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[Senate Report 113-106]
[From the U.S. Government Publishing Office]

                                                       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 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 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 non-service-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 service-related 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 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 fertility-impairing 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 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 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 trauma, suggests that many injured servicemembers may 
have long-term 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 non-service-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' 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 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 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.

------------------------------------------------------------------------
                                By fiscal year, in millions of dollars--
                              ------------------------------------------
                                                                   2014-
                                2014   2015   2016   2017   2018   2018
------------------------------------------------------------------------
              CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Infertility Treatment for
 Veterans
    Estimated Authorization        1     30     95    100    105     331
     Level...................
    Estimated Outlays........      1     27     88     98    104     318
Infertility Treatment for
 Certain Spouses and
 Surrogates
    Estimated Authorization        1     18     58     61     64     202
     Level...................
    Estimated Outlays........      1     16     54     60     63     194
Adoption Assistance
    Estimated Authorization        *      4     12     13     14      43
     Level...................
    Estimated Outlays........      *      4     11     13     14      42
Child Care Programs
    Estimated Authorization        3      3      3      3      3      15
     Level...................
    Estimated Outlays........      3      3      3      3      3      15
Counseling for Women in
 Retreat Settings
    Estimated Authorization        1      1      2      2      2       8
     Level...................
    Estimated Outlays........      1      1      2      2      2       8
Reproduction and Infertility
 Research
    Estimated Authorization        *      *      *      *      0       1
     Level...................
    Estimated Outlays........      *      *      *      *      *       1
                              ------------------------------------------
    Total Changes
        Estimated                  6     56    170    179    188     600
         Authorization Level.
        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 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 service-connected 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.
---------------------------------------------------------------------------
    \1\This 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.
---------------------------------------------------------------------------
    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 
increase 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 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.

                             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:

   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 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 technology 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 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.

           *       *       *       *       *       *       *

                                ------                                

                               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. Sec. 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 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.
    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 assistance 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 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.

           *       *       *       *       *       *       *

                   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.

                        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) * * *

           *       *       *       *       *       *       *

                  (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.

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

           *       *       *       *       *       *       *

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.
    (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 long-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)

           *       *       *       *       *       *       *

[SEC. 203. PILOT PROGRAM ON COUNSELING IN RETREAT SETTINGS FOR WOMEN 
                    VETERANS NEWLY SEPARATED FROM SERVICE IN THE ARMED 
                    FORCES

    [(a) Pilot Program Required.--
          [(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.
          [(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.
    [(b) Covered Services.--The services provided to a woman 
veteran under the pilot program 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 a woman 
        veteran under the pilot program in reintegration into 
        the veteran's family, employment, and community.
    [(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.
    [(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.
    [(e) Report.--Not later than 180 days after the completion 
of the pilot program, the Secretary shall submit to Congress a 
report 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.
    [(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.

           *       *       *       *       *       *       *

  

                                  
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