II Calendar No. 602 116th CONGRESS 2d Session S. 4393 IN THE SENATE OF THE UNITED STATES July 30, 2020 Mr. Tillis (for himself, Mrs. Blackburn , Ms. McSally , and Mrs. Capito ) introduced the following bill; which was read twice and referred to the Committee on Veterans' Affairs December 8, 2020 Reported by Mr. Moran , with an amendment Strike out all after the enacting clause and insert the part printed in italic A BILL To improve the provision of health care and other benefits from the Department of Veterans Affairs for veterans who were exposed to toxic substances, and for other purposes.

1. Short title; table of contents (a) Short title This Act may be cited as the Toxic Exposure in the American Military Act of 2020 or the TEAM Act of 2020 (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. Sec. 2. Definitions. TITLE I—Expansion of health care and benefits for veterans exposed to toxic substances Sec. 101. Consultation, testing, and treatment for certain veterans who received hazardous duty pay or were exposed to toxic substances. Sec. 102. Permanent reauthorization of authority of Secretary of Veterans Affairs to prescribe regulations providing that a presumption of service connection is warranted for a disease associated with exposure to a herbicide agent. Sec. 103. Presumptions of service connection for diseases associated with exposure to certain toxic substances. TITLE II—Research and review regarding exposure to toxic substances Sec. 201. Establishment of Toxic Exposure Review Commission. Sec. 202. Agreement with National Academies of Sciences, Engineering, and Medicine concerning the exposure of humans to toxic substances. Sec. 203. Analysis of results of consultation, testing, and treatment of veterans for disabilities related to exposure to toxic substances. Sec. 204. Report to evaluate and identify groups at-risk of exposure to toxic substances. TITLE III—Improvement of resources of Department of Veterans Affairs regarding exposures to toxic substances Sec. 301. Publication of list of resources of Department of Veterans Affairs for veterans exposed to toxic substances and outreach program for such veterans and caregivers and survivors of such veterans. Sec. 302. Incorporation of toxic exposure questionnaire during primary care appointments. Sec. 303. Portal for access by veterans to individual longitudinal exposure record. Sec. 304. Training of personnel of Department of Veterans Affairs on illnesses related to exposure to toxic substances. 2. Definitions In this Act: (1) Active military, naval, or air service The term active military, naval, or air service has the meaning given that term in section 101(24) of title 38, United States Code. (2) Toxic substance The term toxic substance has the meaning given that term in section 1720J(i) of such title, as added by section 101(a). I Expansion of health care and benefits for veterans exposed to toxic substances 101. Consultation, testing, and treatment for certain veterans who received hazardous duty pay or were exposed to toxic substances (a) In general Subchapter II of chapter 17 of title 38, United States Code, is amended by adding at the end the following new section: 1720J. Consultation, testing, and treatment of veterans for exposure to toxic substances (a) In general The Secretary shall furnish to covered veterans— (1) covered consultation and testing regarding the exposure of those veterans to toxic substances; and (2) treatment for any illness relating to such exposure diagnosed under subsection (b)(2), subject to approval by the Under Secretary for Health. (b) Covered consultation and testing For purposes of this section, covered consultation and testing is— (1) consultation with a primary care physician or other treating physician to determine whether the covered veteran has an illness related to exposure to a toxic substance while serving in the Armed Forces; (2) diagnosis by such physician of any illness related to exposure to a toxic substance; and (3) any medical testing necessary to carry out paragraphs (1) and (2), including a referral to a specialist physician. (c) Covered veterans For purposes of this section, a covered veteran is a veteran who— (1) received hazardous duty incentive pay under section 351 of title 37 for more than one day; or (2) has been identified by the Secretary of Defense to have been possibly exposed, inside or outside the United States, during service in the Armed Forces, to— (A) an open burn pit; (B) a toxic substance; or (C) a site at which members of the Armed Forces were potentially exposed to a toxic substance, as indicated in a database shared by the Department of Defense and the Department of Veterans Affairs. (d) Consultation A covered veteran is eligible under this section for three consultations each year unless a treating physician for such veteran determines that more consultations are necessary under subsection (b)(1). (e) Provision of services Covered consultation and testing and treatment may be provided under this section at facilities of the Department or under contract arrangements with the Department for such services. (f) Determinations relating to treatment (1) When determining whether to approve eligibility for treatment under subsection (a)(2), the Under Secretary for Health shall give heavy weight to the diagnosis by the treating physician under subsection (b)(2). (2) The Under Secretary shall support any denial of eligibility under subsection (a)(2) with specific scientific evidence. (3) Determinations by the Under Secretary under subsection (a)(2) shall be made not later than five business days after a request for approval has been made by the treating physician under subsection (b)(2). (g) Information and training The Secretary shall provide information and training on eligibility for services under this section and the services covered under this section to— (1) health care providers of the Department; (2) health care providers providing services under this section under contract arrangements; and (3) covered veterans. (h) Copayment A covered veteran is not required to pay a copayment for covered consultation and testing or treatment under this section. (i) Definitions In this section: (1) 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). (2) The term toxic substance means a toxicant or a toxin. (3) The term toxicant means any substance that can injure or kill humans, animals, or plants and that is produced by humans or is a by-product of human activities. (4) The term toxin means any substance that can injure or kill humans, animals, or plants and that is produced naturally. (5) The team treatment means any commonly accepted medical treatment practiced by the medical community at large. . (b) Clerical amendment The table of sections at the beginning of subchapter II of chapter 17 of such title is amended by adding at the end the following new item: 1720J. Consultation, testing, and treatment of veterans for exposure to toxic substances. . 102. Permanent reauthorization of authority of Secretary of Veterans Affairs to prescribe regulations providing that a presumption of service connection is warranted for a disease associated with exposure to a herbicide agent (a) In general Section 1116 of title 38, United States Code, is amended by striking subsection (e). (b) Effective date Subsection (a) of this section and subsections (b) through (d) of section 1116 of such title shall take effect on the date of the enactment of this Act. 103. Presumptions of service connection for diseases associated with exposure to certain toxic substances (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: 1119. Presumptions of service connection for diseases associated with exposure to certain toxic substances (a) Presumptions of service connection (1) For purposes of section 1110 of this title, and subject to section 1113 of this title, each disease specified in paragraph (2) becoming manifest as specified in that paragraph shall be considered to have been incurred in or aggravated by service referred to in that paragraph, notwithstanding that there is no record of evidence of such disease during the period of such service. (2) A disease specified in this paragraph is any disease that— (A) the Secretary determines in regulations prescribed under this section warrants a presumption of service connection by reason of having a positive association with exposure to a toxic substance; and (B) becomes manifest within the period, if any, prescribed in such regulations in a veteran who was exposed to that toxic substance during active military, naval, or air service. (3) (A) For purposes of this subsection, the Secretary may presume that a veteran who has a disease specified in paragraph (2) was exposed to the toxic substance for which the Secretary has determined under paragraph (2)(A) warrants a presumption of service connection by reason of having a positive association with exposure to the toxic substance, notwithstanding that there is no record of evidence of such exposure, if the Secretary determines based on one or more of the factors set forth in subparagraph (B) that a presumption of exposure is warranted. (B) The factors set forth in this subparagraph are as follows: (i) The duty location of the veteran. (ii) The length of service of the veteran. (iii) Such other factors as the Secretary considers appropriate. (b) Determinations relating to diseases (1) Whenever the Secretary determines, on the basis of sound medical and scientific evidence, that a positive association exists between the exposure of humans to a toxic substance and the occurrence of a disease in humans, the Secretary shall prescribe regulations providing that a presumption of service connection is warranted for that disease for purposes of this section. (2) In making determinations under paragraph (1), the Secretary shall take into account— (A) reports received by the Secretary from the National Academies of Sciences, Engineering, and Medicine under section 202(g) of the Toxic Exposure in the American Military Act of 2020 ; and (B) all other sound medical and scientific information and analyses available to the Secretary. (3) (A) In evaluating any report, information, or analysis for purposes of making such determinations, the Secretary shall consider only scientific studies that are valid in accordance with contemporary scientific standards. (B) The Secretary may define the standards described in subparagraph (A) for purposes of that subparagraph. (c) Response to reports by the National Academies of Sciences, Engineering, and Medicine (1) Not later than 60 days after the date on which the Secretary receives a report from the National Academies of Sciences, Engineering, and Medicine under section 202(g) of the Toxic Exposure in the American Military Act of 2020 , the Secretary shall determine whether a presumption of service connection is warranted for each disease covered by the report. (2) If the Secretary determines under paragraph (1) that a presumption of service connection is warranted for a disease, the Secretary shall, not later than 60 days after making the determination, issue proposed regulations setting forth the determination. (3) (A) If the Secretary makes a determination described in subparagraph (B), the Secretary shall, not later than 60 days after making the determination, publish in the Federal Register a notice of the determination. (B) A determination described in this subparagraph is a determination by the Secretary under paragraph (1) that— (i) a presumption of service connection is not warranted for a disease; and (ii) (I) sufficient evidence of an association exists between the exposure of humans to a toxic substance and the occurrence of the disease in humans; or (II) limited evidence or suggestive evidence of such an association exists. (C) Any notice published under subparagraph (A) shall include an explanation of the scientific basis for the determination described in subparagraph (B). (D) If a disease already presumed to be service connected under this section is subject to a determination described in subparagraph (B), the Secretary shall, not later than 60 days after publication of the notice under subparagraph (A), issue proposed regulations removing the presumption of service connection for the disease. (4) Not later than 180 days after the date on which the Secretary issues any proposed regulations under this subsection, the Secretary shall issue final regulations. (d) Removal of presumption of service connection Whenever the presumption of service connection for a disease under this section is removed under subsection (c)— (1) a veteran who was awarded compensation for the disease on the basis of the presumption before the effective date of the removal of the presumption shall continue to be entitled to receive compensation on that basis; and (2) a survivor of a veteran who was awarded dependency and indemnity compensation for the death of a veteran resulting from the disease on the basis of the presumption before that date shall continue to be entitled to receive dependency and indemnity compensation on that basis. (e) Reference to National Academies of Sciences, Engineering, and Medicine In the case that the Secretary enters into an agreement with another organization as described in section 202(i)(1) of the Toxic Exposure in the American Military Act of 2020 , any reference in this section to the National Academies of Sciences, Engineering, and Medicine shall be treated as a reference to the other organization. (f) Definitions In this section: (1) The term positive association means, with respect to an association between exposure to a toxic substance and the occurrence of a disease in humans, that there is credible evidence for the association and such evidence is equal to or outweighs the credible evidence against the association. (2) The term toxic substance has the meaning given that term in section 1720J(i) of this title. . (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 service connection for diseases associated with exposure to certain toxic substances. . (c) Conforming amendment Section 1113 of such title is amended by striking or 1118 each place it appears and inserting 1118, or 1119 . II Research and review regarding exposure to toxic substances 201. Establishment of Toxic Exposure Review Commission (a) In general Subchapter III of chapter 5 of title 38, United States Code, is amended by adding at the end the following new section: 547. Toxic Exposure Review Commission (a) Establishment There is established within the Department an independent commission to be known as the Toxic Exposure Review Commission (in this section referred to as the Commission ). (b) Duties The Commission shall carry out the following duties: (1) Collect any relevant public information from the Department of Defense and other sources to identify possible exposures to toxic substances pertaining to active military, naval, or air service. (2) Hold public meetings to gather relevant information regarding exposure to toxic substances. (3) Review such information to assess whether to recommend that a study be conducted under section 202(e) of the Toxic Exposure in the American Military Act of 2020 . (4) Recommend, by majority vote, whether such a study should be conducted. (5) Recommend to the Secretary, by majority vote, whether new, independent studies should be conducted regarding the health outcomes of exposure to toxic substances. (6) Annually report to Congress on progress regarding the duties set forth in paragraphs (1) through (5). (c) Membership (1) (A) The Commission shall be composed of 9 members, appointed as follows: (i) Two members appointed by the Speaker of the House of Representatives. (ii) Two members appointed by the minority leader of the House of Representatives. (iii) Two members appointed by the majority leader of the Senate. (iv) Two members appointed by the minority leader of the Senate. (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 Toxic Exposure in the American Military Act of 2020 . (2) In appointing individuals under paragraph (1)(A), the Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and the Secretary shall ensure that the following fields of experience are represented on the Commission: (A) The field of respiratory medicine. (B) The field of endocrinology and metabolic medicine. (C) The field of hematology. (D) The field of oncology. (E) The field of public health. (F) The field of occupational and environmental health. (3) In appointing individuals under paragraph (1)(A), the Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and the Secretary shall 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 Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and the Secretary shall give consideration to including in the Commission at least one member who works with survivors of illnesses related to exposure to toxic substances and has a background in the field of study of exposure to toxic substances. (d) 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. (e) Chair and Vice Chair At the initial meeting of the Commission under subsection (d), the Commission shall select a Chair and Vice Chair from among the members of the Commission by a majority vote of the members of the Commission. (f) Vacancies 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. (g) 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. (h) 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. (i) 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 Chair, the head of such agency shall furnish such information to the Commission, unless such information is classified. (j) 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. (k) 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. . (b) Clerical amendment The table of sections at the beginning of such subchapter is amended by adding at the end the following new item: 547. Toxic Exposure Review Commission. . 202. Agreement with National Academies of Sciences, Engineering, and Medicine concerning the exposure of humans to toxic substances (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 diseases and exposure to toxic substances. (b) Agreement (1) In general The Secretary of Veterans Affairs shall seek to enter into an agreement with the Academies to perform the services covered by this section. (2) Timing 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 this Act. (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 exposure to toxic substances during active military, naval, or air service and each disease suspected to be associated with such exposure in the human population. (d) Scientific determinations concerning diseases For each disease reviewed under subsection (c), the Academies shall determine, to the extent that available scientific data permit meaningful determinations— (1) whether an association exists between exposure to toxic substances and the occurrence of the disease, 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 disease among those exposed to toxic substances 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 exposure and the occurrence of the disease. (e) Scientific studies (1) In general Under an agreement between the Secretary and the Academies under this section, the Academies shall conduct such scientific studies as the Toxic Exposure Review Commission recommends pursuant to section 547(b)(4) of title 38, United States Code, as added by section 201(a). (2) Recommendations for additional scientific studies (A) In general 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 the exposure of humans to toxic substances. (B) Considerations In making recommendations under subparagraph (A), the Academies shall consider— (i) the scientific information that is available at the time of the recommendation; (ii) the value and relevance of the information that could result from additional studies; and (iii) the cost and feasibility of carrying out such additional studies. (f) Subsequent reviews Under an agreement between the Secretary and the Academies under this section, the Academies shall— (1) conduct as comprehensive a review as is practicable of the evidence referred to in subsection (c) that became available since the last review of such evidence under this section; and (2) make determinations and estimates on the basis of the results of such review and all other reviews conducted for the purposes of this section. (g) Reports (1) Initial report (A) In general Under an agreement between the Secretary and the Academies under this section, not later than one year after the date of the enactment of this Act, 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. (B) Elements The report submitted under subparagraph (A) shall include the following: (i) The determinations described in subsection (d). (ii) A full explanation of the scientific evidence and reasoning that led to such determinations. (iii) Any recommendations of the Academies under subsection (e)(2). (iv) The recommendation described in subparagraph (C). (C) Recommendation for implementation of analysis of examinations and treatment of veterans for disabilities related to exposure to toxic substances (i) In general The recommendation described in this subparagraph is the recommendation of the Academies as to whether section 203 should take effect as provided in subsection (d) of such section. (ii) Considerations In making a recommendation under clause (i), the Academies shall consider— (I) the scientific information that is available at the time of the recommendation; (II) the value and relevance of the information that could result from the implementation of section 203; and (III) the cost and feasibility of such implementation. (iii) Maintenance of clinical data If the Academies recommend that section 203 should take effect, the Academies shall recommend the means by which clinical data referred to in that section could be maintained in the most scientifically useful way. (2) Periodic updates Under an agreement between the Secretary and the Academies under this section, not less frequently than once every two years after the date on which the initial report is submitted under paragraph (1)(A), 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 updated report on the activities of the Academies under the agreement. (h) Limitation on authority The authority to enter into agreements under this section shall be effective for a fiscal year to the extent that appropriations are available for such purpose. (i) Alternative contract scientific organization (1) In general If the Secretary is unable within the time period prescribed in subsection (b)(2) 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) Treatment If the Secretary enters into an agreement with another organization as described in paragraph (1), any reference in this section, section 203, and section 1119 of title 38, United States Code, as added by section 102(a), to the National Academies of Sciences, Engineering, and Medicine shall be treated as a reference to the other organization. 203. Analysis of results of consultation, testing, and treatment of veterans for disabilities related to exposure to toxic substances (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 consultation, testing, and treatment furnished to veterans by the Department under section 1720J of title 38, United States Code, as added by section 101(a); and (2) is likely to be scientifically useful in determining the association, if any, between the disability of a veteran and exposure to a toxic substance. (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 effective date under subsection (d), 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 information compiled under subsection (a); (2) an analysis of such information; (3) a description of the types and incidences of disabilities identified by the Department under such subsection; (4) the explanation of the Secretary for the incidence of such disabilities and other explanations for the incidence of such disabilities as the Secretary considers reasonable; and (5) the views of the Secretary on the scientific validity of drawing conclusions from the incidence of such disabilities, as evidenced by the data compiled under subsection (a), regarding any association between such disabilities and exposure to a toxic substance. (d) Effective date (1) In general Except as provided in paragraph (2), this section shall take effect on the date that is 90 days after the date on which the report submitted by the National Academies of Sciences, Engineering, and Medicine under section 202(g)(1) is received by the Secretary. (2) Exception This section shall not take effect if the Secretary, after receiving the report described in paragraph (1) and before the end of the 90-day period described in such paragraph— (A) determines that it is not feasible or cost-effective to carry out this section or that carrying out this section would not make a material contribution to the body of scientific knowledge concerning the health effects in humans of herbicide exposure; and (B) notifies the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives of that determination and the reasons therefor. 204. Report to evaluate and identify groups at-risk of exposure to toxic substances (a) In general Not later than one year after the date of the enactment of this Act, and every two years thereafter, the Secretary of Defense shall submit to the appropriate committees of Congress and, subject to applicable Federal privacy laws, make available to the public a report evaluating and identifying the groups of members of the Armed Forces and former members of the Armed Forces who are at-risk of exposure to toxic substances. (b) Existing data The Secretary shall use data from existing record and tracking systems to develop each report under subsection (a). (c) Use of capabilities of National Artificial Intelligence Institute In developing each report under subsection (a), the Secretary shall use the capabilities of the National Artificial Intelligence Institute of the Department of Veterans Affairs to interpret the veteran population data within the Individual Longitudinal Exposure Record of the Department, including data compiled under— (1) the Million Veteran Program of the Department; (2) health records of veterans; and (3) benefits records of veterans. (d) Elements of report Each report submitted under subsection (a) shall— (1) identify groups at a high-risk for illnesses relating to exposure to toxic substances and recommend an outreach strategy for those groups; and (2) determine the viability of correlating the Individual Longitudinal Exposure Record and health records maintained by the Veterans Health Administration, including with respect to participation of a veteran in the Million Veteran Program of the Department, to provide more data to epidemiologists of the Department. (e) 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. III Improvement of resources of Department of Veterans Affairs regarding exposures to toxic substances 301. Publication of list of resources of Department of Veterans Affairs for veterans exposed to toxic substances 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) veterans provided disability compensation under chapter 11 of title 38, United States Code, relating to exposure to toxic substances; (B) veterans eligible for consultation, testing, and treatment under section 1720J of such title, as added by section 101(a); (C) caregivers of veterans described in subparagraph (A) or (B) who are participating in the program of comprehensive assistance for family caregivers under section 1720G(a) of such title; and (D) survivors of veterans described in subparagraph (A) or (B) (or who would be described in any such subparagraph were the veteran 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 exposure to toxic substances, including outreach with respect to benefits and support programs. 302. 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 exposure to toxic substances 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 exposure of veterans to toxic substances 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. 303. Portal for access by veterans to individual longitudinal exposure record (a) In general The Secretary of Veterans Affairs shall establish a portal through which a veteran may access documents and information with respect to the veteran contained in the Individual Longitudinal Exposure Record of the Department of Veterans Affairs. (b) Elements of portal The portal established under subsection (a) shall— (1) present documents and information with respect to a veteran contained in the Individual Longitudinal Exposure Record of the veteran in a printable, read-only format; and (2) be hosted on an internet website of the Department that is commonly used by veterans. 304. Training of personnel of Department of Veterans Affairs on illnesses related to exposure to toxic substances (a) In general The Secretary of Veterans Affairs shall ensure that personnel of the Department of Veterans Affairs, including personnel involved with establishing disability ratings under the laws administered by the Secretary, and non-Department health care personnel who provide care to veterans under the laws administered by the Secretary are appropriately trained to identify, treat, and assess the impact of illnesses related to exposure to toxic substances. (b) Elements of training The training required under subsection (a) shall— (1) provide veterans and personnel with specific education with respect to illnesses related to exposure to toxic substances; (2) inform disability raters of secondary effects that can be attributed to exposure to toxic substances; and (3) inform personnel of how to probe for additional information regarding exposures to different toxicants. (c) Toxicant defined In this section, the term toxicant has the meaning given that term in section 1720J(i) of title 38, United States Code, as added by section 101(a).

1. Short title; table of contents (a) Short title This Act may be cited as the Toxic Exposure in the American Military Act of 2020 or the TEAM Act of 2020 . (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. Sec. 2. Definitions. TITLE I—Expansion of health care and benefits for veterans exposed to toxic substances Sec. 101. Expansion of health care eligibility for certain individuals exposed to open burn pits and other toxic substances. Sec. 102. Expansion of health care eligibility for veterans awarded certain medals. Sec. 103. Permanent reauthorization of authority of Secretary of Veterans Affairs to prescribe regulations providing that a presumption of service connection is warranted for a disease associated with exposure to a herbicide agent. Sec. 104. Permanent reauthorization of authority of Secretary of Veterans Affairs to prescribe regulations providing that a presumption of service connection is warranted for an illness associated with service in the Persian Gulf during the Persian Gulf War. Sec. 105. Presumptions of service connection for diseases associated with exposure to certain toxic substances. TITLE II—Research and review regarding exposure to toxic substances Sec. 201. Establishment of Toxic Exposure Review Commission. Sec. 202. Agreement with National Academies of Sciences, Engineering, and Medicine concerning the exposure of humans to toxic substances. Sec. 203. Collection, analysis, and report on treatment of veterans for medical conditions related to exposure to toxic substances. TITLE III—Improvement of resources of Department of Veterans Affairs regarding exposures to toxic substances Sec. 301. Publication of list of resources of Department of Veterans Affairs for veterans exposed to toxic substances and outreach program for such veterans and caregivers and survivors of such veterans. Sec. 302. Incorporation of toxic exposure questionnaire during primary care appointments. Sec. 303. Portal for access by veterans to Individual Longitudinal Exposure Record. Sec. 304. Training of health care personnel of Department of Veterans Affairs on illnesses related to exposure to toxic substances. 2. Definitions In this Act: (1) Active military, naval, or air service The term active military, naval, or air service has the meaning given that term in section 101 of title 38, United States Code. (2) Open burn pit 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). (3) Toxic substance The term toxic substance has the meaning given that term in subparagraph (G)(iv) of section 1710(e)(1) of such title, as added by section 101(a). I Expansion of health care and benefits for veterans exposed to toxic substances 101. Expansion of health care eligibility for certain individuals exposed to open burn pits and other toxic substances (a) In general Section 1710(e) of title 38, United States Code, is amended— (1) in paragraph (1), by adding at the end the following new subparagraph: (G) (i) Subject to paragraph (2), a covered individual 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 individual is an individual 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— (aa) an open burn pit; (bb) a toxic substance; or (cc) a site included in a database maintained by the Department of Defense and shared with the Department of Veterans Affairs to serve as the central portal for exposure-related data that compiles, collates, presents, and provides available occupational and environmental exposure information to support the needs of the Department of Defense and the Department of Veterans Affairs. (iii) A covered individual shall be enrolled in the system of annual patient enrollment of the Department in the priority group under subsection (a)(6) of section 1705 of this title. (iv) 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). (III) The term toxic substance means a toxicant or a toxin. (IV) The term toxicant means any substance that can injure or kill humans, animals, or plants and that is produced by humans or is a by-product of human activities. (V) The term toxin means any substance that can injure or kill humans, animals, or plants and that is produced naturally. ; and (2) in paragraph (2)(B), by striking or (F) and inserting (F), or (G) . (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. (c) Determinations of exposure (1) In general The Secretary of Veterans Affairs shall, to the extent practicable, establish and maintain a mechanism by which veterans may determine whether or not they have been possibly exposed to an open burn pit or toxic substance described in subparagraph (G)(ii)(II) of section 1710(e)(1) of title 38, United States Code, as added by subsection (a), for purposes of being considered as covered individuals under such subparagraph. (2) Approval of Secretary Any determination made under paragraph (1) shall be subject to the approval of the Secretary. (3) Appeals The Secretary shall establish a mechanism for appealing a decision made by the Secretary under paragraph (2). (d) Report (1) In general Not later than 30 days after the date on which the Secretary of Defense identifies the individuals described in subparagraph (G)(ii)(II) of section 1710(e)(1) of title 38, United States Code, as added by subsection (a), the Secretary, in consultation with the Secretary of Veterans Affairs, shall submit to the appropriate committees of Congress a report. (2) Elements The report required by paragraph (1) shall include the following: (A) The duty locations or units of the individuals described in paragraph (1), or other information on groups to which such individuals belong. (B) The evidence considered in identifying individuals who were possibly exposed to an open burn pit, toxic substance, or site as described in subparagraph (G)(ii)(II) of section 1710(e)(1) of title 38, United States Code, as added by subsection (a). (C) The criteria used to determine whether an individual was so exposed. (3) Appropriate committees of Congress In this subsection, the term appropriate committees of Congress 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. 102. 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 101(a), is further amended— (1) in paragraph (1), by adding at the end the following new subparagraph: (H) (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 Armed Forces Service Medal. (II) The Afghanistan Campaign Medal. (III) The Global War on Terrorism Expeditionary Medal. (IV) The Inherent Resolve Campaign Medal. (V) The Iraq Campaign Medal. (VI) The Southwest Asia Service Medal. (ii) A veteran described in clause (i) shall be enrolled in the system of annual patient enrollment of the Department in the priority group under subsection (a)(6) of section 1705 of this title. ; and (2) in paragraph (2), 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. 103. Permanent reauthorization of authority of Secretary of Veterans Affairs to prescribe regulations providing that a presumption of service connection is warranted for a disease associated with exposure to a herbicide agent (a) In general Section 1116 of title 38, United States Code, is amended by striking subsection (e). (b) Effective date Subsection (a) of this section and subsections (b) through (d) of section 1116 of such title shall take effect on the date of the enactment of this Act. 104. Permanent reauthorization of authority of Secretary of Veterans Affairs to prescribe regulations providing that a presumption of service connection is warranted for an illness associated with service in the Persian Gulf during the Persian Gulf War (a) In general Section 1118 of title 38, United States Code, is amended by striking subsection (e). (b) Effective date Subsection (a) of this section and subsections (b) through (d) of section 1118 of such title shall take effect on the date of the enactment of this Act. 105. Presumptions of service connection for diseases associated with exposure to certain toxic substances (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: 1119. Presumptions of service connection for diseases associated with exposure to certain toxic substances (a) Presumptions of service connection (1) For purposes of section 1110 of this title, and subject to section 1113 of this title, each disease specified in paragraph (2) becoming manifest as specified in that paragraph shall be considered to have been incurred in or aggravated by service referred to in that paragraph, notwithstanding that there is no record of evidence of such disease during the period of such service. (2) A disease specified in this paragraph is any disease that— (A) the Secretary determines in regulations prescribed under this section warrants a presumption of service connection by reason of having a positive association with exposure to a toxic substance; and (B) becomes manifest within the period, if any, prescribed in such regulations in a veteran who was exposed to that toxic substance during active military, naval, or air service. (3) (A) For purposes of this subsection, the Secretary may presume that a veteran who has a disease specified in paragraph (2) was exposed to the toxic substance for which the Secretary has determined under paragraph (2)(A) warrants a presumption of service connection by reason of having a positive association with exposure to the toxic substance, notwithstanding that there is no record of evidence of such exposure, if the Secretary determines based on one or more of the factors set forth in subparagraph (B) that a presumption of exposure is warranted. (B) The factors set forth in this subparagraph are as follows: (i) The duty location of the veteran. (ii) The length of service of the veteran. (iii) Such other factors as the Secretary considers appropriate. (b) Determinations relating to diseases (1) Whenever the Secretary determines, on the basis of sound medical and scientific evidence, that a positive association exists between the exposure of humans to a toxic substance and the occurrence of a disease in humans, the Secretary shall prescribe regulations providing that a presumption of service connection is warranted for that disease for purposes of this section. (2) In making determinations under paragraph (1), the Secretary shall take into account— (A) reports received by the Secretary from the National Academies of Sciences, Engineering, and Medicine under section 202(g) of the Toxic Exposure in the American Military Act of 2020 ; and (B) all other sound medical and scientific information and analyses available to the Secretary. (3) (A) In evaluating any report, information, or analysis for purposes of making such determinations, the Secretary shall consider only scientific studies that are valid in accordance with contemporary scientific standards. (B) The Secretary may define the standards described in subparagraph (A) for purposes of that subparagraph. (c) Response to reports by the National Academies of Sciences, Engineering, and Medicine (1) Not later than 60 days after the date on which the Secretary receives a report from the National Academies of Sciences, Engineering, and Medicine under section 202(g) of the Toxic Exposure in the American Military Act of 2020 , the Secretary shall determine whether a presumption of service connection is warranted for each disease covered by the report. (2) If the Secretary determines under paragraph (1) that a presumption of service connection is warranted for a disease, the Secretary shall, not later than 60 days after making the determination, issue proposed regulations setting forth the determination. (3) (A) If the Secretary makes a determination described in subparagraph (B), the Secretary shall, not later than 60 days after making the determination, publish in the Federal Register a notice of the determination. (B) A determination described in this subparagraph is a determination by the Secretary under paragraph (1) that a presumption of service connection is not warranted for a disease as to which the National Academies of Sciences, Engineering, and Medicine determined that there was— (i) sufficient evidence of an association between the exposure of humans to a toxic substance and the occurrence of the disease in humans; or (ii) limited evidence or suggestive evidence of such an association. (C) Any notice published under subparagraph (A) shall include an explanation of the scientific basis for the determination described in subparagraph (B). (D) If a disease already presumed to be service connected under this section is subject to a determination described in subparagraph (B), the Secretary shall, not later than 60 days after publication of the notice under subparagraph (A), issue proposed regulations removing the presumption of service connection for the disease. (4) Not later than 180 days after the date on which the Secretary issues any proposed regulations under this subsection, the Secretary shall issue final regulations. (d) Removal of presumption of service connection Whenever the presumption of service connection for a disease under this section is removed under subsection (c)— (1) a veteran who was awarded compensation for the disease on the basis of the presumption before the effective date of the removal of the presumption shall continue to be entitled to receive compensation on that basis; and (2) a survivor of a veteran who was awarded dependency and indemnity compensation for the death of a veteran resulting from the disease on the basis of the presumption before that date shall continue to be entitled to receive dependency and indemnity compensation on that basis. (e) Reference to National Academies of Sciences, Engineering, and Medicine In the case that the Secretary enters into an agreement with another organization as described in section 202(h)(1) of the Toxic Exposure in the American Military Act of 2020 , any reference in this section to the National Academies of Sciences, Engineering, and Medicine shall be treated as a reference to the other organization. (f) Definitions In this section: (1) The term positive association means, with respect to an association between exposure to a toxic substance and the occurrence of a disease in humans, that there is credible evidence for the association and such evidence is equal to or outweighs the credible evidence against the association. (2) The term toxic substance has the meaning given that term in section 1710(e)(1)(G)(iv) of this title. . (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 service connection for diseases associated with exposure to certain toxic substances. . (c) Conforming amendment Section 1113 of such title is amended by striking or 1118 each place it appears and inserting 1118, or 1119 . II Research and review regarding exposure to toxic substances 201. Establishment of Toxic Exposure Review Commission (a) In general Subchapter III of chapter 5 of title 38, United States Code, is amended by adding at the end the following new section: 547. 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 exposure to toxic substances that require scientific research; and (2) assist in the consideration of possible presumptions of service connection. (c) Duties The Commission shall carry out the following duties: (1) Collect any relevant information from the Department of Defense and other sources to identify possible toxic exposures related 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 under section 202 of the Toxic Exposure in the American Military Act of 2020 . Relevant information may be collected from the following: (A) Any Federal agency, as the Commission considers necessary to carry out this section. Upon request of the Chair, the head of such agency shall furnish such information to the Commission, unless such information is classified. (B) 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. (2) Recommend to the Secretary, by majority vote, whether a comprehensive scientific review should be conducted by the National Academies of Sciences, Engineering, and Medicine under an agreement under section 202 of the Toxic Exposure in the American Military Act of 2020 . (3) Recommend to the Secretary, by majority vote, whether new, independent studies regarding the health outcomes of exposure to toxic substances, or any other new, independent studies that the Commission deems necessary and appropriate, should be conducted. (4) Annually report to Congress on progress regarding the duties set forth in paragraphs (1) through (3), any recommendations made to the Secretary, and any responses of the Secretary to such recommendations. (d) Membership (1) (A) The Commission shall be composed of 9 members, appointed as follows: (i) Two members appointed by the Speaker of the House of Representatives. (ii) Two members appointed by the minority leader of the House of Representatives. (iii) Two members appointed by the majority leader of the Senate. (iv) Two members appointed by the minority leader of the Senate. (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 Toxic Exposure in the American Military Act of 2020 . (2) In appointing individuals under paragraph (1)(A), the Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and the Secretary shall 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 Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and the Secretary shall 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 Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and the Secretary shall give consideration to including in the Commission at least one member who works with survivors of illnesses related to exposure to toxic substances and has a background in the field of study of exposure to toxic substances. (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) Chair and Vice Chair At the initial meeting of the Commission under subsection (e), the Commission shall select a Chair and Vice Chair 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 Chair, 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) Reference to National Academies of Sciences, Engineering, and Medicine In the case that the Secretary enters into an agreement with another organization as described in section 202(h)(1) of the Toxic Exposure in the American Military Act of 2020 , any reference in this section to the National Academies of Sciences, Engineering, and Medicine shall be treated as a reference to the other organization. (n) Toxic substance defined In this section, the term toxic substance has the meaning given that term in subparagraph (G)(iv) of section 1710(e)(1) of this title. . (b) Clerical amendment The table of sections at the beginning of chapter 5 of such title is amended by adding at the end the following new item: 547. Toxic Exposure Review Commission. . 202. Agreement with National Academies of Sciences, Engineering, and Medicine concerning the exposure of humans to toxic substances (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 diseases and exposure to toxic substances. (b) Agreement (1) In general The Secretary of Veterans Affairs shall seek to enter into a five-year agreement with the Academies to perform the services covered by this section. (2) Timing 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 this Act. (3) Extension An agreement under this section may be extended in five-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 exposure to toxic substances during active military, naval, or air service and each disease suspected to be associated with such exposure in the human population. (d) Scientific determinations concerning diseases For each disease reviewed under subsection (c), the Academies shall determine, to the extent that available scientific data permit meaningful determinations— (1) whether an association exists between exposure to toxic substances and the occurrence of the disease, 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 disease among those exposed to toxic substances 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 exposure and the occurrence of the disease. (e) Cooperation of Federal agencies (1) In general 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. (2) Technical and scientific capabilities In performing the services covered by this section, the Academies shall make use of the technical and scientific capabilities of any Federal agency. (f) Recommendations for additional scientific studies (1) In general 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 the exposure of humans to toxic substances. (2) Considerations 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) Initial report (A) In general Under an agreement between the Secretary and the Academies under this section, not later than one year after the date of the enactment of this Act, 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. (B) Elements The report submitted under subparagraph (A) shall include the following: (i) The determinations described in subsection (d). (ii) A full explanation of the scientific evidence and reasoning that led to such determinations. (iii) Any recommendations of the Academies under subsection (f). (2) Periodic updates Under an agreement between the Secretary and the Academies under this section, not less frequently than once every two years after the date on which the initial report is submitted under paragraph (1)(A), 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 updated report on the activities of the Academies under the agreement. (h) Alternative contract scientific organization (1) In general If the Secretary is unable within the time period prescribed in subsection (b)(2) 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) Treatment If the Secretary enters into an agreement with another organization as described in paragraph (1), any reference in this section, section 547 of title 38, United States Code, as added by section 201(a), and section 1119 of such title, as added by section 105(a), to the National Academies of Sciences, Engineering, and Medicine shall be treated as a reference to the other organization. 203. Collection, analysis, and report on treatment of veterans for medical conditions related to exposure to toxic substances (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 exposure to a toxic substance. (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, the Committee on Veterans’ Affairs of the House of Representatives, and the Toxic Exposure Review Commission established by section 547 of title 38, United States Code, as added by section 201(a) of this Act, 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 exposure to a toxic substance. III Improvement of resources of Department of Veterans Affairs regarding exposures to toxic substances 301. Publication of list of resources of Department of Veterans Affairs for veterans exposed to toxic substances 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) veterans provided disability compensation under chapter 11 of title 38, United States Code, relating to exposure to toxic substances; (B) veterans eligible for hospital care, medical services, and nursing home care under section 1710(a)(2)(F) of such title; (C) caregivers of veterans described in subparagraph (A) or (B) who are participating in the program of comprehensive assistance for family caregivers under section 1720G(a) of such title; and (D) survivors of veterans described in subparagraph (A) or (B) (or who would be described in any such subparagraph were the veteran 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 exposure to toxic substances, including outreach with respect to benefits and support programs. 302. 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 exposure to toxic substances 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 exposure of veterans to toxic substances 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. 303. Portal for access by veterans to Individual Longitudinal Exposure Record (a) In general The Secretary of Veterans Affairs shall establish a portal through which a veteran may access documents and information with respect to the veteran contained in the Individual Longitudinal Exposure Record of the Department of Veterans Affairs. (b) Elements of portal The portal established under subsection (a) shall— (1) present documents and information with respect to a veteran contained in the Individual Longitudinal Exposure Record of the veteran in a printable, read-only format; and (2) be hosted on an internet website of the Department that is commonly used by veterans. 304. Training of health care personnel of Department of Veterans Affairs on illnesses related to exposure to toxic substances (a) In general The Secretary of Veterans Affairs shall ensure that health care personnel of the Department of Veterans Affairs are appropriately trained to identify, treat, and assess the impact of illnesses related to exposure to toxic substances. (b) Elements of training The training required under subsection (a) shall— (1) provide health care personnel of the Department with specific education with respect to illnesses related to exposure to toxic substances; and (2) inform such personnel of how to probe for additional information from veterans regarding exposures to different toxicants. (c) Toxicant defined In this section, the term toxicant has the meaning given that term in subparagraph (G)(iv) of section 1710(e)(1) of title 38, United States Code, as added by section 101(a).

December 8, 2020 Reported with an amendment