29–010 

Calendar No. 185 

113TH CONGRESS REPORT " ! SENATE 1st Session 113–106 

WOMEN VETERANS AND OTHER HEALTH CARE 

IMPROVEMENTS ACT OF 2013 

SEPTEMBER 17, 2013.—Ordered to be printed 

Mr. SANDERS, from the Committee on Veterans’ Affairs, 

submitted the following 

R E P O R T 

together with 

MINORITY VIEWS 

[To accompany S. 131] 

The Committee on Veterans’ Affairs (hereinafter, ‘‘Committee’’), 

to which was referred the bill (S. 131) to amend title 38, United 

States Code (hereinafter, ‘‘U.S.C.’’), to improve the reproductive assistance provided by the Department of Veterans Affairs (hereinafter, ‘‘VA’’ or ‘‘the Department’’) to severely wounded, ill, or injured veterans and their spouses, and for other purposes, having 

considered the same, reports favorably thereon with an amendment 

in the nature of a substitute, and recommends that the bill, as 

amended, do pass. 

INTRODUCTION

On January 24, 2013, Senator Murray introduced S. 131, the 

proposed ‘‘Women Veterans and Other Health Care Improvements 

Act of 2013.’’ Senators Begich and Tester were original cosponsors 

of the bill. Senator Blumenthal was later added as a cosponsor of 

the bill. The bill was referred to the Committee upon introduction. 

COMMITTEE HEARING

On May 9, 2013, the Committee held a hearing on legislation 

pending before the Committee. Testimony on S. 131 was received 

from: Heather L. Ansley, Esq., M.S.W., Vice President of Veterans 


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Policy, VetsFirst; Richard F. Weidman, Executive Director for Policy and Government Affairs, Vietnam Veterans of America; and 

Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary for 

Health, U.S. Department of Veterans Affairs. 

COMMITTEE MEETING

On July 24, 2013, the Committee met in open session to consider 

legislation pending before the Committee. Among the measures so 

considered was an amended version of S. 131. The Committee 

voted by voice vote, to report favorably S. 131 as amended (hereinafter, ‘‘the Committee bill’’) to the Senate. One Member was recorded as a no vote. 

SUMMARY OF S. 131 AS REPORTED

Section 1 would provide a short title for the bill and would provide that certain references within the bill are references to title 

38, U.S.C. 

Section 2 would clarify that fertility counseling and treatment 

are medical services which the Secretary may furnish to veterans 

like other medical services. 

Section 3 would authorize reproductive treatment and care for 

spouses and surrogates of veterans. 

Section 4 would authorize adoption assistance for severely 

wounded veterans. 

Section 5 would require the prescription of regulations on furnishing of fertility counseling and treatment and adoption assistance by VA. 

Section 6 would provide for coordination between VA and Department of Defense (hereinafter, ‘‘DOD’’) on furnishing of fertility 

counseling and treatment. 

Section 7 would facilitate research on reproduction and infertility. 

Section 8 would require an annual report on provision of fertility 

counseling and treatment furnished by VA. 

Section 9 would authorize a program on assistance for child care 

for certain veterans. 

Section 10 would authorize a program on counseling in retreat 

settings for women veterans newly separated from service in the 

armed forces. 

BACKGROUND AND DISCUSSION

Sec. 2. Clarification that fertility counseling and treatment are medical services which the Secretary may furnish to veterans like 

other medical services. 

Section 2 of the Committee bill, which is derived from S. 131, as 

introduced, would clarify that fertility counseling and treatment 

are medical services which the Secretary may furnish to veterans 

like other medical services. 

Background. The nature of the most recent conflicts and the increasing use of improvised explosive devices leave servicemembers 

far more susceptible to blast injuries, including spinal cord injury 

and trauma to the reproductive and urinary tracts. According to 

DOD data, between 2003 and June 2013, 2,320 servicemembers 


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suffered genitourinary or pelvic injuries while serving in Iraq or Afghanistan. 

VA currently provides fertility counseling and treatment for all 

enrolled veterans, including to both service-connected and nonservice-connected veterans, as described in the Medical Benefits 

Package contained in section 17.38 of title 38, Code of Federal Regulations (hereinafter, ‘‘C.F.R.’’). The services offered include genetic 

counseling and testing, laboratory tests, biopsies of reproductive organs, hormonal treatments, and intra-uterine insemination. However, VA explicitly prohibits certain types of assisted reproductive 

technology (hereinafter, ‘‘ART’’) in section 17.38(c) of title 38, 

C.F.R., such as in vitro fertilization (hereinafter, ‘‘IVF’’). 

A March 2011 study by Mattocks, et al., entitled ‘‘Women veterans’ reproductive health preferences and experiences: a focus 

group analysis,’’ published in Women’s Health Issues found that 

women veterans felt VA could improve fertility services offered by 

increasing the availability of more advanced procedures. Additionally, the study found: ‘‘[S]everal participants had utilized infertility 

services provided by the VA, including infertility medications and 

artificial insemination, yet were denied VA coverage for assisted reproductive technologies, including in vitro fertilization. Participants 

expressed beliefs that the VA should provide more extensive infertility coverage, including in vitro fertilization, to assist women who 

are having difficulties becoming pregnant.’’ 

According to testimony submitted by the Department for the 

Committee’s May 9, 2013, hearing on pending legislation, providing 

reproductive treatment through ART is in line with VA’s goals to 

provide restorative care to disabled veterans and improve their 

quality of life. Both male and female veterans experience servicerelated reproductive injuries or illnesses that interfere with their 

fertility and fecundity—ability to carry a pregnancy to full-term. 

Among these are: blast injuries that can damage the sexual organs, 

including testicular or uterine rupture, or their nerve and vascular 

supplies, and non-ballistic injuries, such as spinal cord or traumatic brain injury. For these veterans, the use of ART may be their 

only option for achieving a successful pregnancy. 

On April 27, 2010, DOD authorized IVF services for severely 

wounded, ill, or injured servicemembers and their spouses. DOD 

issued guidance on the implementation of this benefit on April 3, 

2012. This resulted in an inequity in the services provided by VA 

and DOD to assist severely wounded veterans or servicemembers 

in becoming parents. Some veterans have difficulty utilizing this 

coverage before they separate from active duty due to timing and 

after separation due to geographic constraints. 

Committee Bill. Section 2 of the Committee bill would modify section 1701(6) of title 38, U.S.C., to clarify that fertility treatments, 

including treatments through ART, are authorized for veterans. It 

is the view of the Committee that veterans should be able to access 

the same level of fertility treatments whether they utilize VA or 

DOD health care. 

Sec. 3. Reproductive treatment and care for spouses and surrogates 

of veterans. 

Section 3 of the Committee bill, which is derived from S. 131, as 

introduced, would require VA to furnish reproductive treatment 


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and care to spouses or surrogates of severely wounded, ill, or injured veterans. It also authorizes VA to coordinate fertility counseling and treatments for spouses and surrogates of veterans whose 

infertility is not related to military service. 

Background. In order to provide comprehensive fertility treatment to a veteran, it is imperative to provide treatment to the veteran’s spouse or surrogate to ensure that treatment results in a 

successful pregnancy. This is particularly significant for wounded, 

ill, or injured veterans. Certain illnesses or injuries necessitate the 

use of ART among veterans who may be clinically unable to 

achieve a successful pregnancy. According to testimony submitted 

by Dr. Mark Edney, Member of the American Urological Association, for the Committee’s June 27, 2012, hearing on pending legislation, blast or gunshot wounds to the male pelvis or spinal cord 

and traumatic brain injury may render male servicemembers and 

veterans incapable of intercourse to achieve a natural pregnancy. 

For other veterans, surrogacy—the process by which a woman 

agrees to become pregnant and give birth to a child on behalf of 

another person—is their only option for having their own children. 

According to testimony submitted by Dr. Edney, ‘‘[b]last or gunshot 

wounds to the female pelvis can also result in a variety of fertilityimpairing injuries * * *[;] penetrating schrapnel injury to the female pelvis can disrupt the ovaries, fallopian tubes, body of the 

uterus or the vaginal vault * * *[;] [u]terine injury can result in 

a uterus incapable of sustaining a pregnancy which then opens the 

issue of surrogacy.’’ 

Committee Bill. Section 3 of the Committee bill would amend 

title 38, U.S.C., by adding a new section 1788. Subsection (a) of 

this new section would require VA to furnish fertility counseling 

and treatment, including ART, to a spouse or surrogate of a severely wounded, ill, or injured veteran who has an infertility condition incurred or aggravated in the line of duty in the active military, naval, or air service. The spouse or surrogate and the veteran 

must apply jointly for such counseling and treatment through a 

process prescribed by VA, and the veteran must be enrolled in the 

health care system established under section 1705(a) of title 38, 

U.S.C. 

While VA provides reproductive counseling and treatment for 

veterans, the Committee notes that infertility management is one 

of many family planning concerns that commonly involves treatment of both parents. The Committee intends that VA make these 

treatments and any necessary components, including those derived 

from third party donation, available to spouses and surrogates of 

severely injured veterans in order to restore their ability to create 

a family. 

Subsection (b) of this new section would authorize VA to coordinate fertility counseling and treatment for spouses or surrogates 

with the veteran’s, when the veteran’s infertility is not related to 

their military service. 

Subsection (c) of this new section would clarify that nothing in 

this section shall be construed to require VA to find or certify a 

surrogate for a veteran or to connect a surrogate with an injured 

veteran. Subsection (c) also clarifies that nothing in this section 

shall be construed to require VA to furnish maternity care to a 


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spouse or veteran who would not otherwise be eligible for VA to 

provide that care. 

Sec. 4. Adoption assistance for severely wounded veterans. 

Section 4 of the Committee bill, which is derived from S. 131, as 

introduced, would authorize VA to provide adoption assistance to 

severely wounded, ill, or injured veterans who have an infertility 

condition incurred or aggravated in the line of duty. 

Background. In light of injuries sustained, servicemembers and 

veterans may need to rely on third-party donation or adoption to 

build their families. The 2002 National Survey of Family Growth, 

conducted by the Centers for Disease Control and Prevention, 

found that approximately three quarters of women who were seeking to adopt a child faced issues with fertility or maintaining a 

pregnancy. 

Committee Bill. Section 4 of the Committee bill would further 

amend title 38, U.S.C., by adding a new section 1789. This new section would authorize VA to assist a covered veteran in the adoption 

of one or more children. Covered veterans would include severely 

wounded, ill, or injured veterans who are enrolled in the VA health 

care system and have an infertility condition incurred or aggravated in the line of duty. This section authorizes VA to set a limitation on the amount that is equal to the lesser of the cost of one 

cycle of fertility treatment through ART or the cost of three adoptions. 

The intent of the Committee is to ensure that veterans, with infertility conditions connected to their military service, have flexibility and options to choose from when deciding how to build their 

families. 

Sec. 5. Regulations on furnishing of fertility counseling and 

treatment and adoption assistance by Department of Veterans 

Affairs. 

Section 5 of the Committee bill, which is derived from S. 131, as 

introduced, would require VA to promulgate regulations on the furnishing of fertility treatments via ART, prior to furnishing counseling or treatment, and on the furnishing of services described in 

sections 1788 and 1789 of title 38, as added by sections 3 and 4 

of the Committee bill, notwithstanding any other provision of the 

law. 

Committee Bill. Section 5 of the Committee bill would require VA 

to promulgate regulations in accordance with section 553 of title 5, 

U.S.C., on the furnishing of fertility treatments and adoptions, as 

added by the Committee bill, prior to furnishing such services. This 

section would require that VA, not later than 540 days after the 

date of the enactment of the Committee bill, prescribe regulations 

to provide fertility treatments to veterans via ART and to carry out 

sections 1788 and 1789 of title 38, U.S.C., as added by the Committee bill. The Committee expects that the regulations required by 

this section would encourage the development of common-sense 

clinical guidance and would allow for stakeholder involvement in 

the decisionmaking process on how best to administer fertility 

counseling and treatment to veterans and their spouses or surrogates. The Committee also intends these regulations allow for collaborative decisionmaking on how to best offer fertility treatment 


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to surrogates and spouses, and adoption assistance to eligible veterans. It is not the intent of the Committee to stop or slow any existing fertility services that VA currently offers. 

Sec. 6. Coordination between Department of Veterans Affairs and 

Department of Defense on furnishing of fertility counseling and 

treatment. 

Section 6 of the Committee bill, which is derived from S. 131, as 

introduced, would require VA to coordinate the furnishing of fertility counseling and treatment by VA with the furnishing of such 

counseling and treatment by DOD. 

Background. DOD, in certain situations and at certain military 

treatment facilities (hereinafter, ‘‘MTFs’’), provides IVF treatments 

to severely wounded, ill, and injured servicemembers and spouses. 

DOD also has several MTFs that offer fertility treatments through 

ART on a cost-sharing basis. Offering these services has resulted 

in an inequity in the extent to which VA and DOD are able to 

assist severely wounded veterans or servicemembers in becoming 

parents. 

Committee Bill. Section 6 of the Committee bill would require VA 

to coordinate its fertility counseling and treatment with that provided by DOD. 

It is the intent of the Committee that VA and DOD coordinate 

their services to address the needs of this unique population. In addition, the Committee encourages VA to work with DOD and understand key lessons learned in DOD’s implementation of guidance 

and delivery of services. The Committee believes that coordination 

will allow both Departments to avoid duplicative efforts while expanding access to fertility counseling and treatment for servicemembers and veterans. 

Sec. 7. Facilitation of reproduction and infertility research. 

Section 7 of the Committee bill, which is derived from S. 131, as 

introduced, would require VA to collaborate with the DOD and the 

Department of Health and Human Services (hereinafter, ‘‘HHS’’) to 

facilitate research on the long-term reproductive needs of veterans. 

This section would also require VA to report to Congress on research activities conducted in response to this section. 

Background. Occupational hazards, including environmental exposures, trauma, and military sexual trauma, can affect the reproductive health of servicemembers. Many serving in Operation Iraqi 

Freedom (hereinafter, ‘‘OIF’’), Operation Enduring Freedom (hereinafter, ‘‘OEF’’), and Operation New Dawn (hereinafter, ‘‘OND’’) are 

of childbearing age, and may have to deal with a lifetime of symptoms related to their military service. For example, according to 

data from DOD, 2,320 servicemembers have suffered reproductive 

and urinary tract trauma on the battlefield between 2003 and June 

2013. These injuries may limit servicemembers’ and veterans’ abilities to reproduce for various reasons, including damage to reproductive organs, pelvic fractures, and others. 

In June 2012, an editorial by Colonel Steve Waxman, M.D., 

U.S.A.R., entitled ‘‘Lower Urinary Tract Injuries in Operation Iraqi 

Freedom (OIF) and Operation Enduring Freedom (OEF)’’ was published in Military Medicine. Colonel Waxman found that the concurrence of bladder and urethral injuries, along with genital trauVerDate Mar 15 2010 20:57 Sep 19, 2013 Jkt 029010 PO 00000 Frm 00006 Fmt 6659 Sfmt 6602 E:\HR\OC\SR106.XXX SR106

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ma, suggests that many injured servicemembers may have longterm hormonal and fertility issues. Limited research is available on 

the reproductive health needs and treatment options available for 

servicemembers and veterans. In testimony submitted for the Committee’s June 27, 2012, hearing on pending legislation, Dr. Mark 

Edney, an urologist and Army Reservist, highlighted the critical 

need for research in this area, including research on strategies for 

preventing reproductive and urinary tract trauma on the battlefield 

and the long-term effects of such trauma on reproductive health. 

Currently, VA has limited ongoing research in this area, including studies on urogenital systems and Post Traumatic Stress Disorder (hereinafter, ‘‘PTSD’’), availability and use of contraceptives, 

and the effects of male reproductive toxicants on the ability to reproduce. In addition to VA, other government research entities can 

play an important role in filling the gap in existing research on the 

long-term reproductive needs of veterans, including DOD, because 

of its role in facilitating research to inform health care services for 

servicemembers, and HHS, because of its role in setting a national 

agenda for detection, prevention, and management of infertility. 

Committee Bill. Section 7 of the Committee bill would amend 

subchapter II of chapter 73 of title 38, U.S.C., to create a new section 7330B. Subsection (a) of this new section would require VA to 

collaborate with DOD and HHS to facilitate research to improve 

VA’s ability to meet the long-term reproductive health needs of veterans. Subsection (b) of this new section would require VA to ensure that information produced by the research facilitated under 

this section is disseminated throughout the VA system. 

Section 7 would also require VA to submit a report to Congress, 

not later than 3 years after the date of the enactment of the Committee bill, on the research activities conducted under new section 

7330B of title 38, U.S.C. 

Sec. 8. Annual report on provision of fertility counseling and treatment furnished by Department of Veterans Affairs. 

Section 8 of the Committee bill, which is derived from S. 131, as 

introduced, would require VA to submit a report to Congress each 

year on the fertility counseling and treatments furnished by VA 

during the year preceding the submittal of the report. 

Background. At present, VA provides limited fertility treatments 

for all enrolled veterans including both service-connected and nonservice-connected veterans. The services available to male veterans 

include laboratory testing, semen analysis, evaluation and treatment of erectile dysfunction interfering with sperm delivery, surgical correction of structural pathology, hormone therapy, sperm 

cryopreservation for certain conditions, genetic testing and counseling, sperm retrieval, post-ejaculatory urinalysis, and transrectal 

or scrotal ultrasonography. The services available to female veterans include laboratory testing, pelvic or transvaginal ultrasound, 

hysterosalpingogram, post-coital testing, diagnostic laparoscopy or 

hysteroscopy, endometrial biopsy, hormone therapy, intrauterine 

insemination, saline infused sonohysterogram, surgical correction 

of structural pathology, and genetic testing and counseling. There 

is no data readily available on usage of these services. 

Committee Bill. Subsection (a) of section 8 of the Committee bill 

would require VA to submit a report to the Committee on Veterans’ 


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Affairs of the Senate and House of Representatives each year on 

the fertility counseling and treatments furnished by VA during the 

year preceding the submittal of the report. 

Subsection (b) of section 8 of the Committee bill describes the information required in each report submitted under subsection (a), 

including the number of veterans and spouses or surrogates of veterans who received fertility counseling or treatments furnished by 

VA, disaggregated by era of military service of such veterans; the 

cost to VA of furnishing fertility counseling and treatment, 

disaggregated by cost of services and administration; the average 

cost to VA per recipient of such counseling and treatment; in cases 

in which the Department furnished IVF, the average number of cycles per person furnished; and a description of how VA fertility 

counseling and treatment services are coordinated with similar 

services provided by DOD. It is the Committee’s view that it is critical to monitor these services to ensure that they are meeting the 

needs of those they are intended to assist. 

Sec. 9. Program on assistance for child care for certain veterans. 

Section 9 of the Committee bill, which is derived from S. 131, as 

introduced, would authorize a permanent program to provide assistance for child care to certain veterans receiving readjustment 

counseling and related mental health services. 

Background. The Caregivers and Veterans Omnibus Health Services Act of 2010, enacted as Public Law (hereinafter, ‘‘P.L.’’) 111– 

163, authorized VA to create a pilot program to provide assistance 

to veterans for child care expenses incurred while receiving care at 

VA Medical Centers via stipend, direct provision of child care, 

interagency collaboration, or payment to private child care agency. 

The pilot was authorized to be carried out in no fewer than three 

Veterans Integrated Service Networks for 2 years, beginning on the 

date the first site began to operate. Subsidies for child care are 

only available during the time period that a veteran is actually receiving specified health care services at a VA Medical Center, and 

during the time required by the veteran to travel to and from the 

site of treatment. Veterans eligible for subsidies are those who are 

the primary caretaker of a child or children and who are receiving 

regular or intensive mental health care, or other intensive health 

care services determined by VA as ones for which access would be 

improved by payment of a subsidy for child care. 

The first child care site opened in Buffalo, NY, on October 3, 

2011. Sites in Northport, NY, and American Lake, WA, opened on 

April 30, 2012, and December 3, 2012, respectively. The Dallas VA 

Medical Center also opened a site on April 1, 2013. Between the 

inception of the pilot program and June 2013, the four sites have 

served 3,817 children. 

Having access to quality and timely mental health care is vital. 

VA’s Vet Centers play an integral role in providing readjustment 

counseling and mental health treatment to combat veterans. Committee oversight has found access to child care can complicate a 

veteran’s ability to consistently adhere to a Vet Center counseling 

and treatment plan. 

Committee Bill. The Committee has recognized the absence of 

adequate child care as a significant barrier to accessing health care 

for veterans who are also primary caretakers of children. This 


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problem is exacerbated for veterans who may need more intensive 

and long-term outpatient services, such as care for PTSD, mental 

health, and other therapeutic programs. 

Section 9(a) of the Committee bill would make permanent the 

pilot program to provide child care subsidies to eligible veterans. 

Section 9(b) would require VA to create a program to offer child 

care assistance to those seeking readjustment counseling and associated mental health services through VA’s network of Vet Centers. 

It is the intent of the Committee to ensure that identified barriers 

to mental health care access are removed. 

Sec. 10. Counseling in retreat settings for women veterans newly 

separated from service in the Armed Forces. 

Section 10 of the Committee bill, which is derived from S. 131, 

as introduced, would make permanent the pilot program on counseling in retreat settings for women veterans newly separated from 

service in the Armed Forces. 

Background. P.L. 111–163, the Caregivers and Veterans Omnibus Health Services Act of 2010, authorized VA to establish a pilot 

program designed to evaluate the feasibility of providing reintegration and readjustment services in group retreat settings to recently 

separated women veterans, after a prolonged deployment. 

Services provided under the pilot program include information 

and assistance on reintegration into family, employment, and community; financial and occupational counseling; information and 

counseling on stress reduction and conflict resolution; and any 

other counseling VA considers appropriate to assist the participants in reintegrating into their families and communities. 

As required by P.L. 111–163, the Department submitted a report 

to the Committees on Veterans’ Affairs on outcomes of the pilot 

program. According to this report, the total cost for both years of 

the pilot program was $398,376. Over the 2-year period, six retreats were held in California, Colorado, Washington, New Mexico, 

and Connecticut. These retreats were attended by 134 women from 

37 States and Territories, and 85 percent of participants had statistically significant improvements in psychological well-being, with 

71 percent of participants maintaining these improvements 2 

months after participation in a retreat. Eighty-one percent of participants showed statistically significant decreases in stress symptoms, 82 percent of participants showed more frequent use of positive coping skills, and 78 percent of those who qualified for a PTSD 

diagnosis prior to participating no longer qualified for that diagnosis 2 months after attendance at a retreat. 

Committee Bill. Section 10 of the Committee bill would make 

permanent the pilot program. Based on reports, this program is 

successful at improving the ability for women veterans to reintegrate and readjust to civilian life. It is the intent of the Committee that VA continue to offer this cost-effective program to more 

women veterans who can benefit from participation. 

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 the Congressional Budget Office (hereinafter, ‘‘CBO’’), estimates 

that enactment of the Committee bill would, relative to current 


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law, have a discretionary cost of $578 million over the 2014–2018 

period, assuming appropriation of the estimated amounts. S. 131, 

as amended, contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act. 

The cost estimate provided by CBO, setting forth a detailed 

breakdown of costs, follows: 

CONGRESSIONAL BUDGET OFFICE, Washington, DC, August 21, 2013. 

Hon. BERNARD SANDERS, 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. 131, the Women Veterans 

and Other Health Care Improvements Act of 2013. 

If you wish further details on this estimate, we will be pleased 

to provide them. The CBO staff contact is Ann E. Futrell. 

Sincerely, 

DOUGLAS W. ELMENDORF, 

Director. 

Enclosure. 

S. 131—Women Veterans and Other Health Care Improvements Act 

of 2013 

Summary: S. 131 would expand the types and availability of infertility treatment provided by the Department of Veterans Affairs 

(VA). CBO estimates that implementing the bill would cost $578 

million over the 2014–2018 period, assuming appropriation of the 

estimated amounts. Enacting S. 131 would not affect direct spending or revenues; therefore, pay-as-you go procedures do not apply. 

S. 131 contains no intergovernmental or private-sector mandates 

as defined in the Unfunded Mandates Reform Act (UMRA). 

Estimated cost to the Federal Government: The estimated budgetary impact of S. 131 is shown in the following table. The costs 

of this legislation fall within budget function 700 (veterans benefits 

and services). 

Basis of estimate: For this estimate, CBO assumes the legislation 

will be enacted early in fiscal year 2014, that the necessary 

amounts will be appropriated for each year, and that outlays will 

follow historical spending patterns for similar and existing 

programs. 

Infertility Treatment for Veterans. Section 2 would expand the 

types of infertility treatments provided by VA to include assisted 

reproductive technology (ART) procedures, of which in vitro fertilization (IVF) is the most widely used. Under current policy, VA 

provides veterans with limited assistance for infertility treatments 

and covers the costs for delivery and newborn care for eligible veterans. CBO’s estimate of the cost of this provision includes two 

components: the cost of providing the additional fertility services 

and the cost of providing additional delivery services for the resulting pregnancies. 


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By fiscal year, in millions of dollars— 

2014 2015 2016 2017 2018 2014- 

2018 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Infertility Treatment for Veterans 

Estimated Authorization Level .......................................... 1 30 95 100 105 331 

Estimated Outlays ............................................................ 1 27 88 98 104 318 

Infertility Treatment for Certain Spouses and Surrogates 

Estimated Authorization Level .......................................... 1 18 58 61 64 202 

Estimated Outlays ............................................................ 1 16 54 60 63 194 

Adoption Assistance 

Estimated Authorization Level .......................................... * 4 12 13 14 43 

Estimated Outlays ............................................................ * 4 11 13 14 42 

Child Care Programs 

Estimated Authorization Level .......................................... 3 3 3 3 3 15 

Estimated Outlays ............................................................ 3 3 3 3 3 15 

Counseling for Women in Retreat Settings 

Estimated Authorization Level .......................................... 1 1 2 2 2 8 

Estimated Outlays ............................................................ 1 1 2 2 2 8 

Reproduction and Infertility Research 

Estimated Authorization Level .......................................... * * * * 0 1 

Estimated Outlays ............................................................ * * * * * 1 

Total Changes 

Estimated Authorization Level ................................. 6 56 170 179 188 600 

Estimated Outlays ................................................... 6 51 158 176 186 578 

Note: * = less than $500,000. 

The inclusion of ART as a covered treatment option would affect 

federal health care spending for female veterans. To determine the 

number of female veterans that would use this new benefit, CBO 

examined the use of ART services among the general population, 

as reported by the Centers for Disease Control (CDC). Based on 

that data, and making adjustments for the age of the veteran population and the number of enrollees in the VA health care system 

(and assuming that additional veterans would enroll to take advantage of the new benefit), CBO estimates that about 3,500 female 

veterans would use this benefit a year. 

CBO estimates that the cost of those services would be about 

$16,000 per user in 2014 or about $57 million once the program is 

fully implemented in 2016; that estimate is based on publicly available pricing information for ART procedures from several fertility 

clinics. 

In addition to the cost of the procedures, VA would incur additional costs for some of the resulting pregnancies. Based on information from the CDC, CBO estimates that about a third of ART 

procedures result in a pregnancy. However, some VA enrollees are 

currently undergoing ART procedures outside of VA, and the department already covers the cost of roughly half of the pregnancies 

that would be covered under the bill’s ART provision. Therefore, 

CBO estimates that about 550 additional pregnancies would be covered by the VA under the bill. Furthermore, CBO estimates the 

cost of each pregnancy would be about $55,000 in 2014, based on 

information from private-sector studies. This amount is significantly higher than the average cost of a pregnancy in the United 

States (about $16,000) because it takes into account the higher percentage of multiple births and pre-term deliveries associated with 

pregnancies that result from fertility treatments. The total cost of 


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1This section also would provide VA with the authority to coordinate infertility counseling and 

treatment for the spouses and surrogates of the broader veteran population. However, absent 

further detail, VA cannot provide information on how they would implement the provision; 

therefore, CBO cannot estimate a cost for that additional authority. 

those pregnancies would be about $31 million once the program is 

fully implemented in 2016. 

After accounting for inflation, and assuming that it would take 

about three years to write regulations and fully implement the proposal, CBO estimates that, in total, implementing section 2 would 

increase costs to VA by $318 million over the 2014–2018 period, assuming appropriation of the necessary amounts. 

Infertility Treatment for Certain Spouses and Surrogates. Section 

3 would require VA to provide fertility assistance services to the 

spouses and surrogates of veterans who, as a result of a serviceconnected disability, have difficulty fathering children.1 CBO’s estimate of the cost of this provision includes the cost of providing the 

fertility services as well as additional child delivery services for the 

resulting pregnancies for individuals eligible for CHAMPVA (11 

percent of the spouses). CHAMPVA is an insurance program run 

by the VA for dependents and survivors of certain disabled 

veterans. 

To estimate the number of veterans that would use this new benefit, CBO examined the use of ART services as reported by the 

CDC. Based on those data, and making adjustments for the age of 

the veteran population, and for the fact that the veteran’s infertility must be caused by a severe service-connected condition in 

order to receive this benefit, CBO estimates that about 3,000 veterans would use this benefit each year. Similar to our analysis for 

section 2, CBO estimates an average cost of $16,000 per user in 

2014. In addition to the cost of the fertility assistance procedures, 

CBO also estimates that VA would incur additional costs of roughly 

$3 million per year, once the program is fully implemented in 2016, 

to cover the cost of additional pregnancies. 

In total, CBO estimates that implementing section 3 would in- crease costs to VA by $194 million over the 2014–2018 period. The 

bill would require VA to establish the rules and regulations to implement section 3 within 18 months of the bill’s enactment; therefore, the costs for treatments would begin in late 2015. 

Adoption Assistance. Section 4 would allow VA to pay for adoption costs for severely wounded veterans with infertility conditions 

related to their service-connected disability. Such payments would 

be limited to the lesser of the cost of one cycle of fertility treatment 

and the costs associated with three adoptions. 

Using data from the CDC on adoption rates, adjusted for the 

number of veterans eligible for the new benefit, CBO estimates 

that about 700 veterans each year would decide to adopt with VA’s 

assistance. Based on information about adoption costs from the Department of Health and Human Services, CBO assumes that the 

cost of three adoptions would be higher than the cost for one cycle 

of IVF (the most commonly used fertility treatment). CBO estimates that implementing this provision would cost $42 million over 

the 2014–2018 period, assuming appropriation of the necessary 

amounts. 

Child Care Programs. Section 9 would allow VA to permanently 

extend existing pilot programs that provide child care for certain 


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13 

veterans who use VA medical facilities in no fewer than three Veteran Integrated Service Networks. Based on the authorization levels for the existing pilot programs, CBO estimates that implementing this program would cost $15 million over the 2014–2018 

period. 

Counseling for Women in Retreat Settings. Section 10 would direct VA to establish a program that provides counseling in group 

retreat settings to certain female veterans who have recently separated from military service. VA recently reported on a completed 

pilot program with similar requirements. Roughly 130 women veterans participated in the program in six retreats over a two-year 

period. Based on the reported spending for the pilot program and 

assuming an increase in participation—to 650 participants in 15 

retreat settings in 2014, and a doubling of the number of participants by 2018—CBO estimates that implementing this program 

would cost $8 million over the 2014–2018 period. 

Reproduction and Infertility Research. Section 7 would require 

the VA to conduct a research study on women’s reproductive health 

in collaboration with the Department of Defense and the National 

Institutes of Health. Based on information from VA on the cost and 

duration of similar studies, CBO estimates the research study 

would run for about three years and cost $1 million over the 2014– 

2018 period. 

Pay-As-You-Go Considerations: None. 

Intergovernmental and private-sector impact: S. 131 contains no 

intergovernmental or private-sector mandates as defined in UMRA 

and would impose no costs on state, local, or tribal governments. 

Estimate prepared by: Federal Costs: Ann E. Futrell; Impact on 

State, Local, and Tribal Governments: Lisa Ramirez-Branum; Impact on the Private Sector: Elizabeth Bass. 

Estimate approved by: Peter H. Fontaine, 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 S. 131, 

as amended, would not entail any regulation of individuals or businesses or result in any 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(b) 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 24, 2013, meeting. On that date, the Committee 

voted, by voice vote, to order reported S. 131, as amended, to the 

Senate. Senator Moran was recorded as a no vote. 


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AGENCY REPORT

On May 9, 2013, Robert L. Jesse, M.D., Ph.D., Principal Deputy 

Under Secretary for Health, Department of Veterans Affairs, appeared before the Committee on Veterans’ Affairs and submitted 

testimony on, among other things, S. 131. In addition, on September 11, 2013, VA provided views on S. 131. Excerpts from both 

the testimony and Department views are reprinted below: 


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STATEMENT OF ROBERT L. JESSE, M.D., PH.D., PRINCIPAL 

DEPUTY UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Good Morning Chairman Sanders, Ranking Member Burr, and 

Members of the Committee. Thank you for inviting me here today 

to present our views on several bills that would affect Department 

of Veterans Affairs (VA) benefits programs and services. Joining 

me today is Susan Blauert, Deputy Assistant General Counsel. 

We do not yet have cleared views on sections 4, 10, 11, or 12 of 

S. 131, S. 287, section 3 of S. 522, S. 800, S. 832, S. 845, S. 851, 

S. 852, or the draft bill described as ‘‘The Veterans Affairs Research Transparency Act of 2013.’’ Also, we do not have estimated 

costs associated with implementing S. 131, S, 422, S. 455, or 

S. 825. We will forward the views and estimated costs to you as 

soon as they are available. 

* * * * * * * 

S. 131, WOMAN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS

ACT OF 2013

Section 2 of S. 131 would amend 38 U.S.C. section 1701(6) to include fertility counseling and treatment, including treatment using 

assisted reproductive technology, among those things that are considered to be ‘‘medical services’’ under chapter 17 of title 38, U.S.C. 

VA supports section 2 of the bill, but must condition this support 

on assurance of the additional resources that would be required 

were this provision enacted. The provision of Assisted Reproductive 

Technologies (including any existing or future reproductive technology that involves the handling of eggs or sperm) is consistent 

with VA’s goal to restore to the greatest extent possible the physical and mental capabilities of Veterans and improve the quality of 

their lives. For many, having children is an important and essential aspect of life. Those who desire but are unable to have children 

of their own commonly experience feelings of depression, grief, inadequacy, poor adjustment, and poor quality of life. 

Section 3 of the bill would add a new section 1788 to title 38, 

U.S.C., that would require VA to furnish fertility counseling and 

treatment, including through the use of assisted reproductive technology, to a spouse or surrogate of a severely wounded, ill, or injured enrolled Veteran who has an infertility condition incurred or 

aggravated in the line of duty, if the spouse or surrogate and the 

Veteran apply jointly for such counseling and treatment through a 

process prescribed by VA. This section would authorize VA to ‘‘coordinate fertility counseling and treatment’’ for other spouses and 

surrogates of other Veterans who are seeking fertility counseling 

and treatment. Section 1788 would not be construed to require VA 

to furnish maternity care to a spouse or surrogate of a Veteran, or 


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to require VA to find or certify a surrogate for or connect a surrogate with a Veteran. Subsection (d) of proposed section 1788 would 

define the term ‘‘assisted reproductive technology’’ to include ‘‘in 

vitro fertilization and other fertility treatments in which both eggs 

and sperm are handled when clinically appropriate.’’ 

VA supports section 3 in part, but must condition this support 

on assurance of the additional resources that would be required 

were this provision enacted. VA supports providing infertility services including assisted reproductive technology to severely wounded, ill, or injured enrolled Veterans described in section 3, and their 

spouses or partners. VA does not, however, support coverage of 

such services for surrogates at this time. The complex legal, medical, and policy arrangements of surrogacy vary from state to state 

due to inconsistent regulations between States, and we believe 

would prove to be very difficult to implement in practice. Moreover, 

the additional coverage of surrogates is inconsistent with coverage 

provided by the Department of Defense (DOD), Medicaid, Medicare, 

and several private insurers and health systems. Current DOD policy addressing assisted reproductive services for severely injured 

Servicemembers specifically excludes coverage of surrogates. VA acknowledges that surrogacy may offer the only opportunity for Veterans and their spouses or partners to have a biological child. However, there may be other options to consider when exploring how 

best to compensate these Veterans for their loss and to facilitate 

procreation. 

VA recommends the language of the bill be modified to account 

for different types of family arrangements, so that benefits are not 

limited to only spouses of Veterans described in proposed section 

1788; VA recommends that section 1788 be revised to refer to a 

‘‘spouse or partner’’ of a specified Veteran. In addition, the meaning 

and scope of the coordination contemplated under proposed section 

1788(b) (which would authorize VA to ‘‘coordinate fertility counseling and treatment’’ for the spouses and surrogates of other Veterans not described in section 1788(a)) is unclear, and could potentially account for spouses and surrogates of all other Veterans. VA 

recommends that this be clarified. 

Section 5 of the bill would require VA to report annually to the 

Committees on Veterans’ Affairs of the Senate and House of Representatives on the fertility counseling and treatment furnished by 

VA during the preceding year. The first report would be required 

no later than 1 year after enactment. Each report submitted under 

section 5 would be required to contain specified information, including the number of Veterans, spouses, and surrogates who received 

fertility counseling and treatment furnished by VA; the costs of furnishing such counseling and treatment; and coordination of such 

counseling and treatment with similar services of DOD. VA does 

not object to such reporting. 

Section 6(a) would require VA, no later than 540 days after enactment, to prescribe regulations to carry out proposed sections 

1788 and 1789, and on fertility treatment to Veterans using assisted reproductive technology. Section 6(b) would prohibit VA from 

providing, until regulations are prescribed, fertility counseling and 

treatment under 1788, assistance under 1789, and to a Veteran 

‘‘any fertility treatment that uses an assisted reproductive techVerDate Mar 15 2010 20:57 Sep 19, 2013 Jkt 029010 PO 00000 Frm 00016 Fmt 6604 Sfmt 6604 E:\HR\OC\SR106.XXX SR106

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nology that the Secretary has not used in the provision of a fertility 

treatment to a veteran before the date of the enactment.’’ The term 

‘‘assisted reproductive technology’’ under section 6 would have the 

same meaning given to the term in proposed section 1788 of section 3. 

VA does not support Section 6(a). While 540 days accorded for 

the drafting of regulations may seem like a long period of time, 

given the complexities of the issues involved, VA estimates that 

amount of time could be insufficient. 

Section 7 of S. 131 would require the Secretary of VA and the 

Secretary of Defense to share best practices and facilitate referrals, 

as they consider appropriate, on the furnishing of fertility counseling and treatment. VA does not object to this requirement. 

Section 8 of the bill would add a new section 7330B to title 38, 

U.S.C., entitled ‘‘Facilitation of reproduction and infertility research.’’ This new section would require the Secretary of VA to ‘‘facilitate research conducted collaboratively by the Secretary of Defense and the Secretary of Health and Human Services’’ to improve 

VA’s ability to meet the long-term reproductive health care needs 

of Veterans with service-connected genitourinary disabilities or 

conditions incurred or aggravated in the line of duty that affect the 

Veterans’ ability to reproduce, such as spinal cord injury. The Secretary of VA would be required to ensure that information produced by research facilitated under section 7330B that may be useful for other activities of the Veterans Health Administration 

(VHA) is disseminated throughout VHA. No later than 3 years 

after enactment, VA would be required to report to Congress on the 

research activities conducted under section 7330B. 

VA supports section 8 of S. 131. Generally, VA supports implementing research findings that are scientifically sound and that 

would benefit Veterans and improve health care delivery to Veterans. VA’s goal is to restore the capabilities of Veterans with disabilities to the greatest extent possible. We utilize new research 

into various conditions to improve the quality of care we provide. 

Of note, rather than requiring VA to conduct research, this section 

would require VA to facilitate research that is conducted collaboratively by the Secretary of Defense and the Secretary of Health 

and Human Services. It is not clear how the term ‘‘facilitate’’ would 

be defined, which could raise privacy and security issues with respect to identifiable Veteran information. Given the ambiguity over 

the meaning of this term, VA is unable to provide a cost estimate 

at this time. If facilitation requires fairly minor involvement (coordination, distribution, etc.), VA expects the costs of this provision 

would be nominal; however, if facilitation is intended to mean direct funding, proposal reviews, and additional staff, costs would be 

greater. 

Section 9 of S. 131 would require VA to enhance the capabilities 

of the VA Women Veterans Call Center (WVCC) in responding to 

requests by women Veterans for assistance with accessing VA 

health care and benefits, as well as in referring such Veterans to 

community resources to obtain assistance with services not furnished by VA. 

VA supports section 9 and has established an inbound calling 

system specifically for women Veterans. By building on capabilities 


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within WVCC, the incoming call center allows women Veterans to 

call WVCC to connect them to resources, assist with specific concerns, and provide information on services and benefits. Many of 

the Veterans are calling VA daily requesting more details on how 

to enroll, how to find their DD–214, and what benefits they have 

earned. WVCC can directly connect women Veterans to Health Eligibility Center employees for enrollment information and to discuss 

the benefits that might be available to them. The call could also be 

transferred to the appropriate medical center to assist eligible Veterans with obtaining a health care appointment. Once the woman 

Veteran is connected to VA health care services, the Women Veterans Program Manager can also assist her in finding community 

resources that may not be provided by VA. 

VA is unable to provide views on sections 4, 10, 11, and 12 at 

this time, but will provide views on those provisions in a later submission to the Committee. 

* * * * * * * 


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ENCLOSURE: 

VA VIEWS

S. 131, WOMAN VETERANS AND OTHER HEALTH CARE

IMPROVEMENT ACT OF 2013

Section 2 of S. 131 would amend 38 U.S.C. § 1701(6) to include 

fertility counseling and treatment, including assisted reproductive 

technology, among those things that are considered ‘‘medical services’’ under chapter 17 of title 38, U.S.C. As discussed in VA’s 

May 9, 2013 testimony, VA supports section 2 of the bill, conditioned on the availability of the additional resources needed to implement this provision. 

VA estimates that section 2 would cost $81.5 million in fiscal 

year (FY) 2015; $296 million over 5 years; and $652 million over 

10 years. These estimates reflect the costs of new services that are 

not included currently in the medical benefits package and costs 

associated with maternity services for additional pregnancies that 


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may result from the use of assisted reproductive technology. These 

estimates do not reflect potential costs associated with additional 

enrollment or utilization of currently covered services that may result if the bill is enacted. 

Among other things, section 3 of S. 131 would add a new section 

1788 to title 38, U.S.C., that would require VA to furnish fertility 

counseling and treatment, including assisted reproductive technology, to a spouse or surrogate of a severely wounded, ill or injured enrolled Veteran who has an infertility condition that was incurred or aggravated in the line of duty, if the spouse or surrogate 

and Veteran apply jointly through a process prescribed by VA. As 

discussed in VA’s May 9, 2013 testimony, VA supports section 3 of 

the bill in part, conditioned on the availability of the additional resources that would be required to implement this provision. VA estimates that section 3 would cost $102 million in FY 2015; 

$319 million over 5 years; and $717 million over 10 years. These 

estimates include coverage of spouses and partners of covered Veterans. These estimates do not include costs associated with coverage of surrogates; as discussed in VA’s May 9, 2013 testimony, 

VA does not support coverage of surrogates at this time. 

Section 4 of S. 131 would authorize the Secretary to provide 

adoption assistance to severely wounded, ill, or injured Veterans 

who suffer from infertility conditions incurred or aggravated in the 

line of duty. VA understands the intent of this provision but has 

numerous concerns that merit further consideration. VA would 

need to consider the possible associated responsibilities that could 

go along with monetary adoption support, including adequate oversight of the agencies or entities that would receive the funds and 

potential issues of State law. VA also must carefully consider additional demands on its resources that would not be directed at core 

medical services for Veterans. 

VA estimates that section 4 would cost $96.27 million in FY 

2015; $521.46 million over 5 years; and $1.16 billion over 10 years. 

Section 10 of S. 131 would expand the locations and duration of 

the pilot program required by section 203 of Public Law 111–163. 

Section 203 required VA to carry out a pilot program to evaluate 

the feasibility and advisability of providing reintegration and readjustment services in group retreat settings to women Veterans recently separated from service after a prolonged deployment. Section 

10(a) would increase the number of locations at which VA is required to carry out the pilot program from three to fourteen. Section 10(b) would extend the duration of the pilot from 2 to 4 years. 

Section 10(c) would amend section 203(f) to authorize the appropriation of $400,000 for each of FY 2013 and FY 2014 to carry out 

the pilot program. 

VA supports section 10 of S. 131. VA has completed the final 

year of the original 2-year pilot program, and the report required 

by section 203 was submitted to Congress on May 9, 2013. Initial 

reports show favorable results, indicating that the retreats, which 

focus on building trust and developing peer support in a therapeutic environment, supply participants with tools needed for successful reintegration into civilian life. Additional retreats would 

generate more data to inform a comprehensive assessment of the 

program during the new final reporting phase under section 10. 


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Although VA supports section 10, there may not be fourteen distinct geographic locations that satisfy the retreat requirements, 

such as the need for specialized locations for outdoor team-building 

exercises. VA would continue to look for new locations, but recommends that section 10(a) be amended to require VA to carry out 

the pilot program in up to fourteen locations, some of which may 

be repeat locations from the original pilot program. 

In addition, VA recommends that section 10(b) be amended to require the pilot program be ‘‘carried out through September 30, 

2015,’’ rather than requiring that it be ‘‘carried out during the 4- 

year period beginning on the date of the commencement of the pilot 

program.’’ This would ensure that VA has a sufficient period of 

time to carry out additional retreats for eligible women Veterans 

and generate data for analysis. For the same reason, we recommend section 10(c) be amended to authorize the appropriation of 

$400,000 ‘‘for each of fiscal years 2013 through 2015’’ to carry out 

the pilot program. VA estimates section 10 would cost $337,320 in FY 2014 and, if 

the pilot extends through FY 2015, $350,520 in FY 2015, for a total 

cost of $687,840. 

Section 11(a) of S. 131 would add a new section 1709B to title 38, 

U.S.C. that would make permanent VA’s authority to provide assistance to qualified Veterans to obtain child care so that such Veterans can receive certain health care services. VA would be required to carry out the program in no fewer than three Veterans 

Integrated Service Networks. This section would also identify certain forms of assistance that may be provided. VA’s pilot program 

providing such services under section 205 of Public Law 111–163 

would expire upon enactment of section 11(a). 

VA does not support a permanent mandatory authority to provide child care assistance. VA has four operational pilot locations 

where child care assistance is provided pursuant to section 205 of 

Public Law 111–163. The first pilot began operation in October 2011. The remaining pilots were set up in a staggered fashion 

with the most recent pilot not beginning until 2013. Under current 

law, all pilots are scheduled to end on October 2, 2013, therefore, 

not affording three pilots the benefit of 2 full years of operation. 

Without 2 full years of operational data from each pilot, VA is 

not able to adequately assess long-term utilization needs and cost 

implications of the program. In light of this longer term analysis 

that includes an evaluation of resources, VA believes permissive 

authority to allow expansion of the program would be preferable to 

a permanent mandatory authority to provide child care assistance. 

Permissive authority would allow facilities at the local level to 

make a determination based on need and utilize resources, space 

and security as necessary. 

VA is unable to provide an accurate cost estimate for a permanent mandatory child care program, in part, because of the lack of 

data on the existing pilots that have run for less than 2 years, but 

also because such an estimate would be dependent on location of 

the sites, the ability to contract in the area of the designated sites, 

and the utilization of services. 

Section 11(b) of S. 131 would add a new section 1709C to title 38, 

U.S.C. that would require VA to carry out a program to provide asVerDate Mar 15 2010 20:57 Sep 19, 2013 Jkt 029010 PO 00000 Frm 00021 Fmt 6604 Sfmt 6604 E:\HR\OC\SR106.XXX SR106

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sistance to qualified Veterans to obtain child care so that such Veterans can receive readjustment counseling and related mental 

health services. The program would be carried out in at least three 

Readjustment Counseling Service Regions selected by VA. This section would identify certain forms of child care assistance that may 

be provided, and it would define ‘‘Vet Center’’ as ‘‘a center for readjustment counseling and related mental health services for veterans under section 1712A of [title 38, U.S.C.].’’ 

VA supports section 11(b) in principle. Some Veterans who use 

Vet Center services, especially those who have served in Iraq or Afghanistan, have voiced concern that a lack of child care has impacted their ability to use Vet Center services consistently. Although Vet Center staff are always searching for new initiatives to 

increase Veteran access to services, VA has concerns about implementing child care assistance under section 11(b) without the opportunity to pilot this type of benefit. A pilot program is needed because VA currently is unable to predict utilization of this type of 

assistance. Comparisons to medical center pilots are not useful because Vet Centers provide services during non-traditional hours, 

including after normal business hours and on weekends when requested by the Veteran. This inability to predict utilization affects 

VA’s ability to budget the program appropriately. VA recommends 

that section 11(b) be modified to authorize a pilot program to determine the feasibility, advisability, and costs of providing child care 

assistance to Veterans who utilize Vet Center services. 

VA is not able to provide an accurate cost estimate for section 

11(b) because VA lacks child-care experience for the special Vet 

Center context as described above and comparable models. 

Section 12 of S. 131 would add a new section 323 to title 38, 

U.S.C., entitled ‘‘Contractor user fees.’’ Under proposed section 

323(a), VA would be required to impose a fee on each person with 

whom the Secretary engages in a contract for a good or service as 

a condition of the contract. The fee amount would be the lesser of: 

(1) seven percent of the total value of the contract, and (2) the total 

value of the contract multiplied by an applicable percentage calculated for the fiscal year. Before each fiscal year, VA would be required to establish an annual estimate of the total value of contracts for the next fiscal year and an annual estimate of the total 

cost of furnishing fertility counseling and treatment—including the 

use of assisted reproductive technology—and payments under proposed section 1789 (under section 4 of S. 131) for the next fiscal 

year, both of which would be used in estimating the applicable percentage for the fiscal year (the percentage by which the former exceeds the latter). The Secretary would have discretion to waive the 

fee for a person as the Secretary considers appropriate if the person is an individual or ‘‘small business concern’’ (as defined in section 3 of the Small Business Act). Fees could not be collected under 

proposed section 323(a) unless the expenditure of the fee is provided for in advance in an appropriations Act. 

Proposed section 323(e) would establish a fund in the Treasury 

to be known as the ‘‘Department of Veterans Affairs Fertility Counseling and Treatment Fund,’’ and all amounts received under proposed section 323(a) would be deposited in the fund. Subject to the 

provisions of appropriations Acts, amounts in the fund would be 


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made available, without fiscal year limitation, to VA to furnish fertility counseling and treatment—including the use of assisted reproductive technology—to eligible individuals and to make payments under proposed section 1789 (under section 4 of S. 131). 

Amounts received by VA under proposed section 323(a) would be 

treated for the purposes of sections 251 and 252 of the Balanced 

Budget and Emergency Deficit Control Act of 1985 as offsets to discretionary appropriations (rather than as offsets to direct spending), to the extent that such amounts are made available for expenditure in appropriations Acts for the purposes specified. 

VA does not support section 12, which VA estimates could result 

in up to 7 percent less money available for contract actions. That 

is because contractors could be expected to pass this cost back to 

VA in the form of higher contract prices. Applying the proposed fee 

to ‘‘a contract for a good or service’’ without limitation would subject VA Administrations’ and Offices’ (e.g., Veterans Benefits Administration, National Cemetery Administration, Office of Human 

Resources and Administration, and Office of General Counsel) 

budget dollars for contracts to funding health care services. This 

would impact these entities’ budgets, particularly in smaller offices, 

for a purpose that is wholly unrelated to their primary functions. 

In this difficult time of budget limitations, this is impractical and 

could negatively impact overall VA performance. In addition, determining a percentage and implementing it for the beginning of each 

fiscal year would be difficult administratively, as would the process 

of collecting and accounting for these funds. (As a technical matter, 

the word ‘‘person’’ should be replaced with ‘‘contractor’’ throughout 

this provision.) 

In many industries and for many contractors, the existing profit 

margins would not tolerate a 7 percent cut. 

* * * * * * * 


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MINORITY VIEWS OF RANKING MEMBER 

HON. RICHARD BURR 

On July 24, 2013, the Senate Committee on Veterans’ Affairs 

(hereinafter, ‘‘the Committee’’) voted, by voice vote, to approve en 

bloc five legislative items and three separate legislative items on 

the Committee’s agenda. One item the Committee voted on individually was S. 131, as amended. In principal, I support several provisions of this legislation, which would improve the care of women 

veterans and reduce barriers to services. However, I was unable to 

support this legislation in Committee. At the time of the Committee meeting, I expressed concerns regarding: How would the 

Committee pay for any increased costs associated with the legislation? Will all of the provisions address real problems in a way that 

will actually help to improve the lives of military personnel, veterans, and their families? Last, the Administration had not yet provided complete views on this legislation. 

Unfortunately, the Committee members were unable to adequately address the concerns of the Administration regarding this 

legislation before, during, or after the July 2013 meeting. My hope 

is that, on all matters before the Committee, the Committee will 

proceed in a more deliberate, informed manner. 


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CHANGES IN EXISTING LAW

In compliance with paragraph 12 of Rule XXVI of the Standing 

Rules of the Senate, changes in existing law made by the bill, as 

reported, are shown as follows (existing law proposed to be omitted 

is enclosed in black brackets, new matter is printed in italic, existing law in which no change is proposed is shown in roman). 

Title 38. Veterans’ Benefits 

* * * * * * * 

Part II. General Benefits 

* * * * * * * 

Chapter 17. Hospital, Nursing Home, Domiciliary, 

and Medical Care 

* * * * * * * 

Sec. 

SUBCHAPTER I. GENERAL 

1701. Definitions. 

* * * * * * * 

1709B. Assistance for child care for certain veterans receiving health care. 

1709C. Assistance for child care for individuals receiving readjustment counseling 

and related mental health services. 

SUBCHAPTER II. HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL TREATMENT 

* * * * * * * 

1720H. Counseling in retreat settings for women veterans newly separated from service in the Armed Forces. 

* * * * * * * 

SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS 

* * * * * * * 

1788. Reproductive treatment and care for spouses and surrogates of veterans. 

1789. Adoption assistance. 

* * * * * * * 

SEC. 1701. DEFINITIONS 

* * * * * * * 

(6) * * * 

* * * * * * * 


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(H) Fertility counseling and treatment, including treatment using assisted reproductive technology. 

* * * * * * * 

SEC. 1709B. ASSISTANCE FOR CHILD CARE FOR CERTAIN VETERANS 

RECEIVING HEALTH CARE 

(a) PROGRAM REQUIRED.—The Secretary shall carry out a program to provide, subject to subsection (b), assistance to qualified 

veterans described in subsection (c) to obtain child care so that such 

veterans can receive health care services described in subsection (c). 

(b) LIMITATION ON PERIOD OF PAYMENTS.—Assistance may only 

be provided to a qualified veteran under this section for receipt of 

child care during the period that the qualified veteran— 

(1) receives health care services described in subsection (c) at 

a facility of the Department; and 

(2) requires travel to and from such facility for the receipt of 

such health care services. 

(c) QUALIFIED VETERANS.—For purposes of this section, a qualified veteran is a veteran who is— 

(1) the primary caretaker of a child or children; and 

(2)(A) receiving from the Department— 

(i) regular mental health care services; 

(ii) intensive mental health care services; or 

(iii) such other intensive health care services that the Secretary determines that provision of assistance to the veteran 

to obtain child care would improve access to such health 

care services by the veteran; or 

(B) in need of regular or intensive mental health care services 

from the Department, and but for lack of child care services, 

would receive such health care services from the Department. 

(d) LOCATIONS.—The Secretary shall carry out the program in no 

fewer than three Veterans Integrated Service Networks selected by 

the Secretary for purposes of the program. 

(e) FORMS OF CHILD CARE ASSISTANCE.—(1) Child care assistance 

under this section may include the following: 

(A) Stipends for the payment of child care offered by licensed 

child care centers (either directly or through a voucher program) which shall be, to the extent practicable, modeled after 

the Department of Veterans Affairs Child Care Subsidy Program established pursuant to section 630 of the Treasury and 

General Government Appropriations Act, 2002 (Public Law 

107–67; 115 Stat. 552). 

(B) Direct provision of child care at an on-site facility of the 

Department. 

(C) Payments to private child care agencies. 

(D) Collaboration with facilities or programs of other Federal 

departments or agencies. 

(E) Such other forms of assistance as the Secretary considers 

appropriate. 

(2) In the case that child care assistance under this section is provided as a stipend under paragraph (1)(A), such stipend shall cover 

the full cost of such child care. 


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SEC. 1709C. ASSISTANCE FOR CHILD CARE FOR INDIVIDUALS RECEIVING READJUSTMENT COUNSELING AND RELATED MENTAL 

HEALTH SERVICES 

(a) PROGRAM REQUIRED.—The Secretary shall carry out a program to provide, subject to subsection (b), assistance to qualified individuals described in subsection (c) to obtain child care so that 

such individuals can receive readjustment counseling and related 

mental health services. 

(b) LIMITATION ON PERIOD OF PAYMENTS.—Assistance may only 

be provided to a qualified individual under this section for receipt 

of child care during the period that the qualified individual receives 

readjustment counseling and related health care services at a Vet 

Center. 

(c) QUALIFIED INDIVIDUALS.—For purposes of this section, a qualified individual is an individual who is— 

(1) the primary caretaker of a child or children; and 

(2)(A) receiving from the Department regular readjustment 

counseling and related mental health services; or 

(B) in need of readjustment counseling and related mental 

health services from the Department, and but for lack of child 

care services, would receive such counseling and services from 

the Department. 

(d) LOCATIONS.—The Secretary shall carry out the program under 

this section in no fewer than three Readjustment Counseling Service 

Regions selected by the Secretary for purposes of the program. 

(e) FORMS OF CHILD CARE ASSISTANCE.—(1) Child care assistance 

under this section may include the following: 

(A) Stipends for the payment of child care offered by licensed 

child care centers (either directly or through a voucher program) which shall be, to the extent practicable, modeled after 

the Department of Veterans Affairs Child Care Subsidy Program established pursuant to section 630 of the Treasury and 

General Government Appropriations Act, 2002 (Public Law 

107–67; 115 Stat. 552). 

(B) Payments to private child care agencies. 

(C) Collaboration with facilities or programs of other Federal 

departments or agencies. 

(D) Such other forms of assistance as the Secretary considers 

appropriate. 

(2) In the case that child care assistance under this subsection is 

provided as a stipend under paragraph (1)(A), such stipend shall 

cover the full cost of such child care. 

(f) VET CENTER DEFINED.—In this section, the term ‘‘Vet Center’’ 

means a center for readjustment counseling and related mental 

health services for individuals under section 1712A of this title. 

* * * * * * * 

Subchapter II. Hospital, Nursing Home, or Domiciliary Care 

and Medical Treatment 

* * * * * * * 


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SEC. 1720H. COUNSELING IN RETREAT SETTINGS FOR WOMEN VETERANS NEWLY SEPARATED FROM SERVICE IN THE ARMED 

FORCES 

(a) IN GENERAL.—The Secretary shall provide, through the Readjustment Counseling Service of the Veterans Health Administration, 

reintegration and readjustment services described in subsection (c) 

in group retreat settings to women veterans who are recently separated from service in the Armed Forces after a prolonged deployment. 

(b) ELECTION OF VETERAN.—The receipt of services under this section by a woman veteran shall be at the election of the veteran. 

(c) COVERED SERVICES.—The services provided to a woman veteran under this section shall include the following: 

(1) Information on reintegration into the veteran’s family, employment, and community. 

(2) Financial counseling. 

(3) Occupational counseling. 

(4) Information and counseling on stress reduction. 

(5) Information and counseling on conflict resolution. 

(6) Such other information and counseling as the Secretary 

considers appropriate to assist the veteran in reintegration into 

the veteran’s family, employment, and community. 

* * * * * * * 

Subchapter VIII. Health Care of Persons Other Than 

Veterans 

* * * * * * * 

SEC. 1787. HEALTH CARE OF FAMILY MEMBERS OF VETERANS STATIONED AT CAMP LEJEUNE, NORTH CAROLINA 

* * * * * * * 

SEC. 1788. REPRODUCTIVE TREATMENT AND CARE FOR SPOUSES AND 

SURROGATES OF VETERANS 

(a) IN GENERAL.—The Secretary shall furnish fertility counseling 

and treatment, including through the use of assisted reproductive 

technology, to a spouse or surrogate of a severely wounded, ill, or 

injured veteran who has an infertility condition incurred or aggravated in line of duty in the active military, naval, or air service and 

who is enrolled in the system of annual patient enrollment established under section 1705(a) of this title if the spouse or surrogate 

and the veteran apply jointly for such counseling and treatment 

through a process prescribed by the Secretary. 

(b) COORDINATION OF CARE FOR OTHER SPOUSES AND SURROGATES.—In the case of a spouse or surrogate of a veteran not described in subsection (a) who is seeking fertility counseling and 

treatment, the Secretary may coordinate fertility counseling and 

treatment for such spouse or surrogate. 

(c) CONSTRUCTION.—Nothing in this section shall be construed to 

require the Secretary— 

(1) to find or certify a surrogate for a veteran or to connect 

a surrogate with a veteran; or 

(2) to furnish maternity care to a spouse or surrogate of a veteran. 


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(d) ASSISTED REPRODUCTIVE TECHNOLOGY DEFINED.—In this section, the term ‘‘assisted reproductive technology’’ includes in vitro 

fertilization and other fertility treatments in which both eggs and 

sperm are handled when clinically appropriate. 

SEC. 1789. ADOPTION ASSISTANCE 

(a) IN GENERAL.—The Secretary may pay an amount, not to exceed the limitation amount, to assist a covered veteran in the adoption of one or more children. 

(b) COVERED VETERAN.—For purposes of this section, a covered 

veteran is any severely wounded, ill, or injured veteran who— 

(1) has an infertility condition incurred or aggravated in line 

of duty in the active military, naval, or air service; and 

(2) is enrolled in the system of annual patient enrollment established under section 1705(a) of this title. 

(c) LIMITATION AMOUNT.—For purposes of this section, the limitation amount is the amount equal to the lesser of— 

(1) the cost the Department would incur if the Secretary were 

to provide a covered veteran with one cycle of fertility treatment 

through the use of assisted reproductive technology under section 1788 of this title, as determined by the Secretary; or 

(2) the cost the Department would incur by paying the expenses of three adoptions by covered veterans, as determined by 

the Secretary. 

(d) ASSISTED REPRODUCTIVE TECHNOLOGY DEFINED.—In this section, the term ‘‘assisted reproductive technology’’ has the meaning 

given that term in section 1788 of this title. 

* * * * * * * 

Part V. Boards, Administrations, and Services 

* * * * * * * 

Chapter 73. Veterans Health Administration-Organization 

and Functions 

* * * * * * * 

Sec. 

* * * * * * * 

SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION 

* * * * * * * 

7330B. Facilitation of reproduction and infertility research. 

* * * * * * * 

Subchapter II. General Authority and Administration 

* * * * * * * 

SEC. 7330B. FACILITATION OF REPRODUCTION AND INFERTILITY 

RESEARCH 

(a) FACILITATION OF RESEARCH REQUIRED.—The Secretary shall 

facilitate research conducted collaboratively by the Secretary of Defense and the Secretary of Health and Human Services to improve 

the ability of the Department of Veterans Affairs to meet the longVerDate Mar 15 2010 20:57 Sep 19, 2013 Jkt 029010 PO 00000 Frm 00029 Fmt 6604 Sfmt 6603 E:\HR\OC\SR106.XXX SR106

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term reproductive health care needs of veterans who have a genitourinary service-connected disability or a condition that was incurred or aggravated in line of duty in the active military, naval, 

or air service, such as a spinal cord injury, that affects the veterans’ 

ability to reproduce. 

(b) DISSEMINATION OF INFORMATION.—The Secretary shall ensure 

that information produced by the research facilitated under this section that may be useful for other activities of the Veterans Health 

Administration is disseminated throughout the Veterans Health Administration. 

* * * * * * * 

Caregivers and Veterans Omnibus Health Services 

Act of 2010 

(Public Law 111–163; 38 U.S.C. 1712A note) 

* * * * * * * 

øSEC. 203. PILOT PROGRAM ON COUNSELING IN RETREAT SETTINGS 

FOR WOMEN VETERANS NEWLY SEPARATED FROM SERVICE IN THE ARMED FORCES 

ø(a) PILOT PROGRAM REQUIRED.— ø(1) IN GENERAL.—Commencing not later than 180 days after 

the date of the enactment of this Act, the Secretary of Veterans 

Affairs shall carry out, through the Readjustment Counseling 

Service of the Veterans Health Administration, a pilot program 

to evaluate the feasibility and advisability of providing reintegration and readjustment services described in subsection 

(b) in group retreat settings to women veterans who are recently separated from service in the Armed Forces after a prolonged deployment. 

ø(2) PARTICIPATION AT ELECTION OF VETERAN.—The participation of a veteran in the pilot program under this section 

shall be at the election of the veteran. 

ø(b) COVERED SERVICES.—The services provided to a woman veteran under the pilot program shall include the following: 

ø(1) Information on reintegration into the veteran’s family, 

employment, and community. 

ø(2) Financial counseling. 

ø(3) Occupational counseling. 

ø(4) Information and counseling on stress reduction. 

ø(5) Information and counseling on conflict resolution. 

ø(6) Such other information and counseling as the Secretary 

considers appropriate to assist a woman veteran under the 

pilot program in reintegration into the veteran’s family, employment, and community. 

ø(c) LOCATIONS.—The Secretary shall carry out the pilot program 

at not fewer than three locations selected by the Secretary for purposes of the pilot program. 

ø(d) DURATION.—The pilot program shall be carried out during 

the 2-year period beginning on the date of the commencement of 

the pilot program. 

ø(e) REPORT.—Not later than 180 days after the completion of 

the pilot program, the Secretary shall submit to Congress a report 


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on the pilot program. The report shall contain the findings and conclusions of the Secretary as a result of the pilot program, and shall 

include such recommendations for the continuation or expansion of 

the pilot program as the Secretary considers appropriate. 

ø(f) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to 

be appropriated to the Secretary of Veterans Affairs for each of fiscal years 2010 and 2011, $2,000,000 to carry out the pilot program.¿ 

* * * * * * * 

(Public Law 111–163; 38 U.S.C. 1710 note) 

* * * * * * * 

SEC. 205. PILOT PROGRAM ON ASSISTANCE FOR CHILD CARE FOR 

CERTAIN VETERANS RECEIVING HEALTH CARE 

* * * * * * * 

(e) DURATION.—The pilot program shall be carried out during the 

2-year period beginning on the date of the commencement of the 

pilot program but not after the date of the enactment of the Women 

Veterans and Other Health Care Improvements Act of 2013. 

* * * * * * * 

Æ 


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