e)] (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 during 
the Persian Gulf War.

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.
    (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 102 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 102 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 Secretarys 
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 
10 years after the first day of the fiscal year in which the 
National Academy of Sciences submits to the Secretary the first 
report under section 102 of the Persian Gulf War Veterans Act 
of 1998.

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


Subchapter II--Hospital, Nursing Home, or Domiciliary Care and Medical 
                               Treatment

Sec. 710. Eligibility for hospital, nursing home, and domiciliary care

    (a) * * *

           *       *       *       *       *       *       *

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

           *       *       *       *       *       *       *

    (3) Hospital care, medical services, and nursing home care 
may not be provided under or by virtue of subsection 
(a)(2)(F)--
          (A) * * *
          (B) in the case of care for a veteran described in 
        paragraph (1)(C), after [December 31, 1998] December 
        31, 2001.

           *       *       *       *       *       *       *

                              ----------                              


              VETERANS' BENEFITS IMPROVEMENTS ACT OF 1994

TITLE I--PERSIAN GULF WAR VETERANS

           *       *       *       *       *       *       *


SEC. 107. EVALUATION OF HEALTH STATUS OF SPOUSES AND CHILDREN OF 
                    PERSIAN GULF WAR VETERANS.

    (a) * * *
          (1) * * *

           *       *       *       *       *       *       *

          (3) * * *
    [Such testing and examinations shall be carried out so as 
to gather such medical data as the Secretary considers relevant 
and appropriate in order to determine the nature and extent of 
the association, if any, between illness or disorder of the 
spouse or child and the illness of the veteran.]
    (b) Duration of Program. The program shall be carried out 
during the period beginning on November 1, 1994, and [ending on 
December 31, 1998.] ending on the earlier of--
          (1) the date of the completion of expenditure of 
        funds available for the program under subsection (c); 
        or
          (2) December 31, 2001.

           *       *       *       *       *       *       *

    (g) Outreach.--(1) The Secretary shall conduct such 
outreach activities as the Secretary determines necessary to 
ensure that implementation of this section results in 
sufficient information to enable the Secretary--
          [(1)] (A) to analyze the health status of large 
        numbers of spouses and children of Persian Gulf 
        veterans; and
          [(2)] (B) to formulate research hypotheses regarding 
        possible association between illnesses or disorders 
        suffered by Persian Gulf veterans and illnesses or 
        disorders (including birth defects, miscarriages, and 
        stillbirths) suffered by their spouses and children.
    (2) In addition to the outreach activities under paragraph 
(1), the Secretary shall also provide outreach with respect to 
the following:
          (A) The existence of the program under this section.
          (B) The purpose of the program.
          (C) The availability under the program of medical 
        examinations and tests, and not medical treatment.
          (D) The findings of any published, peer-reviewed 
        research with respect to any associations (or lack 
        thereof) between the service of veterans in the 
        Southwest Asia theater of operations and particular 
        illnesses or disorders of their spouses or children.
    (3) Outreach under this subsection shall be provided any 
veteran who served as a member of the Armed Forces in the 
Southwest Asia theater of operations and who--
          (A) seeks health care or services at medical 
        facilities of the Department of Veterans Affairs; or
          (B) is or seeks to be listed in the Persian Gulf War 
        Veterans Registry.
    (h) * * *
    (i) Enhanced Flexibility in Examinations.--In order to 
increase the number of diagnostic tests and medical 
examinations under the program under this section, the 
Secretary may--
          (1) reimburse the primary physicians of spouses and 
        children covered by that subsection for the costs of 
        conducting such tests or examinations, with such rates 
        of reimbursement not to exceed the rates paid contract 
        entities under subsection (d) for conducting tests or 
        examinations under the program;
          (2) conduct such tests or examinations of spouses 
        covered by that subsection in medical facilities of the 
        Department; and
          (3) in the event travel is required in order to 
        facilitate such tests or examinations by contract 
        entities referred to in paragraph (1), reimburse the 
        spouses and children concerned for the costs of such 
        travel and of related lodging.
    (j) Enhanced Monitoring of Program.--In order to enhance 
monitoring of the program under this section, the Secretary 
shall provide for monthly reports to the Central Office of the 
Department on activities with respect to the program by 
elements of the Department and contract entities under 
subsection (d).
    [(i)] (k) Reports to Congress.--(1) The Secretary shall 
submit to Congress no later than October 31, 1995, a report on 
the Secretary's implementation of this section.
    (2) The Secretary shall analyze the data entered into the 
registry under this section and shall submit to Congress, not 
later than March 1, 1997, a report on that analysis and on the 
Secretary's recommendation for any further legislation or 
studies regarding the health status of spouses and children of 
Persian Gulf War veterans.
    [(j)] (l) Definitions.--For purposes of this section, the 
terms ``child'' and ``spouse'' have the meanings given those 
terms in paragraphs (4) and (31), respectively, of section 101 
of title 38, United States Code.

           *       *       *       *       *       *       *