[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]




                               before the


                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION


                            OCTOBER 10, 2007


                           Serial No. 110-52


       Printed for the use of the Committee on Veterans' Affairs

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                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S


                            October 10, 2007

Findings of the Veterans' Disability Benefits Commission.........     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    33
Hon. Steve Buyer, Ranking Republican Member......................     3
    Prepared statement of Congressman Buyer......................    34
Hon. Stephanie Herseth Sandlin, prepared statement of............    35
Hon. Ginny Brown-Waite, prepared statement of....................    35
Hon. John T. Salazar, prepared statement of......................    35
Hon. John Boozman, prepared statement of.........................    36


Veterans' Disability Benefits Commission, Lieutenant General 
  James Terry Scott, USA (Ret.), Chairman........................     4
    Prepared statement of General Scott..........................    37

                       SUBMISSIONS FOR THE RECORD

Lamborn, Hon. Doug, a Representative in Congress from the State 
  of Colorado, statement.........................................    46
Miller, Hon. Jeff, a Representative in Congress from the State of 
  Florida, statement.............................................    46
Mitchell, Hon. Harry E., a Representative in Congress from the 
  State of Arizona, statement....................................    47


Post-Hearing Questions and Responses for the Record:
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to LTG 
  James Terry Scott, USA (Ret.), Chairman, Veterans' Disability 
  Benefits Commission, letter dated October 16, 2007.............    47



                      WEDNESDAY, OCTOBER 10, 2007

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 10:02 a.m., in 
Room 334, Cannon House Office Building, Hon. Bob Filner 
[Chairman of the Committee] presiding.
    Present: Representatives Filner, Brown of Florida, Snyder, 
Michaud, Herseth Sandlin, Hall, Hare, Berkley, Salazar, 
Rodriguez, Donnelly, McNerney, Space, Walz, Buyer, Moran, Brown 
of South Carolina, Boozman, Brown-Waite, Bilbray, and 


    The Chairman. Good morning. I call to order this meeting of 
the House Committee on Veterans' Affairs. We have an especially 
important, helpful, and I hope productive hearing with the 
members of the Veterans' Disability Benefits Commission chaired 
by Lieutenant General James Terry Scott.
    We thank all of you for joining us today, and we want to 
thank the Commission for its work for over 2 years. Chairman 
Scott was telling me that you would meet for several days each 
month and more frequently in recent months. So it has been a 
big commitment and we thank all of you for that and trying to 
draw together a mass of information to help us improve this 
    We thank you for the report that you have produced and are 
glad that you felt this call to duty. You met many, many times 
with all of the stakeholders and I think that you have tried to 
fashion a report that honors the sacrifices that our men and 
women in uniform have made.
    The Veterans' Disability Benefits Commission was 
established by the National Defense Authorization Act of 2004 
out of recognition of the impact that the current conflicts of 
Operating Enduring Freedom (OEF) and Operating Iraqi Freedom 
(OIF) would have on our resources in both the U.S. Department 
of Veterans Affairs (VA) and the Department of Defense (DoD).
    It was our hope, and I think you have met that hope, that 
you would provide recommendations to increase the efficiency 
and effectiveness of providing benefits and services to our 
veterans, their dependents, and survivors in a manner that 
reflects the dignity of their service.
    Your report became even more relevant once the conditions 
at Walter Reed were reported and people became very 
knowledgeable of some of the defects of our system, especially 
the growing backlog of the claims at the VA. And you address 
this in a very timely manner as it turns out because the Nation 
is focused on these issues.
    Just as we did in the 1990s when Congress, the 
Administration, Veterans Service Organizations (VSOs), and 
stakeholders partnered to place greater emphasis on turning the 
Veterans Health Administration (VHA) into a world-class, 
technologically adept entity, I think your report tells us that 
we must devote the same resources and brain power to turning 
around the Veterans Benefits Administration (VBA) to become a 
world-class, technologically adept, 21st century organization.
    So I look forward to working with you and your Commission 
and the VA to make that a reality because we have to do this.
    As you point out, as we continue to give full resources to 
the war, let us not forget the warrior and the warrior's 
family. Our men and women should not only get first-class 
weapons to fight and receive third-class benefits after 
fighting, we must make them all first class.
    We all know about the claims backlog, whether from the 
regional offices or the Board of Veterans' Appeals or the U.S. 
Court of Appeals for Veterans Claims, have become intolerable, 
leading to long waiting times, and unmanageable, frankly, given 
the funding shortfalls that have been apparent over the last 
    But I think we have a system that could be improved as you 
point out, and the employees and dedicated people who work for 
the VA will be able to achieve what you want with additional 
resources and the changes.
    The Veterans Benefits Administration, on their Web site and 
in their training, I assume, talk about a covenant that they 
make, a covenant that says we are the leaders in one of our 
Nation's most vital and idealistic service organizations. 
Because we serve veterans and their dependents, our mission is 
    And it quotes both President Lincoln and General Omar 
Bradley, words that many of us have come to know. Of course, 
Lincoln's famous phrase, ``To care for him who shall have borne 
the battle and for his widow and his orphan.'' General Bradley 
in 1947 said, ``We are dealing with veterans, not procedures, 
with their problems, not ours.''
    And that covenant further states as we carry out this 
mission, we willfully enter into a covenant with one another to 
always be guided by the fundamental principles of 
accountability, integrity, and professionalism. These 
principles form the foundation of leadership and service to 
America's veterans. That is what the VBA says is its covenant.
    So we want to extend that covenant, devote all our 
resources, brain power, and willpower, man and woman power to 
improve the current system of delivery of benefits so we 
optimize the outcomes for everyone.
    We have the privilege to be able to serve our veterans and 
their families. You have honored them with your long study, and 
I think you have given us a lot of work to do to follow-up. We 
will give you all the time you need to explain what you have 
done and if you would like to introduce and call on any of the 
Commission Members.
    Mr. Buyer, I would recognize you for an opening statement.
    [The prepared statement of Chairman Filner appears on p. 


    Mr. Buyer. Thank you very much.
    General Scott, thank you for being here and congratulations 
to you and to your Commissioners who are also here with you. I 
consider you and your Commissioners patriots and nobles. You 
have taken on a great cause on behalf of Congress to look at 
these issues that best affect America's most sacred asset, 
those men and women who put on the uniform and are somehow 
hurt, harmed or injured in some way, whether it be in the 
workplace, during peace, or in combat operations.
    Let us also never forget the families, the ones who kept 
the watch fires burning, and their children. And that is why we 
have looked to you on what upgrades, if necessary, must be 
    So I commend all of you for your dedication and your work 
over the past 2\1/2\ years. Your efforts required many long 
hours discussing these issues in meetings and pouring over an 
array of complex materials to arrive at the recommendations you 
have presented to us.
    I heartily agree with the eight guiding principles that you 
identified. These principles provide a sound basis for 
considering any recommendations for improvement to veterans' 
benefits. Clearly you and your fellow Commissioners share my 
sentiments that veterans, the men and women of the Armed 
Forces, are among our Nation's most finest citizens.
    We are in a long war against global terrorism. The enemy we 
encounter has its sights set on objectives it hopes to 
accomplish for many years from now. It is our grandchildren 
they also plan to oppress. We have no choice but to engage 
those who despise free will and wish to destroy us and the 
freedom we cherish.
    It is imperative that we maintain a military that is 
capable of swift response and world-wide theater operations. To 
do so, we must continue to attract the caliber of people our 
military has now, and those who must serve should be confident 
that they and their families will be cared for should harm come 
their way.
    Early during the initial review of your report, I could see 
the Commission understood this fact very well. The Commission 
wisely focused on the veterans' long-term issues such as the 
need to revamp the disability, retirement, and compensation 
    It has been my longstanding view that we must modernize the 
VA and establish a transition process that is seamless in its 
efficiencies between DoD and VA. The Commission's report, along 
with the recommendations of the Dole-Shalala Task Force, is a 
big step toward attaining this goal.
    So I look forward to hearing your testimony. We will 
carefully consider all the Commission's recommendations and 
hopefully use those we determine are most beneficial as a guide 
to meaningful and long-term policies to improve the lives of 
veterans and their families.
    Mr. Chairman, I suggest this Committee consider the 
Commission's priority recommendations first and those that are 
determined to be meritorious should receive prompt legislative 
    Also, Mr. Chairman, along with the recommendations from the 
Dole-Shalala Task Force, there appear to be potential PAYGO 
issues as we consider the Commission's recommendations. While 
we may not have to grapple with these questions today, we must 
be mindful of them. As Congress and the Administration move 
forward, we must deal with the funding issues that pertain to 
these recommendations.
    I also have one last bit of housework and a friendly 
recommendation to the Chairman. You have had some very good 
hearings here over the summer and we have been holding these 
hearings on Wednesday at ten o'clock. This is a Committee and 
many of us have a lot of issues going on in a lot of different 
committees. My recommendation to the Chairman is to hold a 
hearing like this at ten a.m. on Thursday so that these 
hearings could be better attended by the Members. And that is 
my friendly recommendation to you.
    And I thank you and I yield back the time.
    The Chairman. Thank you, Mr. Buyer. I always welcome 
friendly recommendations. I would just amend one part of your 
statement. We are an A+ Committee, not a C Committee.
    I understand what you meant in terms of scheduling, but 
most of us are here because we think, excluding yourself, it is 
such an important Committee. But we will look at the scheduling 
issues that you have raised.
    General Scott, thank you again for being with us and you 
have the floor. And if you would maybe introduce some of your 
Commission Members who are with us today so we can thank them 

                      BENEFITS COMMISSION

    General Scott. Chairman Filner, Ranking Member Buyer----
    The Chairman. Make sure that microphone is on, please.
    General Scott [continuing]. It is my pleasure to be with 
you today. And I will introduce the seven Commissioners that 
were able to be here, seven of the other twelve: Commissioner 
Brown; Commissioner Joeckel; Commissioner Jordan; Commissioner 
Livingston; Commissioner Matz; Commissioner McGinn; and 
Commissioner Wynn.
    As you stated, sir----
    The Chairman. We want to thank all of them, you know. If 
you would just stand up so we can thank you, all of you.
    The Chairman. By the way, I do not know if you were going 
to say it, but on your Web site, amongst your members are 2 
Congressional Medal of Honor recipients, 2 Distinguished 
Service Crosses, 9 Silver Stars, 6 Distinguished Flying 
Crosses, 5 Bronze Stars for Valor, 13 Purple Hearts, and 8 
Combat Infantry Badges or Combat Action Ribbons, so----
    The Chairman [continuing]. It is obviously a very 
distinguished group.
    General Scott. Well, sir, as you mentioned, the Commission 
was established to study the benefits and services that are 
provided to compensate and assist veterans and their survivors 
for disabilities and deaths attributable to military service.
    Specifically we were tasked to examine and make 
recommendations concerning the appropriateness of such 
benefits, the appropriateness of the level of such benefits, 
and the appropriate standard for determining whether a 
disability or death of a veteran should be compensated.
    We conducted an extensive and comprehensive examination of 
the issues relating to veterans' disability benefits. This is 
the first time that we know of that the subject has been 
studied in depth by an outside entity since the Bradley 
Commission in 1956.
    We identified 31 issues for study. We made every effort to 
ensure that our analysis was evidenced based and data driven. 
And we engaged two well-known organizations to provide medical 
expertise and analysis, the Institute of Medicine (IOM) of the 
National Academies of Science and the Center for Naval Analyses 
(CNI) Corp. Both offered tremendous assistance to us, 
particularly the IOM in the fields of medicine for which the 
Commission Members probably were less prepared than we could 
have been.
    So we are offering 113 recommendations covering wide 
spectrums of veterans' disability benefits issues to ensure 
that the benefits fairly and uniformly compensate all service-
disabled veterans and their families.
    Some recommendations are inexpensive, some are not. Some 
can be adopted by the VA and/or DoD. Others will require 
involvement of the Department of Labor and the Social Security 
Administration. Others will require legislation.
    The Commission understands that not all recommendations can 
be adopted immediately. We have identified 14 recommendations 
that in our judgment are higher priority. We hope the Congress 
and the departments will carefully consider all 
recommendations, however.
    Brief summary of our findings. VA compensation currently 
paid to disabled veterans is generally adequate to offset 
average impairment of earnings. A comparison with the earnings 
of veterans who are not service disabled demonstrated that 
disability causes lower earnings and employment levels at all 
levels of severity and all types of disabilities.
    The amount of compensation is generally sufficient to 
offset loss of earnings except for three groups of veterans, 
those whose primary disability is PTSD or Post Traumatic Stress 
Disorder and other mental disorders, those who are severely 
disabled at a young age, and those who are granted maximum 
benefits because their disabilities make them unemployable.
    The Commission particularly focused on the issues 
concerning the care for the severely injured such as amputees 
and those with a Traumatic Brain Injury or TBI. We have not 
demonstrated that we are prepared to provide adequate care and 
support for these veterans.
    The families of the severely injured are assisting in the 
care and rehabilitation of these wounded warriors. Some are 
sacrificing jobs, careers, homes, health insurance, and facing 
tremendous impact on their own health in order to support their 
injured family members. We recommended that Congress should 
provide some healthcare and caregiver allowances for these 
    Quality of Life. We believe that the level of compensation 
should be based on the severity of the disability and should 
make up for the average impairments of earnings capacity and 
the impact of the disability on functionality and quality of 
life. It should not be based on whether it occurred during 
combat or combat training or on the geographic location of an 
injury or whether the disability occurred during wartime or a 
time of peace.
    Current compensation payments do not provide a payment 
above that required to offset earnings loss. Therefore, there 
is no current compensation for the impact of disability on the 
quality of life for most veterans.
    While permanent quality of life measures are developed, 
studied, and implemented, we recommend that compensation 
payments be increased up to 25 percent with priority to the 
more seriously disabled.
    The VA Rating Schedule. The Commission concluded that the 
current VA schedule for rating disabilities which is used to 
evaluate veterans' severity of disability has not been 
adequately revised since 1945. We recommend that the rating 
schedule be updated as soon as possible but certainly within 
the next 5 years.
    As a matter of priority, this update must include specific 
criteria for the evaluation and rating of Traumatic Brain 
Injury and all mental disorders. The schedule should also be 
revised to account for new diagnostic classifications, new 
medical criteria, and medical advances.
    In addition, VA should create a process for keeping the 
rating schedule up to date including publishing a time table 
and creating an Advisory Committee for revising the medical 
criteria for each body system.
    Post Traumatic Stress Disorder. The Commission believes 
that a holistic approach to PTSD should be established that 
couples compensation, treatment, and vocational assessment. We 
also believe that reevaluation should occur every 2-3 years to 
gauge treatment effectiveness and to encourage wellness.
    Individual Unemployability (IU). Veterans with service-
connected disabilities rated 60 percent or more but less than 
100 percent and who are unable to work due to their 
disabilities can be granted what is known as individual 
unemployability and be paid at the 100 percent rate.
    The number of such veterans has increased by 90 percent 
over the past few years causing considerable attention. Our 
analysis found that the increase is largely explained by the 
aging of the cohort of Vietnam veterans and the worsening of 
their service-connected disabilities. As the rating schedule is 
revised, specific focus should be given to the criteria for 
PTSD and other mental disorders so that IU, individual 
unemployability, does not need to be awarded so frequently. And 
I might add that the same goes for other disabilities. We would 
hope that a revision of the rating schedule would dramatically 
decrease the requirement for individual unemployability.
    Presumptions. When there is evidence that a condition is 
experienced by a sufficient cohort of veterans, a presumption 
can be established so that it is presumed to be the result of 
military service. This has been done for radiation exposure, 
Agent Orange defoliant in Vietnam, and other conditions.
    The Commission asked IOM to review the existing process for 
making these decisions and IOM recommended a detailed, 
comprehensive, and transparent framework based on scientific 
principles. Our Commission believes that this framework will 
improve the process. We have some concern over the use of the 
term causal effect as the standard as opposed to the existing 
standard for association of effect.
    I might add parenthetically that this was one of the finest 
reports that the IOM did for the Commission. And if you have 
the opportunity to read just one of these other reports that 
were furnished by the CNAC or the IOM, I would recommend this 
report on presumptions. Dr. Samet from Johns Hopkins chaired it 
and I think you will find it clear, lucid, and it helps get the 
medicine back into presumptions and the politics out of it.
    Moving along, sir, Transition. The Commission recommends a 
realignment of the DoD disability evaluation process used to 
separate retired servicemembers who are not fit for military 
duty. The military services, Army, Navy, and Air Force, should 
determine whether a servicemember is fit for duty and VA should 
determine the level of disability of servicemembers who are 
found unfit for duty. This will ensure equitable and consistent 
    We believe that DoD should also mandate that separation 
examinations be performed on all servicemembers to ensure that 
known conditions at the time of discharge are documented.
    I might add, sir, that the Navy already does this. And we 
strongly recommend that the other services do it because it 
gives you a book end. There is an entry physical when a person 
comes on active duty and there should be an exit physical when 
they go off. And it would make it tremendously easier to work 
the claims in the VA system if this data were available to the 
people that have to make the decisions.
    Regarding concurrent receipt of military retirement and VA 
disability compensation, the Commission's study found these to 
be two different programs with entirely different missions. DoD 
retirement recognizes years of service and VA disability 
payments compensate for impairment in earnings and should 
compensate for impact on quality of life.
    Over time, Congress should eliminate the ban on concurrent 
receipt for all military retirees and for all servicemembers 
who are separated from the military due to service-connected 
disabilities. Priorities should be given to veterans who 
separate or retire with less than 20 years of service and with 
a service-connected disability rating of 50 percent or greater 
or with a disability as a result of combat.
    Payment offsets should also be eliminated for survivors of 
those who die in service or retirees who die of service-related 
causes so that these survivors can receive both VA dependency 
and indemnity compensation and DoD's survivor's benefit plan.
    Compatible Electronic Information Systems. VA and DoD 
should expedite their efforts to implement compatible 
electronic information systems. We believe that this is one of 
the most important actions that can be taken. Not only will 
this improve claims processing, but it will enhance the ability 
to share medical records and avoid some of the unfortunate 
cases that slip through the cracks during transition from DoD 
to VA.
    Claims Processing. We have devoted a significant amount of 
the report to claims processing. I will just say here that we 
studied the existing processing system for disabled veterans 
and we are very disappointed by the burdensome bureaucracy and 
the delays that our veterans face.
    Therefore, we recommend that VA establish a simplified and 
expedited process using best practices and maximum use of 
information technology to improve the claims cycle.
    Again, sir, we talked in great deal about that in the body 
of the report.
    So we generally agree with the advice recently presented by 
the Dole-Shalala Commission. We differ on some small points. We 
believe that all disabilities and injuries should be 
compensated based on the severity of the disability and naval 
to combat or combat-related injuries.
    In conclusion, sir, the Commission believes that if our 
recommendations are implemented, a system for future 
generations of disabled veterans and their families will be 
established that will ensure seamless transition and improve 
their quality of life. It is our hope that the President, the 
Congress, the VA, and the DoD take this opportunity to create a 
veterans disability benefits system that will adapt as the 
needs of future veterans change and grow.
    Speaking on behalf of all the Commissioners, it has been an 
honor and a privilege to serve our current and future veterans 
through this effort. And I would like to personally thank each 
member of the Commission and the Commission staff for their 
hard work and professionalism.
    And, sir, I would be happy to take some questions. I would 
ask that our Executive Summary be accepted into the record. And 
I would also ask that the Executive Director of the study be 
allowed to join me at the table for the question session.
    [The prepared statement of General Scott appears on p. 37. 
The Veterans' Disability Benefits Commission Report will be 
retained in the Committee files. A copy of the report can be 
obtained from the Commission's website at:
    The Chairman. Without objection, so ordered. And if the 
Executive Director would come forward.
    Again, thank you so much, General. That was a very concise 
but important summary.
    We will start comments with Ms. Brown from Florida.
    Ms. Brown of Florida. Thank you, Mr. Chairman, and thank 
you for holding this hearing.
    And thank you, General Scott, for your service to the 
country and your service on this Commission.
    As you know, Congress established this Commission in 2004 
when the war was still beginning and we did not know much about 
what would become the signature injury of the war in Iraq and 
Afghanistan--Traumatic Brain Injury.
    I appreciate the hard work you, your Commissioners and 
staff did to fulfill the requirement and mandates we gave you.
    The very first of your priority recommendations states that 
the VA should immediately begin to update the current rating 
schedule. Your investigation into the rating schedule seemed to 
indicate that it works generally well, except for the lack of 
responsiveness regarding PTSD and mental health.
    While I am disappointed in this, I am not surprised, 
considering the lack of enthusiasm in the private healthcare 
insurance industry to fund mental health.
    Reading over your recommendations, it seems as though the 
major need for Congress is to be involved in more funding. You 
have my 100 percent support of it and I think most Members on 
this Committee would do the same. Thank you for your work.
    And I guess my question is, many of your recommendations 
have been addressed by this Committee in one way or another 
over the past few years. The President's Commission on Care for 
American Returning Wounded Warriors known as the Dole-Shalala 
Commission recommended many of the same things you have, only 
more concisely.
    Do you have any thoughts, more detail that you want to go 
into, comparison of the reports and, you know, your 
recommendations in comparison to their recommendations?
    General Scott. Yes, ma'am. And thank you for the question.
    We reviewed three other Commissions that met essentially 
during this long time frame that our Commission was meeting. We 
also provided raw data that our analysis was turning up as we 
went along to each of these Commissions that were meeting.
    The Independent Review Group on Rehabilitative Care and 
Administration at Walter Reed and the National Naval Medical 
Center directed by the Secretary of Defense, the Task Force on 
Returning Global War on Terror Heroes chaired by Secretary 
Nicholson, the Returning Wounded Warriors, the PCCWW also known 
as the Dole-Shalala Commission, and our own, and we did a side-
by-side comparison of findings and recommendations. And we 
found that in most areas, there was pretty much agreement on 
what should be done. And as you mentioned, ma'am, some of these 
things have been around for a while.
    Where I think we probably put a little more time into some 
of these areas, let me talk briefly. Quality of life. One of 
the things that we did, we had a survey done of disabled 
veterans to try to get some insight as to what the impact of 
their disabilities at different levels was on the quality of 
    And because of the time that we had to do this, we were 
able to do these surveys and do some analysis that the other 
commissions were not, although the Bradley Commission and Dole-
Shalala Commission both recommended that some accommodation be 
made for quality of life of the veterans.
    We spent a good bit of time, and it is certainly in the big 
book, it is not in the summary, on vocational rehabilitation 
and employment (VR&E). We think that is an under-emphasized 
area. It is quite obvious to all of us that the goal is to 
return the veteran to as near whole as can be done and 
reintegrate them into the society to the maximum extent it can 
be done. And we think some emphasis on vocational 
rehabilitation and employment is probably needed in that 
    I will not go into the line by line, but let me just say 
that in most areas, there was a concurrence among these 
reports. We did not look at Walter Reed. It was not in our 
charter. We did not look at the specifics of medical care for 
individual cases. We looked at medical care as a very important 
veterans' disability benefit, but we did not get into it.
    As the Chairman mentioned, you worked that pretty hard in 
years past, so we did not really get into it except to say that 
where the Post Traumatic Stress Disorder and other mental 
problems are concerned, we believe there should be more 
engagement by the medical profession and we believe that the 
clinicians who make these diagnoses, we need to be sure that 
they are trained and experienced in making these diagnoses. And 
we are a little uneasy about the level of that expertise and 
experience among the clinicians that are making diagnoses.
    Now, we also recommended that the adjudicators, the people 
that look at a claim and try to determine what is the level of 
disability, have access to medical expertise so that without 
having to send the whole paper file about that thick all the 
way back to the veterans' health side of it to get it 
reevaluated. In other words, they should have some quick way of 
getting some medical advice to assist them in the adjudication.
    And, again, that impacts in a very large way on this claims 
backlog and trying to make the system smoother and work more 
quickly to the advantage of the veteran.
    Did I answer your question, ma'am?
    Ms. Brown of Florida. Yes, sir. And my time is up. But can 
you say a word about the caregiver because I think it is such 
an important point that so many of the injured, when they go 
home, if it was not for the caregiver, they just cannot make 
it. And we do not have a system in place to assist the 
caregiver in any way.
    General Scott. That is right, ma'am. And we recommended 
that VA be authorized to provide family services and to extend 
healthcare and allowances to caregivers.
    Another way of addressing that would be to eliminate the 
Survivor Benefit Plan/Dependency and Indemnity Compensation 
(SBP/DIC) offset and to allow pending claims and to eliminate 
the TRICARE co-pays and deductibles for the families of 
severely injured people.
    So we have addressed that in several different places 
throughout the body of the report. And I am hopeful that your 
staff can pull that together and make it into something that 
you find useful in trying to offer some relief to these 
    Ms. Brown of Florida. Thank you so much, General Scott.
    I yield back the balance of my time.
    The Chairman. Is that side-by-side comparison included in 
the report or is that an additional thing that you can provide 
    General Scott. It was hastily put together when it became 
apparent that I was not well enough versed on all the detail 
from the other commissions.
    The Chairman. If you can provide that to us, that would be 
    General Scott. We would be happy to provide it for the 
    [The Commission side-by-side comparison appears in 
Enclosure 1 in the post-hearing questions for the record, which 
appear on p. 48.]
    The Chairman. Thank you.
    Mr. Brown, you have the floor.
    Mr. Brown of South Carolina. Thank you, Mr. Chairman.
    And I, too, would like to thank the members of this 
Commission and particularly, General Scott, for your 
    And if I could have the liberty, Mr. Chairman, to say a few 
words about one of my constituents that is on the Commission, 
General James Livingston, who is one of the Medal of Honor 
recipients and also a great friend to the veterans.
    And also in the audience is Mr. John Vogel. John, would you 
stand up. He is former Under Secretary and former Director of 
the VA Hospital in Charleston. He is also a constituent of mine 
    But I really do appreciate the report and particularly one 
item I would like to expand upon is the H.R. 5089, General, 
which I have cosponsored for, I guess, about the last 4 years 
now trying to basically eliminate the survivor benefit offset. 
And I appreciate you bringing that as part of your 
recommendation and we certainly will consider the other 112 
recommendations you brought forward. And thank you for your 
service and to all the other members of the Commission.
    The Chairman. Thank you, Mr. Brown.
    Mr. Snyder.
    Mr. Snyder. Thank you, Mr. Chairman.
    Mr. Chairman and General Scott, I wanted to acknowledge 
Nick Bacon, who is not with us today from Arkansas, is one of 
the Medal of Honor recipients that was on the Commission. And 
he is another example of a veteran who for the rest of his 
professional life has been working on issues involving 
    I also appreciate what you all have said about you think 
the benefits need to be based on the disability and not 
necessarily the geography or how they were caused. Senator Dole 
and I had that discussion when he was here a week or two ago. 
And I gave him an example of, you know, somebody, a painter at 
the Little Rock Air Force Base who falls off a ladder and 
suffers Traumatic Brain Injury. We would hate to have side-by-
side two households of one family getting a whole different 
benefit because of how they were injured. So I appreciate the 
position that you all have taken.
    I want to ask two or three specific questions. It has been 
several years, I do not remember, Mr. Buyer, if it was under 
your chairmanship, but we had a group of Iraqi veterans with 
fairly severe disabilities and one or two of them testified 
that they made the decision not to stay in the service even 
though they think that they--at least one of them thought he 
could have even though he had an artificial limb because of 
apprehension about subsequent loss of disability income if he 
stayed in the service.
    Did you all address that issue or how did you address that 
    General Scott. My recollection is that we never really 
talked about the impact, the financial impact of someone who 
elected to stay in the service and, therefore, decided to 
forego VA compensation at that time.
    But as you point out, sir, the advances in medicine and I 
would say advances in how the services view disabilities has 
led us to a position where we have a number of people who are 
staying in.
    I am aware of two officers from Vietnam who lost a foot or 
a leg and who were allowed to stay on active duty and now it is 
a routine thing to evaluate what the person can do for us in 
the future and, if possible, retain him on active duty.
    Mr. Snyder. I think your report deals with this issue of 
incentives or disincentives for getting better.
    General Scott. Right.
    Mr. Snyder. And we would not want our incentive to be that 
you better get out of the service rather than try to stay in 
and finish your career even though you may have lost one or two 
or even three limbs or had severe injuries in other faculties. 
If there is a way they can be accommodated to complete their 
military career, that may be an issue that we need to follow 
along as we make changes.
    General Scott. Sir, I think the issue in the 
servicemember's mind might be how will this affect my 
opportunity for promotion and future tenure. If a person 
believes that he or she would be allowed to progress, then the 
financial incentive would be on the side of staying in the 
service, I would think.
    Mr. Snyder. I wanted to ask a specific question. I have not 
read the full report. You have a very obviously thoughtful 
report. You put a lot of time into it. It is a very, very 
complex issue which is why this was set up. I am on the House 
Armed Services Committee, why this Commission was set up.
    Did you all come to any kind of ballpark annualized cost 
estimate if everything that you all recommended was implemented 
and you have recommended doing this over several years' time, 
let us suppose 5 years from now, or what the annualized, your 
rough estimate of what the cost would be in new dollars?
    General Scott. Well, for starts, we did, in fact, cost out 
the major recommendations----
    Mr. Snyder. Right.
    General Scott [continuing]. Using data from the 
Congressional Budget Office or from wherever it was available. 
And I would be the first to say that they were ballpark 
figures. In other words, I could not attest----
    Mr. Snyder. No, no. I understand.
    General Scott [continuing]. To the precise accuracy of 
them. But in terms of the quality of life recommendations we 
made, we did a hypothetical that said that at the 100 percent 
disability level, if you increase that person's compensation by 
25 percent and then scaled it back and down to the 10 percent 
disability level where it was 2\1/2\ percent, that we came up 
with a total amount of annual compensation additive of about $3 
    But, again, our hypothetical was if you gave the full 25 
percent quality of life kicker to the 100 percent disabled and 
you scaled that back down as the level of disability was 
reduced down to 10 percent and you gave them essentially what 
amounts to quality of life addition of $3.00 a month----
    Mr. Snyder. Now, that is for that one provision. What if 
everything is in, all your major recommendations, what would be 
the total? You have concurrent receipt recommendations and SBP 
recommendations and----
    General Scott. Well, you know, I am going to have to 
provide that for the record. We can do a quick try to add them 
up here, but I have it broken down by recommendation, but I 
have not aggregated it. But we will provide it for you.
    [The Commission cost estimates for major recommendations 
appears in Enclosure 1 in the post-hearing questions for the 
record, which appear on p. 48.]
    Mr. Snyder. Thank you for your service. This is a very 
complex issue and your report obviously deals with this in a 
very comprehensive way. And the Congress is going to need to 
digest this and move forward on this. But your report is a 
great, great start to this. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Bilirakis, you have the floor.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
    General Scott, as you may know, my father, Congressman Mike 
Bilirakis, played a role in establishing the Veterans' 
Disability Benefits Commission during negotiations on the 
concurrent receipt.
    I have continued my father's work in this matter and 
introduced legislation to provide for full concurrent receipt 
of military retired pay and VA disability compensation.
    Therefore, I was pleased to read the Commission's 
recommendations pertaining to the concurrent receipt issue. I 
am sure that the Commission's positive recommendations on this 
issue will greatly help in the fight to eliminate the unfair 
offset between the military retired and VA disability 
    Along the way to enacting the concurrent receipt and 
disability payment which was established in Public Law, 
Congress enacted several other measures including the Combat 
Related Special Compensation Program. I have heard from some 
retirees that they find the myriad of different benefits 
    In the Commission's deliberations on the concurrent receipt 
issue, did you consider whether or not concurrent receipt 
benefits should be simplified?
    General Scott. The quick answer is, yes, sir, we did. And I 
think you will find in the report a very detailed discussion of 
the overlaps that are in the present system now and the gaps 
that exist in it.
    Mr. Bilirakis. Okay. Thank you very much.
    I would like to talk to you maybe privately a little more 
    General Scott. Yes, sir.
    Mr. Bilirakis. Thank you.
    General Scott. Glad to.
    The Chairman. Thank you.
    Mr. Michaud, who chairs our Health Subcommittee.
    Mr. Michaud. Thank you very much, Mr. Chairman, for having 
this hearing.
    And I, too, want to thank the Commissioners for all your 
hard work.
    In the report, and I would like to quote a part of it, and 
that quote says, ``Little interaction between the Veterans 
Health Administration which examines veterans for evaluation of 
severity of symptoms and treats veterans with PTSD and the 
Veterans Benefit Administration which assign disability ratings 
and may or may not require periodic reexamination.''
    This report talks about a new holistic approach to PTSD 
that would couple treatment, compensation, and vocational 
    Could you, Mr. Chairman, go into greater detail of how this 
approach would be implemented, what benefits it would bring, 
and how we could minimize the potential unintended negative 
incentives in the treatment of PTSD or other mental health 
    General Scott. Sir, we discussed the rationale behind our 
conclusions and recommendations in some detail in the big book 
there. But the perception of a disincentive would be addressed 
by coupling treatment, compensation, and vocational 
rehabilitation and assessment and with periodic reevaluation. I 
believe that would address that perception.
    The perception, as you know, to be sort of short and blunt 
about it is that people who get themselves diagnosed with PTSD 
and then go off and collect a benefit for the rest of their 
life and we did not really find that to be an accurate 
perception, but it is there and has to be dealt with.
    But we really believe that if we come up with this holistic 
approach that really combines treatment, compensation, and 
vocational assessments and training and periodic reevaluation 
that will take care of the perception and it will also perhaps 
give us an opportunity to get some more insights on the disease 
of PTSD.
    As an aside, sir, I was not particularly satisfied that the 
body of literature on PTSD and the methodology that the VHA 
uses to diagnose it and the VBA uses to adjudicate the level of 
disability was necessarily sound. I believe that, speaking for 
myself now, I believe a whole lot more education and training 
is needed by the people that do it.
    I think you need to be sure that you have the right sort of 
clinician doing the diagnosis and you have the right sort of 
training in the adjudicator who tries to make a determination 
of, well, is this PTSD and, if so, how bad is it, and are there 
other co-morbidity factors like depression or maybe bipolar or 
something like that affects this, and then what should the 
treatment regimen be.
    The medical literature that we had access to differentiated 
between curing PTSD and making it better. In other words, there 
seems to be a general concurrence that it is treatable and that 
there will be relapses and remittances throughout a period of 
time, but it is treatable. And so that is where we were headed 
with our recommendations, sir.
    Mr. Michaud. Thank you very much.
    I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Michaud.
    Mr. Boozman, you are recognized.
    Mr. Boozman. Thank you.
    First of all, General, I want to thank you and the rest of 
your Commissioners for the outstanding job and all of the hard 
work. And I know that this was a lot of hard work and we really 
appreciate you all stepping forward and answering the call as 
you have so many times in all of your all's careers. So thank 
you very much.
    I have a statement that I would like to put in the record, 
Mr. Chairman, if that is okay.
    [The prepared statement of Congressman Boozman appears on
p. 36.]
    The Chairman. Thank you.
    And all Members may have any statements put in the record.
    [The prepared statements of Congresswoman Herseth Sandlin, 
Congresswoman Brown-Waite, and Congressman Salazar appear on p. 
    Mr. Boozman. Thank you.
    Let me just ask, do you agree with the VR&E's Task Force 
recommendation that the program should, and I quote, ``Place 
priority on disabled veterans who have the most serious 
disabilities that impact quality of life and employment?'' And 
if so, and I think you do, how do we implement that priority?
    General Scott. Well, we spent a fair amount of space in the 
report talking about vocational rehabilitation. And what we 
found is that the number of counselors is inadequate to ensure 
that the targeted 125 cases per counselor can be met.
    We found that the number of applicants and participants has 
increased, but the number of veterans who are successfully 
rehabilitated by VA standards has remained constant over the 
years and we are kind of puzzled about that.
    The conclusion that we made was that vocational 
rehabilitation is not accomplishing its goal, again, if you 
agree with us that the goal is to return the disabled veteran 
to as near a normal life as they can have both in the economy 
and as an individual.
    We made several recommendations to enhance the service to 
disabled veterans. In the report, they are on page 76, 77 and 
195. Some of the thoughts would be additional employment 
counseling and screening IU applicants for vocational 
rehabilitative possibilities.
    We recommended access to vocational rehabilitation for 
medically separated servicemembers, not just the tremendously 
disabled, but for all. We think that there should be some 
incentives to vocational rehabilitation and we spell them out 
in some more detail.
    And also, we were not convinced that there had been very 
much real research on employment among disabled veterans. A lot 
of it seemed to be just hypotheticals as to what the employment 
among disabled veterans is.
    Some of the data we turned up in our analysis and our 
surveys got at the different levels of employment in certain 
groups. For instance, as should probably come as no surprise, 
the disabled veterans with mental disabilities had a very low 
employment rate, whereas those with physical disabilities had a 
higher rate. And it varied based on the level of disability.
    So basically, the implementation of our recommendation is 
going to require some additional staffing and funding for the 
VR&E, but we really think that is a good place to spend some 
money in terms of getting people back into the society to the 
extent that it can be done.
    And also it may require some legislation because we think 
employment counseling should be expanded from what our 
understanding of the requirement for that is.
    Does that answer your question, sir?
    Mr. Boozman. Yes, sir, very much.
    The Commission noted that the VA does not collect long-term 
data on VR&E participants. Would you recommend that VA conduct 
a longitudinal study of voc rehab participants with regular 
reports to Congress on the outcomes of, you know, the cohort 
being followed? Is that something that you could support?
    General Scott. Well, we think it is something that the data 
should be gathered on. In other words, at the moment, it is too 
easy to declare this veteran is rehabilitated and then move on. 
And nobody ever goes back to see what transpired, how long did 
this rehabilitation last, was this converted into a long-term 
employment opportunity or was it just at the moment that the 
person was employed so they declared it a success and moved on.
    So that is why we think a longitudinal study would be quite 
helpful in determining what is the long-term effect of a 
vocational rehabilitation program.
    Mr. Boozman. Good. Thank you. And, again, thank you to all 
of your Commissioners.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman.
    And, General Scott, thank you so much and to all the 
Commissioners. I cannot tell you as a Member of this Committee, 
as a veteran, and as an American citizen who is concerned about 
this how pleased I am with the work you have done and how 
optimistic I am on this issue.
    The research that you did and the analysis is truly 
complex, but you did it in such a way that I am hoping, and I 
think everyone up here would agree, that we actually move 
forward on these critical issues because this is a very 
emotional issue.
    And I spent yesterday at a field hearing up in Mr. Hall's 
district, with Representative Lamborn, and it was on this 
disability claims problem. And the stories there are 
    A Marine Sergeant who was unable to get his benefit claim 
processed and during the time that he waited, approximately 3 
years, his life degenerated into substance abuse and bankruptcy 
and family problems.
    Once the claim process kicked in, once he started getting 
the help, once he started moving forward, this young Marine is 
moving his life forward and we know how critical that is.
    With that being said, and, as I say, I am optimistic on 
this and looking at this claims processing and backlog, your 
recommendation 9.1, I am looking at this and the report of the 
Veterans Claims Adjudication Commission talks about it is 
perceived as inefficient, untimely, inaccurate, and so on.
    I turn the page and I look at a task force here, a 
Processing Task Force for 2001 needs to be revised. I look at 
the Institute of Medicine. Says it is not efficient and fair. 
They deserve that. The Center for Naval Analysis and what the 
American public and what the veterans are seeing is the same 
old story again.
    You have done a fantastic job of pointing out things that 
need to be addressed, things that I think we all intuitively 
thought but needed the analysis to back it up in a 
comprehensive manual. It is here in front of us.
    I am looking at figure 9.1 on page 306 in here that shows 
me how we can reduce that claims backlog.
    General, can you tell me if it is you and you are telling 
Congress, and I know your recommendations are in here, but sum 
it up, can we get this done? Can we reduce this claim backlog? 
How specifically are we going to do that?
    And I can tell you that I can feel it from yesterday from 
Sergeant Lassos the impact of doing that is going to be 
immeasurable. So if you could walk me through that for just a 
second and talk to this Committee about how that is going to 
happen and the charge that you are giving to us and put that 
onus of responsibility on us to make this happen.
    General Scott. Well, first, the good news, sir. The VBA has 
been authorized to hire, I believe it is 3,000 additional 
adjudicators over the next year and a half. That is a start.
    Now, the question is, how quickly can they be trained to do 
the work? One of the real problems with the claims backlog is 
initial inaccuracies in the claims processing which results in 
appeal after appeal after appeal and it goes up to the Board of 
Veterans Appeals or the Court of Appeals for Veterans Claims. 
And it gets kicked all the way back down and it starts over and 
the file is either mailed or Fed-Ex'd from one of these 
entities to another. It cannot be done electronically at the 
    So it is more people in the right place. You know, as the 
cliche says where the rubber meets the road. Training and 
education and standardization of the claims processing process 
and the processors with the goal of reducing the errors that 
occur initially which just compound as it goes on and in many 
cases, that makes up what the problems are.
    The atrocious figure of the 800 plus days is for appeals 
claims. And for new claims that are in pretty good shape, it is 
still nothing to brag about, but it is somewhere in the 177 or 
something like that. But at any rate, we have to reduce the 
error rate that results in all these appeals.
    There are some possibilities for, and we mentioned in the 
report, best practices of business and some information 
technology. But it has been pointed out by the Dole-Shalala 
Commission IT is not the silver bullet. It would be a great 
assistance for the movement of these claims around, but it is a 
matter of best practices.
    And why can't an adjudicator open a claim on a computer, 
send that forward? Obviously there is some subjectivity 
involved because every person is different. But there is a lot 
of it that is not really subjective. So, you know, if they just 
get into best business practice, train people, keep them on the 
job, keep them doing the adjudication, I think that is probably 
as key as anything else is.
    Then, as you well know, sir, the judicial requirements as 
well as regulatory requirements get pretty complicated. The 
``Veterans Claims Assistance Act'' has, according to the Under 
Secretary for Benefits, in some ways slowed the process down 
because it caused them to do certain things that slow the 
process down.
    So let me give you an example. A veteran gets a letter and 
the first four or five pages is indecipherable legalese. 
Finally, on the last page, it tells the veteran what he or she 
has got to do. Surely we can come up with a letter that meets 
the legal parameters that tells the veteran in the first or 
second paragraph, hey, bud, here is what you have to do to get 
this thing moving and, you know, just things like that.
    Again, we made a lot of recommendations. But on the other 
hand, you know, what we think should happen is that the VBA's 
feet should be held to the fire since you have given them more 
assets of 3,000 more people and set up some goals for reducing 
it and then help them legislatively as they come forward with 
legitimate requirements or legitimate things that would help 
the process.
    But, a lot of it is inside the VBA and I have had this 
conversation with VA and with the Under Secretary for Benefits. 
And they agree. So it is really multifaceted. It is people. It 
is training. It is standardizations. It is best business 
practice. It is finding those documents and processes that can 
be simplified and still stay within the law or change the law 
in some cases to make it a little bit easier to do.
    But right now it is so complicated that it is a wonder to 
me that anyone is ever able to get a claim processed.
    Mr. Walz. I agree. Well, thank you, General. And you can be 
sure that those recommendations are going to sink in up here 
and we want to see it too. So thank you.
    I yield back, Mr. Chairman.
    The Chairman. Thank you.
    Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you very much.
    And thank you, General, and all the Members of your 
Commission for putting together a very good report.
    Your comment on the initial inaccuracy reminded me of a 
case that I was involved in my district where I swear those 
raters once it was stamped as rejected that all the way down 
the line, nobody opened up that folder where that initial error 
was made.
    And when I read through it, and I saw the man and know him, 
I said this is absolutely wrong. I think that happens far too 
many times. It is almost like maybe we should mandate that they 
sign their initials at the bottom that they actually read what 
is in the folder. You know, maybe it is the college professor 
in me coming out, but that happens, I am afraid, far too often. 
And I appreciate your addressing that.
    On page six of the summary, you indicated that you did a 
survey of disabled veterans and survivors. What was the number 
of people who were actually surveyed and what was the error 
    General Scott. Okay. We surveyed 21,000 people.
    Ms. Brown-Waite. Wow.
    General Scott. Twenty-one thousand veterans. And 1,800 
    Ms. Brown-Waite. What was the return rate because I am sure 
if it was a mailed survey----
    General Scott. It was a telephone survey. Let me tell you 
how we did this. The Center for Naval Analyses contracted with 
a company that does telephone surveys and we provided or they 
were provided a list of veterans in certain categories so that 
we were not skewed by either age or geography or particular 
ailment or anything like that. It was across, and I think the 
report explains pretty much, all the different----
    Ms. Brown-Waite. So it was a good survey?
    General Scott [continuing]. Categories that were surveyed.
    Ms. Brown-Waite. Right.
    General Scott. And so that was what was done. And we wanted 
a 95 percent confidence level in the results of the survey and 
so that is why we had to go to such a large number of people.
    Ms. Brown-Waite. The finding that physical disabilities did 
not lead to decreased mental health, was the question asked, 
you know, are you on obviously pain medication because, you 
know, anyone on pain medication usually is pretty happy? Was 
that follow-up question asked?
    General Scott. Well, you know, I will have to furnish that 
for the record. I reviewed the survey. The Commission reviewed 
the survey before it went out and we made sure that we all 
agreed that it was asking the questions that we thought were 
    [The Commission survey results appears in Enclosure 1 in 
the post-hearing questions for the record, which appear on p. 
    I cannot remember exactly where we were on that, but I will 
say this, that broadly speaking, we determined that the people 
that had mental disabilities had poor physical health.
    Ms. Brown-Waite. Right.
    General Scott. Another reason for why we need to do a 
better job of analyzing and treating these people so we can 
improve their physical health as well.
    However, the reverse was not true, that the people with 
physical disabilities did not have more than expected mental 
    Ms. Brown-Waite. Right. So I think the natural follow-up 
question would be, are they on medication because anyone who 
has suffered, say, back pain without medication, you are pretty 
darned depressed.
    My next question is, one of the recommendations that you 
make in your testimony and in the summary that we have involves 
increasing disability compensation payments by 25 percent until 
a systematic compensation methodology is developed. How long do 
you think that this methodology will take to develop? Why has 
it not ever been developed before? And do you know how much 
this 25 percent increase would actually cost?
    General Scott. Let me see if I can start with, again, there 
has been since the Bradley Commission study comments and 
general statements that quality of life should be a 
consideration in compensation.
    The best example is a wheelchair-bound veteran who is able 
to work in the economy, but none of us would willingly trade 
places with that individual because we all know intuitively 
that he has a different quality of life based on the 
    So there has been a lot of discussion about how do you look 
at that, how do you consider disability or how do you consider 
the quality of life as disability. The Dole-Shalala Commission 
studied the same thing and they made the recommendation that a 
study be put together with Congressional oversight to determine 
how best to address the issue of compensation for quality of 
    It is hard for me to estimate how long it would take to do 
that. Certainly if the legislation that gets through has that 
as a requirement for a study, I would hope there would be some 
sort of a time parameter placed on it. And that is a better way 
of determining how to compensate for quality of life than an 
across-the-board increase. We would agree with that.
    But these things have a way of going on and on and on. And 
so particularly and I mentioned that it is up to 25 percent. It 
was not the intent of the Commissioners to say that everyone 
with a 10 percent disability should have a 25 percent increase 
in compensation based on quality of life because clearly the 
degree of disability would have a lot to do with the impact on 
quality of life.
    So we put together a hypothetical as to how that might be 
and let me see if I can get back to them here.
    Ms. Brown-Waite. And did you cross those out?
    General Scott. Pardon me?
    Ms. Brown-Waite. Did you cross those out?
    General Scott. I did or we did. The hypothetical that we 
put together said that a 100 percent disabled person who is now 
receiving $2,393 in individual compensation per month, with a 
quality of life increase of 25 percent, that would be about 
$598 and that would raise them to $2,991.
    Going to the other end of the scale, a 10 percent disabled 
person who is receiving $112 a month, we suggested that the 
quality of life for that person might be 2\1/2\ percent, which 
would be an additional $3 a month.
    So, again, we scaled this out on this hypothetical based on 
the degree of disability, percentage of disability. And the 
particular hypothetical that we ran here showed that the annual 
quality of life compensation additive to the $19 billion 
compensation as it exists now would be $3 billion in rough 
    And we will be happy to furnish you a copy of this 
hypothetical. We will certainly furnish it for the record.
    [The Hypothetical Example appears in Enclosure 2 of the 
post-hearing questions for the record, which appears on p. 56.]
    Now, obviously if you decided that you wanted to give 
everybody a 25 percent quality of life kicker, it would be a 
significantly greater sum. But we said it should be based, we 
thought, on the degree of disability. And we said up to, so, it 
might be that after your deliberations, you came out with 
instead of 25, it was 15 percent.
    But what we said was up to 25 percent on a temporary basis 
until a study could be put together to try to better determine 
how to compensate for quality of life which has been an issue 
that has been talked about and talked about and talked about 
over the years.
    And so we came up with a methodology, you could say a sort 
of rule of thumb methodology to use until this is done. And 
arguably, if the study were done well and quickly, it might 
come up with results that would obviate the necessity for this 
particular kicker.
    Ms. Brown-Waite. Thank you, General.
    I yield back.
    The Chairman. Thank you.
    Mr. Hall. And we thank you for the hearing you held 
yesterday, I guess----
    Mr. Hall. That is right, Mr. Chairman.
    The Chairman [continuing]. In your district on these 
issues. And I understand Mr. Walz was there and Mr. Lamborn, 
and they said it was a very moving hearing in addition to the 
helpful information that came out. So if you can inform us 
about that.
    Mr. Hall. Thank you, Mr. Chairman. Yes.
    And thank you, General, and to all your Commissioners also 
for the work you have done.
    We have a lot of reading to do and I was wondering is this 
entire report available on the Web site?
    General Scott. It is. It is on the Veterans' Commission Web 
site and it will be moved to the VA Web site at some point. So 
the entire report is indeed on a web site.
    Mr. Hall. That is really good news.
    I have only a couple of questions----
    General Scott. Yes, sir.
    Mr. Hall [continuing]. Having not read the report yet. But 
under your eight principles, the second one, the goal of 
disability benefits should be rehabilitation and reintegration 
into civilian life to the maximum extent possible and the 
preservation of the veteran's dignity.
    We had a veteran at the hearing that Congressman Walz, and 
Congressman Lamborn attended with me yesterday who was 
suffering from a Traumatic Brain Injury, a Marine sniper who 
was in a coma for a while and they wondered whether he would 
    And he has not only survived, but he has recovered the use 
of his left arm and is speaking and, you know, what is going on 
inside really seems like it is all there, although the 
reconnection to his physical body is a process that takes 
rehabilitation and therapy, speech therapy and physical therapy 
and so on.
    And he is a year and a half past the injury now. His 
neurosurgeon says this is the most critical time, that, you 
know, the progress that can be made in this case as in the case 
of stroke, for instance, is descending with time and you want 
to get as much therapy and as much stimulation of the right 
kind as soon as possible.
    And there has been sort of a battle going back and forth 
between his parents and the VSOs have been working with him and 
the VA office that they are working with. His neurosurgeon 
suggests and neuropsychologist suggest 5 days a week, 4 hours a 
day of therapy. And the VA is saying 2 days a week, 40 minutes 
a day of therapy.
    So they have that back and forth thing. The parents say 
that every time he is reduced, his therapy is reduced, they can 
see him backsliding.
    I know he was wheeled up to the witness table in front of 
us and I saluted him. And he said do not salute me, I am not an 
officer. And I said I am saluting your courage and your 
sacrifice, sir. And he said, okay. He winked at me.
    So, you know, there is a lot going on in here and he can 
grab you with his left hand really hard. And they said he would 
not be able to do that.
    So in the spirit of the goal being rehabilitation, 
reintegration into civilian life to the maximum extent 
possible, I am wondering how many cases like this there are 
and, you know, whether your Commission talked about in the 
context of TBI cases whether there was a plateau for treatment 
at which you would say there is no point going beyond such and 
such a time.
    General Scott. I do not have a current figure for the 
number of diagnosed TBI cases, but we will get it supplied for 
the record.
    [Commission follow-up information regarding the number of 
TBI disabilities appears in Enclosure 1 in the post-hearing 
questions for the record, which appear on p. 49.]
    The Commission also had the great privilege of hearing from 
disabled veterans who were suffering from TBI and hearing the 
trials and tribulations they went through regarding both 
medical treatment and therapy that followed. And it had quite 
an impact on us and on our recommendations.
    And that is one of the reasons that we went after 
Vocational Rehabilitation and Employment Service pretty hard. 
We think that by spending a few more dollars and taking a hard 
look at eligibility, as one of the other gentlemen mentioned a 
while ago on VR&E, that we can do more for these people. And as 
you point out, sir, that every one of those cases is a little 
bit different. And so we certainly do not agree that a cookie 
cutter approach of so many days or so many minutes is fitting 
for all the cases and it would be the Commission's view that VA 
is going to have to individually tailor the treatment for these 
    And in some cases, where they are nowhere near a VA or DoD 
facility, they are going to have to do it through the fee-based 
or the outsourced medical system. There has got to be a 
provision so that VA can pay for civilian care for people who 
cannot get it because of where they live or whatever. And so we 
took somewhat of a look at the fee-based system and we had some 
recommendations in that regard as well.
    But truly, every one of these cases are individual and has 
to be treated individually. And so I believe we have brought to 
VA's attention that needs to be done and we hope to bring to 
your attention that in some cases, it may be necessary to 
either target funding for these sorts of programs or in some 
way ensure that these vocational and these other rehabilitative 
efforts are properly managed and funded by VA.
    Mr. Hall. Thank you, sir.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Bilbray.
    Mr. Bilbray. Yes, Mr. Chairman.
    Let me just say frankly, General, congratulations. I have 
seen a lot of reports and as far as we have been able to review 
this, it is one of those unique times where we get a report 
that is frank, tough, but fair. And I want to just congratulate 
your entire team and the Commission addressing this issue.
    And hopefully we will be able to take this information and 
turn it into something positive and actually rather than 
sitting around talking about it like so many of us here in D.C. 
do so often, we will be able to put together something that 
actually will help to implement the strategy that you have 
highlighted in this report. So thank you very much. I 
appreciate it.
    And I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Bilbray.
    Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman.
    And thank you so much for all the work that you and the 
Commission did, General. I know it took a lot of time and a lot 
of thought went into it.
    I wanted to get your thoughts on an idea here. We were 
talking about the backlogs and you talked about the 3,000 new 
people being hired over an 18-month period and, you know, to 
simplify the letter so that people do not get caught in this 
    There has been some discussion about when the veteran files 
a disability claim, why err on the side of the VA. Why not 
process the claim and then if we want to take a look at it, 
similar to what we do with an Internal Revenue Service (IRS) 
return, why do we not just go ahead and audit the claim because 
the vast majority of veterans, I would say 99.999 percent, are 
not going to try to take advantage of the system?
    And it seemed to me that is a real effective way. My fear 
is, and this is one question, I have two for you, my fear is 
that by the time we get these 3,000 people up and trained and 
moving in an 18-month period, this backlog is going to get 
worse before it gets better and we are going to be losing some 
people through retirement, so really that number of 3,000 may 
be significantly less.
    I just wanted to see what you thought about the possibility 
of being able to say, look, if the veteran files this claim, 
why do we not process the claim because ultimately the way I 
understand it, if the claim is accepted, we have to pay 
retroactive anyway. So it is not going to cost us any 
additional funds.
    Secondly, if the veteran passes away in the middle of this 
process, I believe we had some people testify that person's 
spouse has to start all over again at square one which to me 
seems to be very disingenuous because they have gone through 
all this process, they could be here for 5 to 6 years, and now 
they have to start all over again. So that would be one 
    Then my second question to you is, using the single rating 
formula, I know you talked about this and you may have in your 
opening statement, I apologize for being late, to rate mental 
conditions with conditions like TBI and Post Traumatic Stress 
Disorder coming back with significant frequency, do you have a 
problem or do you see where we could have a problem with this 
one-size-fits-all approach in terms of being able to handle 
mental conditions and is that a disservice that you think we 
are giving to our returning soldiers because if we are only 
going to use the one rating system and you have two very 
distinct types of problems here? So I just wanted to kind of 
get your thoughts maybe on both.
    General Scott. Well, let me try to answer your second 
question. What we hope to achieve with our recommendations 
regarding mental issues, as they relate to the rating schedule 
was we determined, and I believe that the VA essentially agrees 
with us, that the present rating schedule lumps together 
virtually all mental issues to include TBI, post traumatic 
stress syndrome, and other mental disorders.
    And we suggested as a matter of priority in fixing the VA 
rating schedule that the schedule address those separately in 
such a way to make it easier for the clinicians to properly 
diagnose what is wrong with the person because they basically 
now are required to follow the VA rating schedule. And the same 
with the adjudicators who have to determine what is the level 
of disability.
    So we think it is very important to separate the post 
traumatic stress, Traumatic Brain Injury from other mental 
problems and to have a set of standards and the schedule that 
enables them to properly sort that out so that you know what it 
is you are talking about. And part of that is the clinician has 
got to be able to determine what the problem is, which is a 
training and experience problem. And then the adjudicator has 
to be able to evaluate what level of disability is there.
    Does that get at your second question, sir?
    Mr. Hare. Yes, it does. Thank you.
    General Scott. Okay. And I am sorry, sir. Do you mind 
telling me again what your first question was?
    Mr. Hare. Well, I am new on this Committee. I understand 
that. But I was sitting with Congressman Joe Donnelly and we 
were having coffee one time. We were just talking about wait a 
minute, it seems to me we should be erring on the side of the 
veteran on these disability claims. If we are really going to 
fix the backlog, we can throw more people into the process on 
adjudicating the claim.
    General Scott. Right.
    Mr. Hare. But ultimately if we are going to pay the claim 
out and we trust our veterans, and I certainly do, to submit 
these, why do we not start the claim process and then if we 
want to audit the claim, we treat it like we would when 
somebody files their taxes? So I guess my point is erring on 
the side of the veteran and not the VA.
    General Scott. Uh-huh. Well, we discussed not in great 
detail the work that a Harvard professor, and I cannot recall 
her name right now----
    The Chairman. Bilmes. Professor Bilmes.
    General Scott. Bilmes did and she recommended exactly that, 
that if a veteran comes in and claims a disability, that it be 
stamped approved and the payments start immediately. And then 
at some point later down the line, it would be looked at again.
    And, you know, I think I am speaking for the VA position on 
this as they are very concerned that they would have a very 
difficult time going back and dealing with the claims that were 
either unjustified or that were tremendously overrated during 
that initial process and all of that.
    So I think it is a matter of a view that it might not be 
the best stewardship of the taxpayers' money to just pay claims 
whenever somebody came in and made one rather than try to make 
at least some sort of an attempt to adjudicate what sort of a 
level it would be.
    Now, we did not study that in great detail, but, you know, 
it might be that is something that you would want to commission 
VA to take a look at and see.
    But, again, sir, I think part of the answer is simplifying 
the claims process, the paperwork, getting more trained people 
on the job, cutting the error rate which one of the Members 
mentioned earlier that was a significant problem on individual 
cases and has contributed to the backlog.
    But, you know, I am speaking now for myself and not the 
Commission. You know, there is certainly nothing wrong with 
studying the idea of paying claims when submitted.
    The VA's concern about it is could they ever go back and 
audit it. And VA has had significant difficulties, they tell 
me, in ever going back and recouping money or adjusting ratings 
    Now, my understanding is that there are some either legal 
or regulatory rules in place that after a certain period of 
time that the level of disability cannot be reduced.
    Mr. Hare. I know my time is up, but I just wanted to say 
one thing with regard to that.
    We have had the VA here and they have said the average now 
is 177 days.
    General Scott. Right.
    Mr. Hare. And what they hope to do is get that down to 145 
days. For that veteran and his or her family that is really 
dependent upon that disability, you know, if that is the goal, 
I think they better shoot a lot lower than 145. And, you know, 
I just think that we need to do better.
    But I want to just say again I thank you for everything you 
have done and your Commission. It is a wonderful report and I 
hope we can get to the day where we can err, again, as I say, 
on the side of our veterans and not the bureaucracy that goes 
along with it.
    So thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Hare.
    Mr. Donnelly.
    Mr. Donnelly. Thank you, Mr. Chairman.
    And, General, thank you so much for all your hard work on 
    As Mr. Hare was saying, we have had some discussions about 
this disability claim process and here is my concern is when 
you come back and you still have a mortgage to pay, you still 
have car payments to make, your children do not stop needing to 
be fed, and 177 days later, they are starting to crack open the 
claim and see what we can do. Well, for that 6-month period, 
the mortgage people do not go away and the car payment people 
do not go away.
    And so there is a need to get this right from day one. And 
as Mr. Hare was saying, you know, they tell us, well, we can 
move this from 177 days to 144 days. Well, it puts a number of 
veterans in an almost impossible situation as you can imagine.
    I had a chance again last night to talk to then Secretary 
Nicholson and even he supported for a pilot program for Iraqi 
veterans, Afghanistan veterans, that we take a look at this 
payment from day one, audit the claims. And, you know, I think 
our feeling here is that auditing the claims and if they are 
wrong to adjust them that is the right thing to do. We do not 
think we will be in a position where we say, well, that is not 
fair. The claim is the claim.
    And I know one of the things Mr. Nicholson had or what was 
being discussed was when that claim is put forward, make a set 
payment of a 30 percent disability from the start so it does 
not get out of hand.
    What would you think about that kind of idea?
    General Scott. As a Commission, we really did not study the 
notion of paying up front. But from a personal point of view, I 
could not object to doing it as long as it was some sort of a 
pilot program and as long as it was some sort of a set percent 
that the Congress felt comfortable with in terms of doing that.
    Now, we did make a recommendation that transition payments 
should be made to tide people over through these periods of 
time. And I believe the Dole-Shalala Commission made basically 
the same recommendation that we should offer a transition 
payment that was based on the soldier's or the servicemember's 
monthly payment for a period, and in some cases, it was 3 
months, in some, it was 6 months, to get away from this period 
of absolute destitution for somebody.
    And then also there is the Benefits Delivery at Discharge 
(BDD) Program that if properly advanced at more locations would 
also get the ball rolling a good bit quicker on it.
    A number of the cases that we did examine, and I will be 
perfectly honest with you, we did not study a lot of individual 
cases, we had people that were representative of different 
issues and problems come before the Commission where we talked 
to them. But a number of the problems that we did talk about 
were people who had not filed a claim until well after they got 
out either because they did not know how or they could not or 
something like that. And that has exacerbated the problem by 
making the process longer.
    I would be the first to agree with you that reducing the 
time from 177 to 145 days is not the answer and it should be 
more like 60 to 90 days it would seem to me at the very most to 
get it done.
    Again, I do not know, speaking for myself and not the 
Commission, I do not know that I would have any personal 
problem with some sort of a trial program.
    You know, I think that the VA as an institution has been 
beat about the head and shoulders from so many different 
directions and so many different people that the notion of 
trying something new is met with a fair amount of skepticism 
because they are afraid that at the end of the day that they 
will be left holding the bag on it.
    And so, you know, I am hopeful that a new Secretary will 
come in with some ideas on how to look at some of these 
problems and I hope that new Secretary's relationship with the 
Committees and with the Congress is such that he will be able 
to get some support for some things he wants to do.
    But the notion of paying some people at a relatively low 
rate, 30 percent, just to get the ball rolling is certainly 
something that I have no personal objection to. And I guess if 
we were doing this Commission again, we would probably try to 
do something about it.
    But I think it can be studied in a relatively quick way by 
the VA and maybe a couple of outside agencies to determine what 
are the parameters of something that could make it work so that 
it would not be a headline grabber around town here that, you 
know, VA gives away money without proving claim or something 
like that. I think if it were done properly, it could probably 
be done.
    Does that answer your question, sir?
    Mr. Donnelly. Yes, it does, General. And thank you very, 
very much for your service to our country. We are deeply in 
debt to you.
    The Chairman. Thank you, Mr. Donnelly.
    Ms. Herseth Sandlin.
    Ms. Herseth Sandlin. Thank you, Mr. Chairman.
    Thank you, General Scott, for your hard work and that of 
your fellow Commission members.
    And as the Chairwoman of the Economic Opportunities 
Subcommittee, I wanted to explore a couple of areas with you 
specific to the jurisdiction of that Subcommittee, one that I 
believe the Ranking Member, Mr. Boozman, did talk with you as 
it relates to VR&E benefits. And I may get to that at the end 
of my questioning.
    But if we could talk about specially-adaptive housing for a 
moment, I was particularly interested to review the 
recommendations for the Specially-Adaptive Housing Program. I 
agree that the program has failed to account for the rising 
construction costs that we have seen across the board and we 
have introduced legislation to try to correct that as it 
relates to adjustments for inflation and the overall amount 
that a veteran can receive for the housing modifications.
    You did explain in the report that severe burn victims are 
not eligible for the program. And at one point, a constituent 
of mine was told or his wife was told as she was filling out 
all of the paperwork necessary to receive the grant, kind of 
informed on an informal basis that, well, you know, if he uses 
a wheelchair at all, you should simply note that he is 
wheelchair bound because that essentially enhances the 
likelihood that he will be eligible for the grant.
    Now, you know, as he is undertaking his physical therapy, 
you know, there is the hope that at some point, he will not 
need any type of mobility device.
    But did you uncover any other area where you feel that 
there are deserving disabled veterans who are not qualified, 
who are not eligible for the specially-adaptive housing grants?
    General Scott. Well, I think we did address that 
specifically with the burn victims. And to the best of my 
recollection, we did not encounter any other Catch-22s, you 
could say, where a severely disabled individual for whatever 
reason did not meet the qualifications. But that is not to say 
that there are not some others out there.
    But the burn victim thing became readily apparent to us as 
we worked through it as did the fact that we recommended that 
you take a look at the adaptive housing allowance based on the 
    Now, we looked at, as you may have noted, all these 
different allowances with all the special compensations and 
some of them interestingly are connected to a cost of living 
adjustment (COLA), an annual COLA, and some are not. And it did 
not appear to us that there was a lot of rhyme nor reason to 
which ones were and which ones were not, which ones were only 
updated by legislation and that would tend to be on a less than 
periodic basis.
    So, you know, we had some questions in our own mind as to 
why some of them were treated in one way and some another. And 
so we tried to point that out. We pointed out the anomalies in 
the report and that was certainly one of them, ma'am.
    Ms. Herseth Sandlin. Well, thank you. And thank you again 
specifically for addressing the issue of severe burn victims 
and the current status of ineligibility for the Specially 
Adaptive Housing Program.
    And we have uncovered in a Subcommittee hearing that even 
the building specification document has not even been updated 
for this program since, I believe, the mid 1970s. So I think we 
have a lot of work to do to make it a program that can be 
better utilized by many of our returning servicemembers.
    On Traumatic Servicemembers' Group Life Insurance (TSGLI), 
you outlined in your report that most instances, TSGLI has 
become the intended financial bridge from the time of injury 
until the soldier is eligible for VA benefits. And you 
explained that the April 2007 Independent Review Group report 
recommended that the Secretary of Defense should review TSGLI 
to include TBI, Traumatic Brain Injury, and Post Traumatic 
Stress Disorder.
    Now, while many TBI-related injuries are covered, PTSD is 
not. I believe you may have stated it in the report, but do you 
support providing the TSGLI to those suffering from PTSD and 
would you make the benefits retroactive?
    General Scott. I do not think we addressed that. And, you 
know, my understanding of that particular legislation is that 
it was not intended that it include something like PTSD, that 
it was for the more traumatic type injuries that were readily 
discernible and all that.
    And as you well know, the problem with PTSD is it can be an 
immediate onset or it can be delayed for a long period of time 
and it can remit and relapse and on and on. So I did not 
really, again speaking for myself and not the Commission, I 
really did not categorize PTSD in the same way that I did the 
TBIs and the traumatic amputations and the other disabilities 
that fall under TSGLI.
    Ms. Herseth Sandlin. Thank you.
    And with the indulgence of the Chairman, I would just note 
that on page 352 of the report, the Commission did suggest that 
Congress mandate Transition Assistance Programs (TAP). And I 
agree with you. I agree with the Commission's recommendation.
    And at the very least, as we transition to try to provide 
adequate funding for all of TAP, we should at the very least in 
light of the importance of all the programs, but VR&E in 
particular for service-connected disabled veterans, mandate the 
Disabled Transition Assistance Program (DTAP) for disabled 
veterans who are separating from service.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Ms. Herseth Sandlin.
    Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    General Scott, I certainly want to thank you and the 
Commission for developing this comprehensive report and for 
leadership in this endeavor. It is a big need.
    And I certainly hear a lot from the veterans in my 
district. One of things you have discussed here this morning is 
the claims delay, so I look forward to trying to implement 
these recommendations.
    One of the things that concerns me, of course, was just 
mentioned, is the Post Traumatic Stress Disorder and Traumatic 
Brain Injury. Do you think as a part of a holistic approach 
that we need more inpatient PTSD treatments or do you think 
that the current approach is more effective and is there a need 
for more research in terms of effective PTSD treatments?
    General Scott. Well, let me start off by saying that I 
certainly think there is a need for more research. One of the 
reports that we were not able to take any benefit of because it 
did not get completed, an IOM report, regarding PTSD treatment.
    And I would commend that report to you when it is 
completed. It is actually being done on behalf of VA, but we 
hope to be able to utilize it in our deliberations as well. So 
I would recommend taking a look at it.
    But the Commission's view was that VA really did not know 
as much as it needed to know about PTSD and part of that again 
is we do not have a lot of confidence that the clinicians who 
are making diagnosis were qualified and experienced to do that. 
We do not have a lot of confidence that the adjudicators that 
were establishing levels of disability for PTSD were qualified, 
trained, and experienced to do that.
    So the answer is, yes, there needs to be a fair amount more 
of research done so that VA can state with some authority and 
some research to back it up a little bit more definitively what 
should be done about PTSD as it appears in veterans.
    Did I miss part of your question here, sir?
    Mr. McNerney. Yes. Do you think there is more need for 
inpatient treatments?
    General Scott. We really did not study the need for 
inpatient versus outpatient. A lot of what we did look at was 
the role of the Vet Centers and other what you might call 
outpatient treatment activities. And basically what our concern 
was that there was not a lot of treatment going on.
    Now, I think there are 340,000 people that have been 
diagnosed with PTSD and about 240,000 of them are receiving 
some sort of compensation. But it is not for sure how many of 
those are receiving any treatment at all and, if so, how much 
and is it the right sort of treatment.
    So I do not think I can say definitively there should be 
more or less inpatient vis-a-vis outpatient, but I think there 
probably needs to be, as I said earlier, this connectivity 
between compensation, treatment, vocational rehabilitation, and 
reexamination if we are to achieve our goal of reintegrating 
the veteran into society to the maximum extent possible.
    So I guess I punted your question. I do not think I have an 
answer should there be more inpatient treatment facilities. I 
will ask and try to get you a response to that question, sir, 
but I do not think it came up in our research.
    [The information regarding inpatient PTSD treatment appears 
in Enclosure 1 in the post-hearing questions for the record, 
which appear on p. 49.]
    Mr. McNerney. Thank you, General.
    Another question of concern is complementary alternative 
medicine. I have not really studied the report yet, but do you 
think that we should provide veterans with a mechanism to have 
access to complementary medicine if they feel that is a need or 
if their physician thinks that is a significant need?
    General Scott. Sir, we did not address that. We looked 
largely again at healthcare sort of in the whole as a very 
important disability benefit. And then because of the concern 
and interest of all of the Members and VA and everybody else, 
we took a harder look at PTSD.
    But I do not think I am qualified to comment on the 
complementary care as an issue. I will try to find out what the 
current policy is and get that over to you at the VA because, 
quite frankly, I do not know what it is right now.
    Mr. McNerney. Okay. Thank you, General.
    I will yield back.
    The Chairman. General Scott, thank you so much for being 
here. Your command of the issues is impressive and also your 
humbleness when you do not know something. And I appreciate 
that separation.
    Now, Mr. Wilburn, I am sure your efforts were enormous and 
we thank you also.
    I personally found your discussion both of mental health 
and employability very, very important. These are major areas. 
It is sort of a cultural change. It is hard to legislate. But 
the focus of a system on that is very, very important. We thank 
you for adding your voice.
    Two areas where I thought you might have gone I will say 
more radical or more comprehensive. Number one, on the so-
called presumptive issues.
    General Scott. Right.
    The Chairman. And I do not know if I heard you right or if 
it is explained in the body of the report, but you said that, 
say, for Agent Orange, that has been done, we accept it. And I 
do not think that is true. In fact, a major problem that 
Vietnam vets still have is fighting the system for ailments 
which they are convinced are related to their service in 
Vietnam. And by law, there is a limit on the presumptiveness of 
a whole range of things.
    And, on the issue that Mr. Hare and Mr. Donnelly raised of 
accepting things, maybe the pilot ought to be with Vietnam 
vets. We want to honor the returning vets, but I will tell you 
that the older veterans are so frustrated and so, I do not 
know, just very--they feel victimized by the system for years.
    For example, I was in Illinois. It was Mr. Hare's district, 
I guess. No. It is Mr. Walz's district, I think, where the 
couple that had Parkinson's, is it, and I was handed a list of, 
I do not know, 500 veterans, Vietnam veterans who had 
Parkinson's in their early fifties which is, I do not know, a 
decade or more where, you know, you should get that.
    And it was clear that this had to be related to Vietnam. 
And, yet, by law, which we have introduced a bill to change, 
you could not be compensated for either--it was specifically 
for Parkinson's or Lou Gehrig's disease. And I say, hey, if you 
served. I mean, the presumptive tests are you have to put your 
boots down in a certain place and have a certain, you know, 
prove that the chemical was there at this time.
    It is so burdensome that I think we should just accept the 
presumption. If you were in Vietnam, we treat you. You served 
us, we serve you.
    So I do not know if I misheard you or I took it too far, 
but I do not think that presumptive issue has been solved at 
    General Scott. Well, I may have in an effort to be brief 
overstated the Vietnam reference. But what I had hoped to say 
was that the current law or current way of determining 
presumption does not have as much science or medicine in it as 
it probably ought to and that in some cases, for some ailments 
including radiation ailments and some of the Vietnam-related 
Agent Orange issues, presumptions have been made.
    The Chairman. I understand. It has not gone far enough.
    General Scott. So I did not mean to imply that it covered 
all valid or worthwhile presumptions, just certain ones. And I 
think type two diabetes is one of them and there are some 
others that the presumption does cover.
    The Chairman. Right. I understand. There is a whole range 
that it does. And I hope that before this Congress is over, we 
address that.
    The other issue that I again had wished for a more radical 
approach that Mr. Hare and Mr. Donnelly brought up, and I am so 
glad our new Members are taking this, they have not been beaten 
down yet by the bureaucracy and telling us we cannot do this. I 
mean, to have more people and more time, obviously you are 
going to bring down the backlog, but it is not fast enough and 
it is not complete enough. And as was pointed out, we could 
probably fall behind while we are trying to improve it.
    I think we have to cut through the bureaucracy very quickly 
and do it soon. And whether it was Professor Bilmes' approach 
similar to the IRS, of accepting claims subject to audits--by 
the way, I would add, I think a suggestion to deal with your 
sense of accountability is that if a claim was submitted with 
the help of a properly trained officer either from one of the 
VSOs, they have, you know, service officers, the counties, 
States, and I do not know that they are all equally trained, 
but we could set that up and certify them and if the claim has 
been helped by one of those certified officers, then we can do 
what was suggested except it is subject to audit in addition.
    [Follow-up information from the Commission regarding 
immediate processing of claims subject to post award audits 
appears in Enclosure 1 in the post-hearing questions for the 
record, which appear on p. 49.]
    So I think you can put some accountability in there to 
really get this claims thing down quickly because none of us 
can go to a town meeting without hearing such a sense of 
frustration and fighting the bureaucracy sometimes does more 
harm to the physical health, let alone the mental health of the 
veteran, more than the original ailment probably did. That is, 
we have to stop this adversarial approach where they have to 
prove every little detail and every little place, you know, if 
your boots were not on that ground at that time.
    So if we have to do a pilot program, I do not know if we 
have to, but I might start with those Vietnam vets because we 
owe them so much and we did not treat them with the respect or 
honor they might have had or recognize the mental health issues 
or, of course, for years, they denied that the Agent Orange was 
even a possibility, you know, the causation.
    So I think we would like to take those two areas dealing 
with breaking through this 600,000 backlog. And I understand 
there has been more than 300,000 new claims filed by our Iraqi 
    So you have given us a real good start. It is really 
important that your prestige and the incredible work that you 
all have done on the Commission for a couple years is going to 
give us the sense, and will prove to our colleagues, that what 
we are doing is the right way to go.
    And I accept the charge that you have made, but, you know, 
I am sure you feel from all of us on both sides of the aisle in 
this Committee that we will pursue these recommendations. We 
will try to get enacted as quickly as possible those that can 
be accomplished by legislation and then try to deal with the 
cultural issues with any new leadership that comes to the VA.
    So, General and all of your Commission Members, Mr. 
Wilburn, thank you so much for everything.
    This Committee will be adjourned. Thank you.
    [Whereupon, at 11:51 a.m., the Committee adjourned.]

                            A P P E N D I X


                 Prepared Statement of Hon. Bob Filner,
             Chairman, Full Committee on Veterans' Affairs

    The Committee on Veterans' Affairs will come to order. I would like 
to thank the Members of the Committee, Chairman Scott, and all those in 
the audience for being here today.
    Chairman Scott, let me begin by saying that you, your staff and the 
experts on whom you have relied have done a yeoman's job in producing 
this report and you have honored the call to duty.
    After convening over 50 public business sessions with interested 
stakeholders, the final report is a culmination of 2 years of assessing 
of our Nation's system of compensation and assistance for veterans and 
their survivors and dependents.
    Your mission was an arduous and daunting one--to examine the way 
our benefits systems operate and to provide recommendations on how to 
make the delivery of these benefits and services work better--in a way 
that represents the tremendous sacrifices that our men and women in 
uniform have made.
    As most in this room know, the Commission is a construct of 
Congress, conceived in the Defense Reauthorization Act of 2004. Borne 
primarily out of recognition of the impact that the current conflicts 
of Operation Enduring Freedom and Operation Iraqi Freedom would have on 
VA/DoD resources, it was our hope that you would provide 
recommendations to increase the efficiency and effectiveness of 
providing benefits and services to our veterans and their dependents 
and survivors in a manner that truly reflects the dignity of their 
service to our country.
    To do this, you had the wisdom to know that not only would you need 
to commission studies by the IOM and the Center for Naval Analysis 
Corp., but that you would need to be multi-prospective--looking to the 
past, present and future--to try to fix a system that has suffered from 
serious internal flaws for decades. So you took a look at the 
collection of good ideas that have accumulated over the years, from 
those contained in the Bradley report, to Dole-Shalala and the 
President's Commission Reports, and numerous IOM and Center for Naval 
Analysis reports, to inform your 114 recommendations.
    After the discovery of the conditions at Walter Reed and the many 
reports on the growing backlog at the VA, there are now many resources 
and ideas for the VA to tap about how to best administer its benefits 
and healthcare programs. But this report is unique, because it 
synthesizes these great ideas to provide a roadmap for moving forward.
    I believe that just as we did in the 90's when Congress, the 
Administration, VSOs, veteran advocate organizations and other 
stakeholders, partnered to place greater emphasis on turning the VHA 
into a world-class, technologically adept entity, we must devote the 
same resources and brain power to turning around the VBA. It must 
become a world-class, technologically adept, 21st Century organization.
    I look forward to working with the leadership of the VA to making 
this a reality. Needless to say, we must also apply this same brain 
power and energy to perfecting seamless transition.
    As we continue to give full resources to the war, let us not forget 
the warrior and the warrior's family. Our men and women should not get 
first class weapons to fight only to receive third-class benefits after 
fighting. We must continue on a path to making the benefits provided to 
our veterans first-rate and uncompromised.
    I will not belabor this point, but the current waiting periods at 
all levels in the VA disability benefits system, from 177 days at the 
regional office to 751 days at the VBA or 240 days at the CAVC, are all 
unacceptable. These waiting times became exacerbated to the point of 
unmanageability due to the funding shortfalls over the past 10 years. 
But I firmly believe that they belie a system that is girded by 
dedicated and professional employees committed to our veterans.
    I was looking at the VA's website recently, and I came across the 
Veterans Benefits Administration's (VBA's) covenant. I do not need to 
tell any of you the significance and impact of entering into a 
covenant, so I wanted to share the VBA's with this audience.
    It states that, ``We are the leaders in one of our Nation's most 
vital and idealistic service organizations. Because we serve veterans 
and their dependents, our mission is sacred.'' It then goes on to quote 
both President Lincoln and General Omar Bradley; quotes which are 
posted in all VA offices:

          ``. . . to care for him who shall have borne the battle, and 
        for his widow and his orphan . . .'' President Lincoln; March 
        4, 1865.

          ``We are dealing with veterans, not procedures--with their 
        problems, not ours.'' General Omar Bradley; 1947.

    It further states, that, ``As we carry out this mission, we 
willfully enter into a covenant with one another to always be guided by 
the fundamental principles of Accountability, Integrity, and 
Professionalism. These principles form the foundation of Leadership and 
Service to America's veterans.''
    Today, I want all of us (all relevant stakeholders) to enter into a 
covenant to devote our collective resources, brainpower, willpower and 
manpower to improve the current system of delivery of VA benefits, one 
which will optimize outcomes for all of our Nation's veterans.
    I want us all to remain cognizant of the privilege we have in being 
able to devise the policies and administer the benefits for these brave 
and deserving men and women and their families.
    There is real sanctity in this privilege--we should always be 
mindful of whom we are serving. I think this report is an important 
step on that journey and I look forward to hearing the Chairman's 
testimony today.

                Prepared Statement of Hon. Steve Buyer,
                       Ranking Republican Member

    Thank you Mr. Chairman,
    General Scott, thank you for visiting with us today to testify on 
the recommendations of the Veterans' Disability Benefits Commission.
    This prestigious commission was established by Public Law 108-136, 
the National Defense Authorization Act of 2004, to carry out a study of 
the benefits that are provided to compensate and assist veterans and 
their survivors for disabilities and deaths attributable to military 
    General Scott, you and your fellow members of this commission are 
to be commended for your dedicated work over the past 2\1/2\ years.
    Your efforts required many long hours discussing issues in 
meetings, and poring over an array of complex materials to arrive at 
the recommendations you have presented.
    I heartily agree with the eight guiding principles [included in the 
Executive Summary] you identified.
    These principles provide a sound basis for considering any 
recommendations for improvement to veterans' benefits.
    Clearly, you and your fellow commissioners share my sentiments that 
veterans and the men and women of the armed forces are among our 
Nation's finest citizens.
    We are in a long war against global terrorism.
    The enemy we encounter has its sights set on objectives it hopes to 
accomplish 100 years from now.
    . . . it is our great grandchildren whom they plan to oppress.
    We have no choice but to engage those who despise free will, and 
wish to destroy us, and the freedom we cherish.
    It is imperative that we maintain a military that is capable of 
swift response in a world-wide theatre of operations.
    To do so, we must continue to attract the caliber of people our 
military now has, and those who serve must be confident that they and 
their families will be well cared for should harm come their way.
    Early on during my initial review of your report, I could see the 
Commission understood this fact well.
    The Commission wisely focused on veterans' long-term issues, such 
as the need to revamp the disability retirement and compensation 
    It has been my longstanding view that we must modernize VA and 
establish a transition process that is seamless in its efficiency.
    The Commission's report, along with the recommendations of the 
Dole/Shalala commission, is a big step toward attaining this goal.
    So I look forward to hearing your testimony, General Scott.
    We will carefully consider all of the commission's recommendations, 
and hopefully use those we determine are most beneficial as a guide to 
meaningful and long-term policies to improve the lives of veterans and 
their families.
    Mr. Chairman, I suggest that this Committee consider the 
Commission's priority recommendations first, and that those that are 
determined to be meritorious should receive prompt legislative action.
    Also, Mr. Chairman, there appears to be potential for PAYGO issues, 
as we consider the Commission's recommendations.
    While we may not have to grapple with these questions today, we 
must be mindful that as Congress and the Administration move forward, 
we must deal with the funding issues that pertain to the 
    Thank you, and I yield back my time.

         Prepared Statement of Hon. Stephanie Herseth Sandlin,
      a Representative in Congress from the State of South Dakota

    Thank you Mr. Chairman for holding this hearing today to examine 
the final report of the Veterans' Disability Benefits Committee.
    As the Chairwoman of the Economic Opportunity Subcommittee, which 
maintains jurisdiction over veterans' employment, re-employment, and 
housing matters, among other topics, I am very interested in exploring 
the recommendations of the Commission regarding Vocational 
Rehabilitation and Employment (VR&E) and specially adaptive housing.
    The men and women in uniform who defend this country and make our 
economic and political systems possible, indeed, have earned our best 
efforts to provide them with adequate benefits to help them transition 
from life in the military to the civilian world.
    We can and must do better. Congress must work harder to ensure that 
our Nation's servicemembers, who each day endure the cost of freedom, 
receive the care they have earned and deserve.
    I look forward to hearing from Mr. Scott and to closely examining 
the Commission's findings and recommendations.
    Thank you again Mr. Chairman.

             Prepared Statement of Hon. Ginny Brown-Waite,
         a Representative in Congress from the State of Florida

    Thank you Mr. Chairman.
    I want to thank you for testifying before this Committee today.
    The Veterans' Disability Benefits Commission was established by the 
National Defense Authorization Act of 2004, to consider the 
appropriateness of benefits and services administered by the Department 
of Veterans Affairs and the Department of Defense. Through its hard 
work, the Commission has compiled 113 recommendations to improve care 
for veterans across the Nation.
    This is the second Commission report that this Committee has 
received on ways to improve the benefits and services provided to 
veterans. I eagerly await your testimony on the Commission's findings 
and look forward to working with you to improve the lives of veterans 
across the country.
    Once again, I welcome you to the hearing and look forward to 
hearing your thoughts on the issue before us today.

              Prepared Statement of Hon. John T. Salazar,
        a Representative in Congress from the State of Colorado

    Thank you Mr. Chairman and thank you Mr. Scott for both your 
military service and for your service as Chairman of this commission.
    As the Members of this Committee are aware, legislation relating to 
veterans or veterans benefits have been introduced more often in this 
Congress than any other.
    While preparing for this hearing I searched the L-I-S website just 
to get an idea of just how many that might be.
    I found five hundred and fifty five bills that made some sort of 
reference to veterans.
    What this says to me is this Congress, and those before it are 
committed to finding ways to properly care for those who served and the 
families that support them.
    Yet we have all seen the problems that are facing our veterans, old 
and young--in the case work that our congressional office undertake.
    The issue that I would like to bring up, in part deals with back 
logs, but on a larger scale with just how much can truly be 
accomplished by vets when they try to navigate the process alone.
    I hear stories every week from vets that have disability claims 
open for months, or even years that seem to go nowhere.
    Then when they call my office, often as a last ditch effort, and we 
intercede, miraculously a lost file is found, or things start to move.
    Did the commission examine the success rates of those cases handled 
by the veteran themselves vs. those assisted by a Congressional office?
    And if so what recommendations specifically can be made to both 
simplify and expedite the claims process?

                Prepared Statement of Hon. John Boozman,
        a Representative in Congress from the State of Arkansas

    Good morning General Scott, Members, and staff of the Disability 
Commission. I greatly appreciate the work each of you has put into the 
report. To those of you who are veterans, I thank you for your military 
service and your dedication to improve the lives of those who have 
followed in your footsteps.
    You have produced a significant contribution to our continuing 
quest to care for the 1 percent of America who man the ramparts to 
protect the 99 percent. I hope, at over 550 pages, you were getting 
paid by the word.
    It is going to take some time to absorb and understand your 
thoughts and recommendations. As the Ranking Member on the Economic 
Opportunity Subcommittee, I am especially interested in your work 
regarding the vocational rehabilitation and employment program which 
should be the crown jewel of all VA benefit programs.
    While not specifically in your charter, I do wish you had taken a 
more in-depth look at the complexity of the claims processing system 
because it is impossible to separate the benefits from the processes 
involved. Paygo rules will make it very difficult to make the 
significant increases in benefits you have proposed, but we can do 
something to meet what I believe are the most common complaints from 
veterans and those center on timeliness, consistency and quality.
    This Committee is faced with a balancing act that pits due process 
against efficient and accurate rating. It will be up to what is often 
called the Iron Triangle of the Congress, VSOs and VA to find a way to 
provide sufficient due process without constricting the flow of claims 
through the disability rating system.
    I note that in your recommendations, the commission mentions 
increasing use of information technology to improve and speed 
processing. In my opinion, the closest thing to a silver bullet to fix 
the processing mess is to implement an automated claims processing 
system that actually takes data from multiple sources and produces a 
recommended disability rating. It is being done in the private sector 
and it can be done at VA if they have the will.
    Once again, thanks to you and your fellow commissioners and staff 
members for the work you have done.

 Prepared Statement of Lieutenant General James Terry Scott, USA (Ret.)
           Chairman, Veterans' Disability Benefits Commission

                Veterans' Disability Benefits Commission

               Established Pursuant to Public Law 108-136

                1101 Pennsylvania Avenue, NW, 5th Floor

                          Washington, DC 20004


                         (202) 756-7729 (Voice)

                          (202) 756-0229 (Fax)

James Terry Scott, LTG, USA (Ret.),  Ken Jordan, COL, USMC (Ret.)
Chairman                             William M. Matz, Jr., MG, USA 
Nick D. Bacon, 1SG, USA (Ret.)       (Ret.)
Larry G. Brown, COL, USA (Ret.)      James Everett Livingston, MG, USMC 
Jennifer Sandra Carroll, LCDR, USN,  (Ret.)
(Ret.)                               Dennis Vincent McGinn, VADM, USN 
Donald M. Cassiday, COL, USAF        (Ret.)
(Ret.)                               Rick Surratt (Former USA)
John Holland Grady                   Joe Wynn (Former USAF)
Charles ``Butch'' Joeckel, Jr., 
USMC (Ret.)

Ray Wilburn, Executive Director
October 10, 2007

    The Veterans' Disability Benefits Commission is pleased to submit 
its report, Honoring the Call to Duty: Veterans' Disability Benefits in 
the 21st Century, as the formal written statement to accompany 
testimony before the House Committee on Veterans' Affairs.
    The full 562-page report is available online at 
www.vetscommission.org/reports.asp. Attached is the Executive Summary.

                                 James Terry Scott, LTG, USA (Ret.)

                           Executive Summary

    The Veterans' Disability Benefits Commission was established by 
Public Law 108-136, the National Defense Authorization Act of 2004. 
Between May 2005 and October 2007, the Commission conducted an in-depth 
analysis of the benefits and services available to veterans, 
servicemembers, their survivors, and their families to compensate and 
provide assistance for the effects of disabilities and deaths 
attributable to military service. The Department of Veterans Affairs 
(VA) expended $40.5 billion on the wide array of these benefits and 
services in fiscal year 2006. The Commission addressed the 
appropriateness and purpose of benefits, benefit levels and payment 
rates, and the processes and procedures used to determine eligibility. 
The Commission reviewed past studies on these subjects, the legislative 
history of the benefit programs, and related issues that have been 
debated repeatedly over many decades.
    Congress created the Commission out of concern for a variety of 
issues pertinent to disabled veterans, disabled servicemembers, their 
survivors, and their families. Those matters included care for severely 
injured servicemembers, treatment and compensation for Post Traumatic 
Stress Disorder (PTSD), the concurrent receipt of military retired pay 
and disability compensation, the timeliness of processing disabled 
veterans' claims for benefits, and the size of the backlog of those 
claims. Another area of concern was the program known as Individual 
Unemployability, which allows veterans with severe service-connected 
disabilities to receive benefits at the highest possible rate if their 
disabilities prevent them from working. The Commission gave these 
issues special attention.
    The Commission received extensive analytical support from the CNA 
Corp. (CNAC), a well-known research and consulting organization. CNAC 
performed an in-depth economic analysis of the average impairment of 
earning capacity resulting from service-connected disabilities. In 
addition, to assess the impact of disabilities and deaths on quality of 
life, CNAC conducted surveys of disabled veterans and survivors. To 
gain insight into claims processing issues, CNAC surveyed raters from 
VA and representatives of veterans' service organizations who assist 
veterans in filing claims. CNAC also completed a literature review and 
a comparative analysis of disability programs similar to those provided 
by VA.
    The Commission received expert medical advice from the Institute of 
Medicine (IOM) of the National Academies. Required by statute to 
consult with IOM, the Commission asked the institute to conduct a 
thorough analysis of the VA Schedule for Rating Disabilities (hereafter 
the Rating Schedule) and a study of the processes used to decide 
whether one may presume that a disability is connected to military 
service. In addition, the Commission examined two studies that IOM 
conducted for VA about the diagnosis of PTSD and compensation to 
veterans for that disorder. Unfortunately, a third IOM study--of the 
treatment of PTSD--was not completed in time to be considered by the 
Commission. Additionally, the Commission conducted eight field visits 
and held numerous public sessions.
Guiding Principles
    The Commission wrestled with philosophical and moral questions 
about how a Nation cares for disabled veterans and their survivors and 
how it expresses its gratitude for their sacrifices. The Commission 
agreed that the United States has a solemn obligation, expressed so 
eloquently by President Lincoln, ``. . . to care for him who shall have 
borne the battle, and for his widow, and his orphan . . .'' \1\
    \1\ Lincoln, Abraham, Second Inaugural Address, March 4, 1865, 
    In going about its work, the Commission has been mindful of the 
1956 Bradley Commission principles, which have provided a valuable and 
historic baseline. This Commission's report addresses what has changed 
and what has endured over those five decades and throughout our 
Nation's wars and conflicts since the Bradley report. Many of the 
changes--social, technological, cultural, medical, and economic--that 
have taken place during that time span are significant and must be 
carefully considered as our Nation renews its compact with our disabled 
veterans and their families. This long-term context, a history of both 
significant change and key elements of constancy from the 1950s to the 
21st century, provides the solid basis for this Commission's 
principles, conclusions, and recommendations.
    This Commission identified eight principles that it believes should 
guide the development and delivery of future benefits for veterans and 
their families:

    1.  Benefits should recognize the often enormous sacrifices of 
military service as a continuing cost of war, and commend military 
service as the highest obligation of citizenship.
    2.  The goal of disability benefits should be rehabilitation and 
reintegration into civilian life to the maximum extent possible and 
preservation of the veterans' dignity.
    3.  Benefits should be uniformly based on severity of service-
connected disability without regard to the circumstances of the 
disability (wartime v. peacetime, combat v. training, or geographical 
    4.  Benefits and services should be provided that collectively 
compensate for the consequence of service-connected disability on the 
average impairment of earnings capacity, the ability to engage in usual 
life activities, and quality of life.
    5.  Benefits and standards for determining benefits should be 
updated or adapted frequently based on changes in the economic and 
social impact of disability and impairment, advances in medical 
knowledge and technology, and the evolving nature of warfare and 
military service.
    6.  Benefits should include access to a full range of healthcare 
provided at no cost to service-disabled veterans. Priority for care 
must be based on service connection and degree of disability.
    7.  Funding and resources to adequately meet the needs of service-
disabled veterans and their families must be fully provided while being 
aware of the burden on current and future generations.
    8.  Benefits to our Nation's service-disabled veterans must be 
delivered in a consistent, fair, equitable, and timely manner.

    With these principles clearly in mind, the Nation must set the firm 
foundation upon which to shape and evolve a system of appropriate--and 
generous--benefits for the disabled veterans of tomorrow.
    The Commission believes that just as citizens have a duty to serve 
in the military, the Federal Government has a duty to preserve the 
well-being and dignity of disabled veterans by facilitating their 
rehabilitation and reintegration into civilian life. The Commission 
believes that compensation should be based on the nature and severity 
of disability, not whether the disability occurred during wartime, 
combat, training, or overseas. It is virtually impossible to accurately 
determine a disease's origin or to differentiate the value of sacrifice 
among veterans whose disabilities are of similar type and severity. 
Setting different rates of compensation for the same degree of severity 
would be both impractical and inequitable.
    Disabled veterans require a range of services and benefits, 
including compensation, healthcare, specially adapted housing and 
vehicles, insurance, and other services tailored to their special 
needs. Compensation must help service-disabled veterans achieve parity 
in earnings with nonservice-disabled veterans. Compensation must also 
address the impact of disability on quality of life. Money alone is a 
poor substitute for the consequences of the injuries and disabilities 
faced by veterans, but it is essential to ease the burdens they 
    It is the duty of Congress and VA to ensure that the benefits and 
services for disabled veterans and survivors are adequate and meet 
their intended outcomes. IOM concluded that the VA Rating Schedule has 
not been adequately revised since 1945. This situation should not be 
allowed to continue. Systematic updates to the Rating Schedule and 
assessments of the appropriateness of the level of benefits should be 
made on a frequent basis.
    Excellent healthcare should be provided in a timely manner at no 
cost to veterans with service-connected disabilities (i.e., service-
disabled veterans) and, in the case of severely injured veterans, to 
their families and caregivers.
    The funding and resources necessary to fully support programs for 
service-disabled veterans must be sufficient while ensuring that the 
burden on the Nation is reasonable. Care and benefits for service-
disabled veterans are a cost of maintaining a military force during 
peacetime and of fighting wars. Benefits and services must be provided 
promptly and equitably.
Results of the Commission's Analysis
    The analyses conducted by the Commission with the assistance of IOM 
and CNAC provide a consistent and complementary picture of many aspects 
of veterans' disability compensation.
Ensure Horizontal and Vertical Equity
    For veterans to receive proper compensation for their service-
connected disabilities, the VA Rating Schedule must be designed so that 
ratings result in horizontal and vertical equity in terms of 
compensation for average impairments of earning capacity. Horizontal 
equity means that persons with the same ratings percentage should have 
experienced the same loss of earning capacity. Vertical equity means 
that loss of earning capacity should increase in proportion to an 
increase in the degree of disability. A comparison of the earnings of 
disabled veterans with those of veterans who lacked service-connected 
disabilities revealed that the average amount of earnings lost by 
disabled veterans generally increased as disability ratings increased. 
In addition, mortality rates rose with degree of disability. Thus, 
vertical equity is achieved. The average earnings loss was similar 
across different types of disabilities except for PTSD and other mental 
disorders, indicating that horizontal equity also is generally being 
achieved at the level of body systems.
Ensure Parity with Nondisabled Veterans
    Overall, disabled veterans who first apply to VA for compensation 
at age 55 (the average age) receive amounts of money that are nearly 
equal to their average loss of earnings as a consequence of their 
disabilities among the broad spectrum of physical disabilities.
    The earnings of a representative sample of nondisabled veterans 
were compared with the sum of earnings plus compensation of disabled 
veterans to determine the extent to which disability compensation helps 
disabled veterans achieve parity with their nondisabled counterparts. 
Among veterans whose primary disabilities are physical, those who are 
granted Individual Unemployability are substantially below parity; 
those who are rated 100 percent disabled and who enter the system at a 
younger age (45 years or less) are slightly below parity; and those who 
enter at age 65 or older are above parity. For those whose primary 
disabilities are mental, the sum of earnings plus VA compensation is 
generally below parity at average age of entry, substantially below 
parity for severely disabled individuals who enter the system at a 
younger age, and above parity for those who enter at age 65 or older. 
Also, among veterans whose primary disabilities are mental, those rated 
10 percent disabled are slightly below parity. Thus, parity is 
generally present with respect to earnings loss except among 
individuals whose primary disabilities are mental, among the younger 
severely disabled, and among those granted Individual Unemployability.
Compensate for Loss of Quality of Life
    Parity in average loss of earnings means that disability 
compensation does not compensate veterans for the adverse impact of 
their disabilities on quality of life.
    Current law requires only that the VA Rating Schedule compensate 
service-disabled veterans for average impairment of earning capacity. 
However, the Commission concluded early in its deliberations that VA 
disability compensation should recompense veterans not only for average 
impairments of earning capacity, but also for their inability to 
participate in usual life activities and for the impact of their 
disabilities on quality of life. IOM reached the same conclusion; 
moreover, it made extensive recommendations on steps to develop and 
implement a methodology to evaluate the impact of disabilities on 
veterans' quality of life and to provide appropriate compensation.
    The Commission concluded that the VA Rating Schedule should be 
revised to include compensation for the impact of service-connected 
disabilities on quality of life. For some veterans, quality of life is 
addressed in a limited fashion by special monthly compensation for loss 
of limbs or loss of use of limbs. Some ancillary benefits attempt to 
ameliorate the impact of disability. However, the Commission urges 
Congress to consider increases in some special monthly compensation 
awards to address the profound impact of certain disabilities on 
quality of life and to assess whether other ancillary benefits might be 
appropriate. While a recommended systematic methodology is developed 
for evaluating and compensating for the impact of disability on quality 
of life, the Commission believes that an immediate interim increase of 
up to 25 percent of compensation should be enacted.
    A survey of a representative sample of disabled veterans and 
survivors was conducted to assess their quality of life and other 
issues. The survey found that among veterans whose primary disability 
is physical, their physical health is inferior to that of the general 
population for all levels of disability, and their physical health 
generally worsens as their level of disability increases. Physical 
disabilities did not lead to decreased mental health. For veterans 
whose primary disability is mental, not only were their mental health 
scores much lower than those of the general population, but their 
physical health scores were well below population norms for all levels 
of mental disability. Those veterans with PTSD had the lowest physical 
health scores.
    The survey also sought to address two specific issues through 
indirect questions. There are concerns that service-disabled veterans 
tend not to follow medical treatments because they fear it might impact 
their disability benefits. This premise was not substantiated. 
Likewise, when questioned whether VA benefits created a disincentive to 
work, only 12 percent of respondents indicated they might work or work 
more if not for compensation benefits; thus, this is not a major issue.
Update the Rating Schedule
    The Rating Schedule consists of slightly more than 700 diagnostic 
codes organized under 14 body systems, such as the musculoskeletal 
system, organs of special sense, and mental disorders. For each code, 
the schedule provides criteria for assigning a percentage rating. The 
criteria are primarily based on loss or loss of function of a body part 
or system, as verified by medical evidence; however, the criteria for 
mental disorders are based on the individual's ``social and industrial 
inadaptability,'' meaning the overall ability to function in the 
workplace and everyday life.
    IOM concluded that it has been 62 years since the VA Rating 
Schedule was adequately revised and made a series of recommendations 
for immediately updating the Rating Schedule and requiring that it be 
revised on a systematic and frequent basis. The Commission generally 
agrees with these recommendations; however, the Commission does not 
agree that the revision should begin with those body systems that have 
not been revised for the longest time period. Rather, the Commission 
recommends that first priority be given to revising the mental health 
and neurological body systems to expeditiously address PTSD, other 
mental disorders, and Traumatic Brain Injury. A quick review by VA of 
the Rating Schedule could be completed to determine the sequence in 
which the other body systems should be addressed, and a timeline should 
be developed for completing the revision.
    To emphasize the importance and urgency of revising the Rating 
Schedule, the Commission urges Congress to require that the entire 
schedule be reviewed and updated as needed over the next 5 years. 
Congress should monitor progress carefully. Thereafter, the Rating 
Schedule should be reviewed and updated on a frequent basis.
Individual Unemployability
    The Individual Unemployability (IU) program enables a veteran rated 
60 percent or more but less than 100 percent to receive benefits at the 
100 percent rate if he or she is unable to work because of service-
connected disabilities. IU has received considerable attention recently 
because the number of veterans granted IU increased by 90 percent. The 
Commission found this increase to be explained by the aging of the 
cohort of Vietnam veterans.
Develop PTSD-Specific Rating Criteria and Improve PTSD Treatment
    Concerning PTSD and other mental disorders, it is very clear that 
having one set of criteria for rating all mental disorders has been 
ineffective. IOM recommended separate criteria for PTSD. Similarly, the 
CNAC survey of VA raters found that raters believe separate criteria 
for PTSD would enable them to rate PTSD claims more effectively. In 
addition, the earnings analysis described above demonstrates that there 
is a disparity in earnings of those with PTSD and other mental 
disorders and that the current scheme for rating all mental disorders 
in five categories of severity--10, 30, 50, 70, and 100 percent--does 
not result in adequate compensation. It is also unclear why 31 percent 
of those with PTSD as their primary diagnosis are granted IU, 
especially since incapacity to work is part of the current criteria for 
granting 100 percent for PTSD and other mental disorders. It would seem 
that many of these veterans should be awarded 100 percent ratings 
without IU. The Commission agrees with the IOM recommendation that new 
Rating Schedule criteria specific to PTSD should be developed and 
implemented based on criteria from the Diagnostic and Statistical 
Manual of Mental Disorders.
    The Commission believes that a new, holistic approach to PTSD 
should be considered. This approach should couple PTSD treatment, 
compensation, and vocational assessment. The Commission believes that 
PTSD is treatable, that it frequently recurs and remits, and that 
veterans with PTSD would be better served by a new approach to their 
care. There is little interaction between the Veterans Health 
Administration, which examines veterans for evaluation of severity of 
symptoms and treats veterans with PTSD, and the Veterans Benefits 
Administration, which assigns disability ratings and may or may not 
require periodic reexamination. It is evident that PTSD reexaminations 
have been scheduled with less frequency in recent years due to the 
backlog of disability claims. It is also evident that case management 
of PTSD patients could be improved through greater interaction between 
the therapy received in Vet Centers and treatment in VA medical 
centers. IOM concluded that the use of standardized testing and the 
frequency of reexaminations should be recommended by clinicians on a 
case-by-case basis, but did not suggest how that would be achieved. The 
Commission suggests that treatment should be required and its 
effectiveness assessed to promote wellness of the veteran. 
Reexaminations should be scheduled and conducted every 2 to 3 years.
Improve Performance of Vocational Rehabilitation and Employment
    The Commission believes that the goal of disability benefits, as 
expressed in guiding principle 2, is not being met. In spite of the 
studies done and recommendations made in recent years, the Vocational 
Rehabilitation and Employment (VR&E) program is not accomplishing its 
primary goal. The Commission believes that recent studies have provided 
the necessary analyses and that VA possesses the necessary expertise to 
remedy this failure. Simply put, VA must develop specific plans and 
Congress must provide the resources to quickly elevate the performance 
of VR&E.
Allow Concurrent Receipt
    The Commission carefully reviewed whether disabled veterans should 
be permitted to receive both military retirement benefits and VA 
disability compensation. The Commission also reviewed whether the 
survivors of veterans who die either on active duty or as a result of a 
service-connected disability should be allowed to receive both 
Department of Defense (DoD) Survivor Benefit Plan (SBP) and VA 
Dependency and Indemnity Compensation (DIC). Currently, military 
retirees with service-connected disabilities rated 50 percent or higher 
are authorized to receive both benefits, which are being phased in over 
the next few years. Survivors are not authorized to receive both 
benefits. The Commission is persuaded that these programs have unique 
intents and purposes: military retirement benefits and SBP are intended 
to compensate for years of service, while VA disability compensation 
and DIC are intended to compensate for disability or death attributable 
to military service. It should be permissible to receive both sets of 
benefits concurrently.
    In addition, the Commission believes that those separated as 
medically unfit with less than 20 years of service should also be able 
to receive military retirement and VA compensation without offset. 
Currently, those receiving ratings of less than 30 percent from DoD 
receive separation pay, which must be paid back through deductions from 
VA compensation for the unfitting conditions before VA compensation is 
received. Those receiving DoD ratings of 30 percent or higher and a 
continuing disability retirement have their DoD payments offset by any 
VA compensation. Priority among medical discharges should be given to 
those separated or retired with less than 20 years of service and 
disability rating greater than 50 percent or disability as a result of 
Allow Young, Severely Injured Veterans to Receive Social Security 
        Disability Insurance
    Among the benefits available for disabled veterans, those not able 
to work may be eligible for Social Security Disability Insurance 
(SSDI). To be eligible for SSDI, an individual must have worked a 
minimum number of quarters, be unable to work because of medical 
conditions, not have income above a minimum level, and be less than 65 
years of age. At 65, SSDI converts to normal Social Security at the 
same amount. Some very young servicemembers who are severely injured 
may not have sufficient quarters to qualify for SSDI. The Commission 
recommends eliminating the minimum quarters requirement for the 
severely injured. Only 61 percent of those granted IU by VA and 54 
percent of those rated 100 percent by VA are receiving SSDI. 
Considering the very low earnings by those rated 100 percent and the 
exceptionally low earnings of those granted IU, it is apparent that 
either these veterans do not know to apply for SSDI or are being denied 
the insurance. Increased outreach should be made and better 
coordination between VA and Social Security should result in increased 
mutual acceptance of decisions.
Realign the VA-DoD Process for Rating Disabilities
    The Commission also assessed the consistency of ratings by DoD and 
VA on individuals found unfit for military service by DoD under 10 
U.S.C. chapter 61. Some 83,000 servicemembers were found unfit between 
2000 and 2006. DoD rated 81 percent of those individuals as less than 
30 percent and discharged them with severance pay, including over 
13,000 who were found unfit by the Army and given zero percent ratings. 
Seventy-nine percent of these servicemembers later filed claims with VA 
and received substantially higher ratings. The reasons for the higher 
ratings are that VA rates about three more conditions than DoD, and at 
the individual diagnosis level VA assigns higher ratings than DoD.
    The Commission finds that the policies and procedures used by VA 
and DoD are not consistent and the resulting dual systems are not in 
the best interest of the injured servicemembers nor the Nation. 
Existing practices that allow servicemembers to be found unfit for 
preexisting conditions after up to 8 years of active duty and that 
allow DoD to rate only the conditions that DoD finds unfitting should 
be reexamined. Servicemembers being considered unfit should be given a 
single, comprehensive examination and all identified conditions should 
be rated and compensated.
    The Commission agrees with the President's Commission on the Care 
of Returning Wounded Warriors that the DoD and VA disability evaluation 
process should be realigned so that the military determines if the 
servicemember is unfit for service and awards continuing payment for 
years of service and healthcare coverage for the family while VA pays 
disability compensation. However, in accordance with one of our key 
guiding principles, the Commission believes that benefits should not be 
limited to combat and combat-related injuries. Nor does the Commission 
believe that VA disability compensation should end and be replaced with 
Social Security at retirement age.
Link Benefits to Cost-of-Living Increases
    In its review, the Commission found that the ancillary and special-
purpose benefits payments and award limits are not automatically 
indexed to cost of living. A few of these benefits have not been 
increased in many years, and as a result, some no longer meet the 
original intent of Congress. The Commission recommends that Congress 
raise ancillary and special-purpose benefits to the levels originally 
intended and provide for automatic annual adjustments to keep pace with 
the cost of living.
Simplify and Expedite the Processing of Disability Claims and Appeals
    VA disability benefits and services are not currently provided in a 
timely manner. Court decisions, statutory changes, and resource 
limitations have all contributed to this unacceptable situation. 
Numerous studies over the years have assessed the processing of both 
claims and appeals and have made numerous recommendations for change. 
Still, veterans seeking disability compensation face a complex process. 
The population of veterans is steadily decreasing with the passing of 
veterans of World War II and the Korean war. Yet, the aging of the 
Vietnam Era veterans means that they are filing original and reopened 
claims in large numbers. Technology offers opportunities for 
improvement, but it is unlikely to solve all problems. The Commission 
believes that increased reliance on best business practices and maximum 
use of information technology should be coupled with a simplified and 
expedited process for well-documented claims to improve timeliness and 
reduce the backlog. The Commission is aware that a significant increase 
in claims processing staff has been recently approved but is also aware 
that the time required for training and the slow development of job 
experience will limit the speed with which results can realistically 
    The Commission believes that claimants should be allowed to state 
that claim information submitted is complete and waive the normal 60 
day timeframe permitted for further development.
Improve Transition Assistance
    A smooth transition from military to civilian status is crucial for 
veterans and their families to quickly adjust to civilian life. This 
goal, often expressed as ``seamless transition,'' has yet to be fully 
realized, although VA and DoD have made significant improvements during 
the past few years. The two departments' medical and other systems are 
not truly compatible, and both departments will have to rely on paper 
records for many years. Perhaps the single most important step that can 
be taken to assist veterans, particularly those who are disabled and 
their families, and to reduce the lengthy delays plaguing claims 
processing would be to achieve electronic compatibility. In addition, 
the Commission believes that making VA benefit payments effective the 
day after discharge will help ease the financial aspect of transition.
Improve Support for Severely Disabled Veterans and their Caregivers
    Severely disabled servicemembers who are about to transition into 
civilian life need far more support and assistance than is currently 
provided. An effective case management program should be established 
with a clearly identified lead agent who has authority and 
responsibility to intercede on behalf of disabled individuals. The lead 
agent should be an advocate for servicemembers and their families. In 
addition, VA should be authorized to provide family assistance similar 
to that provided by DoD up until discharge. TRICARE deductibles and 
copays are costs incurred by the severely disabled; the Commission 
believes that these costs should be waived. In addition, consideration 
should be given to expanding healthcare and providing an allowance for 
caregivers of the severely disabled. Currently, healthcare is only 
provided for the dependents of severely disabled veterans but not for 
parents and other family members who are caregivers.
Implement a New Process for Determining Presumption
    Various processes have been used to create presumptions when there 
are uncertainties as to whether a disabling condition is caused by 
military service. Presumptions are established when there is evidence 
that a condition is experienced by a sufficient cohort of veterans and 
it is reasonable to presume that all veterans in that cohort who 
experience the condition acquired the condition due to military 
service. The Commission asked IOM to review the processes used in the 
past to establish presumptions and to recommend a framework that would 
rely on more scientific principles. IOM conducted an extensive analysis 
and recommended a detailed and comprehensive approach that includes the 
creation of an advisory committee and a scientific review board, 
formalizing the process and making it transparent, improving research, 
and tracking military troop locations and environmental exposures. 
Perhaps most importantly, the approach includes using a causal effect 
standard for decisionmaking rather than a less-precise statistical 
association. The Commission endorses the recommendations of the IOM but 
expresses concern about the causal effect standard. Consideration 
should also be given to combining the advisory committee on 
presumptions with the recommended advisory committee on the Rating 
    The Commission made 114 recommendations. All are important and 
should receive attention from Congress, DoD, and VA. The Commission 
suggests that the following recommendations receive immediate 
consideration. Congress should establish an executive oversight group 
to ensure timely and effective implementation of the Commission 

                        Priority Recommendations

Recommendation 4.23
                                                 Chapter 4, Section I.5

    VA should immediately begin to update the current Rating Schedule, 
beginning with those body systems addressing the evaluation and rating 
of Post Traumatic Stress Disorder and other mental disorders and of 
Traumatic Brain Injury. Then proceed through the other body systems 
until the Rating Schedule has been comprehensively revised. The 
revision process should be completed within 5 years. VA should create a 
system for keeping the Rating Schedule up to date, including a 
published schedule for revising each body system.

Recommendation 5.28
                                               Chapter 5, section III.3

    VA should develop and implement new criteria specific to Post 
Traumatic Stress Disorder in the VA Schedule for Rating Disabilities. 
VA should base those criteria on the Diagnostic and Statistical Manual 
of Mental Disorders and should consider a multidimensional framework 
for characterizing disability due to Post Traumatic Stress Disorder.

Recommendation 5.30
                                               Chapter 5, section III.3

    VA should establish a holistic approach that couples Post Traumatic 
Stress Disorder treatment, compensation, and vocational assessment. 
Reevaluation should occur every 2-3 years to gauge treatment 
effectiveness and encourage wellness.

Recommendation 6.14
                                                Chapter 6, section IV.2

    Congress should eliminate the ban on concurrent receipt for all 
military retirees and for all servicemembers who separated from the 
military due to service-connected disabilities. In the future, priority 
should be given to veterans who separated or retired from the military 
under chapter 61 with
      fewer than 20 years service and a service-connected 
disability rating greater than 50 percent, or
       disability as a result of combat.

Recommendation 7.4
                                                Chapter 7, section II.3

    Eligibility for Individual Unemployability (IU) should be 
consistently based on the impact of an individual's service-connected 
disabilities, in combination with education, employment history, and 
medical effects of an individual's age or potential employability. VA 
should implement a periodic and comprehensive evaluation of veterans 
eligible for IU. Authorize a gradual reduction in compensation for IU 
recipients who are able to return to substantially gainful employment 
rather than abruptly terminating disability payments at an arbitrary 
level of earning.

Recommendation 7.5
                                                Chapter 7, section II.3

    Recognizing that Individual Unemployability (IU) is an attempt to 
accommodate individuals with multiple lesser ratings but who remain 
unable to work, the Commission recommends that as the VA Schedule for 
Rating Disabilities is revised, every effort should be made to 
accommodate such individuals fairly within the basic rating system 
without the need for an IU rating.

Recommendation 7.6
                                               Chapter 7, section III.2

    Congress should increase the compensation rates up to 25 percent as 
an interim and baseline future benefit for loss of quality of life, 
pending development and implementation of a quality-of-life measure in 
the Rating Schedule. In particular, the measure should take into 
account the quality of life and other non-work-related effects of 
severe disabilities on veterans and family members.

Recommendation 7.8
                                               Chapter 7, section III.2

    Congress should consider increasing special monthly compensation, 
where appropriate, to address the more profound impact on quality of 
life of the disabilities subject to special monthly compensation. 
Congress should also review ancillary benefits to determine where 
additional benefits could improve disabled veterans' quality of life.

Recommendation 7.12
                                                  Chapter 7, section VI

    VA and DoD should realign the disability evaluation process so that 
the services determine fitness for duty, and servicemembers who are 
found unfit are referred to VA for disability rating. All conditions 
that are identified as part of a single, comprehensive medical 
examination should be rated and compensated.

Recommendation 7.13
                                                 Chapter 7, section V.3

    Congress should enact legislation that brings ancillary and 
special-purpose benefits to the levels originally intended, considering 
the cost of living, and provides for automatic annual adjustments to 
keep pace with the cost of living.

Recommendation 8.2
                                             Chapter 8, section III.1.B

    Congress should eliminate the Survivor Benefit Plan/Dependency and 
Indemnity Compensation offset for survivors of retirees and in-service 

Recommendation 9.1
                                            Chapter 9, section II.5.A.b

    Improve claims cycle time by

      establishing a simplified and expedited process for well-
documented claims, using best business practices and maximum feasible 
use of information technology; and
      implementing an expedited process by which the claimant 
can state the claim information is complete and waive the time period 
(60 days) allowed for further development.

    Congress should mandate and provide appropriate resources to reduce 
the VA claims backlog by 50 percent within 2 years.

Recommendation 10.11
                                                Chapter 10, section VII

    VA and DoD should expedite development and implementation of 
compatible information systems including a detailed project management 
plan that includes specific milestones and lead agency assignment.

Recommendation 11.1
                                                             Chapter 11

    Congress should establish an executive oversight group to ensure 
timely and effective implementation of the Commission's 
recommendations. This group should be cochaired by VA and DoD and 
consist of senior representatives from appropriate departments and 
agencies. It is further recommended that the Veterans' Affairs 
Committees hold hearings and require annual reports to measure and 
assess progress.
    One commissioner submitted a statement of separate views regarding 
four aspects of the report. His statement is in Appendix L.

                         Additional Resources:

    Electronic access to the complete report of the Veterans' 
Disability Benefits Commission is available at: http://
    Also available on the Commission's website are:

      Bios of the Commissioners
      Commission Charter
      Commission Charter (renewed, 2-21-2007)
      Public Law 108-136 establishing the Commission
      Extension of the Commission's Charter in Public Law 109-
      Legislative History of VA Disability Compensation 
Program, Economic Systems Inc., Dec 2004
      Appendices to the Legislative History (Dec 2004)
      Literature Review of VA Disability Compensation Program, 
Economic Systems Inc., Dec 2004
      Appendices to the Literature Review (Dec 2004)
      Commission's Approved Research Questions, October 14, 
      Institute of Medicine (IOM) Summary of the PTSD Review 
contracted by the Veterans Health Administration, Mar 2006
      A History and Analysis of Presumptions of Service 
Connection (1921-1993)
      An Updated Legal Analysis of Presumptions of Service 
Connection (1993-2006)
      Center for Naval Analyses (CNA) Literature Review 
(Final), May 2006
      Appendix to the CNA Literature Review (Final), May 2006
      Veterans' Claims Adjudication Commission (VCAC), also 
known as the Melidosian Commission Report (1996)
      Blue Ribbon Panel on Claims Processing: Proposals to 
Improve Disability Claims Processing in the Veterans Benefits 
Administration, November 1993
      Bradley Commission Report 1956
      IOM Report to VA on Posttraumatic Stress Disorder: 
Diagnosis and Assessment, 2006
      Testimony of Chairman Scott at a Joint Hearing of the 
Senate Armed Services & Veterans' Affairs Committees, April 12, 2007
      CNA Report: Findings from Raters and VSOs Surveys, May 
      IOM Report to VA on PTSD Compensation and Military 
Service, 2007
      A 21st Century System for Evaluating Veterans for 
Disability Benefits, IOM Final Report, June 2007
      Improving the Presumptive Disability Decision-Making 
Process for Veterans, IOM Final Report, and Executive Summary August 
      CNA Final Report: Final Report for the Veterans' 
Disability Benefits Commission: Compensation, Survey Results and 
Selected Topics, August 2007

                    Statement of Hon. Doug Lamborn,
        a Representative in Congress from the State of Colorado

    Thank you, Mr. Chairman, and thank you, General Scott for sharing 
your insight and for your hard work on the commission.
    Fundamentally changing and improving the disability claims system 
in VA is one of the most important challenges facing this Committee and 
    We must ensure that a veteran's claim for disability benefits is 
adjudicated in a prompt and accurate fashion.
    That is why, General Scott, I am so glad you are here today so the 
Committee can gain a better understanding of the Commission's 
    Congress has helped transform the VA healthcare system from one of 
poor quality into one of the best healthcare systems in the country and 
it is now our responsibility to put this same effort toward improving 
the rest of VA.
    Thank you, Mr. Chairman, I yield back.

                     Statement of Hon. Jeff Miller,
         a Representative in Congress from the State of Florida

    Thank you, Mr. Chairman.
    The long-awaited release of the findings of the VDBC has finally 
arrived, and now Congress, the VA, and the veterans' community have 
some serious consideration ahead of them. Several years of careful 
research by the VDBC have led to their findings which can have an 
important impact on the future of veterans' benefits.
    In the report issued by the VDBC, the Institute of Medicine (IOM), 
a key contributor, concluded that the VA rating schedule has not 
undergone a thorough revision since 1945. While change for the sake of 
change is not a good approach, this lengthy passage of time makes clear 
a need for careful review, and I applaud VDBC for having done so.
    While not all of the recommendations require legislative action by 
Congress, many of the ones that do already exist as bills in both the 
House and Senate. I am proud to already cosponsor legislation that 
allows concurrent receipt of military retiree pay and VA benefit 
payments as well as legislation that eliminates the SBP/DIC offset.
    I look forward to the Commission's testimony today that will give 
further detail on the research used and the recommendations put forth 
to Congress. Today's hearing will no doubt help this Committee work 
toward ensuring that the VA benefit system serves our veterans in the 
best way possible.

                  Statement of Hon. Harry E. Mitchell,
         a Representative in Congress from the State of Arizona

    Thank you, Mr. Chairman.
    I would also like to thank Lieutenant General James Terry Scott for 
coming before this Committee to present the findings of the Veterans' 
Disability Benefits Commission.
    Last month, we met to hear from Senator Dole and Secretary Shalala 
about the care of returning veterans, and just last week, we heard from 
a host of experts on the requirements for funding the VA into the 
    While the testimony varied . . . the distinguished panelists all 
echoed a similar concern . . . we have to change the way the VA does 
    Some of this change requires a monetary investment, yet the 
majority of the change requires us to work together in a bipartisan way 
to solve complicated problems.
    Earlier this year we passed a VA appropriations bill which made the 
single-largest investment in veterans' healthcare in the 77-year 
history of the agency.
    And while it represents an important step forward, I think we can 
all agree that we need to do more.
    All veterans deserve the benefits they were promised in exchange 
for their service to our Nation, especially those veterans who 
sustained lifelong service-related injuries.
    Unfortunately, the disability compensation system is outdated and 
burdensome. It fails to effectively address the wide range of 
disabilities that impact the lives of veterans, regardless of age and 
rank. The system also neglects the sacrifices made by the families of 
disabled veterans.
    Next week, the Subcommittee on Oversight and Investigation will 
hold a hearing on disability rating disparities, which is one of the 
major problems identified by the Commission.
    These courageous men and women put their life on the line for our 
country. The least we can do is move quickly to provide them with the 
best benefits possible.
    I am looking forward to hearing from our guest on how we can 
accomplish this, and I yield back.


                                    Committee on Veterans' Affairs,
                                                    Washington, DC.
                                                   October 16, 2007

LTG James Terry Scott, USA (Ret.)
Veterans' Disability Benefits Commission
1101 Pennsylvania Ave., NW, 5th Floor
Washington, DC 20004

Dear General Scott:

    In reference to our Full Committee hearing ``Findings of the 
Veterans' Disability Benefits Commission'' on October 10, 2007, I would 
appreciate it if you could answer the enclosed hearing questions by the 
close of business on November 14, 2007. In addition, please provide the 
side-by-side analysis of the Commission's findings as discussed during 
the hearing as well as any cost analyses conducted by the Commission.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
    Due to the delay in receiving mail, please provide your response by 
fax to 202-225-2034. If you have any questions, please call 202-225-

                                                         Bob Filner
                          Veterans' Disability Benefits Commission,
                         Established Pursuant to Public Law 108-136
                                                    Washington, DC.
                                                  November 13, 2007

Honorable Bob Filner
House Veterans' Affairs Committee
335 Cannon House Office Building
Washington, DC 20515

Dear Chairman Filner:

    Thank you for the opportunity to appear before your Committee on 
October 10, 2007, to present the results of our Commission's analysis 
of benefits and services for disabilities and deaths resulting from 
military service.
    The purpose of this letter is to provide follow up information 
discussed during the hearing (Enclosure 1) and to respond to eight 
post-hearing questions that you provided in your letter of October 16, 
2007 (Enclosure 2.)
    In addition, I would like to take this opportunity to clarify our 
recommendation 4.23 concerning updating the VA rating schedule. Our 
recommendation said that the revision of the rating schedule should be 
completed within 5 years and our report (Prepublication page 80) 
indicated that 5 years is a realistic timetable. Our Commission 
recognized that VA had undertaken a project to revise the rating 
schedule as a result of a critical 1989 GAO report and had published a 
notice of its intent to update the entire schedule in August 1989. IOM 
carefully reviewed the revisions to the rating schedule and found that 
373 of 798 diagnostic codes (47 percent) had been revised since 1990. A 
substantial proportion (281, or 35 percent) of the schedule's 
diagnostic codes had not been revised at all since 1945 and 18 percent 
(144 codes) were revised between 1945 and 1989. Our Commission felt 
that it would be important to establish a deadline that could 
reasonably be met, considering VA's lack of progress in the past. We 
meant that deadline to be a maximum, not an estimate for how long the 
revision should take. In retrospect, we should have expressed this more 
carefully as an outside limit. We did not estimate how long a complete 
revision should take.

                                 James Terry Scott, LTG, USA (Ret.)
                              Enclosure 1
                     Hearing Follow Up Information

    During the October 10, 2007 hearing, additional information was 
promised on the following subjects: Side-by-Side Comparison of Recent 
Reports; Cost Estimates for Major Recommendations; Number of TBI 
Disabilities; Immediate Processing of Claims Subject to Post Award 
Audit; Inpatient PTSD Treatment; and Survey Results on Use of Pain 
Medications and Quality of Life.
Side-by-Side Comparison of Recent Reports
    A matrix was prepared for the Commission's use comparing the 
Commission's recommendations with those of the Independent Review 
Group, the Global War on Terror Task Force, and the President's 
Commission on Care for America's Returning Wounded Warriors. The 
purpose of this matrix is to assist in understanding the relative 
positions of each report. It was not intended to be all inclusive or 
comprehensive. The matrix is enclosed.
Cost Estimates for Major Recommendations
    The Commission considered cost estimates for recommendations on 
concurrent receipt of military retirement and disability compensation 
and on concurrent receipt of Survivors Benefit Payments and Dependency 
and Indemnity Compensation. The source of these estimates was the DoD 
Office of the Actuary.

                                                                              One Year Costs     Ten Year Costs
                                                             Recipients           ($000)             ($000)
Concurrent Receipt
Retirees 10-40 Percent                                            450,000         $1,500,000        $19,300,000
Chapter 61                                                         95,000            357,000          4,600,000
TERA                                                                3,000             10,000            129,000
  Total                                                           548,000          1,867,000         24,029,000
Survivors Concurrent Receipt                                       63,000            660,000          6,600,000

Number of Traumatic Brain Injury (TBI) Disabilities
    The Commission analyzed all 83,008 of the servicemembers discharged 
as unfit during the period 2000 through 2006. During that 7-year 
period, 896 individuals were discharged with TBI. Veterans Benefits 
Administration reported to the Commission that there are currently 
24,095 veterans service connected for TBI.
Immediate Processing of Claims Subject to Post Award Audit
    During the hearing, the possibility was discussed of conducting a 
pilot of processing claims immediately as filed at some minimum level 
and conducting post award audits of a sample of these claims to 
identify and deter fraudulent claims. This approach was recommended by 
Linda Bilmes of the Kennedy School of Government, Harvard University in 
January 2007. While a pilot of this approach could certainly be 
conducted, another alternative authority already exists that could be 
used more frequently. This alternative is the Prestabilization Rating 
(38 CFR Sec. 4.28 enclosed.) These ratings can be assigned immediately 
after discharge and can continue for 12 months. They can be assigned at 
either the 50 percent or 100 percent levels and do not require a VA 
examination. Special Monthly Compensation can be assigned concurrently 
with the award.
    Veterans Benefits Administration reported to the Commission that 
during the period FY 2005-2007 a total of 1,057 prestabilization awards 
were made: 726 at the 100 percent level and 331 at the 50 percent 
level. The number of these awards doubled from FY 2005 to FY 2007. VBA 
averaged 242 and 110 per year at the 100 percent and 50 percent levels, 
respectively. Over the 7-year period analyzed by the Commission, DoD 
averaged 211 servicemembers discharged at the 100 percent level and 512 
at the 50-90 percent level. Thus, it appears that greater use of the 
prestabilization ratings could be made at the 50 percent level.
    The number of servicemembers discharged each year as unfit through 
the DoD Disability Evaluation System is not large enough to have a 
great impact on the size of the claims backlog and expediting these 
cases through use of prestabilization awards will not reduce the 
backlog appreciably. However, it will provide immediate income at a 
time that is most urgent to the servicemembers.
Inpatient PTSD Treatment
    Concerning whether VA has sufficient inpatient treatment capacity 
for PTSD, the Commission did not address this issue. However, I note 
that the recent report of the Institute of Medicine, Treatment of 
Posttraumatic Stress Disorder: An Assessment of the Evidence, did not 
specifically address inpatient versus outpatient treatment. IOM found 
that there is inadequate evidence to determine the efficacy of drug 
therapies and found that only exposure therapy had sufficient evidence 
to conclude that it was effective. IOM concluded that there is not even 
an accepted and used definition for PTSD recovery.
Survey Results on Use of Pain Medications and Quality of Life
    The Commission survey of 23,853 disabled veterans asked those 
surveyed: Do you take pain medication daily to regulate the effects of 
your service connected disability? Forty-seven percent said that they 
did and 53 percent said that they did not take pain medications. In 
comparing those that take pain medications with those who do not, 
respondents who did not take pain medications reported that their 
overall quality of life is better and their physical and mental health 
scores are higher. The differences are statistically significant.
    Other questions asked how much bodily pain they had over the past 4 
weeks and how much did pain interfere with normal work. When comparing 
those who reported less pain or more pain with and without medications, 
the results are largely the same: those who do not take pain 
medications report better quality of life and higher physical and 
mental scores.
                Veterans' Disability Benefits Commission

                 Table 1--Commission/Task Force Comparisons: Primary Topics and Areas of Overlap
                                      Disability      Independent Review
       Study Group Topic:              Benefits              Group          GWOT Task Force          PCCWW
VA/DoD Disability Process         Realign disability         DoD should       Joint process         Restructure
                                         evaluation    overhaul the DES      whereby VA/DoD        disability &
                                  process--Services           system by        cooperate in        compensation
                                  determine fitness      implementing a         assigning a     systems--DoD/VA
                                  for duty, VA rates    single physical          disability     should create a
                                         disability   exam (as described        evaluation,             single,
                                                      by GAO 2004). The         determining       comprehensive
                                                        services should         fitness for        standardized
                                                        consistently be    retention, level   medical exam that
                                                            determining       of disability    DoD administers,
                                                      fitness for duty &    retirement & VA       DoD maintains
                                                            VA provides        compensation      authority over
                                                      disability rating.                      fitness & pays for
                                                        DoD should also                        years of service
                                                             expand the                                while VA
                                                             Disability                             establishes
                                                      Advisory Council,                                 rating,
                                                        Conduct quality                          compensation &
                                                      assurance reviews                                benefits
                                                       on previous 0-20
                                                         percent & EPTS
                                                        cases, Evaluate
                                                       loss of function
                                                           due to burns
                                                             similar to
Case Management                      Intensive case   Create tri-Service   System of case &       Comprehensive
                                  management with an           policy &       co-management    Recovery Plans &
                                  identifiable lead      guidelines for                       Coordinators with
                                              agent     case management                            HHS as lead.
                                                             services &
                                                       training, Assign
                                                         single primary
                                                       care physician &
                                                           case manager
Family Support                      Authorize VA to      Provide family                None   Strengthen support
                                     provide family        education on                            for families
                                   services, Extend    benefits, Survey                         through TRICARE
                                       healthcare &   families on their                          Respite Care &
                                       allowance to       needs, Assign                               *Aide and
                                        caregivers,    family advocates                       Attendant Benefit,
                                  Eliminate SBP-DIC                                                   Caregiver
                                  offset, Eliminate                                            training, Extend
                                  TRICARE co-pays &                                                          FMLA for 6 months,
                                    deductibles for                                           All combat-related
                                   severely injured                                            injured families
                                           families                                            should have full
                                                                                              TRICARE coverage.
IT Compatibility                           Expedite          Streamline          Enhance VA    Rapidly transfer
                                      development &       transition by        computerized             patient
                                  implementation of   rapidly developing     Patient Record        information,
                                         compatible          a standard            System &            Create a
                                        information    automated system          electronic         MyeBenefits
                                     systems with a     interface for a      enrollment, VA             website
                                     detailed plan,   bilateral exchange  needs to develop a
                                  milestones, & lead    of clinical and    patient tracking
                                  agency, Use IT to      administrative         application
                                     improve claims   info between DoD &    compatible with
                                         cycle time    VA (Described in   DoD, Create a TBI
                                                              2003 PTF)   database, Improve
                                                                             VA's access to
                                                                            military health
                                                                           records & create
                                                                          an interface with
                                                                           DoD, Create OIF/
                                                                            OEF identifiers
                                                                            and markers for
                                                                                 Improve IT
                                                                           between VA & HHS
                                                                              Indian Health
PTSD                              Holistic approach         Functional/   Provide Outreach &  VA should care for
                                       that couples   cognitive measures       Education to    all OIF/OEF vets
                                         treatment,   & screenings upon    Community Health   with PTSD & (with
                                    rehabilitation,       entry & post-       Centers on VA        DoD) improve
                                  compensation & re-        deployment,          benefits &         prevention,
                                     evaluation for     comprehensive &   services (to reach        diagnosis &
                                   wellness, Revise   universal clinical    vets with PTSD)   treatment, reduce
                                    Rating Schedule   practice & coding                        PTSD stigma. DoD
                                  for PTSD, Baseline     guidelines for                       should address its
                                  level of benefits,  blast injuries and                          mental health
                                  PTSD exam process,      TBI with PTSD                               shortage,
                                   Examiner & rater   overlay to include                            Disseminate
                                         training &        recording of                       clinical practice
                                     certification,   exposures to blast                      guidelines to all
                                        research on   in patient record.                              providers
                                    Military Sexual       VA/DoD create
                                             Trauma           center of
                                                      excellence for TBI
                                                               and PTSD
                                                             research &
TBI                               Update the Rating         Functional/     Screen all GWOT       DoD/VA should
                                   Schedule for TBI   cognitive measures   veterans for TBI   prevent, diagnose,
                                                      & screenings upon                            & treat TBI,
                                                          entry & post-                        Partner with the
                                                            deployment,                       private sector on
                                                        comprehensive &                               TBI care,
                                                      universal clinical                            Disseminate
                                                      practice & coding                       clinical practice
                                                         guidelines for                       guidelines to all
                                                      blast injuries and                              providers
                                                          TBI with PTSD
                                                      overlay to include
                                                           recording of
                                                      exposures to blast
                                                      in patient record.
                                                          VA/DoD create
                                                              center of
                                                      excellence for TBI
                                                               and PTSD
                                                             research &
Ancillary Benefits                  Adjust & extend   DoD should partner   Expedite Adapted       Transition (3
                                  A&A, Extend auto &  with VA to provide        Housing and   months of base pay
                                  housing allowances         treatment,        Special Home       or long-term)
                                   to veterans with         education &   Adaptation Grants,  payments, Earnings-
                                      severe burns,         research in          Expand HUD   loss payments, All
                                      Eliminate TSGLI  prosthesis care,    National Housing       unfit combat-
                                  premiums, Improve        production &                    Locatrelated injured
                                          SDVI & VMLI, amputee therapy,         capacity to      should receive
                                  Increase benefits   Allow VA patients      provide Dental        full TRICARE
                                        to original     to use Military   care through VA &           coverage.
                                  intention, Adjust         and private     private sector.
                                  automatically for         prosthetist
                                  inflation, Provide
                                    a Stabilization
                                  ancillary benefits
Quality of Life                    Compensate for 3   Survey patients on               None           Determine
                                  consequences: work       their needs.                          appropriate QOL
                                   disability, loss                                                    payments
                                  of functionality &
                                                 QOL, VA develop
                                    measures for QOL
                                   loss, but in the
                                  meantime create up
                                   to 25 percent QOL
                                  payment, Research
                                  health-related QOL
                                         & need for
                                  benefits, Increase
                                     SMC to address
                                       impact on QOL,
Vocational Rehabilitation &               Test VR&E                None         Extend VR&E   VR&E effectiveness
 Employment (VR&E)                incentives, Review                             evaluation         is not well
                                   & revise 12-year                       determination time    established and
                                  time limit, Expand                          limit, Expand        should offer
                                        VR&E to all                         eligibility for          completion
                                          medically                             SBA Patriot    incentives of up
                                         separating                                Express Loansto a 25 percent
                                  servicemembers, &                         Increase Career               bonus
                                  allow all service                       Fairs & integrate
                                  disabled veterans                         Hire Vets First
                                     access to VR&E                       Campaign, Provide
                                   counseling, VR&E                          Credentialing,
                                  should screen all                          Certification,
                                     IU applicants,                           Financial Aid
                                      increase VR&E                               Education
                                          staffing,                           Assistance, &
                                        tracking, &                       Employment rights,
                                         resources,                         Develop Wounded
                                                                           Warrior Intern &
                                                                           Wounded Veterans
                                                                          Readjustment Work
Concurrent Receipt                Eliminate the ban                None                None        Create a DoD
                                                                                                Annuity payment
                                                                                                based on rank &
                                                                                               years of service
Hazards & Exposures                    Create a new                None   Create an embedded               None
                                      structure for                                Fragment
                                  Presumption based                            Surveillance
                                          on casual                              Center and
                                  relationship using                               Registry
                                    four categories
Combat/Combat-Related             Benefits based on                None                None        Benefits and
                                        severity of                                                     process
                                  disability, not on                                           specifically for
                                   circumstances or                                              combat/combat-
                                          location.                                            related injuries
Social Security/Disability         Compensation for                                            Compensation for
 Compensation for Earnings            earnings loss                                           Earnings Ends when
                                      continues for                                           retirement Social
                                              life.                                            Security begins.
Walter Reed National Military                  None     Accelerate BRAC                None    Recruit & retain
 Medical Center (WRNMMC)                                   construction                              first-rate
                                                           projects for                       professionals for
                                                           WRNMMC & new                       WRAMC through 2011
                                                             complex at                       with resources and
                                                           Belvoir, New                       incentives to hire
                                                            command and                                civilian
                                                      control structure                              healthcare
                                                      for WRNMMC, Apply                         professionals &
                                                      regulatory relief                             admin staff
                                                       to A-76 process,
                                                      Survey patients &
                                                      families, Staff &
                                                              train Med
                                                      efficiency wedge,
                                                        Assign a senior
                                                      facility engineer
                                                        to oversee non-
                                                      Modernize facility
                                                      assessment tools &
                                                      prioritize repairs
*This refers to the Aide and Attendant benefit under TRICARE's Extended Care Health Option, and not VA's Aid and
  Attendance benefit.

                               Table 2--Other Veterans' Commissions & Task Forces: Purposes, Findings and Recommendations
                                                                                                                         Report          Findings &
                             Entity                                Chairperson       Charged by          Purpose          Date        Recommendations
IRG on Rehabilitative Care & Admin @ Walter Reed & National           Former VA      Secretary of   Review continuum       Final      Problems resulted
 Naval (Bethesda)                                                Secretary Togo           Defense           of care,     Report:      from a failure of
                                                                  West & Former                         leadership &   April 11,    leadership, loss of
                                                                 Army Secretary                     oversight issues        2007   resources & spending
                                                                  & Congressman                         resulting in               authority under BRAC,
                                                                     John Marsh                         deficiencies                   contracting out,
                                                                                                         reported at                  nursing and other
                                                                                                         Walter Reed                   staff shortages,
                                                                                                       Scope: Walter                      challenges of
                                                                                                     Reed patients &               signature injuries, &
                                                                                                            families                     failure of the
                                                                                                                                       Medical Holdover
                                                                                                                                   system. Other reports
                                                                                                                                       have recommended
                                                                                                                                    changes to the MEB/
                                                                                                                                   PEB process over the
                                                                                                                                     last 10 years, but
                                                                                                                                         none have been
                                                                                                                                     implemented, which
                                                                                                                                    the IRG endorsed as
                                                                                                                                     well as a combined
                                                                                                                                      DoD/VA evaluation
Task Force on Returning Global War on Terror (GWOT) Heroes             R. James   Executive Order        Improve the       Final          There were 25
                                                                     Nicholson,   of the President       delivery of     Report:       recommendations.
                                                                   Secretary of                     Federal services   April 19,   Action areas included
                                                                       Veterans                      and benefits to        2007       healthcare, case
                                                                        Affairs                                 GWOT                        management,
                                                                                                    servicemembers &                continuity of care,
                                                                                                     veterans Scope:                  TBI screening, VA
                                                                                                            All GWOT                                   Liaisons at military
                                                                                                    servicemembers &                  facilities, small
                                                                                                            veterans                    business loans,
                                                                                                                                      education, career
                                                                                                                                   training, employment
                                                                                                                                      rights, financial
                                                                                                                                   aid, housing locator,
                                                                                                                                    electronic tracking
                                                                                                                                       between systems,
                                                                                                                                   dental, rural health,
                                                                                                                                           VA/DoD joint
                                                                                                                                   disability process &
                                                                                                                                            exams, VR&E
                                                                                                                                      extension, & home
                                                                                                                                    Recommendations can
                                                                                                                                        be accomplished
                                                                                                                                        within existing
                                                                                                                                            authority &
                                                                                                                                    resources. Outreach
                                                                                                                                   should cover TAP/DTAP
                                                                                                                                        attendance, job
                                                                                                                                            fairs, vets
                                                                                                                                   preference, & a GWOT
                                                                                                                                    database of Federal
                                                                                                                                   services & benefits.
President's Commission on Care for America's Returning Wounded   Former Senator   Executive Order          Recommend    July 25,           There were 6
 Warriors (PCCWW)                                                    Bob Dole &   of the President  Improvements for        2007    recommendations: 1)
                                                                     Former HHS                     transition, high-              Immediately creating
                                                                 Secretary Donna                    quality services                    a comprehensive
                                                                        Shalala                        for returning               recovery plan with a
                                                                                                     wounded troops,                      lead Recovery
                                                                                                           access to                    Coordinator; 2)
                                                                                                          benefits &                         Completely
                                                                                                     services Scope:                    restructure the
                                                                                                     Wounded OIF/OEF               disability systems so
                                                                                                     servicemembers,                     DoD determines
                                                                                                           veterans,                     fitness and VA
                                                                                                            families               disability benefits;
                                                                                                                                        3) Aggressively
                                                                                                                                   prevent & treat PTSD
                                                                                                                                              & TBI; 4)
                                                                                                                                     strengthen support
                                                                                                                                      for families with
                                                                                                                                   amendments to TRICARE
                                                                                                                                                   & FMLA; 5) Rapidly
                                                                                                                                       transfer patient
                                                                                                                                      info, & develop a
                                                                                                                                       Federal benefits
                                                                                                                                       website, and; 6)
                                                                                                                                       Strongly support
                                                                                                                                         Walter Reed by
                                                                                                                                           recruiting &
                                                                                                                                     retaining 1st-rate
                                                                                                                                   professionals through
Veterans' Disability Benefits Commission                                       LTG James Terry  PL 10Appropriateness      Oct 3,    113 recommendations
                                                                    Scott (USA,                     of Benefit, level       2007       that focused on:
                                                                          Ret.)                          of Benefit,                   compensation for
                                                                                                       Determination                quality of life & a
                                                                                                    Standards Scope:               25 percent allowance
                                                                                                        All disabled                  until VA develops
                                                                                                     servicemembers,                  measures; line of
                                                                                                           veterans,                     duty; earnings
                                                                                                            families               disparity for service
                                                                                                                                     connected veterans
                                                                                                                                   with mental disorders
                                                                                                                                      & young entry; VA
                                                                                                                                        Rating Schedule
                                                                                                                                   revisions, especially
                                                                                                                                   for PTSD, TBI, & IU;
                                                                                                                                    A holistic approach
                                                                                                                                   for PTSD that couples
                                                                                                                                   rehabilitation, & re-
                                                                                                                                   evaluation; caregiver
                                                                                                                                        healthcare & an
                                                                                                                                   presumption standards
                                                                                                                                     for exposures; DoD
                                                                                                                                        evaluations and
                                                                                                                                   separation exams with
                                                                                                                                   Services determining
                                                                                                                                   fitness for duty & VA
                                                                                                                                         adjudicating a
                                                                                                                                     rating; concurrent
                                                                                                                                   receipt and survivor
                                                                                                                                    concurrent receipt;
                                                                                                                                   IT interoperability;
                                                                                                                                      & joint ventures,
                                                                                                                                   sharing agreements, &

                                         Table 3--Total Recommendations
    Veterans' Disability
    Benefits Commission        Independent Review Group         GWOT Task Force                  PCCWW
                   113                           20                          25         6 (23 action items)

                        Prestabilization Ratings

    The following ratings may be assigned for disability from any 
disease or injury from date of discharge from service. The 
prestabilization rating is not to be assigned in any case in which a 
100 percent or total rating is immediately assignable or on the basis 
of individual unemployability. The prestabilization 50 percent rating 
is not to be used in any case in which a rating of 50 percent or more 
is immediately assignable.

Unstabilized condition with severe disability:                      100
  Substantially gainful employment is not feasible or
Unhealed or incompletely healed wounds or injuries:                  50
  Material impairment of employability likely.............

    VA examination is not required prior to assignment of 
prestabilization ratings. If one was done; a prestabilization rating 
can still be assigned. Prestabilization ratings are for assignment in 
the immediate post-discharge period. They will continue for a 12-month 
period following discharge from service. However, prestabilization 
ratings may be changed to a regular scheduler total rating or one 
authorizing a greater benefit at any time. In each prestabilization 
rating, an examination will be requested to be accomplished not earlier 
than 6 months or more than 12 months following discharge. Special 
monthly compensation should be assigned concurrently whenever 
entitlement is shown.
    Source: 38 CFR Sec. 4.28 Prestabilization ratings.

                              Enclosure 2
                Questions from the Honorable Bob Filner
        Before the House Committee on Veterans' Affairs Hearing
             Findings of the Disability Benefits Commission
                            October 10, 2007
1.  As you know, the current system of awarding disability compensation 
        is based on loss of earnings capacity. Based on my reading of 
        your report, you do not propose to do away with this premise. 
        However, you do propose to allow for the award and computation 
        of an additional quality of life benefit. Would you please 
        elaborate on this recommendation--how did you reach this 
        conclusion empirically?
    The Commission reached a conclusion that all of the intended 
outcomes of disability compensation, other than loss of earnings 
capacity, should be better defined. It has been implicitly understood 
that disability caused by military service affects functionality and 
quality of life for such veterans. There is a large body of scientific, 
medical, and sociological literature that supports considering quality 
of life as well as loss of earnings capacity. In the current 
understanding of disability, earnings are no longer the only standard 
used to measure the effect of impairment. Issues such as reduced social 
interaction, diminished mortality, lessened ability to participate in 
activities of normal daily living, and decreased life satisfaction can 
and should be taken into account and compensated fairly.
   a.  On what data/study did you rely to reach this conclusion?
          The majority of the research conducted for the Commission was 
        accomplished by the Institute of Medicine (IOM) and the CNA 
        Corp. (CNAC). The IOM issued a report on the VA's disability 
        evaluation system that recommended that disability compensation 
        should compensate for three consequences of service-connected 
        injuries and diseases: work disability, loss of ability to 
        engage in usual life activities other than work, and loss in 
        quality of life. CNAC provided the Commission with survey data 
        on veteran's quality of life and mortality as compared to non-
        disabled veterans. The survey data clearly shows increased 
        consequences on quality of life as disability severity 
        increases. In addition, the Commission reviewed Government 
        Accountability Office (GAO) reports, which compared benefits 
        for servicemembers to those of public safety officers from 
        various states. The Commission also looked to foreign 
        government veterans' programs--particularly those in the United 
        Kingdom, Australia, and Canada and found that they explicitly 
        compensate for loss of quality of life, or pain and suffering. 
        Finally, the Commission also reviewed the World Health 
        Organization (WHO) interpretations on quality of life and 
   b.  Did you draw on any parallels from private industry (insurance 
          The Commission considered aspects of a wide spectrum of 
        disability programs. A member of the IOM Committee that studied 
        VA's rating schedule, John F. Burton, Jr., Ph.D., is a 
        nationally known specialist in workman's compensation. Also, 
        the GAO report on public safety officers and their benefits was 
        instrumental in shedding light on how other Federal, state, or 
        county safety officers are compensated when injured or ill. 
        However, there was a great deal of variance between these 
        programs and the GAO report w conclusive. Additionally, the 
        Commission looked at Federal Employees' Compensation Act (FECA) 
        and the basis for which it awards workman's compensation. 
        Overall, the Commission did not see insurance as relevant to 
        disability compensation since insurance provides an amount of 
        money based on the level of premiums paid, not on the level or 
        severity of disability.
2.  As an interim measure, you also propose to immediately increase all 
        disability payments to include a quality of life payment 
        available up to 25 percent. Based on your studies, empirical 
        evidence or any other data used by the Commission, can you 
        provide the Committee with any ideas on how this interim 
        payment should be computed by the VA?
    CNAC's analysis compared disabled veterans' earnings loss, impact 
on quality of life, and decreased mortality at various levels of 
disability and among various disabilities and compared the findings to 
non-disabled veterans. The Veterans Health Administration (VHA) 
routinely uses the same instruments (SF-12 and SF-36) to measure health 
status and quality of life. As mentioned previously, the survey data 
clearly shows that impact on quality of life worsens as disability 
severity increases. The Commission believed that a graduated scale 
would be consistent with that data and that veterans' scores from these 
could be used to calculate interim quality of life payments. For 
example, VA could categorize the level of quality of life loss as mild, 
moderate, or severe and compensate as 10, 15, or 25 percent of current 
compensation. We also developed a hypothetical example, graduated by 
severity of disability so that those rated 100 percent would receive a 
full 25 percent increase down to those rated 10 percent who would 
receive 2\1/2\ percent. This example is enclosed. The Commission felt 
that it would be more appropriate for Congress to establish this 
payment than to specify a specific scale.
3.  I think we can all agree that the VASRD needs to be updated and I 
        like your plan of doing so over a specific period of time so as 
        not to disrupt the current system. My concern, like yours, is 
        the current lack of consistency in the rating of PTSD and TBI 
        claims, which is due to an outdated VASRD and poor training of 
        the raters. In order to update the VASRD, did the Commission 
        have any further recommendations on what the VA should look at 
        when revising its PTSD and TBI related systems? For instance, 
        in its report, did the IOM make specific recommendations in 
        this area that this Commission gave more weight than others?
    In order to update the PTSD criteria in the VA Rating Schedule, the 
Commission, along with the IOM, looked to the Diagnostic and 
Statistical Manual, 4th edition (DSM-IV) published by the American 
Psychiatric Association. The DSM outlines criteria for hundreds of 
mental disorders, including PTSD, and is the international psychiatric 
standard for diagnosis to evaluate levels of disability. The current 
Rating Schedule utilizes only one set of criteria for all mental 
disorders. The Global Assessment of Functioning (GAF) Scale is one of 
the measures used to arrive at a level of severity for mental 
disorders. The IOM found the GAF to be an ineffective instrument for 
measuring disability and recommended that VA replace it over time as an 
assessment instrument. In the meantime, IOM recommended increased 
training of examiners and raters to ensure that they are capable of 
using the GAF consistently.
    For TBI, VA should begin by considering the definitions and 
criteria outlined by the World Health Organization (WHO) in its 
International Classification for Diseases, 10th edition (ICD-10). 
However, there is limited TBI knowledge overall, especially those 
resulting from blast injuries. VA has done research into blast injuries 
but will need to conduct expanded research in this realm in order to 
better diagnose the degree of severity of TBI and provide treatment 
that will maximize functioning. Also, the rating criteria for TBI will 
need to reflect the multiple body systems often affected by blasts.
4.  Please elaborate on the Commission's recommendations regarding 
        PTSD, particularly the holistic approach mentioned in 
        Recommendation 5.30, which would include better case 
        management, the coupling of treatment with compensation and 
        vocational assessment and some interaction between the VHA and 
   a.  What was the Commission's underlying premise in making these 
        recommendations? What problems did you uncover, if any? Please 
          The Commission was not satisfied that VA has done all it can 
        to ensure veterans suffering from PTSD have been afforded the 
        best possible recovery plan that incorporates benefits from VBA 
        and care from VHA. Each veteran with PTSD should have a 
        coordinated plan that includes compensation evaluation and a 
        vocational rehabilitation assessment as an integrated component 
        of their mental healthcare plan. A case manager should monitor 
        adherence to the plan. The Commission recommended that these 
        veterans be re-evaluated every 2 to 3 years to monitor progress 
        and asses effectiveness of treatment. The ultimate goal should 
        be the wellness and functionality of the veteran and his/her 
        return to full participation in society.
          The problems uncovered in relation to PTSD diagnosis, 
        compensation, and treatment is the lack of fully trained and 
        certified examiners and raters. The Best Practices for PTSD 
        Compensation and Pension Examinations is not mandated, but 
        should be. There is minimal interaction between VHA and VBA 
        after an examination and a rating have been completed unless 
        the rater decides to schedule a re-examination. There is no 
        feedback loop between treatment providers and examiners and 
        little communication between VBA and VHA. There is also little 
        interaction between medical center clinicians and Vet Center 
        counselors. The Commission believed that veterans with PTSD can 
        be better served.
          Although the IOM report, Treatment of Posttraumatic Stress 
        Disorder, was not completed in time to be considered by the 
        Commission, I reviewed the report and am troubled by its 
        conclusions and recommendations. Basically, the IOM Committee 
        concluded that there is inadequate evidence on the 
        effectiveness of treatment for PTSD and that there is not even 
        an accepted definition for recovery.
5.  Please elaborate on the Commission's recommendation pertaining to 
        presumptions and the causal relationship standard. For instance 
        does the new standard proposed by the IOM increase the hurdle 
        for veterans to prove presumptive disabilities? Would the 
        implementation of an independent Scientific Review Board to 
        determine presumptive conditions as proposed by the IOM allay 
        these concerns?
    A causal relationship standard would give veterans the benefit of a 
more rigorous scientific standard that would make determining 
presumption more equitable across exposures. This standard would be 
more reliable and valid for determining if and how cohorts of veterans 
were exposed to environmental or occupational hazards. However, the 
Commission was concerned that the association level of assigning 
presumption not be ignored if there is appropriate evidence that a 
presumption might still be warranted.
   a.  Did the Commission/IOM find that the VA's system of determining 
        presumptions suffer from internal inconsistencies? If so, how?
          Currently, VA does not have a written process followed 
        whenever a decision must be made on a presumption. Without a 
        written, standard process, variance can occur.
   b.  How has Congress impacted this system of determining 
          Without a standard process soundly based on scientific 
        evidence, Congress is faced with pressure from advocacy groups 
        to approve presumptions that might not be warranted. The 
        proposed process should relieve some of that pressure.
   c.  What role does the Commission envision Congress playing in the 
        future in determining presumptions?
          The Commission hopes that if the IOM framework with its 
        causal standard is implemented, Congress should be able to 
        perform more of an oversight role and have less direct 
        involvement in presumption decisions.
6.  I know that there are a lot of similarities between how your 
        Commission proposes to realign the VA and the DoD process for 
        rating disabilities and those produced by the Dole-Shalala 
        Commission. Please highlight the similarities and differences.
    Both Commissions found the current disability rating process to be 
confusing, duplicative, and time-consuming from the veterans' 
perspective. Our Commission's analysis compared ratings by DoD and VA 
over a 7 year period and found that VA ratings were statistically 
significantly higher than DoD for the same individual conditions and 
combined ratings were higher overall. Both commissions recommended that 
the process be streamlined.
    The Dole/Shalala Commission recommended that DoD restructure its 
disability and compensation systems and that DoD along with VA should 
create a single, comprehensive, standardized medical exam that DoD 
administers. The Services would maintain authority over fitness for 
duty determinations and compensate veterans for years of service. VA 
would establish the disability rating and award compensation and other 
    Our Commission did not specify which department should conduct the 
examinations. We believe that decision can best be made at the local 
level based on the capabilities of the clinical staffs. However, with 
the advice of the Institute of Medicine, we extensively reviewed the 
examination process and made several recommendations to improve the 
examinations and ensure consistency and reliability. These include 
greater use of templates, improved training and certification of 
examiners, and enhanced quality control. These recommendations should 
be implemented no matter which department conducts the examinations.
    Our Commission believes that the process used and the benefits 
available should be appropriate for all veterans and all servicemembers 
found unfit for duty, not just the seriously injured and not just those 
whose injuries result from combat or are combat related. Less than 2 
percent (1,478 of 83,008) of those separated or discharged as unfit 
from 2000 through 2006 were rated by DoD as 100 percent disabled and 
only 6 percent (5,060 of 83,008) were rated 50 percent or higher. A 
separate process for such a small volume of cases would not be 
advisable. And trying to decide whether individual circumstances were 
combat related would be very difficult and often subjective.
7.  I know the VA's disability system is comparable to an insurance 
        company that provides disability coverage and I wondered if 
        your members were able to draw on these parallels in making 
        your recommendations. Did the Commission meet with any private 
        industry entities to help inform its recommendations pertaining 
        to the disabilities system and how it should work?
    Our Commission did not solicit information from private insurance 
companies since those populations insured and the circumstances of 
injuries are vastly different than those of the military. The 
Commission reviewed the GAO study of workman's compensation benefits of 
public safety officers and reviewed the Federal Employees' Compensation 
Act (FECA) that covers civilian Federal employees in the event of a 
work-related injury, illness, or death. GAO also briefed us on its 
report findings.
8.  Your report indicates that based on surveys conducted, most claims 
        raters find that their major source of learning was on-the-job 
        training. In fact, over 50 percent of raters believe that they 
        are ill-equipped to perform their jobs and over 80 percent of 
        raters and VSOs believe that there is too much emphasis placed 
        on speed relative to accuracy. Also, as the recent IDA Report 
        (Analysis of Differences in VA Disability Compensation) on 
        variances in VA's disability compensation awards recommends, 
        the VA undoubtedly needs to:

     1.  standardize initial/ongoing training for rating Specialists;
     2.  increase oversight of rating decisions;
     3.  develop and implement metrics to monitor consistency in 
adjudication results; and,
     4.  increase oversight and review of rating decisions and improve 
and expand data collection and retention.

Would you elaborate on what you witnessed to be the primary problems 
        with the VA rating system?
    The Commission found several problems with the VA rating system. 
Perhaps the most important problem is the lack of trained raters. It 
takes 2 to 3 years to train a rater. Additionally, not all examinations 
are done using templates and the templates are not mandatory; some are 
still under development. Also, VA needs to encourage claimants to 
provide all of the evidence to support their claims at the time the 
claim is filed. These are crucial areas for improving the process and 
action should be expedited. Furthermore, VA has not sufficiently 
employed proven business techniques such as cycle time reduction and 
automated decision support system technology, which could greatly 
enhance the process and allow for real-time decisions once examinations 
and other evidence are submitted. Currently, many veterans do not use 
the electronic application to apply for benefits.
    Concerning the results of the survey of raters, only 3.6 percent 
reported that they were not well trained. 49.8 percent reported that 
they felt very well trained and 46.5 percent felt they were somewhat 
well trained. The amount of time in the position correlated with how 
well the rater felt well trained.
    The raters were asked to assess their top three challenges and 80 
percent said having enough time to process a claim. 83.7 percent of 
raters said that there is too much emphasis on speed, but 61.8 percent 
said that there is the right amount of emphasis on accuracy. 43.1 
percent said speed is more important than accuracy.
    When asked to assess their own degree of proficiency in several 
categories, over 90 percent said their proficiency is good, very good, 
or excellent.
   a.  Other than updating the VASRD, where else would you begin in 
        trying to fix the rating system, in other words to make it more 
        objective and less subjective.
          The utilization of an automated decision support system could 
        apply the Code of law based on the results of an electronically 
        completed medical examination template. Since the templates 
        would be standardized, software could consistently apply the 
        Code of law for a given set of variables. This technology is 
        similar to that in use by professional certification boards 
        that require an examination for licensure. Once the application 
        and examination are completed online, the computer generates a 
        score and a notification of certification if the applicant has 
        met the requirements. This level of technological 
        standardization would lessen the subjective nature inherent in 
        the rating system since it would no longer rely predominately 
        on the training and experience of raters, VSOs, or examiners.
9.  The claims backlog is a serious concern to this Committee, the 
        veterans' community, and I am sure it was to this Commission. 
        Would you elaborate on your simplified and expedited process 
        for well-documented claims as proposed in Recommendation 9.1 of 
        your report. Please explain how you envision this would work in 
        terms of the current claims structure. What would need to 
        change to make it work?
    The rationale behind Recommendation 9.1 was to improve the claims 
process in five ways:

    1.  Best business practices such as cycle time reduction and 
decision support information technology (IT) are techniques used 
extensively in the private sector and could be employed by VA to 
improve their claims processing time.
    2.  Allowing a veteran to bypass some of the ``duty to assist'' 
time requirements could accelerate processing. If a veteran has a claim 
that is well-documented and all evidence is present, then he/she should 
be allowed to state that the claim is ``ready to rate'' and waive the 
current 60 day time period allowed to submit additional evidence. 
Veterans could authorize VA to rate their claims based on the evidence 
    3.  VA could reduce the current 60-day time period allowed for 
submission of additional information to 30 days allowing VA to follow 
up earlier on requests for evidence such as from doctors and hospitals. 
Requests by veterans for additional time could be routinely granted.
    4.  Hiring and training appropriate staff to meet the volume of 
    5.  Funding for expedited implementation of compatible electronic 
records and IT tools such a templates for examinations.

                                                  VETERANS' DISABILITY BENEFITS COMMISSION--GUESTIMATE
                                Hypothetical Example: Disability Compensation plus Prorated Quality of Life (QoL) Payment
                                                    Based on Service-Connected (SC) Disability Rating
                 FY 2007                                 Compensation
 Percent SC     Individual        QoL      Individual      plus QoL        Number of     Annual Compensation  Annual QoL Amount of   Annual Compensation
              Compensation*     Percent    QoL Amount       Payment       Recipients         in FY 2006        Total Compensation     plus QoL Payment
      100         $2,471         0.250           618          3,089          238,966        $7,085,819,832        $1,771,454,958        $8,857,274,790
       90         $1,483         0.225           334          1,817           60,623        $1,078,846,908          $242,740,554        $1,321,587,462
       80         $1,319         0.200           264          1,583          113,549        $1,797,253,572          $359,450,714        $2,156,704,286
       70         $1,135         0.175           199          1,334          165,468        $2,253,674,160          $394,392,978        $2,648,067,138
       60           $901         0.150           135          1,036          184,499        $1,994,803,188          $299,220,478        $2,294,023,666
       50           $712         0.125            89            801          161,774        $1,382,197,056          $172,774,632        $1,554,971,688
       40           $501         0.100            50            551          260,165        $1,564,111,980          $156,411,198        $1,720,523,178
       30           $348         0.075            26            374          335,358        $1,400,455,008          $105,034,126        $1,505,489,134
       20           $225         0.050            11            236          421,709        $1,138,614,300           $56,930,715        $1,195,545,015
       10           $115         0.025             3            118          779,789        $1,076,108,820           $26,902,721        $1,103,011,541
                                                             Totals        2,721,900       $20,771,884,824        $3,585,313,074       $24,357,197,898
*Basic rate, no dependents or Special Monthly Compensation (SMC)
Commission Staff: October 2007