[Senate Report 113-106]
[From the U.S. Government Publishing Office]
Calendar No. 185
113th Congress Report
SENATE
1st Session 113-106
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WOMEN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2013
_______
September 17, 2013.--Ordered to be printed
_______
Mr. Sanders, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
together with
MINORITY VIEWS
[To accompany S. 131]
The Committee on Veterans' Affairs (hereinafter,
``Committee''), to which was referred the bill (S. 131) to
amend title 38, United States Code (hereinafter, ``U.S.C.''),
to improve the reproductive assistance provided by the
Department of Veterans Affairs (hereinafter, ``VA'' or ``the
Department'') to severely wounded, ill, or injured veterans and
their spouses, and for other purposes, having considered the
same, reports favorably thereon with an amendment in the nature
of a substitute, and recommends that the bill, as amended, do
pass.
Introduction
On January 24, 2013, Senator Murray introduced S. 131, the
proposed ``Women Veterans and Other Health Care Improvements
Act of 2013.'' Senators Begich and Tester were original
cosponsors of the bill. Senator Blumenthal was later added as a
cosponsor of the bill. The bill was referred to the Committee
upon introduction.
Committee Hearing
On May 9, 2013, the Committee held a hearing on legislation
pending before the Committee. Testimony on S. 131 was received
from: Heather L. Ansley, Esq., M.S.W., Vice President of
Veterans Policy, VetsFirst; Richard F. Weidman, Executive
Director for Policy and Government Affairs, Vietnam Veterans of
America; and Robert L. Jesse, M.D., Ph.D., Principal Deputy
Under Secretary for Health, U.S. Department of Veterans
Affairs.
Committee Meeting
On July 24, 2013, the Committee met in open session to
consider legislation pending before the Committee. Among the
measures so considered was an amended version of S. 131. The
Committee voted by voice vote, to report favorably S. 131 as
amended (hereinafter, ``the Committee bill'') to the Senate.
One Member was recorded as a no vote.
Summary of S. 131 as Reported
Section 1 would provide a short title for the bill and
would provide that certain references within the bill are
references to title 38, U.S.C.
Section 2 would clarify that fertility counseling and
treatment are medical services which the Secretary may furnish
to veterans like other medical services.
Section 3 would authorize reproductive treatment and care
for spouses and surrogates of veterans.
Section 4 would authorize adoption assistance for severely
wounded veterans.
Section 5 would require the prescription of regulations on
furnishing of fertility counseling and treatment and adoption
assistance by VA.
Section 6 would provide for coordination between VA and
Department of Defense (hereinafter, ``DOD'') on furnishing of
fertility counseling and treatment.
Section 7 would facilitate research on reproduction and
infertility.
Section 8 would require an annual report on provision of
fertility counseling and treatment furnished by VA.
Section 9 would authorize a program on assistance for child
care for certain veterans.
Section 10 would authorize a program on counseling in
retreat settings for women veterans newly separated from
service in the armed forces.
Background and Discussion
Sec. 2. Clarification that fertility counseling and treatment are
medical services which the Secretary may furnish to veterans
like other medical services.
Section 2 of the Committee bill, which is derived from
S. 131, as introduced, would clarify that fertility counseling
and treatment are medical services which the Secretary may
furnish to veterans like other medical services.
Background. The nature of the most recent conflicts and the
increasing use of improvised explosive devices leave
servicemembers far more susceptible to blast injuries,
including spinal cord injury and trauma to the reproductive and
urinary tracts. According to DOD data, between 2003 and June
2013, 2,320 servicemembers suffered genitourinary or pelvic
injuries while serving in Iraq or Afghanistan.
VA currently provides fertility counseling and treatment
for all enrolled veterans, including to both service-connected
and non-service-connected veterans, as described in the Medical
Benefits Package contained in section 17.38 of title 38, Code
of Federal Regulations (hereinafter, ``C.F.R.''). The services
offered include genetic counseling and testing, laboratory
tests, biopsies of reproductive organs, hormonal treatments,
and intra-uterine insemination. However, VA explicitly
prohibits certain types of assisted reproductive technology
(hereinafter, ``ART'') in section 17.38(c) of title 38, C.F.R.,
such as in vitro fertilization (hereinafter, ``IVF'').
A March 2011 study by Mattocks, et al., entitled ``Women
veterans' reproductive health preferences and experiences: a
focus group analysis,'' published in Women's Health Issues
found that women veterans felt VA could improve fertility
services offered by increasing the availability of more
advanced procedures. Additionally, the study found: ``[S]everal
participants had utilized infertility services provided by the
VA, including infertility medications and artificial
insemination, yet were denied VA coverage for assisted
reproductive technologies, including in vitro fertilization.
Participants expressed beliefs that the VA should provide more
extensive infertility coverage, including in vitro
fertilization, to assist women who are having difficulties
becoming pregnant.''
According to testimony submitted by the Department for the
Committee's May 9, 2013, hearing on pending legislation,
providing reproductive treatment through ART is in line with
VA's goals to provide restorative care to disabled veterans and
improve their quality of life. Both male and female veterans
experience service-related reproductive injuries or illnesses
that interfere with their fertility and fecundity--ability to
carry a pregnancy to full-term. Among these are: blast injuries
that can damage the sexual organs, including testicular or
uterine rupture, or their nerve and vascular supplies, and non-
ballistic injuries, such as spinal cord or traumatic brain
injury. For these veterans, the use of ART may be their only
option for achieving a successful pregnancy.
On April 27, 2010, DOD authorized IVF services for severely
wounded, ill, or injured servicemembers and their spouses. DOD
issued guidance on the implementation of this benefit on April
3, 2012. This resulted in an inequity in the services provided
by VA and DOD to assist severely wounded veterans or
servicemembers in becoming parents. Some veterans have
difficulty utilizing this coverage before they separate from
active duty due to timing and after separation due to
geographic constraints.
Committee Bill. Section 2 of the Committee bill would
modify section 1701(6) of title 38, U.S.C., to clarify that
fertility treatments, including treatments through ART, are
authorized for veterans. It is the view of the Committee that
veterans should be able to access the same level of fertility
treatments whether they utilize VA or DOD health care.
Sec. 3. Reproductive treatment and care for spouses and surrogates of
veterans.
Section 3 of the Committee bill, which is derived from
S. 131, as introduced, would require VA to furnish reproductive
treatment and care to spouses or surrogates of severely
wounded, ill, or injured veterans. It also authorizes VA to
coordinate fertility counseling and treatments for spouses and
surrogates of veterans whose infertility is not related to
military service.
Background. In order to provide comprehensive fertility
treatment to a veteran, it is imperative to provide treatment
to the veteran's spouse or surrogate to ensure that treatment
results in a successful pregnancy. This is particularly
significant for wounded, ill, or injured veterans. Certain
illnesses or injuries necessitate the use of ART among veterans
who may be clinically unable to achieve a successful pregnancy.
According to testimony submitted by Dr. Mark Edney, Member of
the American Urological Association, for the Committee's June
27, 2012, hearing on pending legislation, blast or gunshot
wounds to the male pelvis or spinal cord and traumatic brain
injury may render male servicemembers and veterans incapable of
intercourse to achieve a natural pregnancy.
For other veterans, surrogacy--the process by which a woman
agrees to become pregnant and give birth to a child on behalf
of another person--is their only option for having their own
children. According to testimony submitted by Dr. Edney,
``[b]last or gunshot wounds to the female pelvis can also
result in a variety of fertility-impairing injuries * * *[;]
penetrating schrapnel injury to the female pelvis can disrupt
the ovaries, fallopian tubes, body of the uterus or the vaginal
vault * * *[;] [u]terine injury can result in a uterus
incapable of sustaining a pregnancy which then opens the issue
of surrogacy.''
Committee Bill. Section 3 of the Committee bill would amend
title 38, U.S.C., by adding a new section 1788. Subsection (a)
of this new section would require VA to furnish fertility
counseling and treatment, including ART, to a spouse or
surrogate of a severely wounded, ill, or injured veteran who
has an infertility condition incurred or aggravated in the line
of duty in the active military, naval, or air service. The
spouse or surrogate and the veteran must apply jointly for such
counseling and treatment through a process prescribed by VA,
and the veteran must be enrolled in the health care system
established under section 1705(a) of title 38, U.S.C.
While VA provides reproductive counseling and treatment for
veterans, the Committee notes that infertility management is
one of many family planning concerns that commonly involves
treatment of both parents. The Committee intends that VA make
these treatments and any necessary components, including those
derived from third party donation, available to spouses and
surrogates of severely injured veterans in order to restore
their ability to create a family.
Subsection (b) of this new section would authorize VA to
coordinate fertility counseling and treatment for spouses or
surrogates with the veteran's, when the veteran's infertility
is not related to their military service.
Subsection (c) of this new section would clarify that
nothing in this section shall be construed to require VA to
find or certify a surrogate for a veteran or to connect a
surrogate with an injured veteran. Subsection (c) also
clarifies that nothing in this section shall be construed to
require VA to furnish maternity care to a spouse or veteran who
would not otherwise be eligible for VA to provide that care.
Sec. 4. Adoption assistance for severely wounded veterans.
Section 4 of the Committee bill, which is derived from
S. 131, as introduced, would authorize VA to provide adoption
assistance to severely wounded, ill, or injured veterans who
have an infertility condition incurred or aggravated in the
line of duty.
Background. In light of injuries sustained, servicemembers
and veterans may need to rely on third-party donation or
adoption to build their families. The 2002 National Survey of
Family Growth, conducted by the Centers for Disease Control and
Prevention, found that approximately three quarters of women
who were seeking to adopt a child faced issues with fertility
or maintaining a pregnancy.
Committee Bill. Section 4 of the Committee bill would
further amend title 38, U.S.C., by adding a new section 1789.
This new section would authorize VA to assist a covered veteran
in the adoption of one or more children. Covered veterans would
include severely wounded, ill, or injured veterans who are
enrolled in the VA health care system and have an infertility
condition incurred or aggravated in the line of duty. This
section authorizes VA to set a limitation on the amount that is
equal to the lesser of the cost of one cycle of fertility
treatment through ART or the cost of three adoptions.
The intent of the Committee is to ensure that veterans,
with infertility conditions connected to their military
service, have flexibility and options to choose from when
deciding how to build their families.
Sec. 5. Regulations on furnishing of fertility counseling and treatment
and adoption assistance by Department of Veterans Affairs.
Section 5 of the Committee bill, which is derived from
S. 131, as introduced, would require VA to promulgate
regulations on the furnishing of fertility treatments via ART,
prior to furnishing counseling or treatment, and on the
furnishing of services described in sections 1788 and 1789 of
title 38, as added by sections 3 and 4 of the Committee bill,
notwithstanding any other provision of the law.
Committee Bill. Section 5 of the Committee bill would
require VA to promulgate regulations in accordance with section
553 of title 5, U.S.C., on the furnishing of fertility
treatments and adoptions, as added by the Committee bill, prior
to furnishing such services. This section would require that
VA, not later than 540 days after the date of the enactment of
the Committee bill, prescribe regulations to provide fertility
treatments to veterans via ART and to carry out sections 1788
and 1789 of title 38, U.S.C., as added by the Committee bill.
The Committee expects that the regulations required by this
section would encourage the development of common-sense
clinical guidance and would allow for stakeholder involvement
in the decisionmaking process on how best to administer
fertility counseling and treatment to veterans and their
spouses or surrogates. The Committee also intends these
regulations allow for collaborative decisionmaking on how to
best offer fertility treatment to surrogates and spouses, and
adoption assistance to eligible veterans. It is not the intent
of the Committee to stop or slow any existing fertility
services that VA currently offers.
Sec. 6. Coordination between Department of Veterans Affairs and
Department of Defense on furnishing of fertility counseling and
treatment.
Section 6 of the Committee bill, which is derived from
S. 131, as introduced, would require VA to coordinate the
furnishing of fertility counseling and treatment by VA with the
furnishing of such counseling and treatment by DOD.
Background. DOD, in certain situations and at certain
military treatment facilities (hereinafter, ``MTFs''), provides
IVF treatments to severely wounded, ill, and injured
servicemembers and spouses. DOD also has several MTFs that
offer fertility treatments through ART on a cost-sharing basis.
Offering these services has resulted in an inequity in the
extent to which VA and DOD are able to
assist severely wounded veterans or servicemembers in becoming
parents.
Committee Bill. Section 6 of the Committee bill would
require VA to coordinate its fertility counseling and treatment
with that provided by DOD.
It is the intent of the Committee that VA and DOD
coordinate their services to address the needs of this unique
population. In addition, the Committee encourages VA to work
with DOD and understand key lessons learned in DOD's
implementation of guidance and delivery of services. The
Committee believes that coordination will allow both
Departments to avoid duplicative efforts while expanding access
to fertility counseling and treatment for servicemembers and
veterans.
Sec. 7. Facilitation of reproduction and infertility research.
Section 7 of the Committee bill, which is derived from
S. 131, as introduced, would require VA to collaborate with the
DOD and the Department of Health and Human Services
(hereinafter, ``HHS'') to facilitate research on the long-term
reproductive needs of veterans. This section would also require
VA to report to Congress on research activities conducted in
response to this section.
Background. Occupational hazards, including environmental
exposures, trauma, and military sexual trauma, can affect the
reproductive health of servicemembers. Many serving in
Operation Iraqi Freedom (hereinafter, ``OIF''), Operation
Enduring Freedom (hereinafter, ``OEF''), and Operation New Dawn
(hereinafter, ``OND'') are of childbearing age, and may have to
deal with a lifetime of symptoms related to their military
service. For example, according to data from DOD, 2,320
servicemembers have suffered reproductive and urinary tract
trauma on the battlefield between 2003 and June 2013. These
injuries may limit servicemembers' and veterans' abilities to
reproduce for various reasons, including damage to reproductive
organs, pelvic fractures, and others.
In June 2012, an editorial by Colonel Steve Waxman, M.D.,
U.S.A.R., entitled ``Lower Urinary Tract Injuries in Operation
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)'' was
published in Military Medicine. Colonel Waxman found that the
concurrence of bladder and urethral injuries, along with
genital trauma, suggests that many injured servicemembers may
have long-term hormonal and fertility issues. Limited research
is available on the reproductive health needs and treatment
options available for servicemembers and veterans. In testimony
submitted for the Committee's June 27, 2012, hearing on pending
legislation, Dr. Mark Edney, an urologist and Army Reservist,
highlighted the critical need for research in this area,
including research on strategies for preventing reproductive
and urinary tract trauma on the battlefield and the long-term
effects of such trauma on reproductive health.
Currently, VA has limited ongoing research in this area,
including studies on urogenital systems and Post Traumatic
Stress Disorder (hereinafter, ``PTSD''), availability and use
of contraceptives, and the effects of male reproductive
toxicants on the ability to reproduce. In addition to VA, other
government research entities can play an important role in
filling the gap in existing research on the long-term
reproductive needs of veterans, including DOD, because of its
role in facilitating research to inform health care services
for servicemembers, and HHS, because of its role in setting a
national agenda for detection, prevention, and management of
infertility.
Committee Bill. Section 7 of the Committee bill would amend
subchapter II of chapter 73 of title 38, U.S.C., to create a
new section 7330B. Subsection (a) of this new section would
require VA to collaborate with DOD and HHS to facilitate
research to improve VA's ability to meet the long-term
reproductive health needs of veterans. Subsection (b) of this
new section would require VA to ensure that information
produced by the research facilitated under this section is
disseminated throughout the VA system.
Section 7 would also require VA to submit a report to
Congress, not later than 3 years after the date of the
enactment of the Committee bill, on the research activities
conducted under new section 7330B of title 38, U.S.C.
Sec. 8. Annual report on provision of fertility counseling and
treatment furnished by Department of Veterans Affairs.
Section 8 of the Committee bill, which is derived from
S. 131, as introduced, would require VA to submit a report to
Congress each year on the fertility counseling and treatments
furnished by VA during the year preceding the submittal of the
report.
Background. At present, VA provides limited fertility
treatments for all enrolled veterans including both service-
connected and non-service-connected veterans. The services
available to male veterans include laboratory testing, semen
analysis, evaluation and treatment of erectile dysfunction
interfering with sperm delivery, surgical correction of
structural pathology, hormone therapy, sperm cryopreservation
for certain conditions, genetic testing and counseling, sperm
retrieval, post-ejaculatory urinalysis, and transrectal or
scrotal ultrasonography. The services available to female
veterans include laboratory testing, pelvic or transvaginal
ultrasound, hysterosalpingogram, post-coital testing,
diagnostic laparoscopy or hysteroscopy, endometrial biopsy,
hormone therapy, intrauterine insemination, saline infused
sonohysterogram, surgical correction of structural pathology,
and genetic testing and counseling. There is no data readily
available on usage of these services.
Committee Bill. Subsection (a) of section 8 of the
Committee bill would require VA to submit a report to the
Committee on Veterans' Affairs of the Senate and House of
Representatives each year on the fertility counseling and
treatments furnished by VA during the year preceding the
submittal of the report.
Subsection (b) of section 8 of the Committee bill describes
the information required in each report submitted under
subsection (a), including the number of veterans and spouses or
surrogates of veterans who received fertility counseling or
treatments furnished by VA, disaggregated by era of military
service of such veterans; the cost to VA of furnishing
fertility counseling and treatment, disaggregated by cost of
services and administration; the average cost to VA per
recipient of such counseling and treatment; in cases in which
the Department furnished IVF, the average number of cycles per
person furnished; and a description of how VA fertility
counseling and treatment services are coordinated with similar
services provided by DOD. It is the Committee's view that it is
critical to monitor these services to ensure that they are
meeting the needs of those they are intended to assist.
Sec. 9. Program on assistance for child care for certain veterans.
Section 9 of the Committee bill, which is derived from
S. 131, as introduced, would authorize a permanent program to
provide assistance for child care to certain veterans receiving
readjustment counseling and related mental health services.
Background. The Caregivers and Veterans Omnibus Health
Services Act of 2010, enacted as Public Law (hereinafter,
``P.L.'') 111-163, authorized VA to create a pilot program to
provide assistance to veterans for child care expenses incurred
while receiving care at VA Medical Centers via stipend, direct
provision of child care, interagency collaboration, or payment
to private child care agency. The pilot was authorized to be
carried out in no fewer than three Veterans Integrated Service
Networks for 2 years, beginning on the date the first site
began to operate. Subsidies for child care are only available
during the time period that a veteran is actually receiving
specified health care services at a VA Medical Center, and
during the time required by the veteran to travel to and from
the site of treatment. Veterans eligible for subsidies are
those who are the primary caretaker of a child or children and
who are receiving regular or intensive mental health care, or
other intensive health care services determined by VA as ones
for which access would be improved by payment of a subsidy for
child care.
The first child care site opened in Buffalo, NY, on October
3, 2011. Sites in Northport, NY, and American Lake, WA, opened
on April 30, 2012, and December 3, 2012, respectively. The
Dallas VA Medical Center also opened a site on April 1, 2013.
Between the inception of the pilot program and June 2013, the
four sites have served 3,817 children.
Having access to quality and timely mental health care is
vital. VA's Vet Centers play an integral role in providing
readjustment counseling and mental health treatment to combat
veterans. Committee oversight has found access to child care
can complicate a veteran's ability to consistently adhere to a
Vet Center counseling and treatment plan.
Committee Bill. The Committee has recognized the absence of
adequate child care as a significant barrier to accessing
health care for veterans who are also primary caretakers of
children. This problem is exacerbated for veterans who may need
more intensive and long-term outpatient services, such as care
for PTSD, mental health, and other therapeutic programs.
Section 9(a) of the Committee bill would make permanent the
pilot program to provide child care subsidies to eligible
veterans. Section 9(b) would require VA to create a program to
offer child care assistance to those seeking readjustment
counseling and associated mental health services through VA's
network of Vet Centers. It is the intent of the Committee to
ensure that identified barriers to mental health care access
are removed.
Sec. 10. Counseling in retreat settings for women veterans newly
separated from service in the Armed Forces.
Section 10 of the Committee bill, which is derived from
S. 131, as introduced, would make permanent the pilot program
on counseling in retreat settings for women veterans newly
separated from service in the Armed Forces.
Background. P.L. 111-163, the Caregivers and Veterans
Omnibus Health Services Act of 2010, authorized VA to establish
a pilot program designed to evaluate the feasibility of
providing reintegration and readjustment services in group
retreat settings to recently separated women veterans, after a
prolonged deployment.
Services provided under the pilot program include
information and assistance on reintegration into family,
employment, and community; financial and occupational
counseling; information and counseling on stress reduction and
conflict resolution; and any other counseling VA considers
appropriate to assist the participants in reintegrating into
their families and communities.
As required by P.L. 111-163, the Department submitted a
report to the Committees on Veterans' Affairs on outcomes of
the pilot program. According to this report, the total cost for
both years of the pilot program was $398,376. Over the 2-year
period, six retreats were held in California, Colorado,
Washington, New Mexico, and Connecticut. These retreats were
attended by 134 women from 37 States and Territories, and 85
percent of participants had statistically significant
improvements in psychological well-being, with 71 percent of
participants maintaining these improvements 2 months after
participation in a retreat. Eighty-one percent of participants
showed statistically significant decreases in stress symptoms,
82 percent of participants showed more frequent use of positive
coping skills, and 78 percent of those who qualified for a PTSD
diagnosis prior to participating no longer qualified for that
diagnosis 2 months after attendance at a retreat.
Committee Bill. Section 10 of the Committee bill would make
permanent the pilot program. Based on reports, this program is
successful at improving the ability for women veterans to
reintegrate and readjust to civilian life. It is the intent of
the Committee that VA continue to offer this cost-effective
program to more women veterans who can benefit from
participation.
Committee Bill Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the
Standing Rules of the Senate, the Committee, based on
information supplied by the Congressional Budget Office
(hereinafter, ``CBO''), estimates that enactment of the
Committee bill would, relative to current law, have a
discretionary cost of $578 million over the 2014-2018 period,
assuming appropriation of the estimated amounts. S. 131, as
amended, contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act.
The cost estimate provided by CBO, setting forth a detailed
breakdown of costs, follows:
Congressional Budget Office,
Washington, DC, August 21, 2013.
Hon. Bernard Sanders,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 131, the Women
Veterans and Other Health Care Improvements Act of 2013.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann E.
Futrell.
Sincerely,
Douglas W. Elmendorf,
Director.
Enclosure.
S. 131--Women Veterans and Other Health Care Improvements Act of 2013
Summary: S. 131 would expand the types and availability of
infertility treatment provided by the Department of Veterans
Affairs (VA). CBO estimates that implementing the bill would
cost $578 million over the 2014-2018 period, assuming
appropriation of the estimated amounts. Enacting S. 131 would
not affect direct spending or revenues; therefore, pay-as-you
go procedures do not apply.
S. 131 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 131 is shown in the following table. The
costs of this legislation fall within budget function 700
(veterans benefits and services).
Basis of estimate: For this estimate, CBO assumes the
legislation will be enacted early in fiscal year 2014, that the
necessary amounts will be appropriated for each year, and that
outlays will follow historical spending patterns for similar
and existing programs.
Infertility Treatment for Veterans. Section 2 would expand
the types of infertility treatments provided by VA to include
assisted reproductive technology (ART) procedures, of which in
vitro fertilization (IVF) is the most widely used. Under
current policy, VA provides veterans with limited assistance
for infertility treatments and covers the costs for delivery
and newborn care for eligible veterans. CBO's estimate of the
cost of this provision includes two components: the cost of
providing the additional fertility services and the cost of
providing additional delivery services for the resulting
pregnancies.
------------------------------------------------------------------------
By fiscal year, in millions of dollars--
------------------------------------------
2014-
2014 2015 2016 2017 2018 2018
------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Infertility Treatment for
Veterans
Estimated Authorization 1 30 95 100 105 331
Level...................
Estimated Outlays........ 1 27 88 98 104 318
Infertility Treatment for
Certain Spouses and
Surrogates
Estimated Authorization 1 18 58 61 64 202
Level...................
Estimated Outlays........ 1 16 54 60 63 194
Adoption Assistance
Estimated Authorization * 4 12 13 14 43
Level...................
Estimated Outlays........ * 4 11 13 14 42
Child Care Programs
Estimated Authorization 3 3 3 3 3 15
Level...................
Estimated Outlays........ 3 3 3 3 3 15
Counseling for Women in
Retreat Settings
Estimated Authorization 1 1 2 2 2 8
Level...................
Estimated Outlays........ 1 1 2 2 2 8
Reproduction and Infertility
Research
Estimated Authorization * * * * 0 1
Level...................
Estimated Outlays........ * * * * * 1
------------------------------------------
Total Changes
Estimated 6 56 170 179 188 600
Authorization Level.
Estimated Outlays.... 6 51 158 176 186 578
------------------------------------------------------------------------
Note: * = less than $500,000.
The inclusion of ART as a covered treatment option would
affect federal health care spending for female veterans. To
determine the number of female veterans that would use this new
benefit, CBO examined the use of ART services among the general
population, as reported by the Centers for Disease Control
(CDC). Based on that data, and making adjustments for the age
of the veteran population and the number of enrollees in the VA
health care system (and assuming that additional veterans would
enroll to take advantage of the new benefit), CBO estimates
that about 3,500 female veterans would use this benefit a year.
CBO estimates that the cost of those services would be
about $16,000 per user in 2014 or about $57 million once the
program is fully implemented in 2016; that estimate is based on
publicly available pricing information for ART procedures from
several fertility clinics.
In addition to the cost of the procedures, VA would incur
additional costs for some of the resulting pregnancies. Based
on information from the CDC, CBO estimates that about a third
of ART procedures result in a pregnancy. However, some VA
enrollees are currently undergoing ART procedures outside of
VA, and the department already covers the cost of roughly half
of the pregnancies that would be covered under the bill's ART
provision. Therefore, CBO estimates that about 550 additional
pregnancies would be covered by the VA under the bill.
Furthermore, CBO estimates the cost of each pregnancy would be
about $55,000 in 2014, based on information from private-sector
studies. This amount is significantly higher than the average
cost of a pregnancy in the United States (about $16,000)
because it takes into account the higher percentage of multiple
births and pre-term deliveries associated with pregnancies that
result from fertility treatments. The total cost of those
pregnancies would be about $31 million once the program is
fully implemented in 2016.
After accounting for inflation, and assuming that it would
take about three years to write regulations and fully implement
the proposal, CBO estimates that, in total, implementing
section 2 would increase costs to VA by $318 million over the
2014-2018 period, assuming appropriation of the necessary
amounts.
Infertility Treatment for Certain Spouses and Surrogates.
Section 3 would require VA to provide fertility assistance
services to the spouses and surrogates of veterans who, as a
result of a service-connected disability, have difficulty
fathering children.\1\ CBO's estimate of the cost of this
provision includes the cost of providing the fertility services
as well as additional child delivery services for the resulting
pregnancies for individuals eligible for CHAMPVA (11 percent of
the spouses). CHAMPVA is an insurance program run by the VA for
dependents and survivors of certain disabled veterans.
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\1\This section also would provide VA with the authority to
coordinate infertility counseling and treatment for the spouses and
surrogates of the broader veteran population. However, absent further
detail, VA cannot provide information on how they would implement the
provision; therefore, CBO cannot estimate a cost for that additional
authority.
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To estimate the number of veterans that would use this new
benefit, CBO examined the use of ART services as reported by
the CDC. Based on those data, and making adjustments for the
age of the veteran population, and for the fact that the
veteran's infertility must be caused by a severe service-
connected condition in order to receive this benefit, CBO
estimates that about 3,000 veterans would use this benefit each
year. Similar to our analysis for section 2, CBO estimates an
average cost of $16,000 per user in 2014. In addition to the
cost of the fertility assistance procedures, CBO also estimates
that VA would incur additional costs of roughly $3 million per
year, once the program is fully implemented in 2016, to cover
the cost of additional pregnancies.
In total, CBO estimates that implementing section 3 would
increase costs to VA by $194 million over the 2014-2018 period.
The bill would require VA to establish the rules and
regulations to implement section 3 within 18 months of the
bill's enactment; therefore, the costs for treatments would
begin in late 2015.
Adoption Assistance. Section 4 would allow VA to pay for
adoption costs for severely wounded veterans with infertility
conditions related to their service-connected disability. Such
payments would be limited to the lesser of the cost of one
cycle of fertility treatment and the costs associated with
three adoptions.
Using data from the CDC on adoption rates, adjusted for the
number of veterans eligible for the new benefit, CBO estimates
that about 700 veterans each year would decide to adopt with
VA's assistance. Based on information about adoption costs from
the Department of Health and Human Services, CBO assumes that
the cost of three adoptions would be higher than the cost for
one cycle of IVF (the most commonly used fertility treatment).
CBO estimates that implementing this provision would cost $42
million over the 2014-2018 period, assuming appropriation of
the necessary amounts.
Child Care Programs. Section 9 would allow VA to
permanently extend existing pilot programs that provide child
care for certain veterans who use VA medical facilities in no
fewer than three Veteran Integrated Service Networks. Based on
the authorization levels for the existing pilot programs, CBO
estimates that implementing this program would cost $15 million
over the 2014-2018 period.
Counseling for Women in Retreat Settings. Section 10 would
direct VA to establish a program that provides counseling in
group retreat settings to certain female veterans who have
recently separated from military service. VA recently reported
on a completed pilot program with similar requirements. Roughly
130 women veterans participated in the program in six retreats
over a two-year period. Based on the reported spending for the
pilot program and assuming an increase in participation--to 650
participants in 15 retreat settings in 2014, and a doubling of
the number of participants by 2018--CBO estimates that
implementing this program would cost $8 million over the 2014-
2018 period.
Reproduction and Infertility Research. Section 7 would
require the VA to conduct a research study on women's
reproductive health in collaboration with the Department of
Defense and the National Institutes of Health. Based on
information from VA on the cost and duration of similar
studies, CBO estimates the research study would run for about
three years and cost $1 million over the 2014-2018 period.
Pay-As-You-Go Considerations: None.
Intergovernmental and private-sector impact: S. 131
contains no intergovernmental or private-sector mandates as
defined in UMRA and would impose no costs on state, local, or
tribal governments.
Estimate prepared by: Federal Costs: Ann E. Futrell; Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
Impact on the Private Sector: Elizabeth Bass.
Estimate approved by: Peter H. Fontaine, Assistant Director
for Budget Analysis.
Regulatory Impact Statement
In compliance with paragraph 11(b) of rule XXVI of the
Standing Rules of the Senate, the Committee on Veterans'
Affairs has made an evaluation of the regulatory impact that
would be incurred in carrying out the Committee bill. The
Committee finds that S. 131, as amended, would not entail any
regulation of individuals or businesses or result in any impact
on the personal privacy of any individuals and that the
paperwork resulting from enactment would be minimal.
Tabulation of Votes Cast in Committee
In compliance with paragraph 7(b) of rule XXVI of the
Standing Rules of the Senate, the following is a tabulation of
votes cast in person or by proxy by members of the Committee on
Veterans' Affairs at its July 24, 2013, meeting. On that date,
the Committee voted, by voice vote, to order reported S. 131,
as amended, to the Senate. Senator Moran was recorded as a no
vote.
Agency Report
On May 9, 2013, Robert L. Jesse, M.D., Ph.D., Principal
Deputy Under Secretary for Health, Department of Veterans
Affairs, appeared before the Committee on Veterans' Affairs and
submitted testimony on, among other things, S. 131. In
addition, on September 11, 2013, VA provided views on S. 131.
Excerpts from both the testimony and Department views are
reprinted below:
STATEMENT OF ROBERT L. JESSE, M.D., Ph.D., PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS
Good Morning Chairman Sanders, Ranking Member Burr, and
Members of the Committee. Thank you for inviting me here today
to present our views on several bills that would affect
Department of Veterans Affairs (VA) benefits programs and
services. Joining me today is Susan Blauert, Deputy Assistant
General Counsel.
We do not yet have cleared views on sections 4, 10, 11, or
12 of S. 131, S. 287, section 3 of S. 522, S. 800, S. 832,
S. 845, S. 851, S. 852, or the draft bill described as ``The
Veterans Affairs Research Transparency Act of 2013.'' Also, we
do not have estimated costs associated with implementing
S. 131, S, 422, S. 455, or S. 825. We will forward the views
and estimated costs to you as soon as they are available.
* * * * * * *
S. 131, WOMAN VETERANS AND OTHER HEALTH CARE IMPROVEMENTS ACT OF 2013
Section 2 of S. 131 would amend 38 U.S.C. section 1701(6)
to include fertility counseling and treatment, including
treatment using assisted reproductive technology, among those
things that are considered to be ``medical services'' under
chapter 17 of title 38, U.S.C.
VA supports section 2 of the bill, but must condition this
support on assurance of the additional resources that would be
required were this provision enacted. The provision of Assisted
Reproductive Technologies (including any existing or future
reproductive technology that involves the handling of eggs or
sperm) is consistent with VA's goal to restore to the greatest
extent possible the physical and mental capabilities of
Veterans and improve the quality of their lives. For many,
having children is an important and essential aspect of life.
Those who desire but are unable to have children of their own
commonly experience feelings of depression, grief, inadequacy,
poor adjustment, and poor quality of life.
Section 3 of the bill would add a new section 1788 to title
38, U.S.C., that would require VA to furnish fertility
counseling and treatment, including through the use of assisted
reproductive technology, to a spouse or surrogate of a severely
wounded, ill, or injured enrolled Veteran who has an
infertility condition incurred or aggravated in the line of
duty, if the spouse or surrogate and the Veteran apply jointly
for such counseling and treatment through a process prescribed
by VA. This section would authorize VA to ``coordinate
fertility counseling and treatment'' for other spouses and
surrogates of other Veterans who are seeking fertility
counseling and treatment. Section 1788 would not be construed
to require VA to furnish maternity care to a spouse or
surrogate of a Veteran, or to require VA to find or certify a
surrogate for or connect a surrogate with a Veteran. Subsection
(d) of proposed section 1788 would define the term ``assisted
reproductive technology'' to include ``in vitro fertilization
and other fertility treatments in which both eggs and sperm are
handled when clinically appropriate.''
VA supports section 3 in part, but must condition this
support on assurance of the additional resources that would be
required were this provision enacted. VA supports providing
infertility services including assisted reproductive technology
to severely wounded, ill, or injured enrolled Veterans
described in section 3, and their spouses or partners. VA does
not, however, support coverage of such services for surrogates
at this time. The complex legal, medical, and policy
arrangements of surrogacy vary from state to state due to
inconsistent regulations between States, and we believe would
prove to be very difficult to implement in practice. Moreover,
the additional coverage of surrogates is inconsistent with
coverage provided by the Department of Defense (DOD), Medicaid,
Medicare, and several private insurers and health systems.
Current DOD policy addressing assisted reproductive services
for severely injured Servicemembers specifically excludes
coverage of surrogates. VA acknowledges that surrogacy may
offer the only opportunity for Veterans and their spouses or
partners to have a biological child. However, there may be
other options to consider when exploring how best to compensate
these Veterans for their loss and to facilitate procreation.
VA recommends the language of the bill be modified to
account for different types of family arrangements, so that
benefits are not limited to only spouses of Veterans described
in proposed section 1788; VA recommends that section 1788 be
revised to refer to a ``spouse or partner'' of a specified
Veteran. In addition, the meaning and scope of the coordination
contemplated under proposed section 1788(b) (which would
authorize VA to ``coordinate fertility counseling and
treatment'' for the spouses and surrogates of other Veterans
not described in section 1788(a)) is unclear, and could
potentially account for spouses and surrogates of all other
Veterans. VA recommends that this be clarified.
Section 5 of the bill would require VA to report annually
to the Committees on Veterans' Affairs of the Senate and House
of Representatives on the fertility counseling and treatment
furnished by VA during the preceding year. The first report
would be required no later than 1 year after enactment. Each
report submitted under section 5 would be required to contain
specified information, including the number of Veterans,
spouses, and surrogates who received fertility counseling and
treatment furnished by VA; the costs of furnishing such
counseling and treatment; and coordination of such counseling
and treatment with similar services of DOD. VA does not object
to such reporting.
Section 6(a) would require VA, no later than 540 days after
enactment, to prescribe regulations to carry out proposed
sections 1788 and 1789, and on fertility treatment to Veterans
using assisted reproductive technology. Section 6(b) would
prohibit VA from providing, until regulations are prescribed,
fertility counseling and treatment under 1788, assistance under
1789, and to a Veteran ``any fertility treatment that uses an
assisted reproductive technology that the Secretary has not
used in the provision of a fertility treatment to a veteran
before the date of the enactment.'' The term ``assisted
reproductive technology'' under section 6 would have the same
meaning given to the term in proposed section 1788 of
section 3.
VA does not support Section 6(a). While 540 days accorded
for the drafting of regulations may seem like a long period of
time, given the complexities of the issues involved, VA
estimates that amount of time could be insufficient.
Section 7 of S. 131 would require the Secretary of VA and
the Secretary of Defense to share best practices and facilitate
referrals, as they consider appropriate, on the furnishing of
fertility counseling and treatment. VA does not object to this
requirement.
Section 8 of the bill would add a new section 7330B to
title 38, U.S.C., entitled ``Facilitation of reproduction and
infertility research.'' This new section would require the
Secretary of VA to ``facilitate research conducted
collaboratively by the Secretary of Defense and the Secretary
of Health and Human Services'' to improve VA's ability to meet
the long-term reproductive health care needs of Veterans with
service-connected genitourinary disabilities or conditions
incurred or aggravated in the line of duty that affect the
Veterans' ability to reproduce, such as spinal cord injury. The
Secretary of VA would be required to ensure that information
produced by research facilitated under section 7330B that may
be useful for other activities of the Veterans Health
Administration (VHA) is disseminated throughout VHA. No later
than 3 years after enactment, VA would be required to report to
Congress on the research activities conducted under section
7330B.
VA supports section 8 of S. 131. Generally, VA supports
implementing research findings that are scientifically sound
and that would benefit Veterans and improve health care
delivery to Veterans. VA's goal is to restore the capabilities
of Veterans with disabilities to the greatest extent possible.
We utilize new research into various conditions to improve the
quality of care we provide. Of note, rather than requiring VA
to conduct research, this section would require VA to
facilitate research that is conducted collaboratively by the
Secretary of Defense and the Secretary of Health and Human
Services. It is not clear how the term ``facilitate'' would be
defined, which could raise privacy and security issues with
respect to identifiable Veteran information. Given the
ambiguity over the meaning of this term, VA is unable to
provide a cost estimate at this time. If facilitation requires
fairly minor involvement (coordination, distribution, etc.), VA
expects the costs of this provision would be nominal; however,
if facilitation is intended to mean direct funding, proposal
reviews, and additional staff, costs would be greater.
Section 9 of S. 131 would require VA to enhance the
capabilities of the VA Women Veterans Call Center (WVCC) in
responding to requests by women Veterans for assistance with
accessing VA health care and benefits, as well as in referring
such Veterans to community resources to obtain assistance with
services not furnished by VA.
VA supports section 9 and has established an inbound
calling system specifically for women Veterans. By building on
capabilities within WVCC, the incoming call center allows women
Veterans to call WVCC to connect them to resources, assist with
specific concerns, and provide information on services and
benefits. Many of the Veterans are calling VA daily requesting
more details on how to enroll, how to find their DD-214, and
what benefits they have earned. WVCC can directly connect women
Veterans to Health Eligibility Center employees for enrollment
information and to discuss the benefits that might be available
to them. The call could also be transferred to the appropriate
medical center to assist eligible Veterans with obtaining a
health care appointment. Once the woman Veteran is connected to
VA health care services, the Women Veterans Program Manager can
also assist her in finding community resources that may not be
provided by VA.
VA is unable to provide views on sections 4, 10, 11, and 12
at this time, but will provide views on those provisions in a
later submission to the Committee.
* * * * * * *
------
Enclosure:
VA Views
S. 131, WOMAN VETERANS AND OTHER HEALTH CARE
IMPROVEMENT ACT OF 2013
Section 2 of S. 131 would amend 38 U.S.C. Sec. 1701(6) to
include fertility counseling and treatment, including assisted
reproductive technology, among those things that are considered
``medical services'' under chapter 17 of title 38, U.S.C. As
discussed in VA's May 9, 2013 testimony, VA supports section 2
of the bill, conditioned on the availability of the additional
resources needed to implement this provision.
VA estimates that section 2 would cost $81.5 million in
fiscal year (FY) 2015; $296 million over 5 years; and $652
million over 10 years. These estimates reflect the costs of new
services that are not included currently in the medical
benefits package and costs associated with maternity services
for additional pregnancies that may result from the use of
assisted reproductive technology. These estimates do not
reflect potential costs associated with additional enrollment
or utilization of currently covered services that may result if
the bill is enacted.
Among other things, section 3 of S. 131 would add a new
section 1788 to title 38, U.S.C., that would require VA to
furnish fertility counseling and treatment, including assisted
reproductive technology, to a spouse or surrogate of a severely
wounded, ill or injured enrolled Veteran who has an infertility
condition that was incurred or aggravated in the line of duty,
if the spouse or surrogate and Veteran apply jointly through a
process prescribed by VA. As discussed in VA's May 9, 2013
testimony, VA supports section 3 of the bill in part,
conditioned on the availability of the additional resources
that would be required to implement this provision.
VA estimates that section 3 would cost $102 million in FY
2015; $319 million over 5 years; and $717 million over 10
years. These estimates include coverage of spouses and partners
of covered Veterans. These estimates do not include costs
associated with coverage of surrogates; as discussed in VA's
May 9, 2013 testimony, VA does not support coverage of
surrogates at this time.
Section 4 of S. 131 would authorize the Secretary to
provide adoption assistance to severely wounded, ill, or
injured Veterans who suffer from infertility conditions
incurred or aggravated in the line of duty. VA understands the
intent of this provision but has numerous concerns that merit
further consideration. VA would need to consider the possible
associated responsibilities that could go along with monetary
adoption support, including adequate oversight of the agencies
or entities that would receive the funds and potential issues
of State law. VA also must carefully consider additional
demands on its resources that would not be directed at core
medical services for Veterans.
VA estimates that section 4 would cost $96.27 million in FY
2015; $521.46 million over 5 years; and $1.16 billion over 10
years.
Section 10 of S. 131 would expand the locations and
duration of the pilot program required by section 203 of Public
Law 111-163. Section 203 required VA to carry out a pilot
program to evaluate the feasibility and advisability of
providing reintegration and readjustment services in group
retreat settings to women Veterans recently separated from
service after a prolonged deployment. Section 10(a) would
increase the number of locations at which VA is required to
carry out the pilot program from three to fourteen. Section
10(b) would extend the duration of the pilot from 2 to 4 years.
Section 10(c) would amend section 203(f) to authorize the
appropriation of $400,000 for each of FY 2013 and FY 2014 to
carry out the pilot program.
VA supports section 10 of S. 131. VA has completed the
final year of the original 2-year pilot program, and the report
required by section 203 was submitted to Congress on May 9,
2013. Initial reports show favorable results, indicating that
the retreats, which focus on building trust and developing peer
support in a therapeutic environment, supply participants with
tools needed for successful reintegration into civilian life.
Additional retreats would generate more data to inform a
comprehensive assessment of the program during the new final
reporting phase under section 10.
Although VA supports section 10, there may not be fourteen
distinct geographic locations that satisfy the retreat
requirements, such as the need for specialized locations for
outdoor team-building exercises. VA would continue to look for
new locations, but recommends that section 10(a) be amended to
require VA to carry out the pilot program in up to fourteen
locations, some of which may be repeat locations from the
original pilot program.
In addition, VA recommends that section 10(b) be amended to
require the pilot program be ``carried out through
September 30, 2015,'' rather than requiring that it be
``carried out during the 4-year period beginning on the date of
the commencement of the pilot program.'' This would ensure that
VA has a sufficient period of time to carry out additional
retreats for eligible women Veterans and generate data for
analysis. For the same reason, we recommend section 10(c) be
amended to authorize the appropriation of $400,000 ``for each
of fiscal years 2013 through 2015'' to carry out the pilot
program.
VA estimates section 10 would cost $337,320 in FY 2014 and,
if the pilot extends through FY 2015, $350,520 in FY 2015, for
a total cost of $687,840.
Section 11(a) of S. 131 would add a new section 1709B to
title 38, U.S.C. that would make permanent VA's authority to
provide assistance to qualified Veterans to obtain child care
so that such Veterans can receive certain health care services.
VA would be required to carry out the program in no fewer than
three Veterans Integrated Service Networks. This section would
also identify certain forms of assistance that may be provided.
VA's pilot program providing such services under section 205 of
Public Law 111-163 would expire upon enactment of section
11(a).
VA does not support a permanent mandatory authority to
provide child care assistance. VA has four operational pilot
locations where child care assistance is provided pursuant to
section 205 of Public Law 111-163. The first pilot began
operation in October 2011. The remaining pilots were set up in
a staggered fashion with the most recent pilot not beginning
until 2013. Under current law, all pilots are scheduled to end
on October 2, 2013, therefore, not affording three pilots the
benefit of 2 full years of operation.
Without 2 full years of operational data from each pilot,
VA is not able to adequately assess long-term utilization needs
and cost implications of the program. In light of this longer
term analysis that includes an evaluation of resources, VA
believes permissive authority to allow expansion of the program
would be preferable to a permanent mandatory authority to
provide child care assistance. Permissive authority would allow
facilities at the local level to make a determination based on
need and utilize resources, space and security as necessary.
VA is unable to provide an accurate cost estimate for a
permanent mandatory child care program, in part, because of the
lack of data on the existing pilots that have run for less than
2 years, but also because such an estimate would be dependent
on location of the sites, the ability to contract in the area
of the designated sites, and the utilization of services.
Section 11(b) of S. 131 would add a new section 1709C to
title 38, U.S.C. that would require VA to carry out a program
to provide assistance to qualified Veterans to obtain child
care so that such Veterans can receive readjustment counseling
and related mental health services. The program would be
carried out in at least three Readjustment Counseling Service
Regions selected by VA. This section would identify certain
forms of child care assistance that may be provided, and it
would define ``Vet Center'' as ``a center for readjustment
counseling and related mental health services for veterans
under section 1712A of [title 38, U.S.C.].''
VA supports section 11(b) in principle. Some Veterans who
use Vet Center services, especially those who have served in
Iraq or Afghanistan, have voiced concern that a lack of child
care has impacted their ability to use Vet Center services
consistently. Although Vet Center staff are always searching
for new initiatives to increase Veteran access to services, VA
has concerns about implementing child care assistance under
section 11(b) without the opportunity to pilot this type of
benefit. A pilot program is needed because VA currently is
unable to predict utilization of this type of assistance.
Comparisons to medical center pilots are not useful because Vet
Centers provide services during non-traditional hours,
including after normal business hours and on weekends when
requested by the Veteran. This inability to predict utilization
affects VA's ability to budget the program appropriately. VA
recommends that section 11(b) be modified to authorize a pilot
program to determine the feasibility, advisability, and costs
of providing child care assistance to Veterans who utilize Vet
Center services.
VA is not able to provide an accurate cost estimate for
section 11(b) because VA lacks child-care experience for the
special Vet Center context as described above and comparable
models.
Section 12 of S. 131 would add a new section 323 to title
38, U.S.C., entitled ``Contractor user fees.'' Under proposed
section 323(a), VA would be required to impose a fee on each
person with whom the Secretary engages in a contract for a good
or service as a condition of the contract. The fee amount would
be the lesser of: (1) seven percent of the total value of the
contract, and (2) the total value of the contract multiplied by
an applicable percentage calculated for the fiscal year. Before
each fiscal year, VA would be required to establish an annual
estimate of the total value of contracts for the next fiscal
year and an annual estimate of the total cost of furnishing
fertility counseling and treatment--including the use of
assisted reproductive technology--and payments under proposed
section 1789 (under section 4 of S. 131) for the next fiscal
year, both of which would be used in estimating the applicable
percentage for the fiscal year (the percentage by which the
former exceeds the latter). The Secretary would have discretion
to waive the fee for a person as the Secretary considers
appropriate if the person is an individual or ``small business
concern'' (as defined in section 3 of the Small Business Act).
Fees could not be collected under proposed section 323(a)
unless the expenditure of the fee is provided for in advance in
an appropriations Act.
Proposed section 323(e) would establish a fund in the
Treasury to be known as the ``Department of Veterans Affairs
Fertility Counseling and Treatment Fund,'' and all amounts
received under proposed section 323(a) would be deposited in
the fund. Subject to the provisions of appropriations Acts,
amounts in the fund would be made available, without fiscal
year limitation, to VA to furnish fertility counseling and
treatment--including the use of assisted reproductive
technology--to eligible individuals and to make payments under
proposed section 1789 (under section 4 of S. 131). Amounts
received by VA under proposed section 323(a) would be treated
for the purposes of sections 251 and 252 of the Balanced Budget
and Emergency Deficit Control Act of 1985 as offsets to
discretionary appropriations (rather than as offsets to direct
spending), to the extent that such amounts are made available
for expenditure in appropriations Acts for the purposes
specified.
VA does not support section 12, which VA estimates could
result in up to 7 percent less money available for contract
actions. That is because contractors could be expected to pass
this cost back to VA in the form of higher contract prices.
Applying the proposed fee to ``a contract for a good or
service'' without limitation would subject VA Administrations'
and Offices' (e.g., Veterans Benefits Administration, National
Cemetery Administration, Office of Human Resources and
Administration, and Office of General Counsel) budget dollars
for contracts to funding health care services. This would
impact these entities' budgets, particularly in smaller
offices, for a purpose that is wholly unrelated to their
primary functions. In this difficult time of budget
limitations, this is impractical and could negatively impact
overall VA performance. In addition, determining a percentage
and implementing it for the beginning of each fiscal year would
be difficult administratively, as would the process of
collecting and accounting for these funds. (As a technical
matter, the word ``person'' should be replaced with
``contractor'' throughout this provision.)
In many industries and for many contractors, the existing
profit margins would not tolerate a 7 percent cut.
* * * * * * *
MINORITY VIEWS OF RANKING MEMBER
HON. RICHARD BURR
On July 24, 2013, the Senate Committee on Veterans' Affairs
(hereinafter, ``the Committee'') voted, by voice vote, to
approve en bloc five legislative items and three separate
legislative items on the Committee's agenda. One item the
Committee voted on individually was S. 131, as amended. In
principal, I support several provisions of this legislation,
which would improve the care of women veterans and reduce
barriers to services. However, I was unable to support this
legislation in Committee. At the time of the Committee meeting,
I expressed concerns regarding: How would the Committee pay for
any increased costs associated with the legislation? Will all
of the provisions address real problems in a way that will
actually help to improve the lives of military personnel,
veterans, and their families? Last, the Administration had not
yet provided complete views on this legislation.
Unfortunately, the Committee members were unable to
adequately address the concerns of the Administration regarding
this legislation before, during, or after the July 2013
meeting. My hope is that, on all matters before the Committee,
the Committee will proceed in a more deliberate, informed
manner.
Changes in Existing Law
In compliance with paragraph 12 of Rule XXVI of the
Standing Rules of the Senate, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman).
Title 38. Veterans' Benefits
* * * * * * *
Part II. General Benefits
* * * * * * *
Chapter 17. Hospital, Nursing Home, Domiciliary,
and Medical Care
* * * * * * *
SEC.
SUBCHAPTER I. GENERAL
1701. DEFINITIONS.
* * * * * * *
1709B. ASSISTANCE FOR CHILD CARE FOR CERTAIN VETERANS RECEIVING HEALTH
CARE.
1709C. ASSISTANCE FOR CHILD CARE FOR INDIVIDUALS RECEIVING READJUSTMENT
COUNSELING AND RELATED MENTAL HEALTH SERVICES.
SUBCHAPTER II. HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL
TREATMENT
* * * * * * *
1720H. COUNSELING IN RETREAT SETTINGS FOR WOMEN VETERANS NEWLY
SEPARATED FROM SERVICE IN THE ARMED FORCES.
* * * * * * *
SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS
* * * * * * *
1788. REPRODUCTIVE TREATMENT AND CARE FOR SPOUSES AND SURROGATES OF
VETERANS.
1789. ADOPTION ASSISTANCE.
* * * * * * *
SEC. 1701. DEFINITIONS
* * * * * * *
(6) * * *
* * * * * * *
(H) Fertility counseling and treatment,
including treatment using assisted reproductive
technology.
* * * * * * *
SEC. 1709B. ASSISTANCE FOR CHILD CARE FOR CERTAIN VETERANS RECEIVING
HEALTH CARE
(a) Program Required.--The Secretary shall carry out a
program to provide, subject to subsection (b), assistance to
qualified veterans described in subsection (c) to obtain child
care so that such veterans can receive health care services
described in subsection (c).
(b) Limitation on Period of Payments.--Assistance may only
be provided to a qualified veteran under this section for
receipt of child care during the period that the qualified
veteran--
(1) receives health care services described in
subsection (c) at a facility of the Department; and
(2) requires travel to and from such facility for the
receipt of such health care services.
(c) Qualified Veterans.--For purposes of this section, a
qualified veteran is a veteran who is--
(1) the primary caretaker of a child or children; and
(2)(A) receiving from the Department--
(i) regular mental health care services;
(ii) intensive mental health care services;
or
(iii) such other intensive health care
services that the Secretary determines that
provision of assistance to the veteran to
obtain child care would improve access to such
health care services by the veteran; or
(B) in need of regular or intensive mental health
care services from the Department, and but for lack of
child care services, would receive such health care
services from the Department.
(d) Locations.--The Secretary shall carry out the program
in no fewer than three Veterans Integrated Service Networks
selected by the Secretary for purposes of the program.
(e) Forms of Child Care Assistance.--(1) Child care
assistance under this section may include the following:
(A) Stipends for the payment of child care offered by
licensed child care centers (either directly or through
a voucher program) which shall be, to the extent
practicable, modeled after the Department of Veterans
Affairs Child Care Subsidy Program established pursuant
to section 630 of the Treasury and General Government
Appropriations Act, 2002 (Public Law 107-67; 115 Stat.
552).
(B) Direct provision of child care at an on-site
facility of the Department.
(C) Payments to private child care agencies.
(D) Collaboration with facilities or programs of
other Federal departments or agencies.
(E) Such other forms of assistance as the Secretary
considers appropriate.
(2) In the case that child care assistance under this
section is provided as a stipend under paragraph (1)(A), such
stipend shall cover the full cost of such child care.
SEC. 1709C. ASSISTANCE FOR CHILD CARE FOR INDIVIDUALS RECEIVING
READJUSTMENT COUNSELING AND RELATED MENTAL HEALTH
SERVICES
(a) Program Required.--The Secretary shall carry out a
program to provide, subject to subsection (b), assistance to
qualified individuals described in subsection (c) to obtain
child care so that such individuals can receive readjustment
counseling and related mental health services.
(b) Limitation on Period of Payments.--Assistance may only
be provided to a qualified individual under this section for
receipt of child care during the period that the qualified
individual receives readjustment counseling and related health
care services at a Vet Center.
(c) Qualified Individuals.--For purposes of this section, a
qualified individual is an individual who is--
(1) the primary caretaker of a child or children; and
(2)(A) receiving from the Department regular
readjustment counseling and related mental health
services; or
(B) in need of readjustment counseling and related
mental health services from the Department, and but for
lack of child care services, would receive such
counseling and services from the Department.
(d) Locations.--The Secretary shall carry out the program
under this section in no fewer than three Readjustment
Counseling Service Regions selected by the Secretary for
purposes of the program.
(e) Forms of Child Care Assistance.--(1) Child care
assistance under this section may include the following:
(A) Stipends for the payment of child care offered by
licensed child care centers (either directly or through
a voucher program) which shall be, to the extent
practicable, modeled after the Department of Veterans
Affairs Child Care Subsidy Program established pursuant
to section 630 of the Treasury and General Government
Appropriations Act, 2002 (Public Law 107-67; 115 Stat.
552).
(B) Payments to private child care agencies.
(C) Collaboration with facilities or programs of
other Federal departments or agencies.
(D) Such other forms of assistance as the Secretary
considers appropriate.
(2) In the case that child care assistance under this
subsection is provided as a stipend under paragraph (1)(A),
such stipend shall cover the full cost of such child care.
(f) Vet Center Defined.--In this section, the term ``Vet
Center'' means a center for readjustment counseling and related
mental health services for individuals under section 1712A of
this title.
* * * * * * *
Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical
Treatment
* * * * * * *
SEC. 1720H. COUNSELING IN RETREAT SETTINGS FOR WOMEN VETERANS NEWLY
SEPARATED FROM SERVICE IN THE ARMED FORCES
(a) In General.--The Secretary shall provide, through the
Readjustment Counseling Service of the Veterans Health
Administration, reintegration and readjustment services
described in subsection (c) in group retreat settings to women
veterans who are recently separated from service in the Armed
Forces after a prolonged deployment.
(b) Election of Veteran.--The receipt of services under
this section by a woman veteran shall be at the election of the
veteran.
(c) Covered Services.--The services provided to a woman
veteran under this section shall include the following:
(1) Information on reintegration into the veteran's
family, employment, and community.
(2) Financial counseling.
(3) Occupational counseling.
(4) Information and counseling on stress reduction.
(5) Information and counseling on conflict
resolution.
(6) Such other information and counseling as the
Secretary considers appropriate to assist the veteran
in reintegration into the veteran's family, employment,
and community.
* * * * * * *
Subchapter VIII. Health Care of Persons Other Than Veterans
* * * * * * *
SEC. 1787. HEALTH CARE OF FAMILY MEMBERS OF VETERANS STATIONED AT CAMP
LEJEUNE, NORTH CAROLINA
* * * * * * *
SEC. 1788. REPRODUCTIVE TREATMENT AND CARE FOR SPOUSES AND SURROGATES
OF VETERANS
(a) In General.--The Secretary shall furnish fertility
counseling and treatment, including through the use of assisted
reproductive technology, to a spouse or surrogate of a severely
wounded, ill, or injured veteran who has an infertility
condition incurred or aggravated in line of duty in the active
military, naval, or air service and who is enrolled in the
system of annual patient enrollment established under section
1705(a) of this title if the spouse or surrogate and the
veteran apply jointly for such counseling and treatment through
a process prescribed by the Secretary.
(b) Coordination of Care for Other Spouses and
Surrogates.--In the case of a spouse or surrogate of a veteran
not described in subsection (a) who is seeking fertility
counseling and treatment, the Secretary may coordinate
fertility counseling and treatment for such spouse or
surrogate.
(c) Construction.--Nothing in this section shall be
construed to require the Secretary--
(1) to find or certify a surrogate for a veteran or
to connect a surrogate with a veteran; or
(2) to furnish maternity care to a spouse or
surrogate of a veteran.
(d) Assisted Reproductive Technology Defined.--In this
section, the term ``assisted reproductive technology'' includes
in vitro fertilization and other fertility treatments in which
both eggs and sperm are handled when clinically appropriate.
SEC. 1789. ADOPTION ASSISTANCE
(a) In General.--The Secretary may pay an amount, not to
exceed the limitation amount, to assist a covered veteran in
the adoption of one or more children.
(b) Covered Veteran.--For purposes of this section, a
covered veteran is any severely wounded, ill, or injured
veteran who--
(1) has an infertility condition incurred or
aggravated in line of duty in the active military,
naval, or air service; and
(2) is enrolled in the system of annual patient
enrollment established under section 1705(a) of this
title.
(c) Limitation Amount.--For purposes of this section, the
limitation amount is the amount equal to the lesser of--
(1) the cost the Department would incur if the
Secretary were to provide a covered veteran with one
cycle of fertility treatment through the use of
assisted reproductive technology under section 1788 of
this title, as determined by the Secretary; or
(2) the cost the Department would incur by paying the
expenses of three adoptions by covered veterans, as
determined by the Secretary.
(d) Assisted Reproductive Technology Defined.--In this
section, the term ``assisted reproductive technology'' has the
meaning given that term in section 1788 of this title.
* * * * * * *
Part V. Boards, Administrations, and Services
* * * * * * *
Chapter 73. Veterans Health Administration-Organization and Functions
* * * * * * *
SEC.
* * * * * * *
SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION
* * * * * * *
7330B. FACILITATION OF REPRODUCTION AND INFERTILITY RESEARCH.
* * * * * * *
Subchapter II. General Authority and Administration
* * * * * * *
SEC. 7330B. FACILITATION OF REPRODUCTION AND INFERTILITY RESEARCH
(a) Facilitation of Research Required.--The Secretary shall
facilitate research conducted collaboratively by the Secretary
of Defense and the Secretary of Health and Human Services to
improve the ability of the Department of Veterans Affairs to
meet the long-term reproductive health care needs of veterans
who have a genitourinary service-connected disability or a
condition that was incurred or aggravated in line of duty in
the active military, naval, or air service, such as a spinal
cord injury, that affects the veterans' ability to reproduce.
(b) Dissemination of Information.--The Secretary shall
ensure that information produced by the research facilitated
under this section that may be useful for other activities of
the Veterans Health Administration is disseminated throughout
the Veterans Health Administration.
* * * * * * *
Caregivers and Veterans Omnibus Health Services Act of 2010
(Public Law 111-163; 38 U.S.C. 1712A note)
* * * * * * *
[SEC. 203. PILOT PROGRAM ON COUNSELING IN RETREAT SETTINGS FOR WOMEN
VETERANS NEWLY SEPARATED FROM SERVICE IN THE ARMED
FORCES
[(a) Pilot Program Required.--
[(1) In general.--Commencing not later than 180 days
after the date of the enactment of this Act, the
Secretary of Veterans Affairs shall carry out, through
the Readjustment Counseling Service of the Veterans
Health Administration, a pilot program to evaluate the
feasibility and advisability of providing reintegration
and readjustment services described in subsection (b)
in group retreat settings to women veterans who are
recently separated from service in the Armed Forces
after a prolonged deployment.
[(2) Participation at election of veteran.--The
participation of a veteran in the pilot program under
this section shall be at the election of the veteran.
[(b) Covered Services.--The services provided to a woman
veteran under the pilot program shall include the following:
[(1) Information on reintegration into the veteran's
family, employment, and community.
[(2) Financial counseling.
[(3) Occupational counseling.
[(4) Information and counseling on stress reduction.
[(5) Information and counseling on conflict
resolution.
[(6) Such other information and counseling as the
Secretary considers appropriate to assist a woman
veteran under the pilot program in reintegration into
the veteran's family, employment, and community.
[(c) Locations.--The Secretary shall carry out the pilot
program at not fewer than three locations selected by the
Secretary for purposes of the pilot program.
[(d) Duration.--The pilot program shall be carried out
during the 2-year period beginning on the date of the
commencement of the pilot program.
[(e) Report.--Not later than 180 days after the completion
of the pilot program, the Secretary shall submit to Congress a
report on the pilot program. The report shall contain the
findings and conclusions of the Secretary as a result of the
pilot program, and shall include such recommendations for the
continuation or expansion of the pilot program as the Secretary
considers appropriate.
[(f) Authorization of Appropriations.--There is authorized
to be appropriated to the Secretary of Veterans Affairs for
each of fiscal years 2010 and 2011, $2,000,000 to carry out the
pilot program.]
* * * * * * *
(Public Law 111-163; 38 U.S.C. 1710 note)
* * * * * * *
SEC. 205. PILOT PROGRAM ON ASSISTANCE FOR CHILD CARE FOR CERTAIN
VETERANS RECEIVING HEALTH CARE
* * * * * * *
(e) Duration.--The pilot program shall be carried out
during the 2-year period beginning on the date of the
commencement of the pilot program but not after the date of the
enactment of the Women Veterans and Other Health Care
Improvements Act of 2013.
* * * * * * *