[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
FINDINGS OF THE VETERANS' DISABILITY BENEFITS COMMISSION
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
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
U.S. GOVERNMENT PRINTING OFFICE
39-461 PDF WASHINGTON DC: 2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092104 Mail: Stop IDCC, Washington, DC 20402�090001
COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
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
ZACHARY T. SPACE, Ohio
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
Page
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
WITNESSES
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
MATERIAL SUBMITTED FOR THE RECORD
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
FINDINGS OF THE VETERANS' DISABILITY BENEFITS COMMISSION
----------
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
Bilirakis.
OPENING STATEMENT OF CHAIRMAN FILNER
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
system.
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
decade.
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
sacred.
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.
33.]
OPENING STATEMENT OF HON. STEVE BUYER,
RANKING REPUBLICAN MEMBER
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
done.
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
systems.
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
action.
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
also.
STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT, USA (RET.),
CHAIRMAN, VETERANS' DISABILITY BENEFITS COMMISSION; ACCOMPANIED
BY RAY WILBURN, EXECUTIVE DIRECTOR, VETERANS' DISABILITY
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.
[Applause.]
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----
[Applause.]
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
families.
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
ratings.
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:
www.vetscommission.org/pdf/FinalReport10-11-07-compressed.pdf.]
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
life.
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
regard.
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
families.
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
us?
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
wonderful.
General Scott. We would be happy to provide it for the
record.
[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
involvement.
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
now.
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
veterans.
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
issue?
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
billion.
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
compensation.
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
confusing.
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
detailed.
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
assessment.
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
disabilities.
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.
35.]
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
heartbreaking.
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
moment.
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
rate?
General Scott. Okay. We surveyed 21,000 people.
Ms. Brown-Waite. Wow.
General Scott. Twenty-one thousand veterans. And 1,800
survivors.
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
important.
[The Commission survey results appears in Enclosure 1 in
the post-hearing questions for the record, which appear on p.
48.]
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
problems.
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
disability.
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
life.
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
terms.
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
survive.
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
individuals.
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
thing.
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
question.
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
downward.
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
this.
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
update.
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
all.
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
vets.
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
service.
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
systems.
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
recommendations.
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
http://www.vetscommission.org
(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.
Sincerely,
James Terry Scott, LTG, USA (Ret.)
Chairman
__________
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,
www.ourdocuments.gov/doc.php?flash=true&doc=38.
---------------------------------------------------------------------------
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
location.)
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
experience.
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
combat.
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
occur.
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
Schedule.
Conclusion
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
recommendations.
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
deaths.
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://
www.vetscommission.org
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-
163
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,
2005
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
2007
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
2007
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
Congress.
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
recommendations.
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
future.
While the testimony varied . . . the distinguished panelists all
echoed a similar concern . . . we have to change the way the VA does
business.
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.
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs,
Washington, DC.
October 16, 2007
LTG James Terry Scott, USA (Ret.)
Chairman
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
answer.
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-
9756.
Sincerely,
Bob Filner
Chairman
__________
Veterans' Disability Benefits Commission,
Established Pursuant to Public Law 108-136
Washington, DC.
November 13, 2007
Honorable Bob Filner
Chairman
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.
Sincerely,
James Terry Scott, LTG, USA (Ret.)
Chairman
Enclosures
__________
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
----------------------------------------------------------------------------------------------------------------
Veterans'
Disability Independent Review
Study Group Topic: Benefits Group GWOT Task Force PCCWW
Commission
----------------------------------------------------------------------------------------------------------------
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
amputation.
----------------------------------------------------------------------------------------------------------------
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
polytrauma,
Improve IT
interoperability
between VA & HHS
Indian Health
Services.
----------------------------------------------------------------------------------------------------------------
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
treatment,
research &
training
----------------------------------------------------------------------------------------------------------------
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
treatment,
research &
training
----------------------------------------------------------------------------------------------------------------
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
Allowance,
Research
additional
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
additional
ancillary
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
Experience
Programs,
----------------------------------------------------------------------------------------------------------------
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
only.
----------------------------------------------------------------------------------------------------------------
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
Hold(over)
personnel,
reevaluate
efficiency wedge,
Assign a senior
facility engineer
to oversee non-
medical
maintenance,
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
system.
--------------------------------------------------------------------------------------------------------------------------------------------------------
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
adaptation.
Recommendations can
be accomplished
within existing
authority &
resources. Outreach
should cover TAP/DTAP
attendance, job
fairs, vets
preference, & a GWOT
newsletter,
comprehensive
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)
Significantly
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
2011.
--------------------------------------------------------------------------------------------------------------------------------------------------------
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
compensation,
treatment,
rehabilitation, & re-
evaluation; caregiver
healthcare & an
allowance;
presumption standards
for exposures; DoD
disability
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, &
integration.
--------------------------------------------------------------------------------------------------------------------------------------------------------
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.
Rating
Unstabilized condition with severe disability: 100
Substantially gainful employment is not feasible or
advisable................................................
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
disability.
b. Did you draw on any parallels from private industry (insurance
industry)?
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
VBA.
a. What was the Commission's underlying premise in making these
recommendations? What problems did you uncover, if any? Please
elaborate.
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
presumptions?
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
benefits.
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
submitted.
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
claims.
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