Title: Comprehensive and Overdue Support for Troops of War Act of 2021
Policy area: Armed Forces and National Security

Summary:
Comprehensive and Overdue Support for Troops of War Act of 2021 or the COST of War Act of 2021
This bill addresses health care and the presumption of service-connection for certain conditions in veterans who were exposed to toxic substances during service in the Armed Forces.

[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 3003 Reported in Senate (RS)]

<DOC>





                                                       Calendar No. 145
117th CONGRESS
  1st Session
                                S. 3003

   To improve health care and benefits for veterans exposed to toxic 
                  substances, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                            October 19, 2021

   Mr. Tester, from the Committee on Veterans' Affairs, reported the 
    following original bill; which was read twice and placed on the 
                                calendar

_______________________________________________________________________

                                 A BILL


 
   To improve health care and benefits for veterans exposed to toxic 
                  substances, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Comprehensive and 
Overdue Support for Troops of War Act of 2021'' or the ``COST of War 
Act of 2021''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
     TITLE I--EXPANSION OF HEALTH CARE FOR TOXIC EXPOSURE VETERANS

Sec. 101. Health care for certain toxic exposure veterans.
Sec. 102. Expansion of health care eligibility for certain veterans 
                            exposed to open burn pits.
Sec. 103. Expansion of health care eligibility for veterans awarded 
                            certain medals.
Sec. 104. Study on feasibility and advisability of furnishing hospital 
                            care and medical services to dependents of 
                            veterans who participated in toxic exposure 
                            risk activities.
      TITLE II--REFORMS TO THE TOXIC EXPOSURE PRESUMPTION PROCESS

Sec. 201. Improvements to ability of Department of Veterans Affairs to 
                            establish presumptions of service 
                            connection based on toxic exposure.
Sec. 202. Technical corrections.
TITLE III--REFORMS TO THE SERVICE CONNECTION PROCESS FOR TOXIC EXPOSURE 
                                VETERANS

Sec. 301. Presumptions of toxic exposure.
Sec. 302. Presumption of exposure to airborne hazards and substances 
                            from burn pits.
Sec. 303. Medical nexus examinations for toxic exposures.
TITLE IV--EXPANSION OF PRESUMPTIONS OF SERVICE CONNECTION FOR FORGOTTEN 
                                VETERANS

Sec. 401. Mark Takai Atomic Veterans Healthcare Parity Act of 2021.
Sec. 402. Treatment of veterans who participated in nuclear response 
                            near Palomares, Spain, as radiation-exposed 
                            veterans for purposes of presumption of 
                            service-connection of certain disabilities 
                            by Department of Veterans Affairs.
Sec. 403. Presumptions of service connection for diseases associated 
                            with exposures to certain herbicide agents 
                            for veterans who served in certain 
                            locations.
Sec. 404. Addition of additional diseases associated with exposure to 
                            certain herbicide agents for which there is 
                            a presumption of service connection for 
                            veterans who served in the Republic of 
                            Vietnam.
Sec. 405. Improving compensation for disabilities occurring in Persian 
                            Gulf War veterans.
Sec. 406. Presumption of service connection for certain diseases 
                            associated with exposure to burn pits and 
                            other toxins.
       TITLE V--STRENGTHENING FEDERAL RESEARCH ON TOXIC EXPOSURES

Sec. 501. Coordination by Department of Veterans Affairs of toxic 
                            exposure research.
Sec. 502. Collection, analysis, and report on treatment of veterans for 
                            medical conditions related to toxic 
                            exposure.
Sec. 503. Studies relating to veterans who served in Southwest Asia.
Sec. 504. Study on health trends of post 9/11 veterans.
Sec. 505. Study on cancer rates among veterans.
         TITLE VI--IMPROVING SUPPORT TO TOXIC EXPOSURE VETERANS

Sec. 601. Definitions.
Sec. 602. Publication of list of resources of Department of Veterans 
                            Affairs for toxic exposure veterans and 
                            outreach program for such veterans and 
                            caregivers and survivors of such veterans.
Sec. 603. Incorporation of toxic exposure questionnaire during primary 
                            care appointments.
Sec. 604. Training for personnel of the Department of Veterans Affairs 
                            with respect to toxic exposure veterans.
Sec. 605. SFC Heath Robinson Burn Pit Transparency Act.
     TITLE VII--STRENGTHENING RECORD-KEEPING OF TOXIC EXPOSURES BY 
                         DEPARTMENT OF DEFENSE

Sec. 701. Definitions.
Sec. 702. Independent study on Individual Longitudinal Exposure Record.
Sec. 703. Biannual report on Individual Longitudinal Exposure Record.
Sec. 704. Correction of toxic exposure records.

     TITLE I--EXPANSION OF HEALTH CARE FOR TOXIC EXPOSURE VETERANS

SEC. 101. HEALTH CARE FOR CERTAIN TOXIC EXPOSURE VETERANS.

    (a) In General.--Section 1710(e) of title 38, United States Code, 
is amended--
            (1) paragraph (1), by adding at the end the following new 
        subparagraph:
    ``(G) Subject to paragraph (2), any veteran who participated in a 
toxic exposure risk activity while serving on active duty, active duty 
for training, or inactive duty training is eligible for hospital care, 
medical services, and nursing home care under subsection (a)(2)(F) for 
any illness, notwithstanding that there is insufficient medical 
evidence to conclude that such illness is attributable to such toxic 
exposure risk activity.''; and
            (2) in paragraph (2)(B)--
                    (A) by striking ``or (F)'' and inserting ``(F), or 
                (G)''; and
                    (B) by striking ``service or testing'' and 
                inserting ``service, testing, or activity''.
    (b) Definitions.--Section 101 of such title is amended by adding at 
the end the following new paragraphs:
            ``(37) The term `toxic exposure' includes the following:
                    ``(A) A toxic exposure risk activity.
                    ``(B) An exposure to a toxic or hazardous substance 
                that is subject to regulation by the Occupational 
                Safety and Health Administration.
            ``(38) The term `toxic exposure veteran' means any veteran 
        who--
                    ``(A) carried out a toxic exposure risk activity; 
                or
                    ``(B) received or receives hospital care, medical 
                services, or nursing home care pursuant to section 
                1710(e)(1) of this title.
            ``(39) The term `toxic exposure risk activity' means any 
        activity--
                    ``(A) that requires a corresponding entry in the 
                Individual Longitudinal Exposure Record of the veteran 
                who carried out the activity; or
                    ``(B) that the Secretary determines qualifies for 
                purposes of section 1710(e)(1) of this title when 
                taking into account what is reasonably prudent to 
                protect the health of veterans.
            ``(40) The term `Individual Longitudinal Exposure Record' 
        includes any pilot program or other program used by the 
        Department of Veterans Affairs or the Department of Defense to 
        track how members of the Armed Forces or veterans have been 
        exposed to various occupational or environmental hazards.''.

SEC. 102. EXPANSION OF HEALTH CARE ELIGIBILITY FOR CERTAIN VETERANS 
              EXPOSED TO OPEN BURN PITS.

    (a) In General.--Section 1710(e) of title 38, United States Code, 
as amended by section 101(a)(2)(A), is further amended--
            (1) in paragraph (1), by adding at the end the following 
        new subparagraph:
    ``(H)(i) Subject to paragraph (2), a covered veteran is eligible 
for hospital care, medical services, and nursing home care under 
subsection (a)(2)(F) for any illness.
    ``(ii) For purposes of this subparagraph, a covered veteran is a 
veteran who--
            ``(I) is eligible for inclusion in the Airborne Hazards and 
        Open Burn Pit Registry; or
            ``(II) has been identified by the Secretary of Defense to 
        have been possibly exposed, inside or outside the United 
        States, during active duty, active duty for training, or 
        inactive duty training, to an open burn pit.
    ``(iii) In this subparagraph:
            ``(I) The term `Airborne Hazards and Open Burn Pit 
        Registry' means the registry established by the Secretary under 
        section 201 of the Dignified Burial and Other Veterans' 
        Benefits Improvement Act of 2012 (Public Law 112-260; 38 U.S.C. 
        527 note).
            ``(II) The term `open burn pit' has the meaning given that 
        term in section 201(c) of the Dignified Burial and Other 
        Veterans' Benefits Improvement Act of 2012 (Public Law 112-260; 
        38 U.S.C. 527 note).''; and
            (2) in paragraph (2)(B), as amended by section 
        101(a)(2)(A), by striking ``or (G)'' and inserting ``(G), or 
        (H)''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
take effect on the date that is 90 days after the date of the enactment 
of this Act.

SEC. 103. EXPANSION OF HEALTH CARE ELIGIBILITY FOR VETERANS AWARDED 
              CERTAIN MEDALS.

    (a) In General.--Section 1710(e) of title 38, United States Code, 
as amended by section 102(a)(1), is further amended--
            (1) in paragraph (1), by adding at the end the following 
        new subparagraph:
    ``(I) Subject to paragraph (2), a veteran is eligible for hospital 
care, medical services, and nursing home care under subsection 
(a)(2)(F) for any illness if the veteran was awarded any of the 
following:
            ``(i) The Afghanistan Campaign Medal.
            ``(ii) The Armed Forces Expeditionary Medal.
            ``(iii) The Global War on Terrorism Expeditionary Medal.
            ``(iv) The Inherent Resolve Campaign Medal.
            ``(v) The Iraqi Campaign Medal.
            ``(vi) The Southwest Asia Service Medal.''; and
            (2) in paragraph (2)(B), as amended by section 102(a)(2), 
        by striking ``or (H)'' and inserting ``(H), or (I)''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
take effect on the date that is 90 days after the date of the enactment 
of this Act.

SEC. 104. STUDY ON FEASIBILITY AND ADVISABILITY OF FURNISHING HOSPITAL 
              CARE AND MEDICAL SERVICES TO DEPENDENTS OF VETERANS WHO 
              PARTICIPATED IN TOXIC EXPOSURE RISK ACTIVITIES.

    (a) In General.--The Secretary of Veterans Affairs shall conduct a 
study on the feasibility and advisability of furnishing hospital care 
and medical services to qualifying dependents of veterans described in 
section 1710(e)(1)(G) of title 38, United States Code, as added by 
section 101(a)(1), for any illness or condition determined by the 
Secretary to be connected to a toxic exposure risk activity carried out 
by the veteran, as determined by the Secretary, notwithstanding that 
there is insufficient medical evidence to conclude that such illness or 
condition is attributable to such activity.
    (b) Elements of Study.--The study required under subsection (a) 
shall--
            (1) assess the impact of furnishing hospital care and 
        medical services to qualifying dependents as described in such 
        subsection on the ability of the Department of Veterans Affairs 
        to furnish hospital care and medical services to veterans;
            (2) assess the potential cost of furnishing hospital care 
        and medical services to qualifying dependents as described in 
        such subsection;
            (3) estimate the resources required to furnish such care 
        and services;
            (4) assess any stress or other impact furnishing such care 
        and services would have on the claims and appeals system of the 
        Department;
            (5) estimate the number of qualifying dependents who would 
        be eligible for such care and services; and
            (6) assess the feasibility of adjudicating claims for such 
        care and services.
    (c) Phased in Application.--In conducting the study under 
subsection (a), the Secretary shall assess the feasibility and 
advisability of phasing in the furnishing of hospital care and medical 
services to qualifying dependents described in such subsection by the 
decade in which such toxic exposure risk activity occurred, starting 
with the most recent decade.
    (d) Review of Exposure Cases Regarding Liability of Department of 
Defense.--In conducting the study under subsection (a), the Secretary 
shall--
            (1) review known cases of toxic exposure on installations 
        of the Department of Defense in the United States;
            (2) explore the liability of the Department of Defense in 
        each such case; and
            (3) assess whether the Department of Defense should provide 
        care and services relating to such toxic exposures under the 
        TRICARE program.
    (e) Report.--Not later than two years after the date of the 
enactment of this Act, the Secretary shall submit to Congress a report 
on the study conducted under subsection (a).
    (f) Definitions.--In this section:
            (1) Hospital care and medical services.--The terms 
        ``hospital care'' and ``medical services'' have the meanings 
        given those terms in section 1701 of title 38, United States 
        Code.
            (2) Qualifying dependent.--The term ``qualifying 
        dependent'' means--
                    (A) a dependent of a veteran described in section 
                1710(e)(1)(G) of title 38, United States Code, as added 
                by section 101(a)(2) who resided with the veteran 
                during the period in which, and on the installation at 
                which, the veteran participated in a toxic exposure 
                risk activity;
                    (B) an individual who was in utero of such a 
                veteran or other qualifying dependent when the veteran 
                participated in a toxic exposure risk activity; or
                    (C) a dependent of such a veteran who is not 
                described in subparagraph (A) or (B) but who may have 
                an illness or condition that is connected to the toxic 
                exposure risk activity of the veteran, as determined by 
                the Secretary.
            (3) TRICARE program.--The term ``TRICARE program'' has the 
        meaning given that term in section 1072(7) of title 10, United 
        States Code.

      TITLE II--REFORMS TO THE TOXIC EXPOSURE PRESUMPTION PROCESS

SEC. 201. IMPROVEMENTS TO ABILITY OF DEPARTMENT OF VETERANS AFFAIRS TO 
              ESTABLISH PRESUMPTIONS OF SERVICE CONNECTION BASED ON 
              TOXIC EXPOSURE.

    (a) Advisory Committees, Panels, and Boards.--
            (1) Establishment.--Chapter 11 of title 38, United States 
        Code, is amended by adding at the end the following new 
        subchapter:

``SUBCHAPTER VII--RESEARCH AND DETERMINATIONS RELATING TO PRESUMPTIONS 
             OF SERVICE CONNECTION BASED ON TOXIC EXPOSURE

``Sec. 1171. Procedures to determine presumptions of service connection 
              based on toxic exposure; definitions
    ``(a) Procedures .--The Secretary shall determine whether to 
establish, to modify, or to remove presumptions of service connection 
based on toxic exposure pursuant to this subchapter, whereby--
            ``(1) the Toxic Exposure Review Commission advises the 
        Secretary and makes recommendations pursuant to section 1172 of 
        this title;
            ``(2) the National Academies of Sciences, Engineering, and 
        Medicine, reviews and evaluates the available scientific 
        evidence pursuant to an agreement under section 1173 of this 
        title;
            ``(3) the working group established under section 1174 of 
        this title evaluates the conclusions of the National Academies 
        of Sciences, Engineering, and Medicine pursuant to the 
        agreement described in paragraph (2) and makes recommendations 
        to the Secretary under such section; and
            ``(4) the Secretary prescribes regulations under section 
        1175 of this title.
    ``(b) Illness Defined.--In this subchapter, the term `illness' 
includes a disease or other condition affecting the health of an 
individual.
    ``(c) Nonapplication of FACA.--The Federal Advisory Committee Act 
(5 U.S.C. App.) shall not apply to an entity established under this 
subchapter.
``Sec. 1172. Toxic Exposure Review Commission
    ``(a) Establishment.--The Secretary shall establish an independent 
commission to be known as the `Toxic Exposure Review Commission' (in 
this section referred to as the `Commission').
    ``(b) Purpose.--The Commission shall--
            ``(1) advise the Secretary on questions relating to toxic 
        exposures that require scientific research; and
            ``(2) assist in the consideration of possible presumptions 
        of service connection relating to toxic exposure.
    ``(c) Duties.--(1) The Commission shall carry out the following 
duties:
            ``(A) Collect any relevant information from the Department 
        of Defense and other sources to identify possible toxic 
        exposures relating to service during active duty, active duty 
        for training, or inactive duty training in order to determine 
        the need for a comprehensive review under an agreement with the 
        National Academies of Sciences, Engineering, and Medicine under 
        section 1173 of this title.
            ``(B) Recommend to the Secretary, by majority vote, whether 
        a review should be conducted under an agreement with the 
        National Academies of Sciences, Engineering, and Medicine under 
        section 1173 of this title.
            ``(C) Recommend to the Secretary, by majority vote, whether 
        new, independent studies regarding the health outcomes of toxic 
        exposures, or any other new, independent studies that the 
        Commission deems necessary and appropriate, should be 
        conducted.
            ``(D) Annually report to Congress on progress regarding the 
        duties set forth in subparagraphs (A) through (C), any 
        recommendations made to the Secretary, and any responses of the 
        Secretary to such recommendations.
    ``(2)(A) Relevant information may be collected under paragraph 
(1)(A) from the following:
            ``(i) Any Federal agency as the Commission considers 
        necessary to carry out this section.
            ``(ii) Public meetings or hearings, which may be held to 
        take such testimony and receive such evidence as the Commission 
        considers advisable to carry out the duties of the Commission.
    ``(B) Upon request of the chairperson of the Commission, the head 
of a Federal agency shall furnish information collected under 
subparagraph (A)(i) to the Commission unless such information is 
classified.
    ``(d) Membership.--(1)(A) The Commission shall be composed of nine 
members, appointed as follows:
            ``(i) Two members appointed by the majority leader of the 
        Senate.
            ``(ii) Two members appointed by the minority leader of the 
        Senate.
            ``(iii) Two members appointed by the Speaker of the House 
        of Representatives.
            ``(iv) Two members appointed by the minority leader of the 
        House of Representatives.
            ``(v) One member appointed by the Secretary.
    ``(B) The initial members of the Commission shall be appointed 
under subparagraph (A) not later than 180 days after the date of the 
enactment of the Comprehensive and Overdue Support for Troops of War 
Act of 2021.
    ``(2) In appointing individuals under paragraph (1)(A), the 
majority leader of the Senate, the minority leader of the Senate, the 
Speaker of the House of Representatives, the minority leader of the 
House of Representatives, and the Secretary shall jointly ensure that 
at least five members of the Commission are scientists or health care 
professionals--
            ``(A) of whom--
                    ``(i) one has a background in the field of 
                respiratory medicine;
                    ``(ii) one has a background in the field of 
                endocrinology and metabolic medicine;
                    ``(iii) one has a background in hematology;
                    ``(iv) one has a background in oncology; and
                    ``(v) one has a background in occupational and 
                environmental health; and
            ``(B) who are not officials or employees of the Federal 
        Government.
    ``(3) In appointing individuals under paragraph (1)(A), the 
majority leader of the Senate, the minority leader of the Senate, the 
Speaker of the House of Representatives, the minority leader of the 
House of Representatives, and the Secretary shall jointly ensure that 
at least two members of the Commission represent an organization 
recognized by the Secretary for the representation of veterans under 
section 5902 of this title.
    ``(4) In appointing individuals under paragraph (1)(A), the 
majority leader of the Senate, the minority leader of the Senate, the 
Speaker of the House of Representatives, the minority leader of the 
House of Representatives, and the Secretary shall jointly give 
consideration to including in the Commission at least one member who 
works with survivors of illnesses relating to toxic exposures and has a 
background in the field of study of toxic exposures.
    ``(e) Meetings.--(1) The Commission shall meet not less frequently 
than twice each year.
    ``(2)(A) Each meeting of the Commission shall be open to the 
public.
    ``(B) All the proceedings, information, and deliberations of the 
Commission shall be available for review by the public.
    ``(C) Meetings of the Commission may be carried out through the use 
of telephonic or other appropriate telecommunication technology if the 
Commission determines that such technology will allow the members to 
communicate simultaneously.
    ``(f) Chairperson and Vice Chair.--At the initial meeting of the 
Commission under subsection (e), the Commission shall select a 
chairperson and vice chairperson from among the members of the 
Commission by a majority vote of the members of the Commission.
    ``(g) Period of Appointment; Vacancies.--(1) A member of the 
Commission shall be appointed for a term that may not exceed four 
years.
    ``(2) The Secretary shall ensure that terms of members of the 
Commission are staggered so that no such terms end on the same date.
    ``(3) A vacancy in the Commission shall be filled in the same 
manner as the original appointment, but the individual appointed to 
fill the vacancy shall serve only for the unexpired portion of the term 
for which the individual's predecessor was appointed.
    ``(4) In appointing the initial members of the Commission, each 
official who is authorized to appoint two members of the Commission 
shall appoint--
            ``(A) one member whose term expires after two years; and
            ``(B) one member whose term expires after four years.
    ``(h) Pay.--(1) Members of the Commission shall serve without pay.
    ``(2) Each member of the Commission who is an officer or employee 
of the United States shall serve without compensation in addition to 
that received for service as an officer or employee of the United 
States.
    ``(3) Members shall receive travel expenses, including per diem in 
lieu of subsistence, in accordance with sections 5702 and 5703 of title 
5.
    ``(i) Director of Staff.--(1) The Commission shall appoint a 
Director who--
            ``(A) has not served as an employee of the Department 
        during the one-year period preceding the date of such 
        appointment; and
            ``(B) is not otherwise barred or prohibited from serving as 
        Director under Federal ethics laws and regulations, by reason 
        of post-employment conflict of interest.
    ``(2) The Director shall be paid at the rate of basic pay payable 
for level IV of the Executive Schedule under section 5315 of title 5.
    ``(j) Staff.--(1) Subject to paragraphs (2) and (3), the Director, 
with the approval of the Commission, may appoint and fix the pay of 
additional personnel.
    ``(2) The Director may make such appointments without regard to the 
provisions of title 5 governing appointments in the competitive 
service, and any personnel so appointed may be paid without regard to 
the provisions of chapter 51 and subchapter III of chapter 53 of that 
title relating to classification and General Schedule pay rates, except 
that an individual so appointed may not receive pay in excess of the 
annual rate of basic pay payable for GS-15 of the General Schedule.
    ``(3)(A) Not more than two-thirds of the personnel employed by or 
detailed to the Commission may be on detail from the Department.
    ``(B) Not more than half of the professional analysts of the 
Commission staff may be persons detailed from the Department to the 
Commission.
    ``(4) Subject to paragraph (3), the head of any Federal agency, 
upon the request of the Director, may detail any of the personnel of 
that agency to the Commission to assist the Commission in carrying out 
its duties under this section.
    ``(5) The Commission may secure directly from any Federal agency 
such information as the Commission considers necessary to carry out 
this section. Upon request of the chairperson of the Commission, the 
head of such agency shall furnish such information to the Commission, 
unless such information is classified.
    ``(k) Other Authority.--(1) The Commission may procure by contract, 
to the extent funds are available, the temporary or intermittent 
services of experts or consultants pursuant to section 3109 of title 5.
    ``(2) To the extent funds are available, the Commission may lease 
real property and acquire personal property either of its own accord or 
in consultation with the General Services Administration.
    ``(l) Communications.--(1)(A) Except as provided in subparagraph 
(B), no person may restrict an employee of the Department in 
communicating with the Commission.
    ``(B) Subparagraph (A) does not apply to a communication that is 
unlawful.
    ``(2) All ex parte communications with the Commission shall be made 
part of the public record.
    ``(m) Responses by Secretary.--In response to each report submitted 
to the Secretary by the Commission under subsection (c)(1), the 
Secretary shall submit to the Committee on Veterans' Affairs of the 
Senate and the Committee on Veterans' Affairs of the House of 
Representatives and make available to the public a report on--
            ``(1) the findings and opinions of the Secretary with 
        respect to the report most recently submitted under subsection 
        (c)(1);
            ``(2) whether the Secretary intends to nominate for review 
        under an agreement with the National Academies of Sciences, 
        Engineering, and Medicine under section 1173 of this title the 
        review recommended by the Committee in the report, and if not, 
        an explanation of why, including citations and sources; and
            ``(3) whether the Secretary intends to follow any other 
        recommendation made by the Commission.
``Sec. 1173. Science review agreement
    ``(a) Purpose.--The purpose of this section is to provide for the 
National Academies of Sciences, Engineering, and Medicine (in this 
section referred to as the `Academies'), an independent nonprofit 
scientific organization with appropriate expertise that is not part of 
the Federal Government, to review and evaluate the available scientific 
evidence regarding associations between illnesses and toxic exposures.
    ``(b) Agreement.--(1) The Secretary shall seek to enter into a 10-
year agreement with the Academies to perform the services covered by 
this section.
    ``(2) The Secretary shall seek to enter into an agreement described 
in paragraph (1) not later than 60 days after the date of the enactment 
of the Comprehensive and Overdue Support for Troops of War Act of 2021.
    ``(3) An agreement under this section may be extended in five-year 
or 10-year increments.
    ``(c) Review of Scientific Evidence.--Under an agreement between 
the Secretary and the Academies under this section, the Academies shall 
review and summarize the scientific evidence, and assess the strength 
thereof, concerning the association between toxic exposures during 
active military, naval, or air service and each illness suspected to be 
associated with such exposure in the human population.
    ``(d) Scientific Determinations Concerning Illnesses.--For each 
illness reviewed under subsection (c), the Academies shall determine, 
to the extent that available scientific data permit meaningful 
determinations--
            ``(1) whether an association exists between a toxic 
        exposure and the occurrence of the illness, taking into account 
        the strength of the scientific evidence and the appropriateness 
        of the statistical and epidemiological methods used to detect 
        the association;
            ``(2) the increased risk of the illness among those subject 
        to toxic exposures during active military, naval, or air 
        service; and
            ``(3) whether there exists a plausible biological mechanism 
        or other evidence of a causal relationship between the toxic 
        exposure and the occurrence of the illness.
    ``(e) Cooperation of Federal Agencies.--The head of each relevant 
Federal agency, including the Secretary of Defense, shall cooperate 
fully with the Academies in performing the services covered by this 
section.
    ``(f) Recommendations for Additional Scientific Studies.--(1) Under 
an agreement between the Secretary and the Academies under this 
section, the Academies shall make any recommendations for additional 
scientific studies to resolve areas of continuing scientific 
uncertainty relating to toxic exposures.
    ``(2) In making recommendations under paragraph (1), the Academies 
shall consider--
            ``(A) the scientific information that is available at the 
        time of the recommendation;
            ``(B) the value and relevance of the information that could 
        result from additional studies; and
            ``(C) the cost and feasibility of carrying out such 
        additional studies.
    ``(g) Reports.--(1) Under an agreement between the Secretary and 
the Academies under this section, for each review conducted under 
subsection (c), the Academies shall submit to the Secretary, the 
Committee on Veterans' Affairs of the Senate, and the Committee on 
Veterans' Affairs of the House of Representatives an initial report on 
the activities of the Academies under the agreement.
    ``(2) The report submitted under paragraph (1) shall include the 
following:
            ``(A) The determinations described in subsection (d).
            ``(B) A full explanation of the scientific evidence and 
        reasoning that led to such determinations.
            ``(C) Any recommendations of the Academies under subsection 
        (f).
    ``(h) Alternative Contract Scientific Organization.--(1) If the 
Secretary is unable to enter into an agreement with the Academies for 
the purposes of this section on terms acceptable to the Secretary, the 
Secretary shall seek to enter into an agreement for the purposes of 
this section with another appropriate scientific organization that--
            ``(A) is not part of the Federal Government;
            ``(B) operates as a not-for-profit entity; and
            ``(C) has expertise and objectivity comparable to that of 
        the Academies.
    ``(2) If the Secretary enters into an agreement with another 
organization as described in paragraph (1), any reference in this 
subchapter to the National Academies of Sciences, Engineering, and 
Medicine shall be treated as a reference to the other organization.
``Sec. 1174. Working group on presumptions of service connection
    ``(a) Establishment.--The Secretary shall establish a working group 
(in this section referred to as the `Working Group')--
            ``(1) to evaluate the conclusions of the National Academies 
        of Sciences, Engineering, and Medicine contained in each report 
        submitted under section 1173(g) of this title; and
            ``(2) to develop and submit to the Secretary a 
        recommendation within 60 days of the Secretary's receipt of a 
        report under section 1173(g) of this title with respect to 
        whether--
                    ``(A) to establish a presumption of service 
                connection between each toxic exposure and illness 
                covered by a report described in paragraph (1); or
                    ``(B) to modify an existing presumption of service 
                connection covered by a report described in paragraph 
                (1).
    ``(b) Recommendations.--(1) In making a recommendation under 
subsection (a)(2), the Working Group shall, if the Working Group 
determines that additional research, studies, or reports are 
appropriate before making a final recommendation with respect to 
establishing or modifying a presumption of service connection, submit 
to the Secretary a description of such additional research, studies, or 
reports.
    ``(2) In making a recommendation under subsection (a)(2), the 
Working Group shall consider only the positive association between a 
toxic exposure and an illness.
    ``(3) Concurrent with the submittal of a recommendation to the 
Secretary under subsection (a)(2), the Working Group shall submit to 
the Committee on Veterans' Affairs of the Senate and the Committee on 
Veterans' Affairs of the House of Representatives a description of such 
recommendation.
``Sec. 1175. Regulations regarding presumptions of service connection 
              based on toxic exposure
    ``(a) Action Upon Working Group Recommendation.--Not later than 60 
days after the date on which the Secretary receives a recommendation to 
establish or modify a presumption of service connection under section 
1174(a)(2) of this title--
            ``(1) if the Secretary determines that the presumption, or 
        modification, is warranted, the Secretary shall issue proposed 
        regulations setting forth the presumption or revise regulations 
        to carry out such modification; or
            ``(2) if the Secretary determines that the presumption, or 
        modification, is not warranted, the Secretary shall publish in 
        the Federal Register a notice of the determination, including 
        the reasons supporting the determination, and all materials the 
        Secretary relied upon for the determination.
    ``(b) Final Regulation.--Not later than 90 days after the date on 
which the Secretary issues any proposed regulations under subsection 
(a)(1), the Secretary shall issue final regulations. Such regulations 
shall be effective on the date of issuance.
    ``(c) Removal of Presumption.--(1) The Secretary may issue 
regulations to remove an illness from a presumption of service 
connection previously established pursuant to a regulation issued under 
subsection (b).
    ``(2) Whenever an illness is removed from regulations pursuant to 
paragraph (1), or the periods or locations of exposure covered by a 
presumption of service connection are modified under subsection (a)--
            ``(A) a veteran who was awarded compensation for such 
        illness on the basis of the presumption provided under such 
        regulations before the effective date of the removal or 
        modification shall continue to be entitled to receive 
        compensation on that basis; and
            ``(B) a survivor of a veteran who was awarded dependency 
        and indemnity compensation for the death of a veteran resulting 
        from such illness on the basis of such presumption shall 
        continue to be entitled to receive dependency and indemnity 
        compensation on such basis.''.
            (2) Clerical amendment.--The table of sections at the 
        beginning of such chapter is amended by adding at the end the 
        following new items:

 ``subchapter vii--research and determinations relating to presumptions 
             of service connection based on toxic exposure

``1171. Procedures to determine presumptions of service connection 
                            based on toxic exposure; definitions.
``1172. Toxic Exposure Review Commission.
``1173. Science review agreement.
``1174. Working group on presumptions of service connection.
``1175. Regulations regarding presumptions of service connection based 
                            on toxic exposure.''.
    (b) Establishment of Working Group.--Not later than 120 days after 
the date of the enactment of this Act, the Secretary of Veterans 
Affairs shall establish the working group required by section 1174(a) 
of title 38, United States Code, as added by subsection (a).
    (c) Conforming Amendments.--Chapter 11 of title 38, United States 
Code, is amended--
            (1) in section 1116--
                    (A) by striking subsections (b), (c), (d), and (e);
                    (B) by inserting after subsection (a) the following 
                new subsection (b):
    ``(b) The Secretary shall ensure that any determination made on or 
after the date of the enactment of the Comprehensive and Overdue 
Support for Troops of War Act of 2021 regarding a presumption of 
service connection based on exposure to an herbicide agent under this 
section is made pursuant to subchapter VII of this chapter, including 
with respect to assessing reports received by the Secretary from the 
National Academy of Sciences under section 3 of the Agent Orange Act of 
1991 (Public Law 102-4).''; and
                    (C) by redesignating subsection (f) as subsection 
                (c).
            (2) in section 1116B(b)(2)(A), by inserting ``pursuant to 
        subchapter VII of this chapter,'' before ``the Secretary 
        determines''; and
            (3) in section 1118--
                    (A) by striking subsections (b) through (e); and
                    (B) by inserting after subsection (a) the following 
                new subsection (b):
    ``(b) The Secretary shall ensure that any determination made on or 
after the date of the enactment of the Comprehensive and Overdue 
Support for Troops of War Act of 2021 regarding a presumption of 
service connection based on a toxic exposure under this section is made 
pursuant to subchapter VII of this chapter.''.

SEC. 202. TECHNICAL CORRECTIONS.

    (a) In General.--Subchapter VI of chapter 11 of title 38, United 
States Code, is amended--
            (1) by redesignating section 1165 as section 1166; and
            (2) by redesignating the section 1164 that was added by 
        section 5501(a)(1) of the Johnny Isakson and David P. Roe, M.D. 
        Veterans Health Care and Benefits Improvement Act of 2020 
        (Public Law 116-315) as section 1165.
    (b) Conforming Clerical Amendments.--The table of sections at the 
beginning of such chapter is amended by striking the items relating to 
the section 1164 that was added by section 5501(a)(1) of the Johnny 
Isakson and David P. Roe, M.D. Veterans Health Care and Benefits 
Improvement Act of 2020 (Public Law 116-315) and section 1165 and 
inserting the following new items:

``1165. Specialized teams to evaluate claims involving military sexual 
                            trauma.
``1166. Choice of sex of medical examiner for certain disabilities.''.

TITLE III--REFORMS TO THE SERVICE CONNECTION PROCESS FOR TOXIC EXPOSURE 
                                VETERANS

SEC. 301. PRESUMPTIONS OF TOXIC EXPOSURE.

    (a) In General.--Subchapter II of chapter 11 of title 38, United 
States Code, is amended by adding at the end the following new section:
``Sec. 1119. Presumptions of toxic exposure
    ``(a) Presumption of Toxic Exposure.--Except as provided in section 
1120 of this title, if a veteran submits to the Secretary a claim for 
compensation for a service-connected disability under section 1110 of 
this title with indication of a toxic exposure that occurred during 
active military, naval, or air service, the Secretary shall presume 
that the veteran was subject to such toxic exposure--
            ``(1) if the Individual Longitudinal Exposure Record of the 
        veteran includes evidence of the toxic exposure; or
            ``(2) in a case in which the Individual Longitudinal 
        Exposure Record of the veteran does not indicate that the 
        veteran was subject to the claimed toxic exposure during active 
        military, naval, or air service, if credible evidence of the 
        facts, places, and circumstances of the service of the veteran 
        in the active military, naval, or air service, including 
        evidence of the veteran's unit assignments, military specialty, 
        or date and location of service, shows the veteran was subject 
        to the claimed toxic exposure during such service.
    ``(b) Role of Lay Statements.--In a case described in subsection 
(a)(2), the Secretary shall accept as credible evidence under such 
subsection a lay statement by the veteran or another that is consistent 
with the other credible evidence of the facts, places, and 
circumstances of the veteran's service in the active military, naval, 
or air service.''.
    (b) Clerical Amendment.--The table of sections at the beginning of 
chapter 11 of such title is amended by inserting after the item 
relating to section 1118 the following new item:

``1119. Presumptions of toxic exposure.''.
    (c) Conforming Amendment.--Section 1113 of such title is amended by 
striking ``or 1118'' each place it appears and inserting ``1118, or 
1119''.

SEC. 302. PRESUMPTION OF EXPOSURE TO AIRBORNE HAZARDS AND SUBSTANCES 
              FROM BURN PITS.

    (a) In General.--Subchapter II of chapter 11 of title 38, United 
States Code, as amended by section 301(a), is further amended by adding 
at the end the following new section:
``Sec. 1120. Presumption of exposure to certain airborne hazards and 
              substances from participation in contingency operations
    ``(a) In General.--For purposes of section 1110 and chapter 17 of 
this title, any veteran described in subsection (b) shall be presumed 
to have been exposed to the substances, chemicals, and hazards listed 
in subsection (c), unless there is affirmative evidence to establish 
that the veteran was not exposed to any such substances, chemicals, or 
hazards during that service.
    ``(b) Veterans Described.--(1) A veteran described in this 
paragraph is any veteran who--
            ``(A) during active military, naval, or air service, was 
        deployed in support of a contingency operation while so serving 
        and as part of such deployment served in a covered location 
        during a corresponding period set forth under paragraph (2); or
            ``(B) on or after August 2, 1990, was awarded any of the 
        following:
                    ``(i) The Afghanistan Campaign Medal.
                    ``(ii) The Armed Forces Expeditionary Medal.
                    ``(iii) The Global War On Terrorism Expeditionary 
                Medal.
                    ``(iv) The Inherent Resolve Campaign Medal.
                    ``(v) The Iraqi Campaign Medal.
                    ``(vi) The Southwest Asia Service Medal.
    ``(2)(A) The covered locations and corresponding periods set forth 
under this subsection are as follows:
            ``(i) Iraq and the following periods:
                    ``(I) The period beginning on August 2, 1990, and 
                ending on February 28, 1991.
                    ``(II) The period beginning on March 19, 2003, and 
                ending on such date as the Secretary determines burn 
                pits are no longer used in Iraq.
            ``(ii) The Southwest Asia Theater of operations, other than 
        Iraq, and the period beginning on August 2, 1990, and ending on 
        such date as the Secretary determines burn pits are no longer 
        used in such location, including the following:
                    ``(I) Kuwait.
                    ``(II) Saudi Arabia.
                    ``(III) Oman.
                    ``(IV) Qatar.
            ``(iii) Afghanistan and the period beginning on September 
        11, 2001, and ending on such date as the Secretary determines 
        burn pits are no longer used in Afghanistan.
            ``(iv) Djibouti and the period beginning on September 11, 
        2001, and ending on such date as the Secretary determines burn 
        pits are no longer used in Djibouti.
            ``(v) Syria and the period beginning on September 11, 2001, 
        and ending on such date as the Secretary determines burn pits 
        are no longer used in Syria.
            ``(vi) Jordan and the period beginning on September 11, 
        2001, and ending on such date as the Secretary determines burn 
        pits are no longer used in Jordan.
            ``(vii) Egypt and the period beginning on September 11, 
        2001, and ending on such date as the Secretary determines burn 
        pits are no longer used in Egypt.
            ``(viii) Lebanon and the period beginning on September 11, 
        2001, and ending on such date as the Secretary determines burn 
        pits are no longer used in Lebanon.
            ``(ix) Yemen and the period beginning on September 11, 
        2001, and ending on such date as the Secretary determines burn 
        pits are no longer used in Yemen.
            ``(x) Such other locations as are set forth by the Airborne 
        Hazards and Open Burn Pit Registry established under section 
        201 of the Dignified Burial and Other Veterans' Benefits 
        Improvement Act of 2012 (Public Law 112-260; 38 U.S.C. 527 
        note) and corresponding periods set forth in such registry.
            ``(xi) Such other locations and corresponding periods as 
        the Secretary, in collaboration with the Secretary of Defense, 
        may determine appropriate in a report the Secretary of Veterans 
        Affairs shall submit to Congress not later than two years after 
        the date of the enactment of the Veterans Burn Pits Exposure 
        Recognition Act of 2021 and not less frequently than once every 
        two years thereafter.
    ``(B) A location set forth under this paragraph shall not include 
any body of water around or any airspace above such location.
    ``(c) Substances, Chemicals, and Airborne Hazards.--(1) Subject to 
paragraph (2), the substances, chemicals, and airborne hazards listed 
in this subsection are as follows:
            ``(A) Particulate matter, including the following:
                    ``(i) PM-10.
                    ``(ii) PM-2.5.
            ``(B) Polycyclic aromatic hydrocarbons (PAHs), including 
        the following:
                    ``(i) Acenaphthene.
                    ``(ii) Acenaphthylene.
                    ``(iii) Anthracene.
                    ``(iv) Benzo(a)anthracene.
                    ``(v) Benzo(a)pyrene.
                    ``(vi) Benzo(b)fluoroanthene.
                    ``(vii) Benzo(g,h,i)perylene.
                    ``(viii) Benzo(k)fluoroanthene.
                    ``(ix) Chrysene.
                    ``(x) Dibenz(a,h)anthracene.
                    ``(xi) Fluoranthene.
                    ``(xii) Fluorene.
                    ``(xiii) Indeno(1,2,3-cd)pyrene.
                    ``(xiv) Naphthalene.
                    ``(xv) Phenanthrene.
                    ``(xvi) Pyrene.
            ``(C) Volatile organic compounds (VOCs), including the 
        following:
                    ``(i) Acetone.
                    ``(ii) Acrolein.
                    ``(iii) Benzene.
                    ``(iv) Carbon Disulfide.
                    ``(v) Chlorodifluoromethane.
                    ``(vi) Chloromethane.
                    ``(vii) Ethylbenzene.
                    ``(viii) Hexane.
                    ``(ix) Hexachlorobutadiene.
                    ``(x) m/p-Xylene.
                    ``(xi) Methylene Chloride.
                    ``(xii) Pentane.
                    ``(xiii) Propylene.
                    ``(xiv) Styrene.
                    ``(xv) Toluene.
            ``(D) Toxic organic halogenated dioxins and furans 
        (dioxins), including the following:
                    ``(i) 1,2,3,4,6,7,8 HPCDD.
                    ``(ii) 1,2,3,4,6,7,8 HPCDF.
                    ``(iii) 1,2,3,4,7,8,9 HPCDF.
                    ``(iv) 1,2,3,4,7,8 HXCDD.
                    ``(v) 1,2,3,4,7,8 HXCDF.
                    ``(vi) 1,2,3,6,7,8 HXCDD.
                    ``(vii) 1,2,3,6,7,8 HXCDF.
                    ``(viii) 1,2,3,7,8,9 HXCDD.
                    ``(ix) 1,2,3,7,8,9 HXCDF.
                    ``(x) 1,2,3,7,8 PECDD.
                    ``(xi) 1,2,3,7,8 PECDF.
                    ``(xii) 2,3,4,6,7,8 HXCDF.
                    ``(xiii) 2,3,4,7,8 PECDF.
                    ``(xiv) 2,3,7,8 TCDD.
                    ``(xv) 2,3,7,8 TCDF.
                    ``(xvi) octachlorodibenzodioxin.
                    ``(xvii) octachlorodibenzofuran.
            ``(E) Such other substances, chemicals, and airborne 
        hazards as the Secretary, in collaboration with the Secretary 
        of Defense, may add under paragraph (2).
    ``(2) The Secretary may add to or remove from the list under 
paragraph (1) as the Secretary determines appropriate in a report the 
Secretary shall submit to Congress not later than two years after the 
date of the enactment of the Comprehensive and Overdue Support for 
Troops of War Act of 2021, and not less frequently than once every two 
years thereafter.''.
    (b) Clerical Amendment.--The table of sections at the beginning of 
chapter 11 of such title, as amended by section 301(b), is further 
amended by inserting after the item relating to section 1119 the 
following new item:

``1120. Presumption of exposure to certain airborne hazards and 
                            substances from participation in 
                            contingency operations.''.
    (c) Conforming Amendment.--Section 1113 of such title, as amended 
by section 301, is amended by striking ``or 1119'' each place it 
appears and inserting ``1119, or 1120''.

SEC. 303. MEDICAL NEXUS EXAMINATIONS FOR TOXIC EXPOSURES.

    (a) In General.--Subchapter VI of chapter 11 of title 38, United 
States Code, as amended by title II of this Act, is further amended by 
adding at the end the following new section:
``Sec. 1168. Medical nexus examinations for toxic exposures
    ``(a) In General.--Except as provided in subsection (c), if a 
covered veteran submits to the Secretary a claim for compensation for a 
service-connected disability under section 1110 of this title relating 
to a toxic exposure or exposure to a substance, chemical, or hazard 
listed in section 1120(c) of this title during active military, naval, 
or air service, and such evidence is not sufficient to establish a 
service connection for the disability, the Secretary shall--
            ``(1) provide the veteran with a medical examination of the 
        claimed disability relating to such exposure;
            ``(2) provide the veteran the option to have the 
        examination provided under paragraph (1) conducted by a 
        specialist in the field of medicine which covers the 
        specifically claimed disability; and
            ``(3) request a medical opinion, as part of the medical 
        examination provided under paragraph (1), as to whether it is 
        at least as likely as not that there is a nexus between the 
        claimed disability and the exposure.
    ``(b) Covered Veterans.--For purposes of this section, a covered 
veteran is--
            ``(1) a veteran presumed under section 1119(a) of this 
        title to have been subject to a toxic exposure; or
            ``(2) a veteran presumed under subsection (a) of section 
        1120 of this title to have been exposed to a substance, 
        chemical, or hazard listed in subsection (c) of such section.
    ``(c) Exception.--Subsection (a) shall not apply in a case in which 
a covered veteran claims a disability that is clearly unrelated to the 
claimed exposure.
    ``(d) Considerations in Provision of Medical Opinions.--When 
providing the Secretary with a medical opinion requested under 
subsection (a)(3), the examiner shall consider the total potential 
exposure through all applicable military deployments, and the 
synergistic, combined effect of all applicable toxic exposure risk 
activities.''.
    (b) Clerical Amendment.--The table of sections at the beginning of 
chapter 11 of such title, as amended by title II of this Act, is 
further amended by inserting after the item relating to section 1167, 
as added by such title, the following new item:

``1168. Medical nexus examinations for toxic exposures.''.

TITLE IV--EXPANSION OF PRESUMPTIONS OF SERVICE CONNECTION FOR FORGOTTEN 
                                VETERANS

SEC. 401. MARK TAKAI ATOMIC VETERANS HEALTHCARE PARITY ACT OF 2021.

    Section 1112(c)(3)(B) of title 38, United States Code, is amended 
by adding at the end the following new clause:
                    ``(v) Cleanup of Enewetak Atoll during the period 
                beginning on January 1, 1977, and ending on December 
                31, 1980.''.

SEC. 402. TREATMENT OF VETERANS WHO PARTICIPATED IN NUCLEAR RESPONSE 
              NEAR PALOMARES, SPAIN, AS RADIATION-EXPOSED VETERANS FOR 
              PURPOSES OF PRESUMPTION OF SERVICE-CONNECTION OF CERTAIN 
              DISABILITIES BY DEPARTMENT OF VETERANS AFFAIRS.

    Section 1112(c)(3)(B) of title 38, United States Code, as amended 
by section 401, is further amended by adding at the end the following 
new clause:
                    ``(vi) Onsite participation in the response effort 
                following the collision of a United States Air Force B-
                52 bomber and refueling plane that caused the release 
                of four thermonuclear weapons in the vicinity of 
                Palomares, Spain, during the period beginning January 
                17, 1966, and ending March 31, 1967.''.

SEC. 403. PRESUMPTIONS OF SERVICE CONNECTION FOR DISEASES ASSOCIATED 
              WITH EXPOSURES TO CERTAIN HERBICIDE AGENTS FOR VETERANS 
              WHO SERVED IN CERTAIN LOCATIONS.

    (a) In General.--Section 1116 of title 38, United States Code, as 
amended by section 201, is further amended--
            (1) by striking ``, during active military, naval, or air 
        service, served in the Republic of Vietnam during the period 
        beginning on January 9, 1962, and ending on May 7, 1975'' each 
        place it appears and inserting ``performed covered service'';
            (2) by striking ``performed active military, naval, or air 
        service in the Republic of Vietnam during the period beginning 
        on January 9, 1962, and ending on May 7, 1975'' each place it 
        appears and inserting ``performed covered service''; and
            (3) by adding at the end the following new subsection:
    ``(d) In this section, the term `covered service' means active 
military, naval, or air service--
            ``(1) performed in the Republic of Vietnam during the 
        period beginning on January 9, 1962, and ending on May 7, 1975;
            ``(2) performed in Thailand at any United States or Royal 
        Thai base during the period beginning on January 9, 1962, and 
        ending on June 30, 1976, without regard to where on the base 
        the veteran was located or what military job specialty the 
        veteran performed;
            ``(3) performed in Laos during the period beginning on 
        December 1, 1965, and ending on September 30, 1969;
            ``(4) performed in Cambodia at Mimot or Krek, Kompon Cham 
        Province during the period beginning on April 16, 1969, and 
        ending on April 30, 1969; or
            ``(5) performed on Guam or American Samoa, or in the 
        territorial waters thereof, during the period beginning on 
        January 9, 1962, and ending on July 31, 1980, or served on 
        Johnston Atoll or on a ship that called at Johnston Atoll 
        during the period beginning on January 1, 1972, and ending on 
        September 30, 1977.''.
    (b) Eligibility for Hospital Care and Medical Services.--Section 
1710(e)(4) is amended by amending subparagraph (A) to read as follows:
            ``(A) The term `Vietnam-era herbicide-exposed veteran' 
        means a veteran who--
                    ``(i) performed covered service, as defined in 
                section 1116(c) of this title; or
                    ``(ii) the Secretary finds may have been exposed 
                during such service to dioxin or was exposed during 
                such service to a toxic substance found in a herbicide 
                or defoliant used for military purposes during such 
                period.''.
    (c) Clerical Amendments.--
            (1) Section heading.--The heading for section 1116 is 
        amended by striking and ``the Republic of Vietnam'' and 
        inserting ``certain locations''.
            (2) Table of sections.--The table of sections at the 
        beginning of chapter 11 of such title is amended by striking 
        the item relating to section 1116 and inserting the following 
        new item:

``1116. Presumptions of service connection for diseases associated with 
                            exposure to certain herbicide agents; 
                            presumption of exposure for veterans who 
                            served in certain locations.''.

SEC. 404. ADDITION OF ADDITIONAL DISEASES ASSOCIATED WITH EXPOSURE TO 
              CERTAIN HERBICIDE AGENTS FOR WHICH THERE IS A PRESUMPTION 
              OF SERVICE CONNECTION FOR VETERANS WHO SERVED IN THE 
              REPUBLIC OF VIETNAM.

    Section 1116(a)(2) of title 38, United States Code, as amended by 
section 9109 of the William M. (Mac) Thornberry National Defense 
Authorization Act for Fiscal Year 2021 (Public Law 116-283), is further 
amended by adding at the end the following new subparagraphs:
            ``(L) Hypertension.
            ``(M) Monoclonal gammopathy of undetermined 
        significance.''.

SEC. 405. IMPROVING COMPENSATION FOR DISABILITIES OCCURRING IN PERSIAN 
              GULF WAR VETERANS.

    (a) Reduction in Threshold of Eligibility.--Subsection (a)(1) of 
section 1117 of title 38, United States Code, is amended by striking 
``became manifest--'' and all that follows through the period at the 
end and inserting ``became manifest to a degree of 10 percent or more 
at any time.''.
    (b) Permanent Extension of Period of Eligibility.--
            (1) In general.--Such section is amended by striking 
        subsection (b).
            (2) Conforming amendments.--Such section, as amended by 
        paragraph (1), is further amended--
                    (A) by redesignating subsections (c) and (d) as 
                subsections (b) and (c), respectively; and
                    (B) in subsection (a)(2)(C), by striking ``under 
                subsection (d)'' and inserting ``under subsection 
                (c)''.
    (c) Establishing Singular Disability Based Questionnaire.--Such 
section, as amended by subsection (b), is further amended by inserting 
after subsection (c) the following new subsection (d):
    ``(d) The Secretary shall develop a Disability Benefits 
Questionnaire (DBQ), or successor questionnaire, such that if a Persian 
Gulf veteran presents with any one symptom associated with Gulf War 
Illness, use of such questionnaire is mandatory for health care 
personnel of the Department for the identification of Gulf War 
Illness.''.
    (d) Training.--Such section is amended by adding at the end the 
following new subsection:
    ``(i)(1) The Secretary shall take such actions as may be necessary 
to ensure that health care personnel of the Department are 
appropriately trained to effectively carry out this section.
    ``(2) Not less frequently than once each year, the Secretary shall 
submit to Congress a report on the actions taken by the Secretary to 
carry out paragraph (1).''.

SEC. 406. PRESUMPTION OF SERVICE CONNECTION FOR CERTAIN DISEASES 
              ASSOCIATED WITH EXPOSURE TO BURN PITS AND OTHER TOXINS.

    (a) In General.--Subchapter II of chapter 11 of title 38, United 
States Code, as amended by section 302(a), is further amended by 
inserting after section 1120 the following new section:
``Sec. 1120A. Presumption of service connection for certain diseases 
              associated with exposure to burn pits and other toxins
    ``(a) Presumption of Service Connection.--For the purposes of 
section 1110 of this title, and subject to section 1113 of this title, 
a disease specified in subsection (c) becoming manifest in a covered 
veteran shall be considered to have been incurred in or aggravated 
during active military, naval, or air service, notwithstanding that 
there is no record of evidence of such disease during the period of 
such service.
    ``(b) Covered Veterans.--For purposes of this section, a covered 
veteran is a veteran presumed under subsection (a) of section 1120 of 
this title to have been exposed to a substance, chemical, or hazard 
listed in subsection (c) of such section.
    ``(c) Diseases Specified.--The diseases specified in this 
subsection are the following:
            ``(1) Asthma that was diagnosed after--
                    ``(A) a deployment described in subparagraph (A) of 
                section 1120(b)(1) of this title; or
                    ``(B) a period of service for which a medal set 
                forth under subparagraph (B) of such section was 
                awarded.
            ``(2) Chronic obstructive pulmonary disease.
            ``(3) Chronic bronchitis.
            ``(4) Constrictive bronchiolitis or obliterative 
        bronchiolitis.
            ``(5) Emphysema.
            ``(6) Pleuritis.
            ``(7) Pulmonary fibrosis.
            ``(8) Interstitial lung disease.
            ``(9) Sarcoidosis.
            ``(10) Respiratory cancer of any type.
            ``(11) Glioblastoma.
            ``(12) Rhinitis.
            ``(13) Sinusitis.''.
    (b) Clerical Amendment.--The table of sections at the beginning of 
chapter 11 of title 38, United States Code, as amended by section 
302(b), is further amended by inserting after the item relating to 
section 1120 the following new item:

``1120A. Presumption of service connection for certain diseases 
                            associated with exposure to burn pits and 
                            other toxins.''.
    (c) Conforming Amendment.--Section 1113 of such title, as amended 
by section 302, is further amended by striking ``or 1120'' each place 
it appears and inserting ``1120, or 1120A''.

       TITLE V--STRENGTHENING FEDERAL RESEARCH ON TOXIC EXPOSURES

SEC. 501. COORDINATION BY DEPARTMENT OF VETERANS AFFAIRS OF TOXIC 
              EXPOSURE RESEARCH.

    (a) In General.--Subchapter II of chapter 73 of title 38, United 
States Code, is amended by adding at the end the following new section:
``Sec. 7330D. Coordination of toxic exposure research
    ``(a) In General.--The Secretary shall coordinate all research 
activities undertaken or funded by the Executive Branch of the Federal 
Government on the health consequences of toxic exposures experienced 
during service in the Armed Forces.
    ``(b) Strategic Plan.--In carrying out subsection (a), the 
Secretary shall establish a strategic plan, to be known as the `Toxic 
Exposure Research Strategic Plan', to ensure that the research 
activities described in such subsection are collaborative, transparent, 
and highly coordinated.
    ``(c) Report.--Not later than one year after the date of the 
enactment of the Comprehensive and Overdue Support for Troops of War 
Act of 2021, and annually thereafter, the Secretary shall submit to the 
Committee on Veterans' Affairs of the Senate and the Committee on 
Veterans' Affairs of the House of Representatives a report on all 
research activities described in subsection (a) undertaken during the 
year covered by the report.''.
    (b) Clerical Amendment.--The table of sections at the beginning of 
such subchapter is amended by inserting after the item relating to 
section 7330C the following new item:

``7330D. Coordination of toxic exposure research.''.

SEC. 502. COLLECTION, ANALYSIS, AND REPORT ON TREATMENT OF VETERANS FOR 
              MEDICAL CONDITIONS RELATED TO TOXIC EXPOSURE.

    (a) In General.--The Secretary of Veterans Affairs shall compile 
and analyze, on a continuous basis, all clinical data that--
            (1) is obtained by the Department of Veterans Affairs in 
        connection with hospital care, medical services, and nursing 
        home care furnished under section 1710(a)(2)(F) of title 38, 
        United States Code; and
            (2) is likely to be scientifically useful in determining 
        the association, if any, between the medical condition of a 
        veteran and a toxic exposure.
    (b) Consent of Patients.--Compilation and analysis by the Secretary 
of clinical data of a veteran under subsection (a) shall be conducted, 
and such data shall be used, consistent with the informed consent of 
the veteran and in compliance with all applicable Federal law.
    (c) Annual Report.--Not later than one year after the date of the 
enactment of this Act, and annually thereafter, the Secretary shall 
submit to the Committee on Veterans' Affairs of the Senate and the 
Committee on Veterans' Affairs of the House of Representatives a report 
containing--
            (1) the data compiled under subsection (a);
            (2) an analysis of such data;
            (3) a description of the types and incidences of medical 
        conditions identified by the Department under such subsection;
            (4) the explanation of the Secretary for the incidence of 
        such medical conditions and other explanations for the 
        incidence of such conditions as the Secretary considers 
        reasonable; and
            (5) the views of the Secretary on the scientific validity 
        of drawing conclusions from the incidence of such medical 
        conditions, as evidenced by the data compiled under subsection 
        (a), regarding any association between such conditions and a 
        toxic exposure.
    (d) Toxic Exposure Defined.--In this section, the term ``toxic 
exposure'' has the meaning given that term in section 101(37) of title 
38, United States Code.

SEC. 503. STUDIES RELATING TO VETERANS WHO SERVED IN SOUTHWEST ASIA.

    (a) Analysis.--
            (1) In general.--Not later than 180 days after the date of 
        the enactment of this Act, the Secretary of Veterans Affairs, 
        in coordination with the Secretary of Defense, shall conduct an 
        updated analysis of total and respiratory disease mortality in 
        covered veterans.
            (2) Elements.--The analysis required by paragraph (1) shall 
        include, to the extent practicable, the following:
                    (A) Metrics of airborne exposures.
                    (B) The location and timing of deployments.
                    (C) The military occupational specialty.
                    (D) The Armed Force in which the veteran served.
                    (E) Pre-existing health status, including with 
                respect to asthma.
                    (F) Relevant personal information, including 
                cigarette and e-cigarette smoking history, diet, sex, 
                gender, age, race, and ethnicity.
    (b) Epidemiological Study.--Not later than 180 days after the date 
of the enactment of this Act, the Secretary shall conduct an 
epidemiological study of covered veterans that uses the following:
            (1) Improved spatio-temporal estimates of ambient air 
        pollution exposures using advances in retrospective exposure 
        assessment.
            (2) Detailed information on the study subjects obtained 
        through medical records, administrative data, and other 
        existing sources, that include--
                    (A) personal characteristics, including cigarette 
                and e-cigarette smoking history, diet, sex, gender, 
                age, race, and ethnicity;
                    (B) deployment history, including locations, 
                periods, and number of deployments;
                    (C) biospecimen data; and
                    (D) supplementary health status and outcomes data, 
                including imaging and physiological parameters.
    (c) Toxicology Study.--
            (1) In general.--Not later than 180 days after the date of 
        the enactment of this Act, the Secretary shall conduct a 
        toxicology study to include variability to replicate exposures 
        of healthy, young members of the Armed Forces, as well as 
        potentially susceptible members, with preexisting health 
        conditions.
            (2) Elements.--The study required under paragraph (1) 
        shall--
                    (A) analyze the study results for mechanistic 
                markers and clinically relevant outcomes; and
                    (B) validate serum, tissue, and other biomarkers of 
                exposure, susceptibility, or effect.
    (d) Covered Veteran Defined.--In this section, the term ``covered 
veteran'' means any veteran who--
            (1) on or after August 2, 1990, served on active duty in--
                    (A) Bahrain;
                    (B) Iraq;
                    (C) Kuwait;
                    (D) Oman;
                    (E) Qatar;
                    (F) Saudi Arabia;
                    (G) Somalia; or
                    (H) the United Arab Emirates; or
            (2) on or after September 11, 2001, served on active duty 
        in--
                    (A) Afghanistan;
                    (B) Djibouti;
                    (C) Egypt;
                    (D) Jordan;
                    (E) Lebanon;
                    (F) Syria; or
                    (G) Yemen.

SEC. 504. STUDY ON HEALTH TRENDS OF POST 9/11 VETERANS.

    The Secretary of Veterans Affairs shall conduct an epidemiological 
study on the health trends of veterans who served in the Armed Forces 
after September 11, 2001.

SEC. 505. STUDY ON CANCER RATES AMONG VETERANS.

    (a) In General.--The Secretary of Veterans Affairs shall conduct a 
study on the incidence of cancer in veterans to determine trends in the 
rates of the incidence of cancer in veterans.
    (b) Elements.--The study required by subsection (a) shall assess, 
with respect to each veteran included in the study, the following:
            (1) The age of the veteran.
            (2) The period of service and length of service of the 
        veteran in the Armed Forces.
            (3) The military occupational speciality or specialties of 
        the veteran.
            (4) The gender of the veteran.
            (5) The type or types of cancer that the veteran has.

         TITLE VI--IMPROVING SUPPORT TO TOXIC EXPOSURE VETERANS

SEC. 601. DEFINITIONS.

    In this title, the terms ``active military, naval, or air 
service'', ``toxic exposure'', and ``toxic exposure veteran'' have the 
meanings given those terms in section 101 of title 38, United States 
Code.

SEC. 602. PUBLICATION OF LIST OF RESOURCES OF DEPARTMENT OF VETERANS 
              AFFAIRS FOR TOXIC EXPOSURE VETERANS AND OUTREACH PROGRAM 
              FOR SUCH VETERANS AND CAREGIVERS AND SURVIVORS OF SUCH 
              VETERANS.

    (a) Publication of List of Resources.--
            (1) In general.--Not later than one year after the date of 
        the enactment of this Act, and annually thereafter, the 
        Secretary of Veterans Affairs shall publish a list of resources 
        of the Department of Veterans Affairs for--
                    (A) toxic exposure veterans;
                    (B) families and caregivers of toxic exposure 
                veterans; and
                    (C) survivors of toxic exposure veterans (or who 
                would be toxic exposure veterans were the veterans 
                alive) who are receiving death benefits under the laws 
                administered by the Secretary.
            (2) Update.--The Secretary shall periodically update the 
        list published under paragraph (1).
    (b) Outreach.--The Secretary shall develop, with input from the 
community, an informative outreach program for veterans on illnesses 
that may be related to toxic exposure, including outreach with respect 
to benefits and support programs.

SEC. 603. INCORPORATION OF TOXIC EXPOSURE QUESTIONNAIRE DURING PRIMARY 
              CARE APPOINTMENTS.

    (a) In General.--The Secretary of Veterans Affairs shall 
incorporate a clinical questionnaire to help determine potential toxic 
exposures during active military, naval, or air service as part of the 
initial screening conducted for an appointment of a veteran with a 
primary care provider of the Department of Veterans Affairs to improve 
understanding by the Department of toxic exposures of veterans while 
serving in the Armed Forces.
    (b) Determination of Questions.--The questions included in the 
questionnaire required under subsection (a) shall be determined by the 
Secretary with input from medical professionals.

SEC. 604. TRAINING FOR PERSONNEL OF THE DEPARTMENT OF VETERANS AFFAIRS 
              WITH RESPECT TO TOXIC EXPOSURE VETERANS.

    (a) Health Care Personnel.--The Secretary of Veterans Affairs shall 
provide to health care personnel of the Department of Veterans Affairs 
education and training to identify, treat, and assess the impact on 
toxic exposure veterans of illnesses related to toxic exposure and 
inform such personnel of how to ask for additional information from 
veterans regarding different toxic exposures.
    (b) Benefits Personnel.--
            (1) In general.--The Secretary shall establish a training 
        program for processors of claims under the laws administered by 
        the Secretary who review claims for disability benefits 
        relating to service-connected disabilities based on toxic 
        exposure.
            (2) Annual training.--Training provided to processors under 
        paragraph (1) shall be provided not less frequently than 
        annually.

SEC. 605. SFC HEATH ROBINSON BURN PIT TRANSPARENCY ACT.

    (a) Short Title.--This section may be cited as the ``SFC Heath 
Robinson Burn Pit Transparency Act''.
    (b) Quarterly Notifications.--
            (1) In general.--On a quarterly basis, the Secretary of 
        Veterans Affairs shall submit to the appropriate congressional 
        committees a report on each reported case of burn pit exposure 
        by a covered veteran reported during the previous quarter.
            (2) Elements.--Each report submitted under paragraph (1) 
        shall include, with respect to each reported case of burn pit 
        exposure of a covered veteran included in the report, the 
        following:
                    (A) Notice of the case, including the medical 
                facility at which the case was reported.
                    (B) Notice of, as available--
                            (i) the enrollment status of the covered 
                        veteran with respect to the patient enrollment 
                        system of the Department of Veterans Affairs 
                        under section 1705(a) of title 38, United 
                        States Code;
                            (ii) a summary of all health care visits by 
                        the covered veteran at the medical facility at 
                        which the case was reported that are related to 
                        the case;
                            (iii) the demographics of the covered 
                        veteran, including age, sex, and race;
                            (iv) any non-Department of Veterans Affairs 
                        health care benefits that the covered veteran 
                        receives;
                            (v) the Armed Force in which the covered 
                        veteran served and the rank of the covered 
                        veteran;
                            (vi) the period in which the covered 
                        veteran served;
                            (vii) each location that the covered 
                        veteran reported as being a location at which 
                        the veteran was exposed to toxic airborne 
                        chemicals and fumes from an open burn pit;
                            (viii) the medical diagnoses of the covered 
                        veteran and the treatment provided to the 
                        veteran; and
                            (ix) whether the covered veteran is 
                        registered in the Airborne Hazards and Open 
                        Burn Pit Registry.
            (3) Protection of information.--The Secretary shall ensure 
        that the reports submitted under paragraph (1) do not include 
        the identity of covered veterans or contain other personally 
        identifiable data.
    (c) Annual Report on Cases.--
            (1) In general.--Not later than 180 days after the date of 
        the enactment of this Act, and annually thereafter, the 
        Secretary of Veterans Affairs, in collaboration with the 
        Secretary of Defense, shall submit to the appropriate 
        congressional committees a report detailing the following:
                    (A) The total number of covered veterans.
                    (B) The total number of claims for disability 
                compensation under chapter 11 of title 38, United 
                States Code, approved and the total number denied by 
                the Secretary of Veterans Affairs with respect to a 
                covered veteran, and for each such denial, the 
                rationale of the denial.
                    (C) A comprehensive list of--
                            (i) the conditions for which covered 
                        veterans seek treatment; and
                            (ii) the locations that the covered 
                        veterans reported as being locations at which 
                        the veterans were exposed to toxic airborne 
                        chemicals and fumes from open burn pits.
                    (D) Identification of any illnesses relating to 
                exposure to open burn pits that formed the basis for 
                the Secretary to award benefits, including entitlement 
                to service connection or an increase in disability 
                rating.
                    (E) The total number of covered veterans who died 
                after seeking care for an illness relating to exposure 
                to an open burn pit.
                    (F) Any updates or trends with respect to the 
                information described in subparagraphs (A), (B), (C), 
                (D), and (E) that the Secretary determines appropriate.
            (2) Matters included in first report.--The Secretary shall 
        include in the first report under paragraph (1) information 
        specified in subsection (b)(2) with respect to reported cases 
        of burn pit exposure made during the period beginning January 
        1, 1990, and ending on the day before the date of the enactment 
        of this Act.
    (d) Comptroller General Report.--Not later than 180 days after the 
date of the enactment of this Act, the Comptroller General of the 
United States shall submit to the appropriate congressional committees 
a report containing an assessment of the effectiveness of any 
memorandum of understanding or memorandum of agreement entered into by 
the Secretary of Veterans Affairs with respect to--
            (1) the processing of reported cases of burn pit exposure; 
        and
            (2) the coordination of care and provision of health care 
        relating to such cases at medical facilities of the Department 
        of Veterans Affairs and at non-Department facilities.
    (e) Definitions.--In this section:
            (1) The term ``Airborne Hazards and Open Burn Pit 
        Registry'' means the registry established by the Secretary of 
        Veterans Affairs under section 201 of the Dignified Burial and 
        Other Veterans' Benefits Improvement Act of 2012 (Public Law 
        112-260; 38 U.S.C. 527 note).
            (2) The term ``appropriate congressional committees'' 
        means--
                    (A) the Committee on Veterans' Affairs and the 
                Committee on Armed Services of the Senate; and
                    (B) The Committee on Veterans' Affairs and the 
                Committee on Armed Services of the House of 
                Representatives.
            (3) The term ``covered veteran'' means a veteran who 
        presents at a medical facility of the Department of Veterans 
        Affairs (or in a non-Department facility pursuant to section 
        1703 or 1703A of title 38, United States Code) for treatment 
        that the veteran describes as being related to, or ancillary 
        to, the exposure of the veteran to toxic airborne chemicals and 
        fumes caused by open burn pits at any time while serving in the 
        Armed Forces.
            (4) The term ``open burn pit'' has the meaning given that 
        term in section 201(c) of the Dignified Burial and Other 
        Veterans' Benefits Improvement Act of 2012 (Public Law 112-260; 
        38 U.S.C. 527 note).
            (5) The term ``reported case of burn pit exposure'' means 
        each instance in which a veteran presents at a medical facility 
        of the Department of Veterans Affairs (or in a non-Department 
        facility pursuant to section 1703 or 1703A of title 38, United 
        States Code) for treatment that the veteran describes as being 
        related to, or ancillary to, the exposure of the veteran to 
        toxic airborne chemicals and fumes caused by open burn pits at 
        any time while serving in the Armed Forces.

     TITLE VII--STRENGTHENING RECORD-KEEPING OF TOXIC EXPOSURES BY 
                         DEPARTMENT OF DEFENSE

SEC. 701. DEFINITIONS.

    In this title:
            (1) Individual longitudinal exposure record.--The term 
        ``Individual Longitudinal Exposure Record'' has the meaning 
        given that term in section 101(40) of title 38, United States 
        Code, as added by section 101(b).
            (2) Toxic exposure.--The term ``toxic exposure'' has the 
        meaning given that term in section 101(37) of such title, as so 
        added.

SEC. 702. INDEPENDENT STUDY ON INDIVIDUAL LONGITUDINAL EXPOSURE RECORD.

    (a) In General.--Not later than 60 days after the date of the 
enactment of this Act, the Secretary of Defense shall enter into a 
contract with an independent research entity described in subsection 
(b) to carry out a comprehensive study of the development of the 
Individual Longitudinal Exposure Record to evaluate--
            (1) the quality of the location data, occupational and 
        environmental exposure data, and health surveillance data; and
            (2) whether a member of the Armed Forces can be reasonably 
        assured that any toxic exposure experienced by the member 
        during service in the Armed Forces will be accurately reflected 
        in the Individual Longitudinal Exposure Record of the member.
    (b) Independent Research Entity Described.--An independent research 
entity described in this subsection is a federally funded research and 
development center with appropriate expertise and analytical capability 
to carry out the study required under subsection (a).

SEC. 703. BIANNUAL REPORT ON INDIVIDUAL LONGITUDINAL EXPOSURE RECORD.

    (a) In General.--Not later than one year after the date on which 
the Individual Longitudinal Exposure Record achieves full operation 
capability, as determined by the Secretary of Defense, and every 180 
days thereafter, the Secretary of Defense shall, in consultation with 
the Secretary of Veterans Affairs, submit to the appropriate committees 
of Congress a report on the data quality of the databases of the 
Department of Defense that provide the information presented in the 
Individual Longitudinal Exposure Record and the usefulness of the 
Individual Longitudinal Exposure Record in supporting members of the 
Armed Forces and veterans in receiving health care and benefits from 
the Department of Defense and the Department of Veterans Affairs.
    (b) Elements.--Each report required by subsection (a) shall 
include, for the period covered by the report, the following:
            (1) An identification of toxic exposures that may not be 
        fully captured by the current systems of the Department of 
        Defense for environmental and occupational health monitoring, 
        and recommendations for how to improve those systems.
            (2) An analysis of the quality of the location data used by 
        the Department of Defense in determining toxic exposures of 
        members of the Armed Forces and veterans, and recommendations 
        for how to improve the quality of that location data.
    (c) Appropriate Committees of Congress Defined.--In this section, 
the term ``appropriate committees of Congress'' means--
            (1) the Committee on Armed Services and the Committee on 
        Veterans' Affairs of the Senate; and
            (2) the Committee on Armed Services and the Committee on 
        Veterans' Affairs of the House of Representatives.

SEC. 704. CORRECTION OF TOXIC EXPOSURE RECORDS.

    (a) In General.--The Secretary of Defense and the Secretary of 
Veterans Affairs shall provide a means for members of the Armed Forces 
and veterans to update their records as necessary to reflect a toxic 
exposure by such member or veteran in the Individual Longitudinal 
Exposure Record.
    (b) Evidence.--
            (1) In general.--To update a record under subsection (a), a 
        member of the Armed Forces or veteran, as the case may be, must 
        provide such evidence as the Secretary of Defense and the 
        Secretary of Veterans Affairs jointly consider sufficient.
            (2) Regulations.--The Secretary of Veterans Affairs shall 
        prescribe by regulation the evidence considered sufficient 
        under paragraph (1).
                                                       Calendar No. 145

117th CONGRESS

  1st Session

                                S. 3003

_______________________________________________________________________

                                 A BILL

   To improve health care and benefits for veterans exposed to toxic 
                  substances, and for other purposes.

_______________________________________________________________________

                            October 19, 2021

                 Read twice and placed on the calendar