1. 1 FY17 MilConVA (S.Rpt.114-237): New Congressional Guidance on Gulf War Health & Benefits May 2016 Baldwin Gulf War Provisos -- Adopted April 18, 2016

2. 2  Congress has provided VA with substantial added guidance on Gulf War health and benefits issues/  The Baldwin Gulf War provisos are part of the U.S. Senate’s appropriations bill for Fiscal Year 2017 (FY17) for the U.S Department of Veterans Affairs (VA) (FY17 MilConVA). Report & Bill Name/Number: S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017,” (April 18, 2016) accompanying S. 2806 (114 th Congress), the “Military Construction, Veterans Affairs, and Related Agencies Act, 2017.” S. Rpt. 114-237S. 2806S. Rpt. 114-237S. 2806 New Gulf War Guidance from Congress

3. 3  Reports accompany bills and give additional directives  “Report language explains the provisions of a measure to the chamber or chambers that will subsequently consider it.” 1  “Report language may also communicate legislative intent to the agencies that will carry out the measure once it becomes law.” 1  “Not law,” but “agencies usually seek to comply with any directives contained therein.” 1 What is “Report Language” 1 Congressional Research Service, “Appropriations Report Language: Overview of Development, Components, and Issues for Congress,” (Report R44124), July 28, 2015 (p.1) https://www.fas.org/sgp/crs/misc/R44124.pdf https://www.fas.org/sgp/crs/misc/R44124.pdf

4. 4  As noted in a relevant Congressional Research Service Report, “the criticisms and suggestions carried in the reports accompanying each bill are expected to influence the subsequent behavior of the agency. Committee reports are not the law, but it is expected that they be regarded almost as seriously.” 2 Effect of “Report Language” 2 Richard Fenno, The Power of the Purse: Appropriations Politics in Congress (Boston: Little, Brown and Company, 1966), p. 18. Quoted in CRS R44124, p. 1)

5. 5   March 2016: Provisos requested by U.S. Senator Tammy Baldwin (D-WI), a member of the Senate Appropriations Committee and the Subcommittee on Military Construction and Veterans Affairs (MilConVA)   March-April 2016: Provisos reviewed, edited by Senate Appropriations Committee/Subcommittee professional staff, incorporated into final Report   April 2016: Committee Report, with the Baldwin Gulf War provisos included, approved by the Senate Defense Appropriations Subcommittee   April 18, 2016: FY17 MilConVA appropriations bill voted out full Senate Appropriations Committee on with accompanying Report, S.Rpt. 114-237. 3 FY17 MilConVA (S.Rpt.114-237): Timeline 3 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp. 34-35)S. Rpt. 114-237S. 2806

6. 6   The Senate Appropriations Committee has concluded its work on the bill and its accompanying report is final.   The appropriations bills are required to be completed by September 30 (2016); they are frequently completed later than that.   The provisos contained in the Report are highly unlikely to be modified while FY17 MilConVA appropriations proceed through the legislative process to enactment. FY17 MilConVA (S.Rpt.114-237): Status 3 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp. 34-35)S. Rpt. 114-237S. 2806

7. 7 Gulf War-related provisos included at the request of U.S. Senator Tammy Baldwin FY17 MilConVA (S.Rpt. 114-237): Baldwin Gulf War Provisos (2016)

8. 8 Gulf War Veterans Claims for Service-Connected Disability Compensation, currently denied at a greater than 80% rate: 1. 1. “The Committee is concerned by the Department’s [of Veterans Affairs] rates of denial of Gulf War veterans’ claims for undiagnosed illnesses and chronic multi- symptom illnesses.” 3 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Disability Claims 3 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp. 34-35)S. Rpt. 114-237S. 2806

9. 9 2. 2. Helping Standardize Gulf War veterans’ disabilty claims, currently denied at a greater than 80% rate: “The Department [of Veterans Affairs] is directed to provide the Committees on Appropriations of both Houses of Congress with a finalized Disability Benefits Questionnaire (DBQ) within 180 days of the enactment of this act for each of these types of claims for which a DBQ does not currently exist.” 3 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Disability Claims 3 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp. 34-35)S. Rpt. 114-237S. 2806

10. 10 3. 3. Making claims filing period permanent (currently set to expire December 31, 2016 unless VA takes rulemaking action): “The Committee urges the Department [of Veterans Affairs] to make permanent the period for filing Gulf War presumptive claims under 38 CFR 3.317.” 3 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Disability Claims 3 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp. 34-35)S. Rpt. 114-237S. 2806

11. 11 4. 4. Calling on VA to remedy its claims adjudication process: “While the Committee commends VA on its efforts to revise the Compensation and Pension manual for ‘Service Connection for Certain Disabilities Associated with Gulf War Service,’ concern remains that VA claims adjudicators are not consistently following these changes.” 3 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Disability Claims 3 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp. 34-35)S. Rpt. 114-237S. 2806

12. 12 5. 5. Epidemiological studies with disease-specific health and mortality outcomes: “The Committee recommends the Department [of Veterans Affairs] continue to conduct and publish epidemiological studies regarding the prevalence of Gulf War illness and disease- specific morbidity and mortality in Gulf War veterans and the development of effective treatments, preventions, and cures.” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Health Research 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

13. 13 6. 6. New mandated on Gulf War study statutorily mandated in 2008 but never completed by VA as directed: “The Department [of Veterans Affairs] is directed, within 60 days of the enactment of this act, to contract with the National Academy of Sciences (NAS) for a study with the NAS collecting new data to determine the prevalence of ‘diagnosed neurological diseases, including multiple sclerosis, Parkinson’s disease, and brain cancers,’ in Gulf War veterans, as directed by P.L. 110-389, Section 804 and advised in the IOM’s 2015 report on the study’s design.” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Health Research 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

14. 14 7. 7. Gulf War Illness Nomenclature: “The Committee is concerned by VA’s ever-evolving terminology for the signature adverse health outcome of the Persian Gulf War as recognized by the Institute of Medicine (IOM) – Gulf War illness – and encourages the Department [of Veterans Affairs] to utilize the term, ‘Gulf War illness,’ as IOM has recommended.” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Illness Nomenclature 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

15. 15 8. 8. Gulf War Illness Clinical Guideline Revision: “The Committee urges the Secretary to consider revising and updating the Clinical Practice Guideline for Chronic Multisymptom Illness (CMI) consistent with the July 2011 Veterans Health Initiative, “Caring for Gulf War Veterans,” that it, “cannot be reliably ascribed to any known psychiatric disorder,” and to focus on recent Gulf War illness treatment research findings and ongoing Gulf War illness treatment research direction.” 4 9. 9. Training of clinicians on GWI: “Furthermore, the Committee encourages the Department [of Veterans Affairs] to strengthen the training of primary, specialty, and mental healthcare providers on the Gulf War illness case definitions recommended by the IOM. ” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War Clinician Guide Revision 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

16. 16 10. 10. Role of the Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC): “The role of the Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC) – was intended to provide a meaningful consultative role in helping shape the Persian Gulf War research agenda, strengthen the process by which the government sets its Persian Gulf War research agenda, and lend credibility to future research activities. 11. 11. Concerns regarding VA’s fulfillment of that role: “However, concern has been raised that this role has been degraded and compromised.” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War RAC 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

17. 17 12. 12. RAC Charter Concerns: “The RAC charter no longer requires it to assess the effectiveness of Federal Gulf War research, no longer contains a requirement for its own staff, and its purview is presently limited solely to research conducted by the Department [of Veterans Affairs].” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War RAC Charter 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

18. 18 13. 13. RAC Membership Concerns: “Determinations by the RAC and the IOM that Gulf War illness is physiological and not psychological or psychiatric in nature should be the basis in determining the type of medical practitioners and scientific researchers needed to create a well-qualified membership.” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War RAC Members 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

19. 19 14. 14. RAC Activity Concerns: “The Committee notes the RAC has provided no new recommendations since September 2014 and encourages the RAC renew its efforts in studying Gulf War Illness.” 4 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War RAC Activity 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

20. 20 15. 15. VA Health/Benefits Utilization Data Reporting Concerns: “Finally, the Committee urges the Department [of Veterans Affairs] to restore regular reporting throughout the year of healthcare and benefits utilization by Gulf War and post-9/11 veterans, to publish these reports on the Department’s Web site, and to consider for adoption the ‘Recommendations for New VA Gulf War-Era Data Report,’ adopted by the RAC on February 1, 2012.” 4 Baldwin Gulf War Provisos (FY17 MilConVA): VA Gulf War Data Reporting 4 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.58)S. Rpt. 114-237S. 2806

21. 21 16. 16. Sleep Disorders: “The Committee recommends the Department [of Veterans Affairs] assign a program manager for sleep disorders, including sleep apnea, that affect at least 200,000 veterans of the Persian Gulf War and Operations Iraqi Freedom and Enduring Freedom.” 5 Baldwin Gulf War Provisos (FY17 MilConVA): Gulf War/OIF/OEF Sleep Disorders 5 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.50)S. Rpt. 114-237S. 2806

22. 22 FY17 MilConVA (S.Rpt. 114- 237): Additional Provisos of Interest

23. 23   “Functional Gastrointestinal Disorders and Gulf War Illness.— The Committee continues to monitor the Department’s [of Veterans Affairs] plan to address Gulf War Illness and encourages the Department [of Veterans Affairs] to include research on early intervention for functional gastrointestinal disorders related to Gulf War Illness in veterans and military personnel.” 6 FY17 MilConVA (S.Rpt. 114-237): Functional Gastrointestinal Disorders 6 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.45)S. Rpt. 114-237S. 2806

24. 24   “Toxic Exposures.—The Committee wants to ensure VA is actively researching the residual impact to veterans of Agent Orange and other toxic exposures such as oil well fires and burn pits. The Department [of Veterans Affairs] is directed to submit a report to the Committees on Appropriations of both Houses of Congress no later than 180 days after enactment of this act detailing ongoing activities and future plans for research into residual exposure to Agent Orange and other toxins.” 7 FY17 MilConVA (S.Rpt. 114-237): Toxic Exposures 7 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.57)S. Rpt. 114-237S. 2806

25. 25   “National Academy of Medicine Study on Toxic Exposures.— Veterans have expressed growing concern that toxic exposure during their military service is related to adverse health conditions in their children and grandchildren. According to the National Academy of Medicine [NAM], scientific data and research is extremely limited to determine what exposures may cause harm to future generations. The report, ‘Veterans and Agent Orange: Update 2014’, recommended VA pursue further laboratory research to identify toxins and dioxins that may cause epigenetic modifications and invest in epidemiologic protocols that address the challenges of connecting adverse conditions in the children of members of the military with toxic exposure. [ct’d…] FY17 MilConVA (S.Rpt. 114-237): NAM Toxic Exposures Study 8 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp.57-58)S. Rpt. 114-237S. 2806

26. 26 […ct’d.]“The Committee directs the Department [of Veterans Affairs] to contract with NAM on an assessment that will include a review of the scientific literature regarding toxicological and epidemiological research on descendants of individuals with toxic exposure; an assessment of areas requiring further scientific study relating to the descendants of veterans with toxic exposure; an assessment of the scope and methodology required to conduct adequate scientific research relating to the descendants of individuals with toxic exposure; will establish categories and provide definitions for categories that assess the evidence that a particular health condition is related to toxic exposure; an analysis of the feasibility, value and relevance, and need for access to additional information held by a Federal agency of conducting further scientific research; and identification of a research entity or entities with expertise and ability to conduct the relevant scientific research.” 8 FY17 MilConVA (S.Rpt. 114-237): NAM Toxic Exposures Study, ct’d. 8 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp.57-58)S. Rpt. 114-237S. 2806

27. 27   “Research Reports.—The Committee is aware VA publicly reports all of its completed and ongoing VA funded research projects through the NIH Research Portfolio Online Reporting Tools [RePORT]. However, funding information for each project is not provided on the site by VA. The Committee directs VA to report the total cost of each ongoing project and going forward, provide funding information for any new projects, in addition to the information which is already publicly reported. Additionally, the Committee directs VA to prominently place a description and a link to the NIH RePORT Web site on the VA Office Research and Development main Web page so that any veteran may access this information easily.” 9 FY17 MilConVA (S.Rpt. 114-237): VA Research Reports 9 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp.58-59)S. Rpt. 114-237S. 2806

28. 28   “Burn Pits.—The Committee recommends VA continue conducting medical trials, using available treatments for pulmonary, cardiovascular, and other diseases and conditions related to the exposure to open air burn pits.   “The Department [of Veterans Affairs] is directed to provide an update to the Committees on Appropriations of both Houses of Congress no later than 180 days after enactment of this act on the status and progress of such medical trials.” 10 FY17 MilConVA (S.Rpt. 114-237): Burn Pits 10 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.59)S. Rpt. 114-237S. 2806

29. 29   “Furthermore, where appropriate, VA is encouraged to work with private and public institutions which have already begun to research the chronic impacts of exposure to burn pits in order to develop treatments for veterans exposed to burn pits.   “The Department [of Veterans Affairs] is directed to submit a report to the Committees on Appropriations of both Houses of Congress no later than 90 days after enactment of this act regarding the feasibility of entering into cooperative agreements with institutions engaged in the aforementioned research and whether additional authorities and funding are needed to pursue such research.” 10 FY17 MilConVA (S.Rpt. 114-237): Burn Pits 10 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (p.59)S. Rpt. 114-237S. 2806

30. 30   “Promotion of Federal Burn Pits Registry.—The Committee directs the Department to work with State Governors and State veterans affairs agencies to promote and educate State officials about the Federal Airborne Hazards and Open Burn Pit Registry.   “The Committee is concerned that efforts by the States have led to confusion among veterans about which registry is the official registry of the U.S. Department of Veterans Affairs.   “The Committee urges the Department[of Veterans Affairs] to increase outreach to veterans and State governments to communicate the existence and purpose of the Airborne Hazards and Open Burn Pit Registry.” 11 FY17 MilConVA (S.Rpt. 114-237): Airborne Hazards & Open Burn Pit Registry 11 S. Rpt. 114-237, “Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, 2017” (April 18, 2016), accompanying S. 2806 (114 th Congress), the Military Construction, Veterans Affairs, and Related Agencies Act, 2017. (pp. 37-38)S. Rpt. 114-237S. 2806

31. 31 Conclusion