Order Code RL34370
Veterans Affairs: Health Care and Benefits for
Veterans Exposed to Agent Orange
February 11, 2008
Sidath Viranga Panangala
Analyst in Veterans Policy
Domestic Social Policy Division

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Veterans Affairs: Health Care and Benefits for Veterans
Exposed to Agent Orange
Summary
Since the 1970s, Vietnam-era veterans have attributed certain medical illnesses,
disabilities, and birth defects to exposure to Agent Orange and other herbicides
sprayed by the U.S. Air Force to destroy enemy crops and remove forest cover.
During the last 30 years, Agent Orange legislation has established and updated the
health and disability benefits of Vietnam veterans exposed to herbicides.
The Veterans’ Health Care, Training and Small Business Loan Act (P.L. 97-72)
elevated Vietnam veterans’ priority status for health care at Department of Veterans
Affairs facilities by recognizing a veteran’s own report of exposure as sufficient
proof to receive medical care unless there was evidence to the contrary. The
Veterans’ Health Care Eligibility Reform Act of 1996 (P.L. 104-262) completely
restructured VA medical care eligibility requirements for all veterans. Under P.L.
104-262, a veteran does not have to demonstrate a link between a certain health
condition and exposure to Agent Orange; instead, medical care is provided unless the
VA has determined that the condition did not result from exposure to Agent Orange
or the condition has been identified by the Institute of Medicine (IOM) as having
“limited/suggestive” evidence of no association between the occurrence of the
disease and exposure to a herbicide.
The Veterans’ Dioxin and Radiation Exposure Compensation Standards Act of
1984 (P.L. 98-542) required the VA to develop regulations for disability
compensation to Vietnam veterans exposed to Agent Orange. In 1991, the Agent
Orange Act (P.L. 102-4) established for the first time a presumption of service
connection for diseases associated with herbicide exposure. P.L. 102-4 authorized
the VA to contract with the IOM to conduct a scientific review of the evidence
linking certain medical conditions to herbicide exposure. Under this law, the VA is
required to review the reports of the IOM and issue regulations, establishing a
presumption of service connection for any disease for which there is scientific
evidence of a positive association with herbicide exposure.
This report provides a summary of the health care and disability benefits for
exposed veterans, a summary of the epidemiologic research activities related to
Agent Orange, and information on the pending Haas v. Nicholson case.
The report supersedes RS22481, Veterans and Agent Orange: Eligibility for
Health Care and Benefits, by Jacqueline Rae Roche and Sidath Viranga Panangala.
It will be updated as events warrant.

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Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Disability Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Agent Orange Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Non-Vietnam Veterans Exposed to Agent Orange . . . . . . . . . . . . . . . . . . . . 4
Haas v. Nicholson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Current Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Epidemiologic Research on Vietnam Veterans . . . . . . . . . . . . . . . . . . . . . . . 6
Centers for Disease Control and Prevention . . . . . . . . . . . . . . . . . . . . . 6
Air Force Health Study (AFHS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

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Veterans Affairs: Health Care and Benefits
for Veterans Exposed to Agent Orange
Background
Between 1962 and 1971, the U.S. Air Force sprayed approximately 107 million
pounds of herbicides in South Vietnam for the purpose of defoliation and crop
destruction. The herbicides sprayed during the Vietnam era contained mixtures of
2,4-dichlorophenoxyacetic acid (2,4-D), 2,4,5-trichlorophenoxyacetic acid (2,4,5-T),
picloram, and cacodylic acid. The most extensively used defoliant compound, a
50:50 combination of 2,4-D and 2,4,5-T, came to be known as “Agent Orange”
because of the orange-colored band placed on each chemical storage container. One
of the chemicals used in Agent Orange, 2,4,5-T, contained small amounts of dioxin.
Other herbicides employed in Vietnam such as “Agent Purple”and “Agent Green”
also were contaminated with dioxin. Collectively, these compounds were referred
to as the “rainbow defoliants.” The late 1960s saw a decline in the use of these
herbicides when dioxin, already well known to be highly toxic in animals, was
implicated in birth defects seen in mice. By 1969, spraying was restricted to remote
areas, and by 1971, the Air Force ceased all spraying of Agent Orange.
Since the 1970s, Vietnam-era veterans have voiced concerns about how
exposure to Agent Orange may have affected their health and caused certain
disabilities, including birth defects in their children. Initially, the Department of
Defense (DOD) maintained that only a limited number of U.S. military personnel,
such as those operating aircraft or troops engaged in herbicide spraying, could be
positively linked to Agent Orange exposure. However, in 1979, the General
Accounting Office, now the Government Accountability Office (GAO), reported that
ground troops had also been exposed to Agent Orange, and DOD was forced to
reconsider its prior statements.1 In response to these concerns, Congress passed
legislation to research the long-term health effects on Vietnam veterans, and to
provide benefits and services to those who may have been exposed to Agent Orange.
Health Care
Prior to the 1981 Veterans’ Health Care, Training and Small Business Loan Act
(P.L. 97-72), veterans who complained of Agent Orange-related illnesses were at the
lowest priority for treatment at Department of Veterans Affairs (VA) medical
1 U.S. General Accounting Office, Ground Troops in South Vietnam were in Areas Sprayed
with Herbicide Orange, GAO 80-23, November 1979, p. 1.

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facilities because these conditions were not considered “service-connected.”2 P.L.
97-72 elevated Vietnam veterans’ priority status for health care at VA facilities by
recognizing a veteran’s own report of exposure as sufficient proof to receive medical
care unless there was evidence to the contrary. The Veterans’ Health Care Eligibility
Reform Act of 1996 (P.L. 104-262) completely restructured VA medical care
eligibility requirements for all veterans. Under P.L. 104-262, a veteran does not have
to demonstrate a link between a certain health condition and exposure to Agent
Orange; instead, medical care is provided unless the VA has determined that the
condition did not result from exposure to Agent Orange or the condition has been
identified by the Institute of Medicine (IOM) as having “limited/suggestive” evidence
of no association between the occurrence of the disease and exposure to a herbicide.3
The research by the IOM (part of the National Academies) and its significance is
addressed below.4
Disability Compensation
The Veterans’ Dioxin and Radiation Exposure Compensation Standards Act of
1984 (P.L. 98-542) required the VA to develop regulations for disability
compensation to Vietnam veterans exposed to Agent Orange. Veterans seeking
compensation for a condition they thought to be related to herbicide exposure had to
provide proof of a service-connection that established the link between herbicide
exposure and disease onset. P.L. 98-542 authorized disability compensation
payments to Vietnam veterans for the skin condition chloracne, which is associated
with herbicide exposure. In 1991, the Agent Orange Act (P.L. 102-4) established for
the first time a presumption of service connection for diseases associated with
herbicide exposure. Under the Agent Orange Act, veterans seeking disability
compensation for diseases they thought to be associated with herbicides no longer
were required to provide proof of exposure. P.L. 102-4 authorized the VA to contract
with the IOM to conduct a scientific review of the evidence linking certain medical
conditions to herbicide exposure.5 VA is then required to review the reports of the
2 The term “service-connected” means, with respect to disability, that such disability was
incurred or aggravated in the line of duty in the active military, naval, or air service. VA
determines whether veterans have service-connected disabilities, and for those with such
disabilities, assigns ratings from 0% to 100% based on the severity of the disability.
Percentages are assigned in increments of 10%.
3 “Limited/suggestive” evidence of no association is when several adequate studies, covering
the full range of levels of exposure that human beings are known to encounter, are consistent
in not showing a positive association between any magnitude of exposure to herbicides and
the outcome of disease.
4 For detailed information on eligibility for VA health care, see CRS Report RL33409,
Veterans’ Medical Care: FY2007 Appropriations, by Sidath Viranga Panangala.
5 This comprehensive review by the IOM has been repeated at least every two years since
1994 and is authorized to continue until October 2014. Veterans and Agent Orange weighs
the strengths and limitations of the complete body of epidemiologic evidence on herbicide
exposure and manifestation of certain health outcomes. This review then assigns the
investigated medical conditions to one of four categories ranging from “sufficient evidence
of an association” to “limited or suggestive evidence of no association.” For example, in
(continued...)

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IOM and issue regulations, establishing a presumption of service connection for any
disease for which there is scientific evidence of a positive association with herbicide
exposure. Once the VA has established presumption of service connection for a
certain disease or medical condition, a Vietnam veteran with that disease is eligible
for disability compensation. The amount of compensation is based on the degree of
disability and, again, veterans are compensated only for approved conditions that
have demonstrated sufficient evidence of an association with herbicide exposure.
Currently, the conditions that are presumptively recognized for service
connection for Vietnam veterans are chloracne (must occur within one year of
exposure to Agent Orange); non-Hodgkin’s lymphoma; soft tissue sarcoma (other
than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma);
Hodgkin’s disease; porphyria cutanea tarda (must occur within one year of exposure);
multiple myeloma; respiratory cancers, including cancers of the lung, larynx, trachea,
and bronchus; prostate cancer; acute and subacute transient peripheral neuropathy
(must appear within one year of exposure and resolve within two years of date of
onset); type II diabetes; and chronic lymphocytic leukemia.6 In addition, Vietnam
veterans’ children with the birth defect spina bifida are eligible to receive a monthly
monetary allowance in addition to certain health care services. The Veterans
Benefits and Health Care Improvement Act of 2000 (P.L. 106-419) authorized
similar benefits and services for children with certain birth defects who were born to
female Vietnam veterans.7
The Agent Orange Registry
The Agent Orange Registry was established in 1978 by the VA for Vietnam
veterans concerned about the health effects of exposure to Agent Orange. A veteran
choosing to register is eligible for an examination consisting of a medical history, a
physical examination, and a series of laboratory tests. Each veteran is also required
to answer a set of questions relevant to exposure. In September 2000, the Agent
Orange Registry was expanded to include veterans who served in Korea in 1968 and
1969. Since August 2001, the registry is accessible to all U.S. veterans potentially
exposed to dioxin or other toxic substances used in herbicides while engaged in
military activity. Participating in the registry does not give exposed military
personnel automatic access to health and disability compensation benefits. As of
September 2007, more than 490,000 veterans have participated in the registry.8
5 (...continued)
the 2006 Veterans and Agent Orange update, this information is available in Table S-1. The
latest update was compiled in 2006 and released in July 2007, at [http://www.nap.edu/].
6 38.C.F.R. §3.309(e).
7 38 C.F.R. §3.815. For detailed information on eligibility for disability compensation, see
CRS Report RL33113, Veterans Affairs: Basic Eligibility for Disability Benefit Programs,
by Douglas Reid Weimer.
8 There were a total of 439,849 initial examinations, and 50,487 follow-up examinations.

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Non-Vietnam Veterans Exposed to Agent Orange
Under current law, only Vietnam veterans who served in-country are eligible to
receive health care benefits and compensation for service “in Vietnam.”9 However,
under certain circumstances, veterans are eligible for health care and compensation
benefits for service outside of Vietnam. A non-Vietnam veteran who claims that an
injury or illness resulted from exposure to Agent Orange while serving in the military
can apply for service-connected benefits. But unlike Vietnam veterans, they are
required to prove they were exposed to Agent Orange. VA requires the following
information in the veteran’s benefit application: a medical diagnosis of a disease or
condition the VA recognizes as associated with Agent Orange; evidence of exposure
to a chemical contained in the herbicides used in Vietnam; and medical evidence that
the disease began or manifested within the designated time frame, if any, for that
disease.10 Those veterans who served in areas such as the Korean Demilitarized Zone
(DMZ) may be eligible to apply for disability benefits. The DOD has also published
a list of areas outside of Vietnam where Agent Orange was used.11
In 2003, Congress passed the Veterans Benefits Act of 2003 (P.L. 108-183).12
Among other things, the Act expanded health care and other benefits to natural
children of Korea service veterans born with spina bifida.13 To be eligible for
benefits, the veteran must have served in the active military, naval, or air service in
or near the Korean Demilitarized Zone (DMZ) between September 1, 1967, and
August 31, 1971, and must have been exposed to certain herbicides during such
service.14 Furthermore, under P.L. 108-183, the determination of service in the
Korean DMZ is to performed by the VA in consultation with DOD.
9 Service in the Republic of Vietnam includes service in the waters offshore and services in
other locations if conditions of service involved duty or visitation in the Republic of
Vietnam. 38 C.F.R. §3.313(a); 38 C.F.R. 3.307(a)(6)(iii).
10 If a veteran did not serve in the Republic of Vietnam, but was exposed to an herbicide
agent defined in 38 CFR 3.307(a)(6) during active military service, has a disease on the list
of diseases subject to presumptive service-connection, VA will presume that the disease is
due to the exposure to herbicides. Additional information on benefits and compensation for
veterans exposed to Agent Orange is available at the U.S. Department of Veterans Affairs,
“VA’s Guide on Agent Orange Claims, Compensation and Pension Service,” updated April
27, 2004, pp. 1-7, at [http://www.vba.va.gov/bln/21/Benefits/Herbicide/AOno3.htm].
11 [http://www1.va.gov/agentorange/docs/Report_on_DoD_Herbicides_Outside_of_
Vietnam.pdf].
12 P.L. 108-183, among other the bills, contained provisions from H.R. 2297 (H.Rept.
108-211) and S. 1132 (S.Rept. 108-169).
13 This applies to all forms and manifestations of spina bifida, except spina bifida occulta.
14 38 U.S.C. §1821.

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Haas v. Nicholson15
On August 16, 2006, the U.S. Court of Appeals for Veterans Claims (CAVC)
determined that the veterans who had served in the waters off Vietnam (this class of
veterans is generally known as “blue water” veterans) were entitled to a presumption
of exposure to Agent Orange.16 Prior to this CAVC decision,17 VA’s interpretation
of 38 CFR 3.307(a)(6)(iii) was that a service member had to have actually set foot
on Vietnamese soil or served on a craft in its rivers (also known as “brown water”
veterans) in order to be entitled to the presumption of exposure to Agent Orange.
The CAVC specifically held the following: (1) the reference to service “in Vietnam”
as used in the statute was ambiguous because there are many definitions of the
territory of a nation and (2) VA’s regulation defining Vietnam service for purposes
of granting the presumption of exposure to herbicides, 38 CFR 3.307(a)(6)(iii), was
ambiguous when viewed together with 38 CFR 3.313, which also defines service in
Vietnam. Because CAVC determined that ambiguity was present, it also examined
VA’s Adjudication Procedure Manual M21-1 (the M21-1 manual)18 provision from
1991, which stated that the receipt of a Vietnam Service Medal (VSM) would be
considered proof of Vietnam service in the absence of “contradictory evidence.” In
2002, VA issued a new M21-1 provision advising VA benefit adjudicators that the
receipt of the VSM could indicate service on land in Vietnam but, by itself, was not
proof of service in Vietnam because a veteran may have received this medal for
service in locations other than Vietnam.19 The CAVC determined the M21-1
provision to be a substantive rule establishing entitlement to the presumption of
exposure to herbicides, and held that VA’s “attempted rescissions” of that M21-1
provision were void because they failed to comply with the notice and comment
requirements of the Administrative Procedures Act (APA).20
Current Status. On September 21, 2006, Secretary Nicholson issued a
memorandum directing the Board of Veterans Appeals (BVA) to withhold
adjudicating all claims for service-connection based on exposure to herbicides in
15 Jonathan L. Haas was a member of the U.S. Navy Reserve components that served in the
waters off Vietnam and received the Vietnam Service Medal (VSM). He claimed that his
diabetes mellitus and resulting medical complications were related to his exposure to Agent
Orange that drifted offshore, and filed a disability claim with the VA. VA denied the claim
on the grounds that service members had to have actually set foot on Vietnamese soil.
16 For further information on the CAVC, see CRS Report RS22561,Veterans Affairs: The
U.S. Court of Appeals for Veterans Claims — Judicial Review of VA Decision Making, by
Douglas Reid Weimer.
17 U.S. Court of Appeals for Veterans Claims (CAVC), 20 Vet. App. 257 (2006).
18 The M21-1 is an internal manual used to provide guidance to VA benefit adjudicators on
procedures for adjudicating claims for compensation, pension, dependency and indemnity
compensation, accrued benefits, and burial allowance.
19 The VSM was awarded to all members of the Armed Forces who served between July 3,
1965, and March 28, 1973, either (1) in Vietnam and contiguous waters and airspace
thereover or (2) in Thailand, Laos, or Cambodia, or airspace thereover, in direct support of
operations in Vietnam.
20 5 U.S.C. §706(2)(A).

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which the only evidence of exposure is the receipt of the Vietnam Service Medal or
service on a vessel off the shore of Vietnam. At this time, BVA has suspended action
on Haas v. Nicholson claims.21 On December 11, 2006, VA issued a memorandum
to its regional offices, instructing them that claims related to the Haas v. Nicholson
decision should not be adjudicated until the litigation is resolved. VA has appealed
the CAVC decision to the U.S. Court of Appeals for the Federal Circuit in
Washington, D.C. Oral argument was held on November 7, 2007. It may take
several months before the Court of Appeals issues a ruling.
On November 27, 2007, VA published a Federal Register notice proposing to
rescind provisions of its Adjudication Procedures Manual, M21-1 (M21-1), that were
found by the CAVC not to have been properly rescinded under the APA.22 This
action was taken by the VA as a preemptive measure in the event the Department
does not prevail on appeal in Haas v. Nicholson.
Epidemiologic Research on Vietnam Veterans
Because of the controversy surrounding the use of herbicides in Vietnam,
significant research on the health effects of Agent Orange and dioxin exposure has
occurred over the last 30 years. The majority of studies have focused on morbidity
and mortality of Vietnam veterans and are conducted by the VA, the Centers for
Disease Control and Prevention (CDC), the U.S. Air Force, and the various veteran
service organizations (VSOs). Despite the abundance of research completed,
epidemiologic studies on Agent Orange are historically burdened by the lack of
reliable exposure data. The lack of accurate data remains a continued source of
frustration for researchers, government officials, and Vietnam-era veterans seeking
conclusive information on the health risks of exposure to Agent Orange. Below is
a brief description of epidemiologic research conducted by the various agencies.
Centers for Disease Control and Prevention. In 1979, the VA was
authorized to conduct an epidemiologic study to determine the association between
Agent Orange and the medical concerns of Vietnam-era veterans. In carrying out the
congressional mandate, the VA was faced with substantial challenges in determining
study design and research protocol, and in 1982, responsibility for the research was
transferred from the VA to the CDC. The CDC also faced its own obstacles in
research design and were delayed by the lack of exposure data. In response to the
difficulty in obtaining exposure data, the CDC attempted an Agent Orange Validation
Study to see if indirect estimates of exposure from military records and self-reports
could be compared to dioxin serum levels in veterans as a method of determining true
exposure. After investigation, the CDC reported that military records and self-reports
obtained from the Agent Orange Validation Study were inadequate for identifying the
exposed individuals necessary for a large epidemiologic study of dioxin effects.
Secondary to the problems faced by the VA and the CDC, a group of government
21 For further details on the BVA, see CRS Report RL33704, Veterans Affairs: The Appeal
Process for Veterans’ Claims, by Douglas Reid Weimer.
22 Department of Veterans Affairs, “Rescission of Manual M21-1 Provisions Related To
Exposure to Herbicides Based on Receipt of the Vietnam Service Medal,” Federal Register,
vol. 72, no 227 (November 27, 2007), pp. 66218-66219.

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panels and advisory boards determined that the congressionally mandated Agent
Orange Study was improbable, and the CDC investigation ended.23
Air Force Health Study (AFHS). Operation Ranch Hand was responsible
for spraying herbicides in Vietnam between 1962 and 1971. In 1982, Air Force
investigators began a study investigating the long-term health problems of pilots and
ground crews engaged in spraying herbicides in Vietnam. The study cohort consisted
of more than 1,200 Ranch Hand veterans and more than 19,000 comparison Air
Force veterans who did not spray herbicides. AFHS data collected between 1979 and
1993 revealed no statistically significant differences between the Ranch Hand
personnel and the comparison cohort both for all-cause mortality and for cause-
specific mortality. The exception was an increased mortality rate for circulatory
diseases seen in enlisted ground crew personnel, a group at higher risk for skin
exposure to herbicides. In 2005, an AFHS update reviewing 20 years of
epidemiologic data on mortality rates reported a small, but significant, increase in all-
cause death rates for Ranch Hand veterans. This was the first published research to
find a statistically significant increase in the relative risk for all-cause mortality
among Ranch Hand veterans.24 After 20 years of analysis, data collection, and
review, a recent IOM publication indicated that diabetes presented as the most
serious health problem observed in the AFHS. Type II diabetes was added to the list
of service-connected diseases for Vietnam veterans exposed to Agent Orange in
2001.25 The long-standing AFHS ended on September 30, 2006.
Section 714 of the John Warner National Defense Authorization Act, 2007 (P.L.
109-364), requires the Secretary of the Air Force to transfer custody of the AFHS
data to the IOM. This decision to retain the AFHS materials was based on the
scientific merit of maintaining herbicide exposure records as a valuable source of
medical and epidemiologic data as recommended by the IOM study.26 Furthermore,
P.L. 109-364 required the Secretary of Defense to make $850,000 available to the Air
Force in preparation for the transfer of study data to the IOM. An additional
$200,000 was to be reimbursed from the DOD to the IOM for costs related to the
transfer of study materials from the Air Force.27 Under this provision, the Air Force
is required to submit a report on the transfer to the Armed Services Committees of
Congress
23 The government panel and advisory groups included the CDC advisory group, the Science
Panel of the Domestic Policy Council’s Agent Orange Working Group, and the Agent
Orange Advisory Panel of the Congressional Office of Technology Assessment.
24 Norma Ketchum and Joel Michalek, “Postservice Mortality of Air Force Veterans
Occupationally Exposed to Herbicides During the Vietnam War: 20-year follow-up results,”
Military Medicine, vol. 170, no. 5 (May 2005), pp. 406-413.
25 National Academies, Institute of Medicine, Disposition of the Air Force Health Study,
2006, p. 55.
26 Ibid., p. 4.
27 U.S. Congress, Conference Committees, National Defense Authorization Act for Fiscal
Year 2007, a report to accompany H.R. 5122, 109th Congress, 2nd sess., H.Rept. 109-702.
Congressional Record, daily edition, vol. 152 (September 29, 2006), pp. H8061-H8536.

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