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[Senate Report 111-189]
[From the U.S. Government Publishing Office]

                                                       Calendar No. 377
111th Congress                                                   Report
                                 SENATE
 2d Session                                                     111-189

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

 
   EXAMINATION OF EXPOSURES TO ENVIRONMENTAL HAZARDS DURING MILITARY 
SERVICE AND HEALTH CARE FOR CAMP LEJEUNE AND ATSUGI NAVAL AIR FACILITY 
                VETERANS AND THEIR FAMILIES ACT OF 2010

                                _______
                                

                  May 17, 2010.--Ordered to be printed

                                _______
                                

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

                              R E P O R T

                             together with

                           SUPPLEMENTAL VIEWS

                         [To accompany S. 3378]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee'') unanimously reports favorably, without amendment, 
an original bill to authorize health care for certain 
individuals exposed to environmental hazards at Camp Lejeune 
and the Atsugi Naval Air Facility, to establish an advisory 
board to examine exposures to environmental hazards during 
military service, and for other purposes, and recommends that 
the bill do pass.

                              INTRODUCTION

    On January 28, 2010, the Committee met in open session to 
consider a number of measures pending before the Committee, 
including an original measure proposed by Chairman Daniel K. 
Akaka to authorize health care for certain individuals exposed 
to environmental hazards at Camp Lejeune, North Carolina, and 
the Atsugi Naval Air Facility (hereinafter, ``NAF Atsugi'') in 
Japan, to establish an advisory board to examine exposures to 
environmental hazards during military service, and for other 
purposes.
    Earlier, on July 27, 2009, Committee Ranking Member Richard 
Burr introduced S. 1518, the proposed ``Caring for Camp Lejeune 
Veterans Act of 2009.'' Later Senators Begich, Burris, Byrd, 
Feingold, Graham, Grassley, Hagan, Harkin, Isakson, Johanns, 
LeMieux, Lincoln, Nelson (FL), Stabenow, and Wicker were added 
as cosponsors. S. 1518 would amend title 38, United States 
Code, to authorize the Department of Veterans Affairs 
(hereinafter, ``VA'') to furnish hospital care, medical 
services, and nursing home care to veterans who were stationed 
at Camp Lejeune, North Carolina, while the water was 
contaminated at Camp Lejeune.
    On October 21, 2009, the Committee held a hearing on the 
above-mentioned bill and other veterans-related legislation. 
Testimony was offered on S. 1518 by: Gerald M. Cross, MD, 
FAAFP, Acting Under Secretary for Health, Veterans Health 
Administration, Department of Veterans Affairs; Robert Jackson, 
Assistant Director, National Legislative Service, Veterans of 
Foreign Wars of the United States; and Ian de Planque, 
Assistant Director for Claims Service, The American Legion.

                           COMMITTEE MEETING

    After carefully reviewing the testimony from the foregoing 
hearing, the Committee met in open session on January 28, 2010, 
to consider, among other legislation, the original bill, 
consisting of provisions from S. 1518, and several freestanding 
provisions. The Committee voted, without dissent, to report 
favorably the original bill.

                SUMMARY OF THE ORIGINAL BILL AS REPORTED

    The original bill as reported (hereinafter, ``the Committee 
bill''), would authorize health care for certain individuals 
exposed to environmental hazards at Camp Lejeune and the Atsugi 
Naval Air Facility and establish an advisory board to examine 
exposures to environmental hazards during military service.

                       BACKGROUND AND DISCUSSION

    In a few specific instances, Congress has acted to provide 
benefits and health care to veterans who may have been exposed 
to environmental hazards during their military service. 
Generally, these benefits and health care services have been 
provided after Congress determined that there was sufficient 
evidence to link certain disabilities to an environmental 
hazard or hazards. On a few other occasions, Congress has 
extended health care and benefits to the children of 
servicemembers and veterans based on a concern that they were 
born more susceptible to certain diseases or conditions because 
of a parent's exposure to an in-service environmental 
hazard.
    What has emerged from this process is a largely piecemeal 
approach to addressing environmental exposures--with Congress, 
VA, and the National Academy of Sciences (hereinafter, ``NAS'') 
each playing a role.
    Not addressed in Congress' prior actions on environmental 
exposures are those exposures that have occurred only on 
military installations and that may affect not only 
servicemembers and veterans, but also their dependents who 
reside with them on or near a particular installation.
    Background. Since Congress began legislating on 
environmental hazards, it has taken a piecemeal approach to 
addressing military exposures. It became apparent at the 
Committee's October 8, 2009, hearing on VA and DOD's Response 
to Certain Military Exposures that such an approach to 
allegations of exposure during military service was not the 
most effective or appropriate approach. One point that was 
clear in that hearing was that Congress has historically not 
been an effective forum for resolving scientific questions of 
environmental exposures or the consequences of such exposures.
    Four exposures were specifically addressed during the 
hearing: exposure to smoke from an incinerator at the Naval Air 
Facility Atsugi in Japan; water contamination at Camp Lejeune; 
exposure to sodium dichromate at the Qarmat Ali Water Treatment 
Plant in Iraq; and burn pit exposures during the current 
conflicts in Iraq and Afghanistan. The exposures at NAF Atsugi 
and Camp Lejeune presented questions that were both significant 
and unprecedented because of alleged exposures to the 
dependents of active duty military personnel.
    Camp Lejeune: Marine Corps base Camp Lejeune is an active 
military base located on 236 square miles of land in Onslow 
County, North Carolina, adjacent to the southern side of the 
City of Jacksonville. It was commissioned in 1942 as a training 
area to prepare Marines for combat. It is the major East Coast 
base of the U.S. Marine Corps.
    As explained by the Government Accountability Office 
(hereinafter, ``GAO''), the drinking water at Camp Lejeune is 
obtained from groundwater pumped from a freshwater aquifer 
located approximately 180 feet below the ground. Groundwater is 
pumped through wells located near the water-treatment plant. 
After the water is treated, it is stored in ground and elevated 
storage reservoirs. When needed, treated water is pumped from 
the reservoirs 
and tanks to facilities such as offices, schools, or houses on t
he base.
    According to the U.S. Marine Corps, Camp Lejeune officials 
first became aware of volatile organic compounds (hereinafter, 
``VOCs'') in drinking water samples in 1981 that were collected 
to comply with future drinking water standards. In January 
1982, the Naval Assessment and Control of Installation 
Pollutants (hereinafter, ``NACIP'') Program at Camp Lejeune 
began to identify potentially contaminated sites on the base. 
In 1982 and 1983, additional testing identified two VOCs--
trichloroethylene (hereinafter, ``TCE''), a metal degreaser, 
and tetrachloroethylene (hereinafter, ``PCE''), a dry cleaning 
solvent--in two water systems that served Camp Lejeune base 
housing areas: Hadnot Point and Tarawa Terrace. Base officials 
did not know the source of VOCs; water treatment plants and 
piping infrastructure were investigated as the possible 
sources. In 1983, the NACIP initial assessment study was 
published. This study led to the subsequent sampling of 
individual water supply wells in 1984. A direct association 
between VOCs in Hadnot Point and Tarawa Terrace drinking water 
and VOCs in the wells and groundwater was established when the 
water supply wells were sampled (beginning in 1984). Officials 
at Camp Lejeune confirmed the wells impacted by VOCs and shut 
them down in late 1984 and early 1985.
    Measurements of mixed water samples suggest that supply 
wells TT-23 and TT-26 were major contributors to contamination 
of the Tarawa Terrace water supply. The Agency for Toxic 
Substances and Disease Registry (hereinafter, ``ATSDR'') lists 
16 wells that served the Tarawa Terrace water-supply system. 
According to GAO, two wells, TT-23 and TT-26, were shut down on 
February 8, 1985, because of PCE contamination. However, well 
TT-23 was used briefly after that date--at least on March 11-
12, 1985, and on April 22, 23, and 29, 1985. The ATSDR 
indicates that TT-23 was removed from service in May 1985.
    According to the National Research Council (hereinafter, 
``NRC''), which functions under the auspices of the NAS, there 
were multiple sources of potential pollutants, including an 
industrial area, a drum dump, a transformer storage lot, an 
industrial fly ash dump, an open storage pit, a former fire 
training area, a site of a former on-base dry cleaner, a 
liquids disposal area, a former burn dump, a fuel-tank sludge 
area, and the site of the original base dump. The NRC stated 
that the contamination appears to have begun in the middle 
1950s and continued until the middle 1980s, when contaminated 
supply wells were shut down. According to the Marine Corps, 
nine of ten wells taken out of service have been permanently 
demolished (piping removed and holes filled in). One well was 
returned to service in 1993 following multiple clean samples. 
This well is in service today. Currently, drinking water is 
checked for VOCs quarterly to ensure water is not impacted.
    Camp Lejeune was placed on the Environmental Protection 
Agency (hereinafter, ``EPA'') National Priorities List in 1989. 
The National Priorities List is part of the Superfund cleanup 
process, and lists the most hazardous environmental sites 
across the United States and its territories. It serves 
primarily for informational purposes, identifying for the 
States and the public those sites that appear to warrant 
remedial actions. Today, Camp Lejeune is still on that list, as 
are approximately 130 other military installations.
    From 1991 to 1997, the ATSDR conducted a public health 
assessment at Camp Lejeune that was required by law because of 
the installation's listing on the National Priorities List. The 
ATSDR was particularly interested in routine drinking water 
tests, conducted in the 1980s, that found VOCs at detectable 
levels in some on-base drinking water supply wells. The ATSDR's 
1998 health study, ``Volatile Organic Compounds in Drinking 
Water and Adverse Pregnancy Outcomes,'' found a link between 
PCE-contaminated drinking water and lower birth weights for 
infants of older mothers and mothers with histories of fetal 
loss. PCE-contaminated drinking water was also linked with 
small-for-gestational-age infants for older mothers and mothers 
with two or more fetal losses. However, the findings from these 
analyses are no longer valid. After the study was completed, 
the ATSDR discovered that a residential area it classified as 
unexposed, Holcomb Boulevard, received water from the Hadnot 
Point system for the first 4 years of the study period, and the 
study results must be reanalyzed to correct for this mistake in 
classification. The ATSDR has indicated that it will reanalyze 
the results of the study using exposure estimates from its 
groundwater modeling of the Tarawa Terrace and Hadnot Point 
systems.
    In response to concerns from many Marines and their 
families who had been present at Camp Lejeune and to supplement 
the few studies that had been undertaken and to help inform 
decisions about addressing health claims, Congress mandated in 
Public Law 109-364, the John Warner National Defense 
Authorization Act for Fiscal Year 2007, that the Secretary of 
the Navy enter into an agreement with the NAS to examine 
whether adverse health effects are associated with past 
contamination of the water supply at Camp Lejeune. The NRC 
published its report on June 13, 2009, listing possible health 
consequences of exposure to the contaminated water at Camp 
Lejeune during the period from 1957-1985. All the health 
outcomes listed in its report were placed into one of two 
categories: limited/suggestive evidence of an association or 
inadequate/insufficient evidence to determine whether an 
association exists.
    The strongest evidence was in the category of limited/
suggestive evidence of an association, which means there is 
some evidence that people who were exposed to TCE or PCE were 
more likely to have a certain disease or disorder but that the 
studies were either few in number or had limitations. However, 
associations between exposures and diseases or disorders placed 
in the limited/suggestive evidence of an association category 
cannot be ruled out. The other health outcomes reviewed were 
placed in the category of inadequate/insufficient evidence to 
determine whether an association exists, which means that the 
studies were too few in number, limited in quality, 
inconsistent, or inconclusive in results to make an informed 
assessment. Fourteen of the 59 health outcomes reviewed by the 
NRC were placed in the limited/suggestive evidence of an 
association category, and 45 were placed in the inadequate/
insufficient evidence of an association category. According to 
the NRC, in many cases the study subjects were exposed to 
multiple chemicals, making it impossible to separate the 
effects of individual chemicals.
    In 2007, the GAO reported that former residents and 
employees of Camp Lejeune had filed more than 750 claims 
against the federal government related to the contamination. 
Adjudication of these claims and similar claims filed since 
then has been postponed until completion of an ongoing study 
being performed by the ATSDR. This study on specific birth 
defects and childhood cancers includes children born from 1968 
through 1985 to mothers who, for some time during their 
pregnancy, were exposed to drinking water contaminated with 
VOCs at Camp Lejeune. It is scheduled to be completed in 2011. 
However, Dr. John R. Nuckols, a member of the NRC's Committee 
on Contaminated Drinking Water at Camp Lejeune, testified at 
the October 8 hearing that, because further research was 
unlikely to provide definitive information, his committee had 
concluded that there was no scientific justification for the 
Navy and Marine Corps to wait for the results of additional 
health studies before making decisions about how to follow up 
on the evident solvent exposures on the base and their possible 
health consequences.
    Also at the October 8 hearing, Michael Partain, the son of 
a Marine Corps officer, testified that he was conceived, 
carried and born at Camp Lejeune in 1968. He stated that at age 
39 he was diagnosed with male breast cancer and that he is one 
of approximately 40 men who were exposed to Camp Lejeune tap 
water and who have breast cancer. VA's Michael R. Peterson, 
Chief Consultant, Environmental Health Strategic Health care 
Group, Office of Public Health and Environmental Hazards, 
Veterans Health Administration, testified that more than one 
million people may have been exposed to hazardous chemicals in 
the Camp Lejeune well water.
    Naval Air Facility Atsugi: The NAF Atsugi is located in the 
Kanto Plain area on the island of Honshu, Japan. The Japanese 
Navy constructed the base in 1941 and it was commissioned in 
1950 as U.S. Air Station Atsugi. In 1971, the name of the base 
was changed to NAF Atsugi and the official joint use of the 
base with the Japanese Maritime Self Defense Force began.
    In 1985, a private waste incinerator--owned and operated by 
Shinkampo Incineration Complex (hereinafter, ``SIC'')--was 
built and began operations approximately 150 meters south of 
the NAF Atsugi fence line. This complex was approximately five 
acres in size and was comprised of three incinerators, a waste 
staging area, and an ash holding area. The discharge heights of 
the incinerator stacks were only slightly higher than the 
ground surface of the plateau on which NAF Atsugi is located. 
Due to the complex topography and short incinerator stack 
heights relative to the plateau, emissions from the 
incineration complex were regularly carried parallel to the 
stack height downwind towards the base resulting in a 
fumigation condition.
    Complaints by the residents on NAF Atsugi about air quality 
due to the incinerator plume led to a series of evaluations and 
attempts to quantify pollution levels emitted from the 
incinerator. The first of these evaluations was conducted in 
1988 by the U.S. Navy Aircraft Environmental Support Activity. 
Subsequent environmental testing was conducted in 1989, 1995, 
1998, and 2002. Health risk communication activities began in 
1995 based on the 1994 air quality studies and the 1995 Health 
Risk Assessment. A formal program of Health Risk Communication 
and Medical Consultation was initiated in 1998 to give 
individuals necessary and appropriate 
information and to involve them in making decisions that affect 
them.
    Demonstration of the potential health risks related to poor 
air quality at Atsugi led to efforts by representatives of the 
United States Government to close the incinerator. After a 
number of years, these efforts resulted in a financial payment 
by the Japanese government to the incinerator operator to close 
the facility in May 2001.
    After the SIC shut down in 2001, outreach and health 
consultation activities centered on the specific environmental 
health exposures for the NAF Atsugi base population were 
discontinued. The final health risk assessment performed by the 
Navy Environmental Health Center, forwarded for release in 
2002, did not find any major changes in the types of materials 
that posed risk to base residents nor the potential 
consequences to their health as determined in the 1995 and 1998 
health risk assessments.
    In June 2009, the DOD-VA Deployment Health Working Group 
agreed the VA would receive a list of all affected active duty 
personnel stationed at NAF Atsugi from 1985-2001. These data 
come to the Navy and Marine Corps Public Health Center from the 
NAF Atsugi Retrospective Cohort Study of Disease, a cohort 
epidemiology investigation that utilized personnel records from 
the Defense Manpower Data Center to assemble the two cohorts 
for analysis. There were 5,635 active duty servicemembers 
identified from the Defense Manpower Data Center personnel 
records as being stationed at NAF Atsugi from 1985 to 2001. 
This collection of information will aid in any future outreach 
or surveillance activities for this population as indicated.
    However, that number is drastically different than another 
estimate provided in a report by the Battelle Memorial 
Institute entitled, ``Review of NAF Atsugi Health Risk 
Assessments and Related Environmental Data to Determine if 
Additional Population-Based Medical Screening is Indicated,'' 
dated June 3, 2008, illustrating the need for an accurate 
measurement. According to this report:

          No estimates of the exposed population during the 
        years of the incinerator operation (1985-2001) are 
        available in any of the documentation. In order to 
        arrive at an order-of-magnitude estimate, 
        extrapolations were made from the description of the 
        on-base population during 1998. At that time, NAF 
        Atsugi had a population of about 3,500 active duty 
        personnel and 1,700 dependents, of which about 1,100 
        were children. Assuming a typical residence time of 
        three years, annual turnover in the base population 
        would be estimated to be about 1,700 of which 400 would 
        be children. If this was characteristic of the 
        population dynamic for the entire exposure period, then 
        about 18,000 adults and 8,000 children would have 
        possibly been exposed to the contaminated environmental 
        conditions during on-station assignments of one to 
        three years. In the case of dependents, a typical 
        duration of exposure would have been three years.

    There is currently no registry for individuals who were 
present at NAF Atsugi during the years of the incinerator's 
operation. Voluntary enrollment into such a database was 
offered to residents stationed at NAF Atsugi but according to 
the U.S. Navy, there was so little interest that the effort was 
discontinued. The Navy also claims there has been no need for 
such a database because the long-term health risks were 
determined to be very small.
    Committee Bill. The Committee bill would establish a new 
mechanism for responding to issues related to exposures that 
occur at military installations. Rather than have Congress 
provide health care, benefits, and other services to 
servicemembers, veterans, and their dependents in a piecemeal 
fashion, the Committee bill would create an Advisory Board that 
would be tasked with reviewing and making recommendations on 
how to respond to concerns about possible exposure to hazards 
on military installations. It is the Committee's intent that 
the process will streamline the overall consideration of 
environmental hazard exposures. It is the Committee's 
expectation that, by ensuring that scientific experts analyze 
potential exposure issues on a global level, later outcomes on 
claims for benefits and assistance will be both fairer and 
justifiable to potentially exposed individuals.
    Because issues relating to the exposures at Camp Lejeune 
and NAF Atsugi have already been heard by the Committee, the 
Committee bill would provide access to immediate health care 
relief to those servicemembers, veterans, and dependents who 
were potentially exposed to contaminated water at Camp Lejeune 
and polluted air at NAF Atsugi.
    Section 2 of the Committee bill would define ``military 
exposure'' for the purposes of the new Advisory Board as an 
exposure to an environmental hazard on a military installation. 
``Military exposure claim'' would be defined as a formal claim 
of a military exposure submitted by or on behalf of an 
individual. This section would exclude individuals whose 
exposure occurred at a military installation during a period in 
which imminent danger pay is authorized because circumstances 
surrounding military exposures in war or conflict zones are 
often fluid and difficult to review appropriately while events 
are ongoing.
    It is the Committee's intent that the new Advisory Board 
will consider the exposure of a specific cohort of people at a 
military installation, not adjudicate individual claims of 
exposure. The goal would be for the Board to investigate the 
various elements related to a claimed exposure at a given 
location so as to help frame any subsequent action on 
individual claims. It is the Committee's expectation that the 
process for reviewing overall claims of exposures not supplant 
VA's current process of adjudicating an individual's claim for 
service-connected disability.
    Section 3 of the Committee bill would establish the 
Advisory Board on Military Exposures, which would provide 
advice to the Department of Defense (hereinafter, ``DOD'') and 
VA regarding matters relating to exposures of current and 
former members of the Armed Forces and their dependents to 
environmental hazards on military installations.
    It is the Committee's intent that the Advisory Board, 
through a non-political, scientific analysis, will make 
recommendations to DOD and VA on matters relating to claimed 
exposures on military installations. The Committee's 
expectation is that this process will give an appropriate body 
of scientific experts and veterans an opportunity to review 
matters relating to claimed exposures thoroughly and that this 
approach will result in a more consistent approach to military 
exposures than Congress or the Committee has taken in the past.
    The seven-member Board would be appointed by the President, 
and would consist of two members from military service 
organizations or veterans service organizations; two members 
from federal agencies (other than DOD and VA) with backgrounds 
in environmental exposure or environmental exposure 
assessments, health monitoring, or other relevant fields; and 
three members with backgrounds in environmental exposure or 
environmental exposure assessments, health monitoring, or other 
relevant fields, none of whom may be federal officials or 
employees. This section would also outline terms of office, 
compensation, and staffing for the Board.
    Section 4 of the Committee bill would set forth the purpose 
of the new Advisory Board on Military Exposures. The Board 
would consider and study the matters relating to claims of 
exposure of current and former members of the Armed Forces and 
their dependents to potential environmental hazards at military 
installations. It is the Committee's expectation that, while 
DOD and VA would collaborate in this endeavor, DOD would take 
the lead role in this initiative because DOD is better 
positioned to provide information on particular hazards on 
military installations.
    This section would also specify the parties who may submit 
material relating to claimed exposures to the Advisory Board: 
members of the Armed Forces, veterans, dependents of members of 
the Armed Forces and veterans; veterans advocacy groups; and 
DOD and VA officials. It also includes a 180-day deadline for 
the Board to consider the initial claim and what recommended 
actions may include. Again, it is the Committee's expectation 
that the Board consider an exposure of a specific cohort of 
people at a military installation rather than any individual's 
claim of exposure.
    Section 4 would also authorize the Board to convene a 
science advisory panel to assist with exposure claims and it 
outlines the membership of the science advisory panel. It would 
require a 180-day deadline for the science advisory panel to 
review the overall exposure claim and take action, and would 
outline what those recommended actions may include. The 
Committee intends this to be a settled, scientifically-sound, 
non-political process that will be duplicated for all military 
exposure claims. This section includes subpoena authority for 
both the Advisory Board and the science advisory panels in 
order to ensure attendance and testimony of witnesses to 
consider military exposure matters. It is the Committee's 
expectation that relevant federal agencies, including the EPA, 
will work cooperatively with the Advisory Board and science 
advisory panels.
    Finally, this section would specify that the Advisory 
Board's first cases shall be exposure matters related to Camp 
Lejeune and NAF Atsugi.
    Section 5 of the Committee bill would authorize DOD to 
provide servicemembers, veterans, and dependents who were 
exposed to environmental hazards at military installations the 
health care benefits recommended by the Advisory Board. Under 
current law, there is no authority for DOD to provide health 
care for these individuals.
    Section 6 of the Committee bill would require DOD, in 
coordination with VA and after consultation with the ATSDR, to 
assemble a list of individuals, which may include those who 
were fetuses in utero, exposed to environmental hazards at Camp 
Lejeune during the period which DOD and VA determine that water 
was contaminated with volatile organic compounds. The Committee 
believes that DOD should take the lead role in compiling this 
list because DOD is in a better position to identify which 
servicemembers and dependents were at a particular military 
installation during a particular time. Individuals on this list 
would be immediately eligible for health care in the following 
manner: servicemembers and veterans would be eligible for 
health care from or through VA or DOD; dependents would be 
eligible for care from or through DOD for conditions that are 
associated with exposure to contaminated water at Camp Lejeune. 
This approach reflects the Committee's view that dependents' 
health care should be provided by DOD. In a letter dated 
January 26, 2010, VA Secretary Eric K. Shinseki stated, ``. . . 
VA suggests that dependents' health care would be better placed 
under TRICARE, a health system much better suited to treatment 
of dependents,'' thereby endorsing the Committee's approach to 
dependent care.
    This section would also require that the Secretary of 
Defense, in consultation with the Secretary of Veterans 
Affairs, report to Congress within 30 days of assembling the 
list of individuals who were exposed on the evidence and 
criteria used to compile the list in order to make the process 
as transparent as possible. After five years, no additional 
names would be able to be added to the list. It is the 
Committee's expectation that the Advisory Board will have made 
recommendations regarding the exposure at Camp Lejeune within 
that five-year window.
    Section 7 of the Committee bill is comparable to section 6 
except that it relates to exposures at NAF Atsugi. This section 
would require DOD, in coordination with VA, to assemble a list 
of individuals, which may include those who were fetuses in 
utero, exposed to environmental hazards at NAF Atsugi during 
the period which they determine that the air was contaminated 
due to the operation of an incinerator. Consistent with the 
Committee's approach of assembling a list for those potentially 
exposed to contaminated water at Camp Lejeune, it is the 
Committee's intent that DOD take the lead role in compiling 
this list because DOD is in a better position identify which 
servicemembers and dependents were at a particular military 
installation during a particular time. After five years, no 
additional names would be able to be added to the list. It is 
the Committee's expectation that the Advisory Board will have 
made recommendations regarding the exposure at NAF Atsugi 
within that five-year window.
    Just as is proposed for those exposed at Camp Lejeune, 
individuals on this list shall be immediately eligible for 
health care. As is the case with dependents of servicemembers 
who were stationed at Camp Lejeune, the Committee believes that 
DOD is the more appropriate agency to provide health care to 
dependents of servicemembers. This section would also require 
that the Secretary of Defense, in consultation with the 
Secretary of Veterans Affairs, report to Congress within 30 
days of assembling the list of individuals who were exposed on 
the evidence and criteria used in compiling the list.
    Section 8 of the Committee bill would require DOD, in 
consultation with VA, to submit annual reports to the 
Committees on Armed Services and Veterans' Affairs in the House 
of Representatives and the Senate. The section also outlines 
required content for these reports, including a description of 
the classes of individuals who have received health care and 
other benefits as a result of this bill, a description of the 
health care benefits that have been provided to individuals, 
and recommendations for any necessary additional legislation.
    Section 9 of the Committee bill would require DOD and VA to 
prescribe joint regulations to carry out the provisions of this 
Act.
    Section 10 of the Committee bill would authorize the 
necessary appropriations to carry out the Act.

Concerns with Cost Estimate

    The Congressional Budget Office (CBO) estimates that the 
Committee bill would increase direct spending by about $2.7 
billion over the 2012-2020 period and increase spending subject 
to appropriation, discretionary spending, by about $4 billion 
over the same period. While the Committee is not satisfied with 
the accuracy of the discretionary cost estimate, it understands 
that it is appropriate to allocate such costs to this 
legislation. Indeed, Congress should be prepared to appropriate 
the necessary funds to cover the discretionary costs of this 
bill so that the health care needs of those exposed to 
environmental hazards while at a military installations can be 
satisfied.
    However, it is the Committee's view that the portion of the 
CBO estimate relating to mandatory costs is wholly without 
merit or basis. It is the Committee's view that the narrative 
accompanying the estimate betrays a fundamental 
misunderstanding of the intention of the bill and makes many 
assumptions that are simply not supported by the plain language 
of the legislation.
    In its estimate, CBO clearly misconstrues the role and 
purpose of the Advisory Board. The Advisory Board has no power 
to provide benefits--health care or monetary--to any 
individual. Its function is simply to review information--
including data on the number of individuals who might have been 
at a particular military installation at a given time, and on 
any environmental hazards that might have been present on that 
installation--and then make recommendations. With the possible 
assistance of a scientific review panel, the Advisory Board 
also would be expected to review the available science on both 
potential exposures to environmental hazards and the possible 
consequences of those exposures. After reviewing and discussing 
such information, the Advisory Board would be expected to 
submit recommendations to DOD and VA, not take any action with 
respect to individual claims.
    To take such an information gathering process and project a 
specific increase in the number of veterans receiving 
compensation from VA, as CBO does in its estimate, is to pile 
speculation--what the Advisory Board might find with reference 
to a specific installation--on speculation--what the Advisory 
Board might recommend based on such findings--on speculation--
what VA would do in response to such recommendations.
    Based on the cost estimate, it appears that CBO believes 
that there are populations of servicemembers, veterans, and 
their dependents who were exposed to environmental hazards to 
such a degree that there are present health consequences. The 
Committee does not start with that assumption and certainly 
does not expect that the Advisory Board will do so.
    The Committee is aware of no other instance in which 
possible actions by Executive Branch agencies or departments, 
in response to an advisory body's work product, was assigned a 
mandatory score by CBO. A mandatory score would more 
appropriately be assigned when Congress directs an agency to 
provide some specific benefit to a specified beneficiary or 
group of beneficiaries. In this instance, this is neither the 
intention nor the expectation. If the Advisory Board determines 
that servicemembers, veterans, and their dependents were 
exposed to a sufficient level of environmental hazards to 
warrant health care or a monetary benefit, the Advisory Board 
must submit recommendations to DOD and VA on health care or 
compensation that such individuals should receive. The 
discretion to provide those benefits remains with DOD and VA. 
CBO fails to distinguish this difference throughout its cost 
estimate.
    CBO also sets up a false comparison between the Advisory 
Board in the Committee bill and two existing programs under 
which certain individuals receive compensation from the federal 
government. As discussed above, the Advisory Board that would 
be established by the Committee bill is mandated to simply 
study and evaluate information and make recommendations. Under 
the two programs referenced by CBO in its estimate--the 
Radiation Exposure Compensation Program (RECA) and the Energy 
Employees Occupational Illness Compensation Program (EEOICP)--
both of which represent final Congressional resolution on 
specific, difficult issues relating to claims for exposures, 
specified populations are made entitled to specified 
compensation for defined and described exposures. Under RECA, 
an apology and monetary compensation are provided to 
individuals who contracted certain cancers and other diseases 
following exposure to radiation released during atmospheric 
nuclear weapons tests or occupational exposure while employed 
in the uranium industry during the Cold War. Under EEOICP, 
lump-sum compensation and health benefits are provided to 
eligible Department of Energy nuclear weapons workers, 
contractors, or subcontractors, and atomic weapons employees 
with radiation-induced cancer. Lump-sum compensation is also 
provided to certain survivors if the worker is deceased. There 
is simply no basis for the suggested comparison between those 
two programs and the work of the Advisory Board in the 
Committee bill.
    As explained earlier in this report, the Advisory Board 
would be comprised of two members of military service 
organizations or veterans service organizations; two members 
who are officials of government agencies (other than DOD and 
VA) with backgrounds in environmental exposure or environmental 
exposure assessments, health monitoring, or other relevant 
fields; and three members with backgrounds in environmental 
exposure or environmental exposure assessments, health 
monitoring, or other relevant fields who are not federal 
employees. CBO's cost estimate refers to this group as ``the 
government''--an incorrect characterization. The Advisory Board 
is purely an advisory body that makes recommendations to DOD 
and VA--who, in turn must make an affirmative decision to 
provide health care and benefits to the affected populations.
    CBO appears to rest its basis for the mandatory cost 
estimate on ``determinations by the government'' that the 
affected population has suffered health effects from exposure 
to environmental contamination that will, in turn, increase the 
likelihood that veterans submitting disability compensation 
claims would be deemed service-connected by VA. This 
understanding is also flawed. The claims submitted to VA would 
still require the same rigorous adjudication that all others 
undergo. The individual must be a veteran impacted by an in-
service event that caused or aggravated a named condition.
    Also troublesome is CBO's estimate that half of all 
military installations could be studied in the first ten years 
of enactment of this bill. The order of magnitude for the 
number of affected installations is unknown. However, as 
discussed earlier in the report, approximately 130 
installations are on the EPA's National Priorities List. Given 
that number of sites alone, it would be ambitious for half of 
all military installations to be reviewed in a ten-year period.

                      COMMITTEE BILL 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 CBO, estimates that enactment of the 
Committee bill would, relative to current law, not increase 
direct spending in 2011, and would increase direct spending by 
about 2.7 billion over the 2012-2020 period. In addition, CBO 
estimates that implementing the bill would increase spending 
subject to appropriation by $40 million in 2011; $558 million 
over the 2011-2015 period; and about $4 billion over the 2011-
2020 period. According to CBO, the Committee bill would impose 
an intergovernmental mandate as defined by the Unfunded Mandate 
Reform Act (hereinafter, ``UMRA'') by authorizing subpoena 
authority. However, CBO estimates that the cost of complying 
with the authority would be small and well below the thresholds 
established in UMRA.
    The cost estimate provided by CBO, setting forth a detailed 
breakdown of costs, follows:

                               Congressional Budget Office,
                                       Washington, DC, May 4, 2010.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for the Examination of 
Exposures to Environmental Hazards During Military Service and 
Health Care for Camp Lejeune and Atsugi Naval Air Facility 
Veterans and their Families Act of 2010.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contacts are Matthew 
Schmit and Dwayne Wright.
            Sincerely,
                                      Douglas W. Elmendorf,
                                                          Director.

  Enclosure.

Examination of Exposures to Environmental Hazards During Military 
        Service and Health Care for Camp Lejeune and Atsugi Naval Air 
        Facility Veterans and their Families Act of 2010

    Summary: This bill would authorize a new federal health 
benefit for former military members and their dependents whose 
health was affected by exposure to environmental contaminants 
at Camp Lejeune, North Carolina, or at the Atsugi Naval Air 
Facility in Japan. The bill also would establish a new advisory 
board to study environmental contamination at other military 
facilities and would authorize health benefits for former 
military personnel and their dependents who were present at 
sites identified by the board as having environmental hazards.
    CBO expects that the determination that individuals were 
exposed to environmental contaminants on military installations 
would increase the likelihood that certain disability 
compensation claims submitted to the Department of Veterans 
Affairs (VA) would be deemed ``service-connected.'' Those 
additional claims would increase VA compensation payments and 
CBO estimates that direct spending would increase by about $2.7 
billion over the 2012-2020 period.\1\ In addition, CBO 
estimates that implementing the bill would increase spending 
subject to appropriation by about $4 billion over the 2011-2020 
period, mainly to cover the cost of the new health benefits and 
the administration of claims.
---------------------------------------------------------------------------
    \1\Different time periods are relevant for enforcing the current 
pay-as-you-go rules in the Senate and the House of Representatives. CBO 
estimates that enacting the bill would increase direct spending by $80 
million over the 2010-2014 period and $1,655 million over the 2010-2019 
period.
---------------------------------------------------------------------------
    Pay-as-you-go procedures apply because enacting the 
legislation would affect direct spending. Pursuant to section 
311 of the Concurrent Resolution on the Budget for Fiscal Year 
2009 (S. Con. Res. 70), CBO estimates this bill would increase 
projected deficits by more than $5 billion in at least one of 
the four consecutive 10-year periods starting in 2020.
    The bill includes new subpoena authority that would impose 
an intergovernmental and private-sector mandate as defined in 
the Unfunded Mandates Reform Act (UMRA), but CBO estimates the 
cost of complying with the mandate would be small and well 
below the thresholds established in UMRA ($70 million for 
intergovernmental mandates and $141 million for private-sector 
mandates in 2010, adjusted annually for inflation).
    Estimated cost to the Federal Government: The estimated 
budgetary impact of this bill is shown in the following table. 
The costs of this legislation fall within budget functions 050 
(national defense) and 700 (veterans benefits and services). 
This estimate assumes that the bill will be enacted near the 
beginning of fiscal year 2011.

                                                                        Table 1.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                      By fiscal year, in millions of dollars--
                                                           ---------------------------------------------------------------------------------------------
                                                             2011   2012   2013   2014   2015   2016   2017   2018   2019    2020   2011-2015  2011-2020
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               CHANGES IN DIRECT SPENDING
Veterans Compensation
    Estimated Budget Authority............................      0      5     25     50     75    100    225    450     725   1,075      155       2,730
    Estimated Outlays.....................................      0      5     25     50     75    100    225    450     725   1,075      155       2,730

                                                      CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Health Care Benefits
    Estimated Authorization Level.........................      0      5     25     50     75    125    275    525     875   1,325      155       3,280
    Estimated Outlays.....................................      0      4     21     44     68    113    241    466     788   1,210      137       2,955
Administrative Costs
    Estimated Authorization Level.........................     50    100    100    100    100    100    100    125     125     150      450       1,050
    Estimated Outlays.....................................     40     88     97     98     99     99     99    119     123     143      421       1,004
                                                           ---------------------------------------------------------------------------------------------
      Total Changes in Spending Subject to Appropriation
        Estimated Authorization Level.....................     50    105    125    150    175    225    375    650   1,000   1,475      605       4,330
        Estimated Outlays.................................     40     92    117    142    167    212    340    585     911   1,353      558       3,958
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Basis of estimate: This bill would authorize a new federal 
health benefit for former military members and their dependents 
whose health was affected by environmental contamination at 
Camp Lejeune, North Carolina, or at the Atsugi Naval Air 
Facility in Japan. It is alleged that the drinking water at 
Camp Lejeune was contaminated from 1957 through 1987 and that 
the air around the Atsugi Naval Air Facility was contaminated 
by a nearby trash incinerator from 1985 through 2001, causing 
higher incidence rates of cancer, birth defects, and other 
physical ailments associated with exposure to toxic substances. 
The bill also would establish a new advisory board to study 
environmental contamination at other military facilities and 
would authorize health benefits for former military personnel 
and their dependents who would be determined to have been 
exposed at those facilities.
    Veterans can currently receive compensation from VA for 
disabilities incurred as a result of their time in the service. 
However, because studies of contamination at Camp Lejeune, 
Atsugi Naval Air Facility, and other military bases are not yet 
complete, VA compensation for ailments allegedly caused by 
environmental contamination at those facilities is generally 
approved only after overwhelming evidence is submitted. CBO 
expects that the determination by the government that the 
affected population has suffered health effects from exposure 
to environmental contamination on military bases would increase 
the likelihood that disability compensation claims submitted to 
the VA by such veterans would be deemed ``service-connected,'' 
causing an increase in VA compensation payments relative to the 
expected payments under current law. CBO estimates those 
additional payments would increase direct spending by about 
$2.7 billion over the 2012-2020 period.
    In addition, CBO estimates that implementing this bill 
would increase spending subject to appropriation by about $4 
billion over the 2011-2020 period, mainly to cover the cost of 
the new health benefits and the costs to administer claims. 
This bill also would create a new federal advisory board to 
study and make recommendations on benefits to individuals 
affected by environmental contamination at military facilities 
and would require the Secretary of Defense to compile lists of 
all individuals exposed to contamination at Camp Lejeune and 
Atsugi.

Estimating the Number of Potential Claims

    To estimate the number of people who would eventually be 
approved for government benefits under this bill, CBO divided 
the potential population into two groups: the first group 
consists of those potentially affected by contamination at Camp 
Lejeune and Atsugi; and the second population consists of 
potential claims from other military facilities that would be 
identified by the new advisory board. CBO then used observed 
take-up rates from other government programs for occupational 
illnesses to estimate the number of individuals who would 
eventually receive benefits.
    Camp Lejeune and Atsugi Naval Air Facility. Based on 
information from the Department of Defense (DOD), CBO estimates 
about 675,000 military personnel and dependents lived or worked 
at Camp Lejeune and the Atsugi Naval Air Facility during the 
periods of alleged contamination. In the first 10 years after 
enactment of this bill, CBO estimates that about 20,000 of 
those former members and dependents would be approved for 
benefits. That estimate is based on take-up rates for two other 
government programs that provide compensation for occupational 
illnesses: the Radiation Exposure Compensation Program (RECA) 
and the Energy Employees Occupational Illness Compensation 
Program (EEOICP). The number of people approved for benefits 
would be significantly smaller than the population potentially 
exposed because many of those potential claimants would have 
long since died, would not have adequate proof of a compensable 
ailment, or would not be able to be located.
    Of those approved for benefits in the first 10 years, CBO 
estimates just under 75 percent would be former military 
members, while the rest would be spouses and children of former 
servicemembers. CBO derived this breakdown by looking at 
marriage rates as well as prevalence rates for some of the 
ailments connected with environmental contamination. Disease 
prevalence rates are typically higher for older males (most of 
the veterans affected by this legislation would be over the age 
of 65). CBO assumes that no cases would be approved for 
benefits prior to fiscal year 2012, because it would take time 
to establish regulations and train adjudication officials.
    Other Military Facilities. The bill also would create a new 
advisory board that would examine environmental contamination 
at other military facilities and make recommendations as to 
whether personnel exposed to contamination at those facilities 
should receive health benefits or other compensation. DOD would 
be authorized to provide any health benefits recommended by the 
advisory board.
    A review of information from the Environmental Protection 
Agency and other sources reveals that environmental 
contamination at current and former military facilities is a 
widespread problem. Combined with the fact that military 
personnel frequently work with hazardous chemicals and other 
dangerous substances, such as jet fuel and cleaning agents, it 
is possible that anyone who has ever lived or worked on a 
military facility was exposed to a variety of contaminants. 
Depending on how the new advisory board chooses to conduct its 
work, the number of additional claims that would be approved 
for benefits could be quite large.
    Based on information from VA on the number of living 
veterans and adjusting that number to account for spouses and 
children, CBO estimates that as many as 50 million former 
members and dependents have lived or worked on military 
installations and are still living. (This figure does not 
include any civilian employees who may have worked at military 
installations. Benefits for those individuals are not addressed 
by this bill.) Because of time and resource constraints, it 
would take many years for the new advisory board to review all 
reported instances of environmental contamination. For this 
estimate, CBO assumes that about half of all military 
installations could be studied in the first 10 years after 
enactment of this bill.
    To estimate the number of people who would eventually be 
approved for benefits, CBO applied take-up rates derived from 
the RECA and EEOICP programs, with adjustments to take into 
account the higher probability of exposures in those 
programs.\2\ Using this methodology, CBO estimates that an 
additional 100,000 claims would be approved for federal 
benefits by 2020. However, CBO assumes no claims, with the 
exception of those for Camp Lejeune and Atsugi Naval Air 
Facility, would be approved prior to 2016, because of the time 
needed to establish the new advisory board and the time needed 
by the board to conduct studies and establish benefit 
procedures for the additional sites identified as having 
contamination.
---------------------------------------------------------------------------
    \2\RECA and EEOICP provide compensation and health benefits to 
people who worked in the production and testing of nuclear weapons. The 
exposures that occurred in the nuclear program were widespread, 
affecting entire factories (in the case of weapons production) or large 
geographic areas (in the case of testing). While CBO considers it 
appropriate to apply benefit take-up rates from those programs to the 
allegedly large-scale exposures at Camp Lejeune and Atsugi, many of the 
incidents of contamination examined by the new advisory board would be 
limited to certain sections of military bases, limiting the probability 
of exposure for the general base populations. Therefore, CBO reduced 
the estimated take-up rates for the additional sites that would be 
identified by the board.
---------------------------------------------------------------------------
    In total, CBO estimates the number of people that would be 
approved for benefits because of environmental exposures under 
this legislation would total about 700 in 2012 and expand to 
almost 120,000 by 2020. Of those approved for benefits, just 
under 75 percent would be veterans and the rest would be 
dependents of former military personnel.

Direct Spending

    VA pays compensation to veterans for disabilities that 
result from their military service. While VA compensates 
veterans for various forms of cancer because of exposure to 
contaminants--Agent Orange, for example--disability 
compensation related to exposure at Camp Lejeune has only been 
granted under very limited circumstances. Implementing this 
bill would result in additional individuals being certified as 
needing health care because of exposure to contaminants on 
military facilities. CBO expects that such certification would 
increase the likelihood that VA would determine that such 
veterans had compensable, service-connected disabilities. The 
resulting increase in disability compensation payments would 
represent an increase in direct spending.
    In total, CBO estimates that enacting this bill would 
increase direct spending by $2.7 billion over the 2012-2020 
period, including costs for new accessions (newly approved 
beneficiaries), veterans currently on the rolls, and surviving 
spouses.
    New Accessions. Based on the population information 
described above, CBO estimates that about 75 percent of the 
newly eligible pool of veterans are not currently receiving 
veterans disability compensation. Therefore, in 2012--the first 
year CBO expects veterans to begin receiving disability 
compensation under this bill--we estimate that about 350 newly 
eligible veterans would apply for and be granted benefits, 
increasing to about 60,000 by 2020 as other facilities are 
identified by the advisory board. VA rates veterans with 
service-connected disabilities from zero to 100 percent, 
according to their degree of disability. CBO assumes that the 
newly eligible veterans would enter the disability compensation 
rolls at the average disability rating of 40 percent.
    In 2009, the average annual benefit payment for a 
disability rated at 40 percent was $7,262 (or $605 monthly). 
Adjusting for cost-of-living increases, the annual payment for 
a veteran rated at 40 percent in 2012 would be $7,356 (or $613 
monthly). After accounting for mortality and cost-of-living 
adjustments, CBO estimates that, under the bill, direct 
spending for new accessions would increase by about $1.3 
billion over the 2012-2020 period.
    Veterans Currently on the Rolls. The bill also would make 
some veterans who are currently receiving disability 
compensation for other disabilities eligible to have their 
compensation increased because of ailments associated with 
service-connected, environmental contamination. Many veterans 
who are receiving a disability compensation payment are rated 
for more than one disability. The average rating for veterans 
on the disability compensation rolls in 2009 was 40 percent and 
the average increased rating--the rate for which a veteran was 
compensated after receiving an additional compensation rating--
was 70 percent.
    About 15 percent of the current veterans population (23 
million) receives disability compensation from VA. However, CBO 
assumes that the eligible population under this bill would be 
more likely to have applied for disability compensation due to 
the information about environmental contamination available and 
would thus be more likely to have received a disability rating 
for some other disability. Therefore, CBO assumes that of the 
eligible population discussed above, 25 percent would already 
be receiving disability compensation and would receive an 
increased rating. In 2012, CBO estimates about 120 veterans 
would become eligible for and receive an increased rating 
increasing to about 20,000 by 2020.
    In 2009, the average annual disability payment for a 
veteran rated at 40 percent was $7,262 and the average payment 
for a veteran rated at 70 percent was $23,760--a difference of 
$16,498. After adjusting for cost-of-living, CBO estimates that 
enacting the bill would increase direct spending for existing 
recipients by about $1 billion over the 2012-2020 period.
    Surviving Spouses. VA provides dependency and indemnity 
compensation (DIC) payments to the surviving spouses of certain 
deceased veterans. CBO expects that some of the spouses of 
veterans who died because of ailments related to exposure to 
environmental contamination would become eligible for DIC 
payments under this bill. Based on the population figures 
derived above, CBO estimates that about 50 spouses would become 
eligible for and receive DIC payments in 2012 increasing to 
about 8,500 by 2020. The average annual DIC benefit payment in 
2009 was $14,683. After adjusting for cost-of-living increases, 
CBO estimates that enacting the bill would increase direct 
spending for DIC by about $440 million over the 2012-2020 
period.
    Other Direct Spending. In addition to the direct spending 
for VA compensation, this bill could increase mandatory outlays 
from the Medicare-Eligible Retiree Health Care Fund (MERHCF). 
Some of the people approved for health benefits (see below) 
would be military retirees or retiree dependents. While they 
are already eligible for health care from DOD, it is possible 
that they could become eligible for treatments not currently 
available through the regular DOD health programs. In some 
instances, DOD might seek reimbursement of those expenses from 
the MERHCF, although CBO estimates those additional expenses 
would not be significant.

Spending Subject to Appropriation

    In addition to the direct spending discussed above, the 
bill would increase spending subject to appropriation. Those 
costs would be primarily for the health benefits authorized by 
the bill as well as for various administrative costs incurred 
by DOD and, to a lesser extent, VA.
    This bill would authorize DOD and VA to provide health care 
to individuals exposed to environmental contamination at Camp 
Lejeune, Atsugi, and other military facilities identified by 
the new advisory board. Based on the cost of health benefits 
provided by EEOICP and the Federal Black Lung Program, CBO 
estimates that the annual cost of the new health benefit would 
be about $7,700 (in 2010 dollars) for each approved claim. 
Costs would be lower than the average annual medical costs for 
persons in those age groups because not everyone would use the 
new health benefit and the bill specifies that only diseases 
and conditions directly related to the exposures in question 
would be covered. CBO estimates that per capita costs would 
increase by about 6 percent each year, based on national per 
capita health expenditure projections published by the Centers 
for Medicare and Medicaid Services. In total, CBO estimates the 
new health benefit would cost about $3 billion over the 2012-
2020 period, subject to appropriation of the necessary amounts.
    This bill also has several requirements that would increase 
administrative costs for DOD and VA. In addition to the cost of 
adjudicating and administering claims, appropriations would be 
needed to fund the activities of the new advisory board. CBO 
estimates the cost of administering claims and the activities 
of the advisory board would average about $65 million per year, 
or about $650 million over the 2010-2020 period, subject to 
appropriation of the necessary amounts. That estimate is based 
on the administrative costs for the Federal Black Lung Program 
and the EEOICP, government compensation programs that require 
complex determinations for health benefits. Administrative 
costs would increase as the advisory board identifies 
additional sites and more people seek benefits.
    In addition, DOD would be required to compile lists of 
individuals exposed to contamination. Because older base 
housing reports are often incomplete or nonexistent, compiling 
lists of individuals who served at various military 
installations would be a very labor-intensive process requiring 
the review of millions of individual service records. Based on 
information from DOD, CBO estimates that DOD would spend about 
$35 million a year for this purpose, subject to appropriation 
of the necessary amounts.
    In total, CBO estimates the administrative costs of this 
bill would total about $1 billion over the 2011-2020 period. 
When combined with the cost of providing the new health 
benefits, CBO estimates that this bill would have a 
discretionary cost of about $4 billion over the 2011-2020 
period.

Pay-As-You-Go Considerations

    The Statutory Pay-As-You-Go Act of 2010 establishes budget 
reporting and enforcement procedures for legislation affecting 
direct spending. The net changes in outlays that are subject to 
those pay-as-you-go procedures are shown in the following 
table.

  Table 2.--CBO Estimate of Pay-As-You-Go Effects for the Examination of Exposures to Environmental Hazards During Military Service and Health Care for
 Camp Lejeune and Atsugi Naval Air Facility Veterans and their Families Act of 2010, as ordered reported by the Senate Committee on Veterans' Affairs on
                                                                    January 28, 2010
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                   By fiscal year, in millions of dollars--
                                                     ---------------------------------------------------------------------------------------------------
                                                       2010   2011   2012   2013   2014   2015   2016   2017   2018   2019   2020   2010-2015  2010-2020
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                       NET INCREASE OR DECREASE (-) IN THE DEFICIT

Statutory Pay-As-You-Go Impact                            0      0      5     25     50     75    100    225    450    725   1,075      155       2,730
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Impact on long-term deficits: Pursuant to section 311 of 
the Concurrent Resolution on the Budget for Fiscal Year 2009 
(S. Con. Res. 70), CBO estimates this bill would increase 
projected deficits by more than $5 billion in at least one of 
the four consecutive 10-year periods starting in 2020.
    Intergovernmental and private-sector impact: The bill would 
impose both intergovernmental and private-sector mandates as 
defined in the Unfunded Mandates Reform Act because it would 
establish an advisory board with the authority to subpoena 
information. State, local, and tribal governments, as well as 
private-sector entities, if subpoenaed by the board, would be 
required to provide testimony, documents, or other evidence. 
CBO expects that the advisory board would likely exercise this 
authority sparingly, and the costs to comply with subpoenas 
would not be significant. Thus, we estimate that the costs to 
comply with the mandates would be small and well below the 
annual thresholds established in UMRA ($70 million for 
intergovernmental mandates and $141 million for private-sector 
mandates in 2010, adjusted annually for inflation).
    Estimate prepared by: Federal Costs: Veterans' 
Compensation--Dwayne Wright; Health Benefits and 
Administration--Matthew Schmit and Sunita D'Monte.
    Impact on state, local, and tribal governments: Lisa 
Ramirez-Branum.
    Impact on the private sector: Elizabeth Bass.
    Estimate approved by: Theresa Gullo, Deputy 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 that 
would be incurred in carrying out the Committee bill. The 
Committee finds that the Committee bill would not entail any 
regulation of individuals or businesses and that the paperwork 
resulting from enactment would be minimal. Finally, the 
Committee finds that the only impact on personal privacy would 
be in the context of providing access to health care services 
and compiling lists of names of individuals who were present 
during the time exposures occurred at Camp Lejeune, North 
Carolina, or at the Naval Air Facility in Atsugi, Japan. It is 
the Committee's expectation that any individual would be able 
to have his/her name removed from any such list if the 
individual did not wish to receive health care services 
specified in the legislation.

                 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 January 28, 2010, meeting. The 
Committee, by voice vote, ordered the original bill reported 
favorably to the Senate, subject to amendment.

                             AGENCY REPORT

    On October 21, 2009, Gerald M. Cross, MD, FAAFP, Acting 
Under Secretary for Health, Veterans Health Administration, 
Department of Veterans Affairs, appeared before the Committee 
and submitted testimony of the Department's views of the bills. 
Excerpts from this statement are reprinted below:

  STATEMENT OF GERALD M. CROSS, MD, FAAFP, ACTING UNDER SECRETARY FOR 
  HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                                AFFAIRS

    Good Morning Mr. Chairman and Members of the Committee: 
Thank you for inviting me here today to present views on 
several bills that would affect Department of Veterans Affairs 
(VA) benefits and services. Joining me today are Mr. Brad 
Mayes, Director of the Compensation and Pension Service, Mr. 
Richard Hipolit, Assistant General Counsel, and Mr. Walter 
Hall, Assistant General Counsel. Unfortunately, we do not have 
views and estimates on several bills including S. 1109, 
S. 1467, S. 1556, S. 1753, and a draft bill regarding exposure 
to chemical hazards referred to in the list of bills provided 
in the Committee's witness letter of October 8. We will forward 
those as soon as they are available. We appreciate the 
opportunity to address these bills that would affect the 
Department's health care and benefits programs.

           *       *       *       *       *       *       *

       S. 1518--``CARING FOR CAMP LEJEUNE VETERANS ACT OF 2009''

    S. 1518 would amend title 38 to extend eligibility for 
hospital care, medical services and nursing home care for 
certain Veterans stationed at Camp Lejeune during a period in 
which well water was contaminated notwithstanding that there is 
insufficient medical evidence to conclude that a particular 
illness is attributable to such contamination. It would also 
make family members of those Veterans who resided at Camp 
Lejeune eligible for the same services, but only for those 
conditions or disabilities associated with exposure to the 
contaminants in the water at Camp Lejeune, as determined by the 
Secretary.
    VA takes the Camp Lejeune matter very seriously but has 
concerns with the legislation as written. S. 1518 would provide 
a very broad enrollment and treatment authority for 
servicemembers and their families. As the legislation is 
written, any condition that cannot be specifically eliminated 
as related to the contaminated water at Camp Lejeune would 
require VA to provide treatment. We note this authority is 
broader than that conferred on radiation-exposed Veterans. 
Moreover, the legislation would also require VA to provide 
medical services and nursing home care to those family members 
who either consumed contaminated water or were in utero at the 
time of consumption if the condition or disability can be 
associated with exposure to contaminated water at Camp Lejeune.
    From the 1950s through the mid-1980s, persons residing or 
working at the U.S. Marine Corps Base Camp Lejeune were 
potentially exposed to drinking water contaminated with 
volatile organic compounds. Two of the eight water treatment 
facilities supplying water to the base were contaminated with 
either tricholoroethylene (TCE) or tetrachloroethylene 
(perchloroethylene, or PCE). The Department of Health and Human 
Services' Agency for Toxic Substances and Disease Registry 
(ASTDR) estimated that the level of PCE in drinking water 
exceeded current standards from 1957 to 1987 (when the 
contaminated wells were shut down) and represented a potential 
public health hazard.
    An ATSDR study begun in 2005 is evaluating whether children 
of mothers who were exposed while pregnant to contaminated 
drinking water at Camp Lejeune are at an increased risk of 
spina bifida, anecephaly, cleft lip or cleft palate, and 
childhood leukemia or non-Hodgkin's lymphoma. The results of 
this report have not yet been released. In the same year, a 
panel of independent scientists convened by the ATSDR 
recommended the agency identify cohorts of individuals with 
potential exposure, including adults who lived or worked on the 
base and children who lived on the base (including those that 
may have been exposed while in utero), and conduct a 
feasibility assessment to address the issues involved in 
planning future studies at the base.
    In October 2008, the Department of the Navy issued a letter 
to Veterans who were stationed at Camp Lejeune while in 
military service between 1957 and 1987. This letter informed 
Veterans that the Navy had established a health registry and 
encouraged them to participate. VA currently provides Veterans 
with information about this issue and referrals to the Navy 
registry. Veterans who are a part of this cohort may also apply 
for enrollment if they are otherwise eligible, and are 
encouraged to discuss any specific concerns they have about 
this issue with their health care provider. Veterans are also 
encouraged to file a claim for VA disability compensation for 
any injury or illness they believe is related to their military 
service. VA environmental health clinicians can provide these 
Veterans with information regarding the potential health 
effects of exposure to volatile organic compounds and VA's War-
Related Illness and Injury Study Centers are also available as 
a resource to providers.
    It is unclear exactly how many people were potentially 
affected, but some estimates place the number at one million 
Veterans and family members. Though the Department of the Navy 
has attempted to contact all servicemembers who were stationed 
at Camp Lejeune during the three decades of potential exposure, 
it is possible not everyone was reached or identified. Records 
over a half-century old may not be available, and the 
legislation leaves open-ended what ``resided'' or ``stationed'' 
means because there is no limitation such as a minimum time 
requirement on the base. Consequently, a broad definition of 
these terms may mean VA's estimates of 500,000 Veterans and 
500,000 family members are too conservative.
    Because of these concerns, VA recommends that if any 
enhanced Veteran care is authorized, it should be modeled upon 
the authority providing for benefits and services for 
radiation-exposed Veterans and limited to conditions that can 
be associated with consumption of contaminated water. VA also 
would recommend that any care for potentially eligible family 
members be provided by DOD as the exposure is directly related 
to service at Camp Lejeune.
    VA estimates the legislation, as written, would cost $299.7 
million in FY 2010, $319.5 million in FY 2011, $1.71 billion 
over 5 years and $4.16 billion over 10 years.

           *       *       *       *       *       *       *

    This concludes my prepared statement. I would be pleased to 
answer any questions you or any of the Members of the Committee 
may have.
                                ------                                

                         The Secretary of Veterans Affairs,
                                  Washington, DC, January 26, 2010.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The Department of Veterans Affairs (VA) 
understands that the Committee will be considering S. 1518 
during the mark-up scheduled for January 28, 2009. VA 
recognizes that servicemembers sometimes face exposure to 
toxicants or materials in the course of their military service 
that can have deleterious health effects. We take this issue 
very seriously; however, VA would like to reiterate several 
concerns with the bill that were previously discussed in our 
October 21, 2009, testimony. In particular, we would like to 
emphasize the following:

     Should it be enacted, S. 1518 would provide new 
and unprecedented eligibility for VA health care to certain 
dependents who resided at Camp Lejeune over a more than thirty-
year period.
     VA estimated that the legislation could apply to 
500,000 dependents, although this number could be conservative. 
VA recommends that if any enhanced Veteran care is authorized, 
it should be modeled upon the authority providing benefits and 
services to radiation-exposed Veterans and limited to 
conditions that can be associated with consumption of 
contaminated water.
     If enacted, VA suggests that dependents' health 
care would be better placed under TRICARE, a health system much 
better suited to treatment of dependents.
     VA estimated that the legislation, as written, 
would cost $299.7 million in FY 2010, $319.5 million in FY 
2011, $1.71 billion over 5 years, and $4.16 billion over 10 
years.

    VA very much appreciates your leadership and support of 
programs to assist our Nation's Veterans. Should your staff 
need additional information, please have them contact David 
Ballenger in the Office of Congressional and Legislative 
Affairs.
            Sincerely,
Eric K. Shinseki.

           *       *       *       *       *       *       *

               SUPPLEMENTAL VIEWS OF MR. RICHARD M. BURR

    Although I appreciate the Committee's effort to provide a 
mechanism through which veterans, servicemembers, and 
dependents exposed to water contaminants at Camp Lejeune can 
receive necessary medical treatment based on their exposure, I 
believe the approach taken in the Committee bill is flawed. 
Furthermore, I believe this report does not fully account for 
the contentious debate within the scientific community 
regarding the extent of water contamination at Camp Lejeune, 
the revelations about additional contaminants (most 
prominently, benzene) that have recently come to light, and the 
erosion of confidence that many affected individuals have in 
the Department of Defense because of its slow and, often, 
adversarial role in bringing facts of the contamination into 
full public view.
    As mentioned in the report above, in June 2009, the NRC 
issued a report entitled ``Contaminated Water Supplies at Camp 
Lejeune--Assessing Potential Health Effects.'' Not mentioned, 
however, is the fact that this congressionally-mandated report 
has been criticized by certain members of the scientific 
community, including one of the peer reviewers who provided the 
NRC with input on the report, primarily because it failed to 
conduct a hazard assessment of the two known carcinogens 
present in the base water system, benzene and vinyl chloride. 
The most significant of these is benzene, an ingredient in 
gasoline that is known to cause childhood and adult leukemia. 
The absence of a comprehensive analysis of the presence and 
harmful effects of benzene in the NRC report has become a 
significant issue, particularly since it was disclosed in March 
2010 that the ATSDR, the Federal agency statutorily tasked with 
studying the contamination at Camp Lejeune, discovered 
documents from Navy contractors working at Camp Lejeune 
indicating the fuel losses from underground storage tanks at 
the base may have reached 800,000 to 1,000,000 gallons and 
spanned the period 1957 to 1987. It is the regularity of new 
information surfacing regarding the water contamination that is 
disturbing, and it calls into question whether DOD is fully 
committed to resolving this matter in a way that fulfills its 
stated concern for the health and welfare of the affected 
Marines, sailors, civilian employees, and their families who 
lived and worked at Camp Lejeune.
    For this primary reason, the Committee bill fails to 
recognize the distinct distrust of the Navy, Marine Corps, and 
DOD that is felt by Camp Lejeune Marines, sailors, and their 
families. Those personally affected by the contamination on the 
base find it objectionable that the organizations they hold 
responsible for their medical conditions would become 
responsible for their health care, especially when those same 
organizations have yet to accept responsibility for the 
contamination that occurred.
    Furthermore, I take issue with this report's reference to 
Secretary Shinseki's letter which states that ``dependents' 
health care would be better placed under TRICARE, a health 
system much better suited to treatment of dependents.'' That 
letter, and this report, makes no mention of exactly why that 
would be the case. First, all of the affected ``dependents'' 
from the Camp Lejeune water contamination are now adults. So, 
if it is a question of lacking pediatric providers that the 
Secretary was referring to, that is not an issue here. 
Secondly, VA has an entire health care program (CHAMPVA) 
devoted to the treatment needs of certain dependents of 
veterans; it has a specific program of health care for children 
of Vietnam veterans born with certain birth defects; and it 
provides health care to veterans who have conditions related to 
myriad exposures, including radiation exposure, Agent Orange 
exposure, exposure to contaminants present during Project 
Shipboard Hazard and Defense tests, and others. The assertion 
that somehow TRICARE is ``better suited'' to provide care to 
affected individuals is contradicted by these facts.
    In addition, from a functional perspective, the DOD TRICARE 
program is comprised of hundreds of independent providers of 
medical care loosely organized in three regional networks, 
whereas VA is an integrated health care delivery system. 
TRICARE is not structured to identify and effectively treat 
individuals who are eligible for care only associated with 
exposure-related illnesses or conditions. In contrast, VA has a 
history of delivering health care to those specific 
populations, to include affected family members. I am highly 
skeptical that the TRICARE network would be able to care for 
such a unique group without significant complications and 
inefficiencies. At the very least, the Committee should have 
explored this question before acting. That is why the bill I 
introduced (S. 1518), and the amendment I offered at the 
Committee's markup, follows existing precedent and recognizes 
VA as the sole government agency with resident expertise in 
such specific treatment and care.
    I would like to make one additional point about my bill 
before I continue. At the Committee's October 21, 2009, 
legislative hearing the Administration offered its views on 
S. 1518, the Caring for Camp Lejeune Veterans Act of 2009. The 
Administration testified that an estimate of 500,000 dependents 
would be eligible for VA health care under my bill, a number it 
later called as potentially ``too conservative.'' The 
Administration then recommended an approach ultimately adopted 
in the Committee bill, i.e., that DOD be the provider of health 
care for affected Lejeune family members. To the extent the 
majority relied on VA's estimates to inform its policy on this 
matter, I would like to point out that the Congressional Budget 
Office provided preliminary views on S. 1518 in which it 
estimated fewer than 10,000 affected Lejeune family members 
would receive VA health care between 2011 and 2015. Thus, there 
is reason to believe that VA's estimates are significantly off 
the mark. It is regrettable if those estimates, or a misreading 
of them, led to the policy contained in the Committee bill.
    I am also concerned with the aspect of the Committee bill 
that would establish a Science Advisory Panel to support an 
Advisory Board tasked with making benefit recommendations to 
both VA and DOD. The members of the Science Advisory Panel 
would have the responsibility to review exposure claims at 
military installations and recommend action, but the Committee 
bill does not address whether this panel would duplicate or 
influence the current Title 42, United States Code, 
responsibilities vested in the ATSDR to conduct scientific 
inquiries of military installations where environmental 
contamination and human exposure has occurred and has been 
verified by the Environmental Protection Agency.
    Further, the Committee bill would task DOD with the lead 
role in providing information to the Advisory Board, but there 
is no requirement in the Committee bill that DOD do so, or that 
DOD collaborate in good faith with the VA or the Advisory 
Panel. As I discussed above, there is a tremendous suspicion of 
the military's involvement in these matters. The Committee bill 
would only serve to amplify that distrust.
    And finally, a glaring procedural problem with the 
Committee bill is that it was advanced without the support of 
the Armed Services Committee, the Senate Committee which has 
sole jurisdiction over the TRICARE program. Veterans and family 
members have waited too long for action by the Congress on 
their exposure claims. By reporting a bill that arguably is 
within another Committee's jurisdiction, I fear the only thing 
the Committee has advanced on their behalf is more delay and 
frustration.

           *       *       *       *       *       *       *

                        CHANGES IN EXISTING LAW

    In compliance with paragraph 12 of rule XXVI of the 
Standing Rules of the Senate, the Committee notes that no 
changes in existing law are made by the original bill as 
ordered reported.

                                  
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