[Senate Hearing 111-326]
[From the U.S. Government Publishing Office]
S. Hrg. 111-326
REVIEW OF VETERANS' DISABILITY COMPENSATION: BENEFITS IN THE 21ST
CENTURY
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 17, 2009
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Roger F. Wicker, Mississippi
Jim Webb, Virginia Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
----------
September 17, 2009
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 2
Tester, Hon. Jon, U.S. Senator from Montana...................... 3
Johanns, Hon. Mike, U.S. Senator from Nebraska................... 4
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 5
Begich, Hon. Mark, U.S. Senator from Alaska...................... 31
Burris, Hon. Roland W., U.S. Senator from Illinois............... 33
WITNESSES
Dunne, Patrick W., Under Secretary for Benefits, U.S. Department
of Veterans Affairs............................................ 6
Prepared statement........................................... 7
Kettner, George, Ph.D., President, Economic Systems, Inc......... 11
Prepared statement........................................... 13
Scott, LTG James Terry, USA (Ret.), Chairman, Advisory Committee
on Disability Compensation..................................... 22
Prepared statement........................................... 23
Response to request arising during
the hearing by Hon. Daniel K. Akaka........................ 38
Neas, Katy, Vice President, Government Relations, Easter Seals... 44
Prepared statement........................................... 46
Prokop, Susan, Associate Advocacy Director, Paralyzed Veterans of
America........................................................ 48
Prepared statement........................................... 49
Wilson, LTC John L., USAF (Ret.), Associate National Legislative
Director, Disabled American Veterans........................... 55
Prepared statement........................................... 56
REVIEW OF VETERANS' DISABILITY COMPENSATION: BENEFITS IN THE 21ST
CENTURY
----------
THURSDAY, SEPTEMBER 17, 2009
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:34 a.m., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Brown, Tester, Begich, Burris,
Burr, and Johanns.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. This hearing will come to order.
This morning the Committee continues our work on veterans'
disability compensation. Specifically, we will be focusing on
issues relating to compensation payments for service-connected
disabilities.
Discussions about the veterans' disability compensation
system often involve two separate but related elements of how
the government pays compensation to those injured in military
service. The first part is the timeliness and accuracy of
compensation decisions, which we held a hearing on in July.
This is an important issue which requires reforming the current
process by which VA adjudicates claims for benefits. The
Committee agrees that veterans deserve timely, accurate
adjudication of their claims for benefits. We are now working
to determine how best to meet that goal.
The second issue relates to the factors that determine how
much a veteran should be compensated for his or her disability.
This is a very complex question that the Committee continues to
consider and is a topic for today's hearing.
There are a number of considerations that must be taken
into account when we look at what influences how much a veteran
is compensated for injuries related to military service. How is
a veteran's quality-of-life affected by a disability? How do we
calculate loss of earnings related to the disability? How
accurate is VA's current ratings schedule? What is the role of
rehabilitation in making a disability determination? These are
but a few of the questions that we are addressing today.
Calculating the appropriate level of compensation for those
disabled in service is a complex matter. For example, there is
data, based on comprehensive studies, suggesting that some
veterans do not receive an appropriate level of compensation,
while some others may be overcompensated. As a result, efforts
designed to help some veterans could inadvertently hurt others.
We need to be deliberate as we work to develop solutions that
will result in appropriate reform of the disability
compensation system.
Again, I want to welcome everyone to today's hearing. I
look forward to the testimony from our two panels and to
continuing to work with the many interested parties in the
months ahead as we seek to craft a workable reform of the VA
disability compensation system.
Senator Burr?
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Thank you, Mr. Chairman. Aloha.
Chairman Akaka. Aloha.
Senator Burr. Thank you for calling this hearing. I want to
welcome our panel of experts and committed individuals to solve
this.
Mr. Chairman, the brave men and women who have served and
sacrificed on our behalf deserve a disability system that meets
their needs and, more importantly, a system that helps them to
achieve full and productive lives. But in reality, the outdated
disability system our Nation's veterans currently have may not
be able to meet the needs of the 21st century veteran.
As far back as 1956, the commission chaired by General
Bradley stressed that, and I quote, ``Our philosophy of
veterans' benefits must . . . be modernized, and the whole
structure of traditional veterans' programs brought up to
date.'' But no fundamental changes were made then or since,
despite a number of reports laying out for all of us the
system's shortcomings.
Just last Congress, the Veterans Disability Benefits
Commission and the Dole-Shalala Commission again stressed the
need to update the system. Those commissions outlined many
fundamental problems, including the fact that the purpose of
disability compensation, and I quote, ``Is unduly restrictive .
. . and inconsistent with current models of disability.'' They
also found that the aim of the veterans' disability program
should be rehabilitation, but the goal has not been met.
Both commissions recommended updating the VA Schedule for
Rating Disabilities to reflect modern medical criteria and
current injuries. They recommended compensating veterans for
loss of quality-of-life in addition to the loss of earnings
capacity. And perhaps more importantly, they stressed the need
to emphasize treatment and rehabilitation of injured veterans.
In light of these commissions' reports, VA requested a
detailed study of how the recommended changes could be made,
and today we will hear about the results of that study. We will
also discuss a recent report from VA suggesting maybe even more
studies are needed before changes should be made to the
disability system.
Although I realize the VA may be reluctant to take on
additional challenges at this time, it is understandable that
many veterans, including a group in North Carolina that write
me frequently, have quite frankly lost patience with five
decades of studies that have not been acted on by this
Committee or by the VA. Our Nation's veterans, particularly
those now coming back from war with devastating injuries,
deserve better than a system that was outdated before they were
born.
As we now know, their disabilities may affect all aspects
of their lives, including community activities, household
chores, and time spent with family. They deserve a system that
will compensate them for the full impact of their injuries and
will give them every opportunity to overcome their disabilities
and succeed in civilian life.
Mr. Chairman, I hope--I desperately hope--this is the last
hearing we have to have on the recommendations for changes to
our disability system. I know that Admiral Dunne, General
Scott, Senator Dole, Secretary Shalala didn't do this just
because it was a job or it was an offer. They did it because
there is a problem. And many have spent countless hours
preparing reports that, if this Committee doesn't act, will
continue to collect dust like the studies that have come before
them.
At a time that we take every opportunity to talk about the
increased investment we make in veterans services, now is not
the time to fall short of what is tough, and that is getting
the disability schedule right, making sure that the next
generation of warriors understand that we understand them now,
but more importantly that we understand their expectations. We
are willing to make sure that they have got the tools to meet
those expectations--not just in treatment--but in the way we
treat the reimbursements.
So, it is my hope that we will see today a commitment to
move forward and I look forward to working with my colleagues
on whatever that path is. I thank the Chair.
Chairman Akaka. Thank you very much, Senator Burr.
Now we will hear from Members of the Committee with their
opening statements. Senator Tester?
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman. I want to thank
you for holding this hearing. Thank you for your statements;
and I want to thank the Ranking Member for his statement, too.
I want to thank the witnesses for being here. Admiral Dunne and
General Scott, thank you both particularly for your service and
thank you for your continued service to the country by being
here today.
I meet regularly with veterans across the State of Montana.
I have been at homeless shelters and visited amputees. I have
talked with men and women who have suffered from PTSD and TBI.
I have been to Walter Reed and Bethesda Naval to see young men
from Montana whose lives have been profoundly changed by
serious injury in their service to this country.
Today, I am thinking about them, and quite honestly, I am
worried about them. I am worried about those physically and
mentally disabled folks who suffer from injuries both invisible
and all too visible. How do we put a price tag on traumatic
disability and diminished quality-of-life caused by war? We
have established commissions and committees, reorganized,
restructured, and revamped.
Today, we once again talk about the complexity of
overhauling an outdated schedule for rating disabilities, and
it seems we have been here before. In fact, General Scott, I
believe I first met you in 2007 when you were before this
Committee presenting your work from the Veterans Disability
Benefits Commission. Now you are back with a new commission and
new recommendations; and don't get me wrong, I love to see you
here, it is good to see you again, but on this complicated
issue, there is no doubt that we need to measure twice and cut
once, not the other way around.
Ultimately, we are here to get things done for the
veterans. We all know that. They are an important part of this
process and I want to thank the VSOs for answering the call to
duty once again by preparing some important recommendations for
disability claims and disability benefit reform. Those are
voices that we need to listen to, as well, during this
discussion.
So thank you, Mr. Chairman. I look forward to the solutions
that we will be offered toward getting the rating system right.
Thank you.
Chairman Akaka. Thank you very much, Senator Tester.
Senator Johanns?
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Mr. Chairman, thank you very much. To the
Chairman and Ranking Member, thank you for your determination
here. These are enormously important issues.
I don't want to speak long, because I don't want to be
repetitious. I could just add my words of support to so much of
what has been said this morning, and that actually would be
sufficient for an opening statement.
I did want to underscore something. I was especially
interested in the Economic Systems, Inc. report that found that
mental disabilities are oftentimes more disabling in terms of
the loss of earning capacity than physical ones, yet our
disability system really doesn't mirror that. This is an area
of significant interest for me--it was when I was the Governor
of Nebraska, and continues to be as I am a Member of the U.S.
Senate.
So, my hope is that as we concentrate on what we need to do
here, we concentrate on that mental disability aspect in a
very, very aggressive way, because I think it has just been
left way behind. We have so much better understanding of mental
disability today than we did even 5 or 10 years ago. It is time
to bring that to our age, if you will.
So, I do appreciate your dedication. One thing I have
especially appreciated about being on this Committee is working
with the people who work in this area. I think they care deeply
about the veterans, want to do the right thing, and are
frustrated when things aren't going the way they should. And
now we just simply have to figure out how we grab these issues
and move them forward. My hope is that in a very bipartisan way
we can do that. Thank you.
Chairman Akaka. Thank you very much, Senator Johanns.
Senator Brown?
STATEMENT OF HON. SHERROD BROWN,
U.S. SENATOR FROM OHIO
Senator Brown. Thank you, Mr. Chairman and Ranking Member
Burr for holding his hearing.
Like many of my colleagues, as Senator Tester said, in
August we went home to listen on a whole host of issues. One of
the most productive couple of hours I spent was listening to--
really doing a roundtable with--veterans and veterans advocates
and people who had served their country--like Admiral Dunne and
General Scott--in Chillicothe, Ohio, in the heart of
Appalachia.
Chillicothe is home to a VA medical center which serves
veterans in Southeast Ohio in its main medical center and its
five community-based outreach clinics, which are increasingly
important, especially in rural areas around my State and other
States. There were 3,500 inpatient admissions last year. The
hospital is known for its excellence in psychiatric services,
in primary and secondary medical services, and in post-acute
care.
About 90,000 Ohio veterans receive monthly disability
compensation. Many of them were in the audience that day, some
were in the roundtable and some were watching. Each is
affected, as we know, by the VA schedule of rating
disabilities. Each faces a difficult task of understanding its
complexities.
We need to continue to dig deeper--as this Committee is
doing, as you three are doing--into why there is not uniform
disability compensation. A service-connected disability should
be rated the same whether the veteran is in Dayton, Ohio, or
Daytona Beach, Florida. These problems--the backlog in the
rating disparities--in many ways relate back to the VA's
schedule of rating disabilities. There must be commonalities
with veterans at every rating level, wherever they may live,
yet we aren't seeing that.
I am concerned, too, about the quality-of-life component of
disability compensation. It is a qualitative evaluation that
produces a quantitative result. We need to be sure that this
evaluation isn't creating arbitrary benefit differentials.
Trust in the VA is eroded when a complicated, subjective
formula spits out a rating and a dollar amount, leaving the
veteran in the dark as to the process and the rationale behind
the compensation. You could just feel that frustration in the
hearts and minds of so many veterans that were at that
roundtable that morning.
VA could improve the situation by simplifying and
rationalizing the benefits formula. More broadly, we should
simplify the process by which veterans receive these earned
benefits. By providing a fully-integrated system from the
Veterans Health Administration to the Veterans Benefits
Administration, we could make VA run more efficiently and be
more veteran-friendly.
There is also an information overflow problem. Veterans are
inundated with paper. This only adds confusion to an already
confusing system. As it stands, there is a brisk market for VA
``how-to'' books. [Laughter.]
The system is that complicated. One book, The Complete
Idiot's Guide to Your Military and Veteran Benefits, is 400
pages. Another book, The Veterans Survival Guide: How to File
and Collect on VA Claims, is almost 300 pages. The VA's own
guide for Federal benefits for veterans is more than 150 pages.
If we work to modernize the payment structure, four
principles should be followed. One, any change to the system
must make it more fair.
Two, transparency must be an overarching goal. Veterans
must be able to much more easily understand the system, the
reasons, and the amounts of their compensation.
Third, it must reduce red tape and focus on increasing
efficiency in order to increase timeliness of claims processing
and payments.
And last, the system must be designed to maximize earned
benefits for veterans, not to minimize compensation awards or
the size of those awards.
I am glad we are having this hearing today. I am encouraged
that VA and Congress are working together with veterans and
with VSOs to find ways to modernize and bring into the 21st
century the way that VA handles veterans disability
compensation. And I thank all three of you for your service to
our country.
Chairman Akaka. Thank you, Senator Brown.
And now we will hear from Senator Begich.
Senator Begich. Mr. Chairman, I will pass and am anxious to
hear from the witnesses.
Chairman Akaka. Thank you.
I want to welcome our principal witness from VA, the
Honorable Patrick W. Dunne, Under Secretary for Benefits. I
also want to welcome Dr. George Kettner, who is President of
Economic Systems, and General James Terry Scott, who is the
Chairman of the VA Advisory Committee on Disability
Compensation.
Thank you all for being here this morning. Your full
testimony will, of course, appear in the record.
Admiral Dunne, will you please proceed?
STATEMENT OF PATRICK W. DUNNE, UNDER SECRETARY FOR BENEFITS,
VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS
Admiral Dunne. Mr. Chairman, Ranking Member Burr, and
Members of the Committee, thank you for inviting me here today
to speak on the timely and important issues related to
disability compensation for our Nation's disabled veterans.
Compensation for service-connected disabilities is based on
replacing the average loss in veterans' wage earning capacity.
The Congressional directive mandates that ratings shall be
based, as far as practicable, upon the average impairments of
earning capacity. As a result, the VA ratings schedule was
developed as a means to compensate veterans for the income from
employment that they would have received if not for the
service-connected disability.
Recently, this approach to disability compensation has been
challenged as inadequate because it focuses only on employment
loss and not on the larger issue of quality-of-life loss.
Definitions of quality-of-life loss vary and may focus on the
domains of physical and mental health or may address the
individual's general overall satisfaction with life.
The Dole-Shalala Commission recommended compensating a
veteran for: the inability to participate in favorite
activities; social problems related to disfigurement or
cognitive difficulties; and the need to spend a great deal of
time performing activities of daily
living.
General Scott and Dr. Kettner have also overseen studies on
quality-of-life, and I look forward to their testimony today.
Each of these studies has provided valuable information about
quality-of-life and has also shown there are many issues to be
addressed. My written testimony provides written comments, and
I would like to highlight several areas.
First, VA does not have statutory authority to incorporate
quality-of-life payments into its disability compensation
scheme.
Second, there is no universally recognized method to
determine how to adequately and fairly compensate for the
impact of a disability or combination of disabilities on a
veteran's quality-of-life.
Third, VA already has a number of special benefits that
implicitly compensate for quality-of-life loss; among these are
ancillary benefits, special monthly compensation, and total
disability based on individual unemployability. Special monthly
compensation and ancillary benefits are provided to veterans in
addition to compensation for service-connected disabilities
under the current rating schedule.
Fourth, any proposal must, in our view, be administratively
feasible and ensure consistency across decisionmakers.
And finally, VA stands ready to work closely with this
Committee and Congress to ensure that all veterans' benefits
meet the criteria to care for him who has borne the battle.
Mr. Chairman, this completes my statement, and I would be
happy to respond to questions.
[The prepared statement of Admiral Dunne follows:]
Prepared Statement of Patrick W. Dunne, Under Secretary for Benefits,
Veterans Benefits Administration, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee, Thank you for inviting
me to speak today on the timely and important issues related to
providing disability compensation to our Nation's disabled Veterans,
with particular attention to issues related to loss of quality of life
(QOL).
I. QUALITY OF LIFE LOSS
Background
Compensation for service-connected disabilities provided by the
Department of Veterans Affairs (VA) is based on replacing the average
loss in Veterans' wage-earning capacity. The Congressional directive at
38 U.S.C. Sec. 1155 mandates that ``ratings shall be based, as far as
practicable, upon the average impairments of earning capacity.'' As a
result, the VA rating schedule was developed as a means to compensate
Veterans for the income from employment that they would have received
if not for the service-connected disability. In recent years, this
approach to disability compensation has been challenged as inadequate
because it focuses only on employment loss and not on the larger issue
of QOL loss. VA has received input on QOL loss from numerous sources.
As a result, an effort has been made to clarify the implications for
adopting a policy of QOL loss compensation in conjunction with the
current average earnings loss compensation system. Those sources
providing information and recommendations to VA include: the
President's Commission on Care for America's Returning Wounded Warriors
(Dole-Shalala Commission); the Veterans' Disability Benefits Commission
(Benefits Commission); the Center for Naval Analyses (CNA); the
National Academy of Sciences' Institute of Medicine (IOM); and Economic
Systems, Incorporated (EconSys).
Definitions of QOL loss vary and may focus on the domains of
physical and mental health or may address the individual's overall
satisfaction associated with life in general. The IOM traces the
concept back to the Greek philosopher Aristotle's description of
``happiness.'' The IOM uses a definition encompassing the cultural,
psychological, physical, interpersonal, spiritual, financial,
political, temporal, and philosophical dimensions of life. A more
succinct definition utilized by EconSys refers to an overall sense of
well-being based on physical and psychological health, social
relationships, and economic factors.
Dole-Shalala Commission
QOL loss was addressed in the 2007 Report of the President's
Commission on Care for America's Returning Wounded Warriors, also
referred to as the Dole-Shalala Commission. Although the report was
primarily focused on ways to assist severely wounded servicemembers
returning from Iraq and Afghanistan, it recommended that Congress
should restructure VA disability payments to include compensation for
non-work-related effects of permanent physical and mental combat-
related injuries. According to the report, this would compensate a
disabled Veteran for the inability to participate in favorite
activities, social problems related to disfigurement or cognitive
difficulties, and the need to spend a great deal of time performing
activities of daily living. As a result of the report, VA contracted
for a study on QOL loss with EconSys, which was completed in 2008.
In terms of existing compensation, the EconSys study agrees with
prior studies that earnings loss is on average at least fully
compensated under the current system and in some cases overcompensated.
However, studies agree that certain conditions such as mental health
are undercompensated. Prior studies found that QOL loss does exist for
service-disabled Veterans and recommended that VA examine possibilities
for QOL compensation, acknowledging that implementation would be
lengthy and have significant cost implications.
Veterans' Disability Benefits Commission
The Benefits Commission was created by the National Defense
Authorization Act of 2004 and produced a final report in 2007 that
provided recommendations to VA on a wide range of issues related to the
claims process and the benefits award system. Among the issues
addressed was QOL loss. The report included recommendations that VA
disability compensation should account for QOL loss. In addition, it
recognized special monthly compensation benefits and ancillary benefits
as existing vehicles to assist with QOL loss among disabled Veterans.
The Benefits Commission incorporated information from the CNA and IOM
studies into its final report, agreeing with these organizations that
QOL loss existed among disabled Veterans and that VA disability
compensation should address it. The Benefits Commission also supported
the idea that VA should undertake studies designed to research and
develop QOL measurement tools or scales and ways to determine the
degree of loss of QOL on average resulting from disabling conditions in
the rating schedule. However, it acknowledged that QOL loss assessment
is a relatively new field and still at a formative stage. Therefore,
implementation would be a long-term, experimental, and costly activity.
Center for Naval Analyses
A major study on QOL loss among Veterans was conducted by CNA at
the request of the Benefits Commission. It focused on whether the
current VA benefits program takes into account QOL loss. A survey was
conducted to determine whether QOL loss existed among disabled Veterans
and whether parity existed between the amounts of VA compensation
received by disabled Veterans and the average earned income of non-
disabled Veterans. CNA determined that QOL loss does exist among
disabled Veterans. It was also determined that VA generally compensated
adequately for lost earnings and in some cases overcompensated, as with
Veterans who enter the system at retirement age, which CNA stated
implies a built-in QOL loss payment for these Veterans. However, CNA
found that undercompensation occurred for younger Veterans with more
severe disabilities and for all categories of mental disabilities
compared to physical disabilities. It was also pointed out that, while
QOL loss was greater among disabled Veterans than non-disabled Veterans
and the general population, those Veterans with mental disabilities
showed the greatest QOL loss.
Institute of Medicine
A second QOL loss analysis incorporated by the Benefits Commission
into its final report came from the 2007 report, A 21st Century System
for Evaluating Veterans for Disability Benefits, produced by IOM at the
commission's request. This lengthy review of the VA disability benefits
process addressed QOL loss. A distinction was made by IOM between
current VA compensation for a Veteran's work impairment and a
compensation system based on ``functional limitations'' on usual life
activities, which would include non-work disability. IOM concluded that
the Veterans' disability compensation program should compensate for:
work disability, loss of ability to engage in usual life activities
other than work, and QOL loss. IOM also recommended that VA develop a
tool for measuring QOL loss validly and reliably and develop a
procedure for evaluating and rating the QOL loss among disabled
Veterans.
II. ECONOMIC SYSTEMS REPORT
The most recent study of QOL loss was conducted by EconSys and
reported in its Study of Compensation Payments for Service-Connected
Disabilities, Volume III, Earnings and Quality of Life Loss Analysis,
released in September 2008. VA tasked EconSys with analyzing potential
methods for incorporating a QOL loss component into the current rating
schedule and with estimating the costs for implementing these methods.
The EconSys study proposed three methods that might be utilized by VA.
The first and simplest method would be to establish statutory QOL
loss payment rates based only on the combined percentage rate of
disability. This method would ``piggy-back'' the QOL loss payment on
top of the assigned disability evaluation under the current rating
schedule. The amount of the payment would be determined by assigning a
QOL score, ranging from -2 to 4, with 4 representing death and negative
values representing an increase in the QOL of the Veteran. Although
this method would be the easiest to administer because significant
changes to the VA medical examination and rating process would be
unnecessary, it raises issues of fairness. EconSys found that the
severity of QOL loss does not mirror the severity of earnings loss
captured in the ratings schedule. Moreover, EconSys found that QOL loss
varies greatly both by condition and by individual, meaning that
different Veterans with the same disability rating or the same
condition could vary widely in their QOL. Under this method, a Veteran
with minimal actual QOL loss could receive the same extra QOL loss
payment as a Veteran with severe actual QOL loss. EconSys has estimated
that additional program costs for implementing this method range from
$10 billion to $30.7 billion annually.
A second optional method proposed by EconSys would key QOL loss
payment amounts to the medical diagnostic code of the primary
disability, as well as the combined percentage rate of disability. This
option anticipates that Congress would create a separate pay scale
based on the Veteran's combined degree of disability and primary
disability. This method would arguably produce more accurate QOL loss
payments because two variables rather than one would be involved and
previous studies have shown that some disabilities, such as mental
disorders, are associated with greater actual QOL loss than others.
However, implementing this would involve conducting large sample-size
surveys to assess the average QOL loss for each of over 800 diagnostic
codes and then factoring in the additional loss for each of the ten
percent increments of the rating schedule up to 100 percent. No surveys
like this have been conducted in the past as a means to assign a dollar
value to QOL loss. Inherent in such surveys is the potential for
inconsistency and inaccuracy because the data would involve Veterans'
self-reported answers to subjective questions. Given the number of
``diagnostic code-evaluation percentage'' combinations involved, a QOL
loss scale developed under this method would be extremely complex and
require extensive computer system modifications. In the event that this
optional method was implemented, it would likely be subject to the same
issues of fairness as the first method. A Veteran with a low combined
degree of disability may receive more total compensation than a Veteran
with a high combined degree of disability because of a difference in
the QOL loss value assigned to different diagnostic codes. Moreover,
the disability identified as primary for existing compensation may not
be the primary cause of a Veteran's QOL loss. EconSys has estimated
that this method would result in program costs of $9 to $22 billion
annually.
A third optional method proposed by EconSys would involve an
individual assessment of each Veteran for QOL loss by both a VA medical
examiner and a VA claims adjudicator. EconSys describes the process as
involving a QOL loss assessment component to the medical examination.
The claims adjudicator would review the medical examiner's report on
QOL and assign a QOL rating based on the diagnosis and rating for the
primary diagnosis. This method would involve establishing separate
rating tables for earnings loss and QOL loss and using these in
combination with subjective information received from the Veteran on
perceived QOL loss. This method would arguably allow for the most
accurate assessment of QOL loss because of its individualized nature.
However, it would require extensive training of VA personnel to
administer and interpret QOL loss assessment tools and then apply them
to the rating process. Once again, issues of subjectivity and fairness
would likely be involved. Timeliness of decisions would be negatively
affected based on the complexity of the adjudicator's required QOL loss
assessment. EconSys has estimated that this method would result in
annual administrative costs of approximately $71.5 million, plus
program costs of $10 to $25.7 billion dollars annually.
III. IMPLEMENTING QUALITY OF LIFE LOSS COMPENSATION
VA Challenges
Implementing a disability rating system that included compensation
for QOL loss would involve at least two major challenges. The first
would be to accurately and reliably determine whether, and to what
extent, a disabled Veteran suffers from QOL loss. The second would be
to establish equitable compensation payments for varying degrees of QOL
loss. The first challenge has been addressed by other organizations and
has led to the development of QOL loss assessment tools. The most well
known of these is the RAND Corporation's Short Form 36 Health Survey
(SF-36) and Short Form 12 Health Survey (SF-12). These are survey
questionnaires that measure physical functioning, role limitations due
to physical health, bodily pain, general health perceptions, vitality,
social functioning, role limitations due to emotional problems, and
mental health. The questionnaires yield numerical scores that are
interpreted to measure QOL loss in relation to the non-disabled
population.
The CNA study conducted for the Benefits Commission utilized a
survey instrument derived from the SF-36 and SF-12. The results showed
that service-connected disabled Veterans were more likely to report QOL
loss than non-disabled Veterans. However, CNA made it clear that the
results were based on subjective self-reporting by Veterans and that,
although survey instrument scoring showed a difference between disabled
and non-disabled Veterans, the instruments were not able to show how
much difference in QOL loss existed between the two groups. This is
problematic because the second challenge of assigning a dollar value
for compensation purposes depends on distinguishing different degrees
of QOL loss among disabled Veterans. VA is unaware of whether this
problem has been addressed by other
organizations.
As EconSys stated in its study, users of existing QOL loss
assessment instruments seek to make comparisons of QOL loss between
different groups or to measure improvements in QOL loss as a result of
treatment interventions. However, they are not trying to attach a
dollar value to these differences. For example, the CNA study indicated
a greater QOL loss among disabled Veterans compared to non-disabled
Veterans, but it does not provide a model to measure the extent of
differences and provide fair compensation accordingly.
The EconSys study, described above, provides options for
implementing a compensation procedure for QOL loss among Veterans, but
is not specific about how new assessment instruments would be
developed. For example, in the second option offered by EconSys, part
of the QOL loss payment would be tied to the medical diagnostic code
for which the Veteran is service-connected. This is based on the
assumption that certain medical disabilities generally produce greater
QOL loss than others. To implement this option, VA would be required to
develop new survey instruments that target specific diagnostic codes
and minimize variations in reporting due to subjectivity. Surveys now
in use, such as the SF-36 and SF-12, are generic and would be of little
help. The burden of establishing appropriate QOL loss compensation
would remain with VA and Congress.
VA would face many additional problems in the attempt to implement
QOL loss compensation. Among them would be the potential for a change
in the Veteran's QOL loss. Since a major goal of VA is successful
treatment and rehabilitation for disabilities, it is likely that the
mental and physical health of some Veterans would improve over time and
QOL loss would be reduced. On the other hand, a Veteran's circumstances
may lead to an increase in QOL loss. Therefore, the issue of how to
adjust compensation payments for changes in a Veteran's QOL loss over
time would need to be addressed.
An additional concern presented by two of the EconSys options is
the potential for appeals of Veterans' ratings. In options two and
three, it is highly likely that Veterans with similar conditions of
similar severity would receive different ratings and awards. This
inconsistency introduces an equity issue that could lead to additional
appeals and therefore a more frustrating process for Veterans.
Current VA Compensation
Most of the organizations that have provided input to VA on QOL
have stated that VA already has a number of special benefits that
implicitly, if not expressly, compensate for QOL loss. Among these are
ancillary benefits, special monthly compensation, and total disability
based on individual unemployability. Special monthly compensation and
ancillary benefits are provided to Veterans in addition to compensation
for service-connected disabilities under the current rating schedule.
Ancillary benefits include the extensive programs of Home Loan
Guaranty and Vocational Rehabilitation and Employment Services. Certain
ancillary benefits are intended to provide assistance to Veterans with
special needs due to exceptional handicaps that result from service-
connected disabilities. One major ancillary benefit, authorized by 38
U.S.C. Sec. 3902, is assistance with the purchase of an automobile or
other conveyance with adaptive equipment necessary to ensure that the
Veteran can safely operate the vehicle. Another ancillary benefit
provides assistance with housing needs for certain severely disabled
Veterans. Authorization for providing assistance to Veterans in
acquiring housing with special features and residential adaptations is
provided by 38 U.S.C. Sec. 2101(a) and (b). Additionally, a yearly
clothing allowance is authorized by 38 U.S.C. Sec. 1162 when a service-
connected disability requires a Veteran to use a prosthetic or
orthopedic appliance, including a wheelchair, which tends to wear out
or tear the Veteran's clothing. A clothing allowance is also authorized
when a physician prescribes medication for a service-connected skin
condition that causes irreparable damage to a Veteran's outer garments.
In addition to these benefits, special monthly compensation,
authorized by 38 U.S.C. Sec. 1114, provides a range of special monthly
payments over and above the current rating schedule disability
compensation for Veterans with service-connected disability who are
housebound, in need of aid and attendance from others to accomplish
daily living activities, have severe hearing loss or visual impairment,
or have loss, or loss of use, of extremities or reproductive organs. In
addition, VA is authorized to pay special monthly compensation to
female Veterans for breast tissue loss.
VA regulations authorize a rating of total disability based on
individual unemployment if a Veteran is unable to obtain, or maintain,
substantially gainful employment because of service-connected
disabilities. This is an extra-schedular benefit resulting in
compensation paid at the 100-percent schedular rate for Veterans who
have been awarded a single 60-percent or a combined 70-percent
disability rating and are unable to work as a result of their service-
connected disability. The benefit is also available based on a VA
administrative review, if the schedular requirements are not met.
IV. CONCLUSION
This testimony attempts to outline some of the issues and
challenges that VA would face if authorized to provide QOL loss
compensation. If VA is to provide QOL loss compensation consistent with
the proposed options in the EconSys study, statutory changes would be
required. Additional administrative costs for training VA personnel and
reconfiguring VA computer systems, as well as the costs for providing
additional benefits to Veterans, would be considerable. The
implications for adopting such a policy are significant for VA. This
testimony also illustrates how, in addition to compensation provided
under the rating schedule, VA provides special monthly compensation,
ancillary benefits, and extra-schedular ratings to Veterans with
certain service-connected disabilities, which multiple studies have
recognized as existing tools to promote the QOL of Veterans.
As always, VA maintains its dedication to fairly and adequately
serving the disabled Veterans who have sacrificed for our country.
Chairman Akaka. Thank you very much, Admiral Dunne.
Dr. Kettner, your testimony, please.
STATEMENT OF GEORGE KETTNER, Ph.D., PRESIDENT,
ECONOMIC SYSTEMS, INC.
Mr. Kettner. Chairman Akaka, Ranking Member Burr, and
Members of the Committee, thank you for the opportunity to
appear before you today.
I served as Project Director of a recent study of lost
earnings and loss of quality-of-life for veterans with service-
connected disabilities, and a transition benefit for veterans
undergoing vocational rehabilitation. We compared veterans with
service-connected disabilities to a matched group of veterans
without service-connected disabilities.
We found that, overall, actual earnings plus disability
compensation for veterans with service-connected disabilities
was 7 percent above the earnings of the respective comparison
group without service-connected disabilities. On average,
veterans rated 30 percent or less did not experience serious
wage loss. Approximately 55 percent of 2.6 million veterans
receiving disability compensation are rated at 30 percent or
less. Veterans rated 40 to 90 percent experienced wage loss,
but their VA disability compensation more than made up for the
loss. For veterans rated at 100 percent, their earnings and
disability compensation was 9 percent less than expected and,
hence, did not fully compensate for lost earnings.
We also found considerable differences in earnings loss
across different diagnoses for a given rating level, resulting
in serious inequity in the disability payment system. Several
of the most prevalent diagnostic codes are candidates for
changes to the rating schedule because there is no earnings
loss associated with those diagnoses at the 10 percent or 20
percent rating levels. Examples include arthritis, hemorrhoids,
tinnitus, and diabetes.
We found that mental health disorders, in general, have a
much more profound impact on employment and earnings than do
physical disabilities. Adjustments to the ratings criteria
could overcome much of this disparity, but not for those
already rated 100 percent, unless the benefit amount for the
100 percent rating were increased, as well.
Veterans receiving disability compensation have, on
average, 3.3 rated disabilities. VA uses a look-up table for
combining individual disability ratings into a combined degree
of disability rating. The earliest known table dates from 1921
and has changed very little since then. These formulas result
in ratings that overcompensate veterans for lost earnings,
particularly when combining multiple disabilities with loss
ratings.
Special monthly compensation is a series of awards for loss
of limbs, organs, or functional independence. SMCs are not
awarded to compensate for average loss of earnings capacity and
can be viewed as payments for loss of quality-of-life. The
amount of SMC monthly payments above the regular scheduled
payment for the 100 percent rating ranges from about $600 to
$1,900 for the most severely disabled veterans. SMC payments
are not made for PTSD and other mental health conditions.
Certain SMCs are paid to veterans for assistance with
activities of daily living. For example, SMC-L provides $618
per month above the normal 100 percent amount, and SMC-S for
housebound veterans provides $302. Survey results indicate that
the monthly cost of hiring an assistant ranges from about $500
to $11,000, depending on how many hours of care are provided. A
recent study estimated the lost wages and benefits of family
caregivers of severely injured and active duty servicemembers
at $2,800 per month. The current amount of the SMCs for
assistance is well below these estimated costs.
The literature generally defines quality-of-life as an
overall sense of well-being based on physical and psychological
health, social
relationships, and economic factors. We found that quality-of-
life loss occurred for veterans at all levels of disability. We
also found that loss of quality-of-life increases as disability
increases, but there are wide variations in the loss of
quality-of-life with each disability rating.
QOL is an individualized perception and people adjust to
disability differently. About half of those individuals with
severe disabilities report relatively high degrees of life
satisfaction. We also found that veterans receiving individual
unemployability and SMC payments report significantly greater
QOL loss, as well as greater earnings loss. Veterans with
mental disabilities rated 100 percent show much greater
quality-of-life loss than veterans with physical disabilities
rated at 100 percent.
Putting an economic value on quality-of-life is subjective
and value-laden. Hence, we developed different options for
quality-of-life loss payments, ranging from an average amount
of $100 a month to almost $1,000 a month, depending on the
benchmark for measuring loss of quality-of-life. Examples of
benchmarks include veteran self-assessment, societal views,
awards made by foreign governments, SMC payments, and
Individual Unemployability benefits for veterans over the age
of 65.
We identified options for payment of living expenses for
disabled veterans participating in vocational rehabilitation
and employment. Options include monthly payment for core living
expenses of about $1,900 to $3,000 for veterans living alone,
or with two dependents to cover housing, food, and
transportation. Additional daily living costs, such as apparel
and services, could be provided for about $500 to $935 per
month.
A major issue to be decided in providing a transition
benefit is which VR&E participants would be eligible depending
on severity of disability, medical discharge, and time since
discharge. Options presented range from as few as 3,400
applicants per year to as many as 29,000 applicants.
Mr. Chairman, I thank you for the opportunity to appear
before you today. I welcome any questions you or the Committee
Members may have.
[The prepared statement of Mr. Kettner follows:]
Prepared Statement of George Kettner, Ph.D., President,
Economic Systems, Inc.
Chairman Akaka, Ranking Member Burr, and Members of the Committee,
thank you for the opportunity to appear before you today to present the
major results of Economic Systems' Study of Compensation Payments for
Service-Connected Disabilities completed last year for VA. This study
was requested largely as a follow on to the President's Commission on
Care for America's Returning Wounded Warriors, known as the Dole-
Shalala Commission.
VA DISABILITY COMPENSATION RATING SYSTEM
The VA Disability Compensation Program provides monthly benefit
payments to veterans who become disabled as a result of or coincident
with their military service. Payments generally are authorized based on
an evaluation of the disabling effects of veterans' service-connected
physical and/or mental health impairments. Monthly payments are
authorized in percentage increments from 10% ($117 in 2008) to 100%
($2,527 in 2008). The process for determining ratings for disability
compensation benefits uses the VA Schedule for Rating Disabilities
(VASRD) to assign the level of severity of the disabilities.
The VASRD contains over 700 diagnoses or disability conditions,
each of which may have up to 11 levels of medical impairment. The
lowest level of impairment starts at 0% then increases in 10%
increments up to a maximum of 100%. Disability compensation, as
determined by the VASRD, is intended to replace average impairment in
earnings capacity.
Eligibility requires that a determination be made that the
condition is a service-connected disability. Service-connected means
that the condition occurred during or was aggravated by military
service, is one of several ``presumed'' conditions, or, for chronic
conditions, became evident within one year of discharge from the
military. It does not require that the disability be work related or be
caused by conditions in the work environment. In this regard the VA
Disability Compensation Program combines elements of both disability
insurance voluntarily provided by employers and workers' compensation
programs mandated by government.
Claimants with a combined rating between 60 to 90% who are
determined to be unemployable solely as a result of service-connected
conditions qualify for Individual Unemployability (IU). Claimants
determined to be entitled to IU receive the same benefit payment amount
as those rated at the 100% disability level. Conditions or
circumstances that result in the claimant not being employable override
the medical impairment rating. IU is similar to the Social Security
Disability Insurance (SSDI) program in that both provide payments
because the beneficiary is deemed to be unemployable.
Special monthly compensation (SMC) is a benefit paid in addition to
or instead of the VASRD-based benefits. Examples include: loss of or
loss of use of organs, sensory functions, or limbs; disabilities that
confine the veteran to his/her residence or result in the need for
regular aid and attendance; a combination of severe disabilities that
significantly affect mobility; and the existence of multiple,
independent disabilities each rated at 50% or higher.
We were asked by VA to address three major areas in our analysis:
earnings loss resulting from service-connected disabilities, the impact
of those disabilities on quality of life, and a possible transition
benefit for veterans engaging in VA's vocational rehabilitation and
employment program. Some of our most significant findings relate to the
following topics:
Adequacy of Disability Compensation
Disabilities Without Earnings Loss
Additional Diagnostic Codes
Earnings Loss for Veterans with Post Traumatic Stress
Disorder (PTSD), Other Mental Health Disorders, and Traumatic Brain
Injury (TBI)
Methodology Used to Calculate Combined Degree of
Disability
Individual Unemployability Benefits
Special Monthly Compensation
Quality of Life Payment Options
Transition Benefit Options.
ADEQUACY OF DISABILITY COMPENSATION
A crucial part of the loss of earnings analysis is determining the
wages that the veteran would have received if he or she had not
experienced a service-connected disability (SCD). The estimates of
these potential earnings depend on tracking the actual earnings of
individuals in a comparison group who did not have SCDs but who were
otherwise matched to the disabled veterans on personal characteristics.
The personal characteristics used to match the disabled veterans and
the veterans without SCDs were age, gender, education at the time of
entry into the service, and status as an officer or enlisted person
when discharged from active duty. The analysis of loss of earnings was
primarily based on comparisons of the earnings in 2006 of veterans with
SCDs and without SCDs as provided to the study by the Social Security
Administration.
Assessment of the adequacy of disability compensation in relation
to earnings loss requires determining if the payments are equitable
vertically and horizontally. Vertical equity means that actual earnings
loss should increase in proportion to increases in disability ratings
and that compensation should offset that earnings loss. We found that
overall, veterans with service-connected disabilities have earnings
plus disability compensation 7 percent above their average expected
earnings. The average was higher at each rating level except at the
100% rating level where the combined earnings and compensation was 9
percent less than expected. On average, veterans with a 30% or less
combined disability rating did not experience serious wage loss.
Approximately, 55% of 2.6 million veterans receiving disability
compensation in 2007 were rated at 30% or less. Earnings losses for
veterans with 40% to 90% combined rating did have wage losses, but
their VA disability compensation more than made up the loss. In
contrast, actual earnings losses plus disability compensation for
veterans with 100% combined rating fall short of average expected
earnings by about 9%. In 2007, 9.1 percent of veterans receiving
disability compensation had a combined rating of 100%, up from 7.5
percent in 2001. Thus, vertical equity is not fully achieved.
Horizontal equity means that actual earnings loss should be the
same or similar for the same disability ratings but with different
types of disabilities. We found considerable differences in earnings
loss across different diagnoses for a given rating level, resulting in
serious inequity in the payment system. For example, for veterans with
a 50% combined rating, the range was from no earnings losses for
genitourinary or endocrine medical conditions to over 40 percent
earnings losses for non-PTSD mental conditions. Veterans with PTSD,
Other Mental Disorders, and infectious diseases experience greater
earnings losses than veterans diagnosed with other medical conditions
rated at the same level. Thus, horizontal equity is not achieved.
One factor that is important to understanding the results of our
earnings analysis is that it concentrates on veterans discharged since
1980. Our results, therefore, differ from the previous study conducted
by CNA Corporation for the Veterans' Disability Benefits Commission as
that study included veterans discharged before 1980. Our study does not
include veterans of World War II, Korea, and Vietnam (relatively few)
because they are largely past or approaching retirement age and because
data on their essential demographic and human capital characteristics
are not available from the Department of Defense (DOD) for analysis. We
believe that this focus on more recent veterans is more appropriate for
policy considerations for the future. More detailed discussion of the
differences between our study and the study for the Veterans'
Disability Benefits Commission (VDBC) is provided later.
DISABILITIES WITHOUT EARNINGS LOSS
In addition to examining the broad comparisons cited above, our
analysis identified several diagnostic codes that are candidates for
changes to the rating schedule because the impact of these conditions
on earnings is not commensurate with the level of the rating. In
particular, for several of the most prevalent diagnostic conditions,
there is no earnings loss at the 10% or 20% combined rating levels.
Examples of these diagnoses include: arthritis; lumbosacral strain;
arteriosclerotic heart disease; hemorrhoids; and diabetes mellitus. The
rating schedule criteria for the rating of these conditions could be
adjusted so that a rating of zero percent instead of 10% or 20% would
be assigned in the future to reflect that no earnings loss occurs at
this level for these conditions.
ADDITIONAL DIAGNOSTIC CODES
We were asked to identify diagnostic codes that could be added to
the over 700 existing codes in the rating schedule. Analogous codes are
currently used in 9 percent of all cases. By sampling 1,094 cases in
which analogous codes were used, we identified 33 ICD-9 codes that were
used often enough to warrant addition to the rating schedule. These
include disturbance of skin sensation, mononeuritis of lower limb, and
unspecified hearing loss.
PTSD, OTHER MENTAL DISORDERS, AND TBI
Our analysis and previous studies conducted by the Bradley
Commission in 1956, the Economic Validation of the Rating Schedule in
1972, and the Veterans' Disability Benefits Commission in 2007, are
consistent in finding that mental health disorders in general have a
much more profound impact on employment and earnings than do physical
disabilities. We found that earnings loss for PTSD is 12 percent for
veterans rated 10% and up to 92 percent for those rated 100%. For other
mental disorders (other than PTSD), the earnings loss is 14 percent for
those rated 10% and 96 percent for those rated 100%. Earnings loss for
TBI rated 100% is similar at 91 percent.
A policy option for consideration is to adjust the VA Schedule of
Rating Disabilities to eliminate rating PTSD at 10% and use the rating
criteria for 10% to rate 30%, 30% to 50%, 50% to 70%, and combine the
criteria for 70% and 100% at 100%. We note that this will not eliminate
the deficiency at 100%; veterans rated 100% will still be receiving
less in disability compensation and earnings combined than their
expected level of earnings. We also note that these changes, especially
if also made for mental health disorders in general, would have a
significant impact on the issue of Individual Unemployability (IU).
Veterans whose primary diagnosis is PTSD made up 32 percent of IU cases
on the rolls in 2007 and 47 percent of new IU cases during the period
2001-2007. Including PTSD with all mental disorders, 44 percent of IU
cases on the rolls in 2007 were mental disorders and 58 percent of new
IU cases from 2001-2007 had mental disorders. Since the criteria for
rating mental disorders at 100% require veterans to be unemployable, it
is not clear why veterans with mental disorders who are unemployable
are not rated 100% instead of IU.
METHODOLOGY USED TO CALCULATE COMBINED DEGREE OF DISABILITY
VA has used certain formulas over the years to assign a Combined
Degree of Disability (CDD) when veterans have more than one service-
connected disability. Veterans receiving disability compensation have
on average 3.3 disabilities that they are rated for. The earliest known
formula dates from 1921 and has changed very little since then. The CDD
determines the amount of the disability compensation payment. The table
below provides examples of how various individual ratings are combined
using the four formulas. The formulas do not take into account the
types of disabilities being combined.
----------------------------------------------------------------------------------------------------------------
Rating Schedule 1921 1930 1933 1945 to Present
----------------------------------------------------------------------------------------------------------------
Two 10% Ratings.......................................... 19 19 20 20
Three 10% Ratings........................................ 28 19 30 30
Four 10% Ratings......................................... 37 19 30 30
----------------------------------------------------------------------------------------------------------------
Five 10% Ratings......................................... 46 19 40 40
One 30% and four 10%..................................... 58 58 50 50
One 70% and four 10%..................................... 82 82 80 80
----------------------------------------------------------------------------------------------------------------
A claimant who has three disabilities with each disability rated at
10%, receives a combined rating of 30%. A veteran with two service-
connected disabilities, one rated 60% and one rated 10%, receives
compensation only at the 60% rate. The current formula for combining
additional ratings gives greater weight to multiple 10% ratings. The
effect of additional 10% ratings is diminished if the primary diagnosis
has a high rating. Having multiple low ratings increases the payment
dramatically for a veteran whose primary diagnosis has a low rating; it
has a negligible or much smaller effect for veterans who have a single
condition with a high rating such as 80%.
In our analysis we found that actual earnings, on average, were
higher for veterans with more disabilities at a given rating level such
as 30%. This paradoxical result suggests that the rating for the first
medical condition captures most of the impact of the veteran's overall
medical conditions on his or her potential earnings. The ratings for
the second, third, or additional medical conditions increase the CDD
but the additional conditions do not further affect the veteran's
earning capacity. The formula for combining disabilities results in
ratings that over compensate veterans for lost earnings.
An option to the current single lookup table is to replace the
current table with tables that reflect specific combinations of
different disabilities. This will require conducting additional
analysis of the impact of combinations of disabilities on earnings. The
tables could be programmed for ease of use rather than manually applied
as is the current practice. Such programmed tables could actually
reduce the burden on raters.
Medical science has established for many years that certain
diseases are prevalent together, examples of which include PTSD and
major depressive disorder, and diabetes and cardiovascular diseases. It
is quite likely that there are many diseases that are present together
in individuals and that they cause a greater impact on the individual's
earning capacity than would be the case with multiple unrelated minor
ailments. Additional analysis of the impact of multiple diseases or
disabilities could result in an enhanced approach to ratings for
combinations of diagnoses. For example, nearly 30,000 service-connected
veterans have a diagnosis of traumatic brain disorder and some 4,600 of
these (15 percent) also have a service-connected diagnosis of PTSD and
almost 800 (3 percent) also have a diagnosis of major depressive
disorder. Likewise, of some 307,000 veterans with a service-connected
diagnosis of PTSD, some 5,200 (1.7 percent) also have a service-
connected diagnosis of major depressive disorder. Further analysis
could determine if these diagnoses in combination have a greater or
lesser impact on earnings.
INDIVIDUAL UNEMPLOYABILITY BENEFITS
The number of IU cases has grown from about 101 thousand in
September 2001 to 190 thousand cases in September 2007, an increase of
almost 90 percent. PTSD cases constituted about one-third of the IU
cases in 2007 and one-half of new IU cases between 2001 and 2007.
Forty-four percent of the IU cases in 2007 were for veterans age 65 and
older; 64 percent for veterans age 55 and older.
Although age is clearly related to employment, it is not considered
in IU determinations. While IU is not intended for veterans who
voluntarily withdraw from the labor market because of retirement, new
awards are often made to veterans who are near or past normal
retirement age for Social Security. In light of these circumstances it
appears that IU determinations are made for veterans approaching or
past retirement age based on providing retirement income or in
recognition of loss of quality of life rather than for employment loss.
IU determinations depend on decisions about substantially gainful
employment. In order to further facilitate the decisionmaking process
for IU determinations, a work-related set of disability measures would
be worth assessing. Consideration of this could supplement the medical
impairment criteria in the VASRD.
An option for consideration would be for VA to adopt a patient-
centered, work disability measure for IU evaluations. As with the
current IU evaluation, assessments would address the individual's work
history but also consider other factors including motivation and
interests. Work disability evaluations would include relevant measures
of impairment, functional limitation, and disability. Particular care
should be taken to include measures of physical, psychological, and
cognitive function. Assessments would evaluate the individual in the
context of his or her total environment.
SPECIAL MONTHLY COMPENSATION FOR QUALITY OF LIFE
Special Monthly Compensation (SMC) is a series of awards for
anatomical loss or loss of functional independence. These awards are
evaluated outside of the Rating Schedule. SMCs are known by the letter
designations K, L, M, N, O, P, R, and S. SMC K is the only award that
can be made to veterans who are rated less than 100% and can be awarded
one, two, or three times with each award $91 per month (2008 rates).
SMC K is paid in addition to the amount paid for the Combined Degree of
Disability rating. As of December 1, 2007, there were 188,747 veterans
receiving SMC K awards. SMCs other than K are paid instead of the
amount payable for 100% ratings, not in addition to the amount paid for
100% ratings. Since SMCs are not awarded with the intent of
compensating for average loss of earnings capacity, they can be thought
of as payments for the impact of disability on quality of life.
smc for assistance
Four different SMCs can be paid to veterans for assistance: L, S,
R1, and R2. SMC L can be awarded either for loss of or loss of use of
limbs or organs or to veterans rated 100% without such loss if they are
in need of regular Aid and Attendance; in other words, if they need
assistance with activities of daily living. In 2007, 48 percent of
13,928 veterans receiving SMC L were receiving that award because they
needed assistance, rather than for loss of or loss of use of organs or
limbs. SMC S can also be awarded to veterans rated 100% if they are
housebound but do not meet the required level of assistance for SMC L.
SMC R1 and R2 are awarded to catastrophically injured veterans,
primarily to those with spinal cord injuries, who need the highest
levels of assistance. The table below depicts the number of veterans
receiving SMCs other than K and the amount of the award that is above
the normal amount paid to veterans rated 100% without SMC. In the case
of R1 and R2, the veteran must be awarded SMC O or P due to the
severity of disability in order to qualify for the additional
assistance provided by R1 or R2. Thus, if a veteran receives SMC L for
assistance, the veteran is receiving only $618 per month above the
normal 100% amount; and a veteran receiving SMC S for housebound is
receiving only $302 above the 100% amount.
In 2007, 45,773 veterans received SMC L, S, R1, or R2 for
assistance and $30,223,540 above the amount paid for the 100% rating.
This was an average of $660 per month.
Special Monthly Compensation Rates Compared with Schedular 100% Rating
----------------------------------------------------------------------------------------------------------------
Veteran Amount for 100% Increased Amount Number of
SMC Code Alone or SMC O/P for SMC Veterans Monthly Benefit
----------------------------------------------------------------------------------------------------------------
Quality of Life
L.............................. $3,145 $2,527 $618 5,355 $3,309,390
L\1/2\......................... $3,307 $2,527 $780 1,887 $1,471,860
M.............................. $3,470 $2,527 $943 1,839 $1,734,177
M\1/2\......................... $3,709 $2,527 $1,182 1,650 $1,950,300
N.............................. $3,948 $2,527 $1,421 477 $677,817
N\1/2\......................... $4,180 $2,527 $1,653 250 $413,250
O/P............................ $4,412 $2,527 $1,885 2,661 $5,015,985
------------------------------------------------------------------------------
Total........................ 14,119 $14,572,779
----------------------------------------------------------------------------------------------------------------
Assistance
L.............................. $3,145 $2,527 $618 4,944 $3,055,392
L\1/2\......................... $3,307 $2,527 $780 1,742 $1,358,760
S.............................. $2,829 $2,527 $302 31,361 $9,471,022
R1............................. $6,305 $4,412 $1,893 5,576 $10,555,368
R2............................. $7,232 $4,412 $2,820 2,151 $6,065,820
------------------------------------------------------------------------------
Total........................ 45,773 $30,506,362
----------------------------------------------------------------------------------------------------------------
Source: Department of Veterans Affairs, Special Monthly Compensation, 12/1/07
Using the results of surveys conducted by the National Alliance for
Caregiving and the American Association of Retired Persons and by the
Veterans' Disability Benefits Commission, we estimated monthly costs of
hiring assistance ranging from $520 for 8 hours of caregiving per week
to $10,800 for full time, around the clock 24/7 care. The CNA
Corporation issued a report for the Department of Defense in September
2008 on the average earnings and benefits loss of caregivers of
seriously wounded, ill, and injured active duty servicemembers and
estimated those losses as $33,500 annually or $2,800 per month.
Regardless of which estimates are used, the current amount of the SMCs
for assistance is well below either the cost of hiring such care or of
the lost earnings and benefits of family caregivers.
QUALITY OF LIFE PAYMENT OPTIONS
Our review of the literature led us to define quality of life (QOL)
for veterans as an overall sense of well-being based on physical and
psychological health, social relationships, and economic factors. Our
in-depth analysis of the data from the Veterans' Disability Benefits
Commission's survey of more than 21,000 disabled veterans found that
QOL loss occurred for veterans at all levels of disability and for all
40 diagnostic codes for which sufficient responses were available. We
also found that loss of QOL increases as disability increases, but it
does not increase as sharply as disability does, and that there is wide
variation in the loss of quality of life at each disability rating. QOL
is an individualized perception, and people adjust to disability. About
one-half of individuals with severe disabilities report high degrees of
life satisfaction.
The quality of life loss analysis paralleled the earnings loss
analysis in many regards. In particular, we found that veterans
receiving Individual Unemployability benefits and those receiving SMC
payments report mental and physical QOL loss significantly greater than
for other service-connected veterans. Fewer severe disabilities are
associated with a greater loss of quality of life than a greater number
of less severe conditions at a given level of combined disability.
Three broad options were presented to VA for implementing a QOL
payment:
1. Statutory rates for QOL payments by combined degree of
disability
2. Separate, empirically-based normative rates for QOL loss
3. Individual clinical and rater assessments plus separate
empirically-based rates for QOL loss.
All three options would require periodic surveys to assess QOL
impact. Option 3 would be the most complex and costly to implement and
would require clinical and rater assessments each time a claim is
filed. Options 1 and 2 would not be subject to veteran appeal if
Congress approves the rate scale. However, in conjunction with
implementing any QOL options, the criteria and benefits contained in
the VA Schedule for Rating Disabilities should be adjusted to reflect
average actual lost earnings, to ensure an overall equitable system.
Payment rates for QOL would have to be set by policy or statute and
placing an economic value on QOL would be subjective and value laden.
Options that use empirical data are provided in our report as examples
of how such rates could be established. The monthly amounts depicted in
the options range from $99 to $974. Volume III of our report contains
an extensive description of the findings of the QOL analysis and of the
possible rationales or bases for setting the amounts.
Foreign countries that award QOL payments link them closely to
impairment and consider the circumstances of the individual veteran.
QOL payments are considered the primary disability benefit and earnings
loss payments are made only for actual earnings loss or a specified
loss of earnings capacity. A veteran in Canada, for instance, must
demonstrate inability to work in order to receive an earnings loss
payment in addition to a QOL payment and must complete three years of
vocational rehabilitation that results in unemployment before receiving
ongoing earnings loss payments.
VA could structure its disability benefits like the foreign
programs so that they are based primarily on QOL. QOL could be inferred
from impairment, or it could be measured directly, with earnings loss
paid only when an actual earnings loss occurred.
The systems used in both the United Kingdom (UK) and Canada pay QOL
in lump sum payments and have several low rating levels for QOL
payments. While making QOL payments in all 15 of its ratings, the UK
system does not pay for earnings loss in the 4 lowest ratings of its
15-point rating scale. The Canadian schedule increases proportionally
so that in 2008, after the 10% rating, each 5% rating increase in
Canada has a payment increase of $12,909. The UK payments do not
increase with a multiplicative constant. For instance, the highest
payment is $565,000, the second highest payment is $399,000, the third
highest is $228,000. The lowest pain and suffering payment in UK is
$2,080. These payment schedules reflect their societies' view that
severe disability merits very high QOL payments and low levels of
disability merit recognition payments. These benchmarks suggest great
flexibility in establishing payment levels for U.S. veterans.
Although our study focused on monetary compensation for QOL, the
literature review and the analysis of the survey data indicates that
greater QOL is supported by a strong family or social network and that
employment is associated with a better quality of life. QOL of service-
connected veterans may be improved by programs aimed at family members
to help them to understand and support the disabled veteran, through
case management directed to the holistic needs of the veteran, and
employment assistance programs.
Our earnings analysis found that on average veterans' earnings plus
disability compensation exceeds the expected earnings level by 7
percent. There are exceptions such as for mental health and TBI and
those rated 100% where earnings plus compensation is significantly less
than expected earnings. Some SMC payments can be thought of as payment
for QOL. Taken together, a judgment could be made that veterans are
currently compensated for QOL.
TRANSITION BENEFIT OPTIONS
Disabled veterans face a number of living expenses during their
transition to civilian life before and during their participation in
the VA Vocational Rehabilitation and Employment (VR&E) Program.
Providing transition assistance payments offset the foregone cost
of earnings (time spent in rehabilitation and not working), which in
turn increases the likelihood of entry and completion of
rehabilitation. Providing transition assistance benefits to caregivers
and family members could reduce the levels of stress and depression for
veterans and caregivers, which in turn could raise the overall quality
of life for both the patient and family members and caregivers.
Providing and aligning financial incentives with successful completion
of specific rehabilitation tasks could increase the likelihood that
patients enter and successfully complete rehabilitation.
In order to estimate what an appropriate level of transition
benefit should be, we selected housing, food, and transportation
expenses to comprise a core group of living expenses that one would
expect a living expense benefit to cover. We also considered additional
``menu items'' such as apparel and services, health care (for
dependents of disabled veterans not rated 100%), personal care products
and services, household operations, and child care. Based on
statistical analysis of average living expenses, the core living
expense option would be $1,898 for the veteran alone or $2,981 for a
veteran with two dependents. This includes the average monthly housing
allowance paid by DOD in the 11 most populous veteran population
centers, the same rates that would be paid under the Chapter 33
Education program. The payment for additional expenses would be $511
for the veteran alone or $935 for a veteran with two dependents. A new
transition benefit would be in lieu of the current subsistence
allowance and precede the start of permanent disability compensation
benefit. The 2007 monthly subsistence allowance was $521 (no
dependents) and $761 (two dependents).
We identified several groups of veterans who could be eligible for
such payments based on medical discharges, severity of disability, and
time since discharge. Defining the purpose of a transition benefit is
essential: would it be intended to ease the transition from military
service to civilian life? If so, it is important to realize that
veterans participating in the VR&E program fall into three groups:
those who applied from just before discharge to two years after
discharge (39 percent), those who applied from three years to ten years
after discharge (29 percent), and those who applied more than 10 years
after discharge (32 percent).
The possible eligibility groups would range from a small group
consisting of severely injured/ill who are medically discharged with
ratings of 70% or higher who enter rehabilitation within two years of
discharge, to a much larger group that would include all veterans
currently eligible for VR&E. The most limited option would include
3,400 applicants per year and the most inclusive option would include
approximately 29,000 each year.
Important policy decisions would need to be made in order to
determine which veterans participating in VR&E would be eligible for a
transition benefit.
METHODOLOGY DIFFERENCES WITH THE PREVIOUS STUDY
As discussed previously, our methodology differed in significant
ways from the approach taken by the CNA Corporation in 2007 for the
Veterans' Disability Benefits Commission (VDBC). Our study focused on
service-connected and non service-connected veteran populations
discharged since 1980. Data from the Defense Manpower Data Center
(DMDC) is reliable for veterans discharged since that time and provides
important demographic or human capital characteristics for individuals
such as education level at time of entry into the military, gender, and
officer or enlisted status. These characteristics can be used to ensure
that the observed differences in earnings are due to the service-
connected disabilities and not some demographic differences.
The study for the VDBC also used earnings data for non service-
connected veterans from the Current Population Survey (CPS) which were
self reported, in comparison with the actual earnings of service-
connected veterans discharged prior to 1980. We conducted a thorough
analysis of the CPS data and concluded that it was not reliable for
this purpose for several reasons. Self-reported earnings are not as
accurate as actual Social Security Administration earnings data and the
CPS sample has 50 percent fewer veterans than the general population.
Post 1980 veterans have better health, fewer limitations from
disabilities, and higher rates of employment. Thus we focused on
comparing earnings of veterans discharged since 1980. Although we
obtained actual earnings data from the Social Security Administration
on the entire population of 2.6 million veterans receiving disability
compensation, we limited our analysis to the 1,062,809 service-
connected disabled veterans discharged since 1980 and a demographically
selected sample of 432,947 non service-connected veterans also
discharged since 1980. These two populations were compared to determine
the impact of service-connected disabilities on earnings. Actual
earnings were compared, thus avoiding the use of survey data. A
detailed explanation of why CPS data is not reliable for this
comparison is provided in pages 132-136 of Volume III of our report. We
believe that this comparison of veterans discharged since 1980 enables
policymakers to focus more on veterans that VA rates today and will be
rating in the future.
Another difference between our analysis and the CNA analysis was
that we conducted a more detailed analysis of rating levels using the
entire range of rating levels (10% through 100%, in 10% increments)
while CNA used four groupings of ratings (10%, 20-40%, 50-90%, and
100%). We did this so as to be able to analyze all ten rating levels
individually. We also used individual diagnostic codes to the maximum
extent possible within the restrictions on release of individual-level
data. The over 700 codes in the Rating Schedule were grouped into 240
similar diagnoses so as to avoid the possibility of individual veterans
being identified. In contrast, the CNA study aggregated veterans into
the 15 body systems with PTSD the only individually analyzed diagnosis.
We also placed emphasis on analysis of veterans receiving Special
Monthly Compensation and Individual Unemployability. Finally, we used
2006 earnings without estimating lifetime earnings while CNA used 2004
earnings to estimate lifetime earnings. We obtained annual earnings for
veterans since 1951 but time constraints prevented including this
information in our analysis as we would have preferred.
We realize that limiting the earnings analysis to veterans
discharged since 1980 excludes 1.6 million of the 2.6 million veterans
receiving disability compensation, especially most Vietnam veterans.
However, demographic and human capital data available from DMDC is not
considered accurate on veterans discharged prior to 1980. Therefore, it
is not possible to identify a sample of non service-connected veterans
from DMDC data closely matched on human capital characteristics to
serve as a comparison group in an analysis of the impact of disability
on earnings. It could be possible to randomly select a sample of non
service-connected veterans from either the DMDC data or from the VA
Beneficiary Identification and Records Locator Subsystem (BIRLS)
matched on a more limited set of known characteristics such as age,
military rank, and date of discharge. This sample would lack key
characteristics such as education level, military occupational series,
and Armed Forces Qualification Test scores as is available on the post
1980 group and may not be as well matched to the service-connected
veteran population. This limitation would need to be recognized.
In addition, if more time were available for the analysis, more
detailed analysis of the earnings data for veterans discharged prior to
1980 and since 1980 could be completed, especially an analysis of
lifetime earnings. Social Security Administration retains annual
earnings for individuals from 1951. These annual earnings were captured
last year but there was not sufficient time to analyze that data.
We note that of the estimated seven million living Vietnam Era
veterans, 28.4 percent are age 65 or older and 44.6 percent are age 60
to 64 and thus are nearing the normal retirement age. Thus, the
earnings of Vietnam Era veterans are likely to be already diminishing
or very limited already.
For those already service-connected, it is unlikely that benefits
would be reduced in any way. We suggest that the focus of policy or
statutory adjustments should be on future earnings and that the
emphasis of future analysis should be on veterans discharged since 1980
so that more precise comparisons can be made, even if veterans
discharged prior to 1980 are also analyzed.
CONCLUDING REMARKS
In closing, our study completed last year provides a great deal of
information on the adequacy of disability compensation and ways in
which the program can be improved to better serve veterans. There are
clear indications that overall the amount of compensation exceeds the
average expected earnings loss yet it is inadequate for mental health
and for those rated 100%. The methodology used to assign the overall
combined degree of disability, and hence the amount of compensation
paid, results in over compensating many veterans, especially at the
lower rating levels. There are several diagnoses that either do not
result in loss of earnings or the rating is higher than necessary. It
could be concluded that quality of life is somewhat compensated by the
amount compensation exceeds expected earnings loss and by some SMC
payments. SMC payments for assistance are not equal to either the cost
of hiring assistance or the lost earnings and benefits of family
caregivers.
While the findings cited in this testimony provide accurate and
reliable information upon which to base policy decisions, the timeframe
for that study (seven months) did not permit a thorough analysis of
certain aspects of the disability compensation program and of the
inter-related nature of the findings. We would recommend that
additional analyses be conducted. Restrictions intended to safeguard
the privacy of individuals prevented the Social Security Administration
from providing earnings at the individual veteran level. This meant
that we could not analyze the impact on earnings of combinations or
comorbidities of disabilities. We have discussed this issue with the
Social Security Administration and believe a methodology could be used
that safeguards the privacy of individuals yet enables such analysis.
For the long term, we agree with the recommendation of the VDBC that VA
and DOD should be granted statutory authority to collect and study
appropriate data from the Social Security Administration and the Office
of Personnel Management, namely earnings data, only for the purpose of
assessing the appropriateness of benefits.\1\
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\1\ Veterans' Disability Benefits Commission, 2007, pp. 318 and
320.
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Additional demographic or human capital characteristics could be
analyzed in future studies to ensure that the impact on earnings is not
due to factors such as education level at discharge, military
occupational series, or Armed Forces Qualification Test scores. Also,
consideration of such factors as time in service, period of service,
and timing of diagnosis could shed additional light on the impact of
disability on earnings.
In addition to analysis of earnings at the individual veteran
level, earnings and quality of life results should be integrated so as
to see the overall impact of disability on veterans. This could include
assessing how comorbidities and the timing of the diagnoses as
indicated by the date of original service-connected disability impact
earnings and QOL. A technique called shadow pricing could also be used
to measure the economic impact on quality of life.
Mr. Chairman, I thank you for the opportunity to appear before you
today and would welcome any questions you or the Committee members may
have.
Chairman Akaka. Thank you very much, Dr. Kettner.
And now we will receive testimony from General Scott.
STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT, USA (RET.),
CHAIRMAN, ADVISORY COMMITTEE ON DISABILITY COMPENSATION
General Scott. Chairman Akaka, Ranking Member Burr, Members
of the Committee, it is a real pleasure to be with you today
representing the Advisory Committee on Disability Compensation.
The Committee is charged by the Secretary of Veterans
Affairs under the provision of 38 U.S.C. Section 546 in
compliance with Public Law 110-389 to advise the Secretary with
respect to the maintenance and periodic readjustment of the VA
Schedule for Rating Disabilities. Our charter is to assemble
and review relevant information relating to the needs of
veterans with disabilities, provide information relating to the
character of disabilities arising from services in the Armed
Forces, provide ongoing assessment of the effectiveness of the
VA's schedule for rating disabilities, and provide ongoing
advice on the most appropriate means of responding to the needs
of veterans relating to disability compensation in the future.
The Committee has met ten times and has forwarded an
interim report to the Secretary that addresses our efforts as
of July 7, 2009. Copies of this interim report were furnished
to majority and minority staff in both Houses of Congress, and
I can provide additional copies for the record if so desired.
Our focus is in three areas of disability compensation:
requirements and methodology for reviewing and updating the
VASRD; adequacy and sequencing of transition compensation and
procedures for servicemembers transitioning to veteran status,
with special emphasis on seriously ill or wounded
servicemembers; and disability compensation for non-economic
loss, often referred to as quality-of-life.
You asked me to present the views of my committee on the
structure of payments for disability compensation and what
reform, if any, the Advisory Committee recommends. Our efforts
to date have addressed the structure of payments for disability
compensation in the following ways.
We believe that an updated and clarified ratings schedule
will enable rating, examining, and reviewing officials to make
a more accurate and timely assessment of a veteran's disability
and its effect on average earnings loss. An updated and
clarified ratings schedule should improve first-time accuracy
and reduce the number of appeals and backlog that the appeals
create. The Updated Rating Schedule should address the
recognized inconsistencies in the mental versus physical
disabilities and in the differences in age at entry into the
disability system. Any remaining discrepancies between mental
and physical disabilities could be addressed via the SMC
system.
Recent studies by the Veterans Disability Benefits
Commission, the Institute of Medicine, the Government
Accountability Office, and the others have consistently
recommended a systematic review and update process for the
VASRD. The Congress has repeatedly demanded the same. I believe
that the case for such a system is made and that sufficient
data currently exists to proceed with a review and update.
My committee has informally recommended to the Secretary
that the Deputy Secretary be tasked with oversight of the VASRD
systematic review and update process to ensure that the VBA,
VHA, and General Counsel are fully integrated into the process.
We are also offering a proposed level of permanent staffing in
both VBA and VHA to ensure that all 15 body systems are
reviewed and updated as necessary in a timely way. We are
proposing a priority among the body systems that takes into
account the following: body systems that are at greater risk of
inappropriate evaluation;
body systems that are considered problem-prone; and relative
numbers of veterans and veterans' payments associated with each
body system.
At a previous hearing, I was asked if I thought the review
and update of the VASRD could be done by contract. If the VA is
unable to devote the entire resources to accomplish a timely
review and update, contract assistance is a possibility.
However, I believe that the expertise and background knowledge
of the VA professionals are critical in this process and I
encourage the VA to accomplish this very high priority task
internally.
Regarding disability compensation for non-economic loss,
also referred to as quality-of-life, we are reviewing the
special monthly compensation program as a potential model for a
quality-of-life system and we are analyzing options for the
forms of compensation beyond a monetary stipend. One of our
concerns is to avoid a compensation system for economic loss
that encourages seeking increasingly higher levels of
compensation. Our current view is that the quality-of-life
compensation should be limited to clearly defined and very
serious disabilities.
Regarding disability compensation related to the transition
from servicemember to veteran status, we are reviewing the many
recent changes and improvements to the transition program to
determine if and where gaps in coverage and assistance may
remain for veterans and families. We are also reviewing the
vocational rehabilitation and education program as it relates
to transition for disabled veterans.
In summary, our committee's work is progressing on a broad
front. The parameters of our charter offer us the opportunity
to look at all aspects of disability compensation and we are
doing so. The committee has excellent access to the Secretary
and his staff. The VA staff is responsive and helpful to the
committee's request for information. It is our intent to offer
interim reports to the Secretary semi-annually and to provide
copies to the Veterans' Committees of both Houses.
Mr. Chairman, this concludes my statement and I welcome
comments or questions.
[The prepared statement of General Scott follows:]
Prepared Statement of James Terry Scott, LTG USA (RET), Chairman,
Advisory Committee on Disability Compensation
Chairman Akaka, Ranking Member Burr, and Members of the Committee:
It is my pleasure to appear before you today representing the Advisory
Committee on Disability Compensation. The Committee is chartered by the
Secretary of Veterans Affairs under the provisions of 38 U.S.C. 546
in compliance with Public Law 110-389 to advise the Secretary with
respect to the maintenance and periodic readjustment of the VA Schedule
for Rating Disabilities. Our charter is to ``(A)ssemble and review
relevant information relating to the needs of veterans with
disabilities; provide information relating to the character of
disabilities arising from service in the Armed Forces; provide and on-
going assessment of the effectiveness of the VA's Schedule for Rating
Disabilities; and provide on-going advice on the most appropriate means
of responding to the needs of veterans relating to disability
compensation in the future.''
The Committee has met ten times and has forwarded an interim report
to the Secretary that addresses our efforts as of July 7, 2009, to
date. (Copies of this interim report were furnished to majority and
minority staff in both Houses of
Congress.)
Our focus is in three areas of disability compensation:
Requirements and methodology for reviewing and updating the VASRD;
adequacy and sequencing of transition compensation and procedures for
servicemembers transitioning to veteran status with special emphasis on
seriously ill or wounded servicemembers; and disability compensation
for non-economic loss (often referred to as quality of life).
You asked me to present the views of my Committee on the structure
of payments for disability compensation, and what reform, if any, the
Advisory Committee
recommends.
The Committee's efforts to date have addressed the structure of
payments for disability compensation in the following ways:
1. An updated and clarified Rating Schedule will enable examining,
rating and reviewing officials to make a more accurate and timely
assessment of a veteran's disability and its effect on his or her
average earnings loss. An updated and clarified Rating Schedule should
improve first time accuracy and reduce the number of appeals and the
backlog that appeals create. The updated Rating Schedule should address
the recognized inconsistencies in mental versus physical disabilities
and in differences in age at entry into the disability system.
Recent studies by the Veterans Disability Benefits Commission, the
Institute of Medicine, the General Accounting Office and others have
consistently recommended a systematic review and update process for the
VASRD. The Congress has repeatedly demanded the same. I believe that
the case for such a system is made and that sufficient data currently
exists to proceed with a review and update. My Committee has informally
recommended to the Secretary that the Deputy Secretary be tasked with
oversight of the VASRD systematic review and update process to insure
that the VBA, VHA and General Counsel are fully integrated into the
process. We are also offering a proposed level of permanent staffing in
both VBA and VHA to insure that all fifteen body systems are reviewed
and updated, as necessary, in a timely way. We are proposing a priority
among the body systems that takes into account the following: body
systems that are at greatest risk of inappropriate evaluations; body
systems are considered problem prone, and relative number of veterans
and veterans' payments associated with each body system.
At a previous hearing, I was asked if I thought the review and
update of the VASRD could be done by contract. If the VA is unable to
devote the internal resources to accomplish a timely review and update,
contract assistance is a possibility. However, I believe that the
expertise and the background knowledge of the VA professionals are
critical in the process and I encourage the VA to accomplish this very
high priority task internally.
2. Regarding disability compensation for non-economic loss, also
referred to as quality of life, we are reviewing the Special Monthly
Compensation program as a potential model for quality of life system
and we are analyzing options for forms of compensation beyond a
monetary stipend. One of our concerns is to avoid a compensation system
for non-economic loss that encourages seeking increasingly higher
levels of compensation. Our current view is that quality of life
compensation should be limited to clearly defined and very serious
disability.
3. Regarding disability compensation related to transition from
servicemember to veteran status, we are reviewing the many recent
changes and improvements to the transition programs to determine if and
where gaps in coverage and assistance may remain for veterans and
families. We are also reviewing the Vocational Rehabilitation and
Education program as it relates to transition for disabled veterans.
In summary, our Committee's work is progressing on a broad front.
The parameters of our charter offer us the opportunity to look at all
aspects of disability compensation and we are doing so. The Committee
has excellent access to the Secretary and his staff. The VA staff is
responsive and helpful to the Committee's requests for information. It
is our intent to offer interim reports to the Secretary semi-annually
and to provide copies to the Veterans Committees of both Houses of
Congress.
Mr. Chairman, this concludes my statement. I welcome any comments
or
questions.
Chairman Akaka. Thank you very much, General Scott.
I would like to open with a question to all witnesses.
If we are going to act as a Committee, as some of our
colleagues suggest, what would you suggest as the highest
priority, or what would you suggest we tackle immediately here?
Let me start with Admiral Dunne.
Admiral Dunne. Sir, I wouldn't be so bold as to tell the
Committee what responsibilities they should take on. We are
working as quickly as we can to work on the recommendations
that have been given to us.
Specifically, just to give you an example, General Scott
talked about personnel, et cetera. We have already hired two
clinicians to work on modifying the schedule. We are
coordinating with VHA to set up a committee that will be
working very closely with the folks in VBA who are working on
changing the schedule, and we have already done some
preliminary work over the past couple of months to start in the
mental health part of the rating schedule. By coincidence,
tomorrow is the first all-day meeting with the VHA and VBA
experts to start looking at mental health, to include review of
PTSD, sir.
Chairman Akaka. Thank you.
Dr. Kettner?
Mr. Kettner. Well, I would agree with what Admiral Dunne
just said. I think the burden is really on VA to work at
adjusting, revising the rating schedule. I would say that over
the past several decades, the rating schedule has never really
been based on an economic analysis of lost earnings. It has
been based on medical criteria and decisions made by medical
practitioners, but the underlying benefit amounts linked to
different criteria have never really been based on economic
analysis of lost earnings. So this would be an opportunity, for
the first time, to really integrate the economic loss analysis
into revising the schedule along with reviewing and revising
medical criteria.
Chairman Akaka. General Scott?
General Scott. Well, I certainly agree that the VASRD
should be the initial priority because it, if done properly,
accurately, and on a timely basis, will address many of the
anomalies that we face and many of the concerns that the
Members of this Committee have expressed in their opening
statements, to include timeliness, accuracy, the backlog, et
cetera. So, I really believe that a concerted effort by the VA
to update and revise, as necessary, the 15 body systems that
make up the VASRD will go a long way toward solving a number of
these issues.
I think that both the Economic Systems studies and the
study done by CNA, chartered by the Veterans Disability
Benefits Commission, indicate that there is a solid economic
basis for the VASRD in terms of average loss of earnings.
Arguably, there are pluses and minuses and puts and takes in
there that need to be looked at, and I believe that most of
them can be addressed in the revision of the VASRD.
As I commented, I think that we might have to look at
something extra-schedular, so to speak, for the 100 percent
mentally disabled--something along the lines of an SMC--if we
can't get the VASRD to address that.
But I believe the data is there to validate the VASRD as a
measure of average economic loss, and that we should proceed
with the revisions to try to fix the different problems that
have come up and have been cited in terms of percentage--
particularly for mental disability and the like--and age of
entry. I think we are ready to go with that and we should move
out with it.
I think the quality-of-life assessment, as a system, is a
second but close-behind priority. Again, we are looking now at
something that might be modeled on the SMC system so that it
addresses the loss of quality-of-life at the extreme levels of
disability and does not burden VA with a grafted system or some
sort of a need for a totally different analysis to come up with
a quality-of-life assessment for each veteran.
As you know, sir, as well as anybody else, the VA struggles
with the administrative load as presently constituted in terms
of processing claims on a fair, equitable, and timely basis.
Then I believe the third thing is--as has been pointed out
in the Dole-Shalala Commission and others--that the transition
from servicemember to veteran needs a continuing look.
Particularly, the emphasis that was made in one of the opening
statements that the goal should be to return the veteran to, as
nearly as possible, full membership in society, and the VR&E
program is a great opportunity for improvement to accomplish
that end. Thank you, sir.
Chairman Akaka. Thank you very much.
We will have other rounds here, so let me call on Senator
Burr for his questions.
Senator Burr. Thank you, Mr. Chairman.
Admiral Dunne, in July you were here and I discussed with
you my desire that the reports from the Disability Benefits
Commission and from Dole-Shalala not become part of that
repository that everything else has. I asked you specifically
to discuss it with General Shinseki and specifically what the
next steps were in moving forward on their recommendations.
Have you had an opportunity to do that?
Admiral Dunne. Yes, sir. I discussed with the Secretary my
evaluation of the Economic Systems report in terms of the
action that we would take within VA to respond. We first
discussed evaluations and if we compensate too much, too
little, et cetera. While I recognize that Dr. Kettner and his
group had a very short period of time to work with and only 1
year's worth of data, I was not prepared to recommend any
changes based solely on 1 year's worth of data.
I was not about to recommend that all of our veterans who
are currently receiving compensation for tinnitus should go to
zero percent disability ratings immediately, because as you
know, you can only get a 10-percent disability ratings for
tinnitus. So, if you are receiving disability compensation for
that right now, if we were to follow this recommendation, no
one would be receiving compensation for that anymore, so----
Senator Burr. The Secretary was in agreement with your
conclusions?
Admiral Dunne. With my discussion, yes, sir.
Senator Burr. And would it be safe for me to make the
statement that VA feels that further studies are required
before they could make any changes, act on any of the
recommendations out of this----
Admiral Dunne. No, sir. I can give you a few examples.
First off, in the transition benefits area, there is already an
additional study going on, which actually Economic Systems is
performing for us, to take a look at the rehabilitation program
that we currently have. As you know, there are some
recommendations in there about levels of potential compensation
during a transition period. We want to get the results from
that study, which should be available by late spring next year
and provide additional information on veterans' reaction to the
VR&E program----
Senator Burr. What was the VA's expectations of Dr.
Kettner's 6-month study?
Admiral Dunne. That there would be some options presented,
sir.
Senator Burr. And those options all require further study
to refine, is sort of the way I interpret everything. Is that
accurate?
Admiral Dunne. No, sir, I----
Senator Burr. Most of them?
Admiral Dunne. In----
Senator Burr. Most of them require further study?
Admiral Dunne. Most of them, yes, sir, require more
evaluation.
Senator Burr. Let me just ask Dr. Kettner, was it your
understanding that you were going to do a study that had
recommendations that required additional study or
recommendations that were--is this indicative of the study, the
6-month study?
Mr. Kettner. Yes. That is our report right there.
Senator Burr. And in your estimation, does that lack the
specificity needed to make a determination?
Mr. Kettner. Well, I think where the issue lies on this is
the level of analysis we were able to perform in the 7-month
study that we did. We were hindered to a certain degree in not
being able to analyze data at the individual level.
Senator Burr. Was that discussed at----
Mr. Kettner. Oh, yes. Right.
Senator Burr [continuing]. At the preliminary review, did
you share with the VA----
Mr. Kettner. Absolutely. Yes, sir.
Senator Burr. We are not provided this information. We are
not going to be able to give you specific recommendations that
you can act on?
Mr. Kettner. Well, I may differ in assessing which options
might be more practical to act on versus other options we
presented. I think that where we had the most difficulty in our
analysis was in looking at different combinations of
disabilities. We were not able to sort out exactly what were
the combinations in terms of identifying exactly what was
second or third disability, and----
Senator Burr. I am trying to better understand for the
Committee. Listen, I am not trying to play ``gotcha'' on any of
this. I am trying to figure out, what did they share with you
that they wanted to accomplish from a standpoint of the
information that came out of your study? Because other than
compiling in these books information that was available and
making recommendations off of it, the recommendations don't
seem to have the basis proven in them to move forward. They
require additional studies. I am trying to figure out, why did
we do this?
Mr. Kettner. We asked for and were not able to get earnings
data at the individual level.
Senator Burr. And was that discussed during the review----
Mr. Kettner. Yes.
Senator Burr. Before the review?
Mr. Kettner. Before, during, and after.
Senator Burr. So what was the answer before the review? If
you said, we can't get to it----
Mr. Kettner. The answer is that the Social Security
Administration, which is the source of our data, does not
release data at the individual level. We have recommended that
we obtain the data at the individual level so that we can do a
more detailed analysis.
Senator Burr. And before this process started to take
place, that one thing triggered you that you would not get the
degree of clarity that would trigger VA to say, we need to move
forward?
Admiral Dunne. Senator, I had the privilege of being
involved in setting up the statement of work for this study in
a prior job. We realized after we got into it that we would be
unable to get the data from Social Security in the timeframe to
enable Dr. Kettner to finish the study within the amount of
time that was available to do it. We are continuing to pursue
that.
One of the things that we need to do to be able to maintain
a viable rating schedule, is to get this data routinely--almost
on an annual basis from Social Security--so that we can process
it in-house every year and be able to recommend or evaluate
where the disparities exist over a period of time.
Senator Burr. I am going to get into the annual update of
the rating schedule in the next pass, and the Chairman and the
Members have been very accommodating to me to let me run over.
Let me just ask one last question. How much did this study
cost?
Admiral Dunne. I would have to get you that answer for the
record, sir. I don't recall.
Senator Burr. Dr. Kettner, do you know how much you charged
for it?
Mr. Kettner. Approximately $3 million.
Senator Burr. Three million dollars. I find it incredible
that we knew before it started that we couldn't access the
information we needed to conclusively come to a determination
and we invested $3 million in a product that would do little
more than trigger additional studies. I would only say that I
guess my expectations shouldn't have been different because we
do have five decades of this.
I will only say to my colleagues and to those from the VA,
I am not going to let this out of my teeth. I don't care who I
insult as I go through it, but we are going to get to the
bottom of this and we are either going to move forward or we
will find another avenue to use within or outside of the VA to
accomplish it. It is not a promise to veterans out there that
they are going to get a windfall check or that they are going
to lose something. But we can come to a determination as to how
broken this is, and more importantly, how we fix it. Then we
can get on a pathway to fixing it and quit studying the thing.
I thank the Chair.
Chairman Akaka. Thank you, Senator Burr.
Now, Senator Tester, your questions.
Senator Tester. Yes. Thank you, Mr. Chairman. I am going to
follow up a little bit on Senator Burr's questions.
The answer you gave indicated to me that if you would have
had the information from Social Security, the wage information,
then you could have come forth with recommendations. Is that
accurate?
Mr. Kettner. Well, we were not asked to provide
recommendations. We were asked to provide options, and that is
what we did. We pointed out where there was economic loss and
where there was not economic loss. So, for example----
Senator Tester. OK. I appreciate that, and I don't mean to
cut you off. But what you are saying is when it comes to
quality-of-life issues, based around what kind of compensation
they are going to get, your study based it off of wages?
Mr. Kettner. We conducted two separate studies within our
study: one on earnings loss; and another on quality-of-life
loss. The two were very separate and distinct from each other.
Senator Tester. OK. So what went into the quality-of-life
loss?
Mr. Kettner. We analyzed loss of quality-of-life based on a
sample of 21,000 veterans. The survey of that information was
conducted by a previous contractor. We took that study. We
analyzed the----
Senator Tester. Do you remember the criteria that was used?
In other words, what were you using for criteria to determine
quality-of-life lost? What were they using?
Mr. Kettner. The survey was based on a series of questions
that get a loss of quality-of-life. The instruments--the
questions--were largely based on a set of questions developed
by RAND Corporation many years ago and have been repeatedly
used by many organizations in assessing loss of quality-of-
life.
Senator Tester. But what are those issues? I mean, I know
they asked----
Mr. Kettner. They cover a variety of different dimensions,
loss of functional independence; the ability to walk or climb
stairs; quality-of-life in terms of self-perception----
Senator Tester. OK.
Mr. Kettner [continuing]. One's satisfaction----
Senator Tester. OK. That is good. So, when you make your
recommendations for further study, how do you dovetail wage
loss in with some of those quality-of-life things? Did you make
any recommendation on that, because from my perspective, you
have got two issues that are very distinct. You have got one,
the ability to make a few bucks, and then the other one, the
ability to actually do things like go fishing or go swimming. I
am an outdoors kind of guy, so those are the kinds of things I
relate to; whereas for somebody else it might be the ability to
read books or something like that.
Mr. Kettner. Right.
Senator Tester. So, were you able to make a recommendation
on how you value those?
Mr. Kettner. We presented a range of different options for
payments for loss of quality-of-life. There is--it is a very
subjective kind of thing to make judgment on, and the judgments
could rest on the veteran's self-perception of loss of quality-
of-life, SMCs, or other criteria.
Senator Tester. All right. I think you stated in your
testimony, I think both you and Dr. Kettner stated that the
studies agree that certain mental health conditions in
particular are undercompensated. Are they undercompensated
because of the rating system, because of a bias in the rating
system, or because of a bias somewhere else?
Mr. Kettner. I believe that where the VASRD is off the mark
is simply for the reason that the criteria and the benefit
amounts are linked to specific criteria which have never been
based on economic analysis. If you don't do the economic
analysis, you are never going to hit your target.
Now, is the VASRD in the general ballpark? Perhaps, yes.
But within the ballpark, it is totally misaligned in terms of
certain codes----
Senator Tester. OK. It wasn't based on economic analysis.
Was it based on quality-of-life analysis?
Mr. Kettner. No. The economic loss analysis is totally
separate from the quality-of-life analysis.
Senator Tester. I would like you to give your opinion on
that same question, Admiral Dunne. Is the rating system
deficient in the things that Dr. Kettner talked about or is it
something else?
Admiral Dunne. Sir, in the mental health area, the rating
schedule has been called into question as to whether it
adequately compensates the veteran, and we are determined to
investigate that. As I mentioned to the Chair earlier, we are
into that already. There is a meeting tomorrow with experts to
take a look at it and to evaluate the current rating schedule
and see if it needs----
Senator Tester. Do you have a timeline for that?
Admiral Dunne. As soon as possible, sir; and I don't mean
to say that flippantly, sir. I have learned from the TBI reg--
which we did modify last year--that when we get these experts
in the room and get them talking and consulting about the
impact of these disabilities and how it should be evaluated and
subsequently compensated, I can't really put a clock on it.
They have to talk it out until they are able to reach consensus
because that is really what we need in order to go forward.
Senator Tester. First of all, I, like the Ranking Member,
don't want to be critical on anything that is being done
because you have got a difficult job--make no mistake about it.
I would hope that part of that group of experts that you get in
the room are some of the fighting men and women that have come
back, because quite honestly, as I went around Montana--and I
don't think Montana is any different than anywhere else--they
are not afraid to give you their opinion. They also understand
when people deserve the benefits and they understand when
people don't deserve the benefits, and they are willing to tell
it straight up both ways. So, I hope that you do use the VSOs
or whatever method you want to use, but get the information
from the folks that are receiving the benefits because I think
it is critically important.
Admiral Dunne. Sir, one thing I might add to that. When we
do get to a proposed rating schedule on mental health or any
other area, we publish it in the Federal regulations for
comments from anyone, and we will address those comments, sir.
Senator Tester. This is my opinion, you guys have to do
your business, but I will push for this. I would bring them
into the process much more than after the fact. I would bring
them in early. I could make a lot of comparisons to what
happens in offices; but if you bring them in early, you get
their perspective early and it is more likely to be included in
the final analysis that is put out for publication and still
have them comment.
Chairman Akaka. Senator Begich?
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Thank you, Mr. Chairman. I am going to
follow up a little bit on Senator Tester and Senator Burr and
your comments, Mr. Chairman.
First, again, not to be critical, but you spend
$3+ million, you expect some steps that will be pretty
aggressive. But let me put that aside.
I am going to take what Senator Tester has said and go one
more step, and that is my father-in-law is a retired veteran
receiving disability. He doesn't read the Federal Register. I
would venture to say most veterans aren't sitting around
pulling out the Federal Register. You must engage them in the
beginning of the process, not after. I have seen this Federal
process where they do the 30-day notification, and then once it
is done, they check the box and they say they are done.
Honestly, that is unacceptable.
So, I would ask you to take what Senator Tester has said
and make it a real step. Do it early. Engage them and not the
Federal process way of posting it in the Federal Register. I
mean, if I called my father-in-law right now and asked, have
you looked at the Federal Register today, I know what he would
say to me. I bet you if I called my brother-in-law and asked
him the same thing--he was active--he would say the same thing.
I would just encourage you to step it up to a little different
level; not just consider it, but do it, to be very frank with
you. You run the show, and I am just giving you my two bits
here.
Admiral Dunne. Senator, I have no problem with including
veterans in the process, and we will find a way to do it.
Senator Begich. Thank you very much.
I am trying to figure out your response in regards to the
questions with the rating system. Mr. Dunne, I know you are
doing an analysis, because we have heard more about it today,
but do you think, personally, there is a problem with the
system? Do you?
Admiral Dunne. I believe that we need to go through and
evaluate the rating schedule and determine how we can improve
it. We need to bring the appropriate experts together to take
each of the disabilities, pull it apart, look at it, update it,
and make that presentation. I do believe that.
Senator Begich. So, if you--I don't want to put words in
your mouth--do you think there is room for improvement?
Admiral Dunne. Yes, sir. There is always room for
improvement.
Senator Begich. Here is the difficulty, Dr. Kettner and Mr.
Dunne, you have the economic analysis and then you have the
quality-of-life. I am not an attorney and wish no disrespect to
any attorneys, but if I was a trial lawyer, they would argue
economic damage and punitive damages. The punitive is always
very difficult based on the circumstances. I mean, you see
juries all the time kind of trying to figure that out.
I would imagine as you get to whatever proposal or
recommendation that you recognize to put a finite number on
that quality-of-life will be very difficult, and creating a
range may be more reasonable, because the conditions can vary
based on the person. I mean, you see juries going through this
all the time. So, as you described, when you get a bunch of
consultants in a room, I can only visualize what that is like.
As a former mayor, I have experienced that many times. Yet,
sometimes you have got to just pull the trigger and say, this
is what we are doing, here is the range, move forward and see
how it works.
I would hope that at some point, maybe both or either one
could respond to this, that that would be kind of the
objective, that we--to find a perfect system will be very
difficult, but finding a system that we can move forward to
start getting realistic results out of knowing the system needs
to be improved is what should be the goal. Any comment? Mr.
Dunne?
Admiral Dunne. Well, yes, sir. I agree that we need to
evaluate things and we need to move forward, but exactly how
that is structured, I don't think is defined yet. There is no
definitive decision on if quality-of-life should be an element
of the compensation process. We are still struggling with that
and trying to figure out the right answer. You can see I have
one recommendation for quality-of-life. I have another
recommendation to take it out of the SMC tables.
Senator Begich. Right.
Admiral Dunne. I want to do the right thing for veterans. I
don't want to jump into this fast, and I want to get the
benefit of the Advisory Committee which the Secretary has set
up, as well as the consideration of the work that Dr. Kettner
has done, before I make any recommendations on something that
impacts the lives of our veterans.
Senator Begich. I appreciate that.
My time is up, and I heard your response to Senator Tester
on the timing. I know it is difficult to give some sort of
timeline, and as you said, as soon as possible. I would ask,
can you be a little bit more definitive? The reason I ask is, I
have never known anyone in the military to not be able to have
a time schedule with a goal and target. So, is it within 6
months? Three months? A year? I mean, when will we see a reform
to the system----
Admiral Dunne. Sir----
Senator Begich [continuing]. Whatever that reform might be?
Admiral Dunne. Our estimate is that if you take an
individual body system of the rating schedule, take that apart,
and build that back up again, that is a year process.
Senator Begich. OK. Thank you very much. Thank you all
three for your testimony.
Chairman Akaka. Senator Burris?
STATEMENT OF HON. ROLAND W. BURRIS,
U.S. SENATOR FROM ILLINOIS
Senator Burris. Thank you, Mr. Chairman.
Interesting. Interesting testimony. I want to follow up on
Senator Burr's question. Dr. Kettner, were you a sole source or
did you do this competitively?
Mr. Kettner. It was competitively awarded--full and open
competition.
Senator Burris. Full and open competition?
Mr. Kettner. Yes.
Senator Burris. Can you tell us how many--maybe Admiral
Dunne can tell us--how many contractors were there, or you
weren't there at the time----
Admiral Dunne. Sir, I don't recall that I ever knew the
answer to that, but I can find that out.
Senator Burris. OK. I assume, now, we are saying that there
are further studies, so this will follow the Federal guidelines
for dealing with contracting; and I would assume that there are
some budget dollars for these. Do you have any idea what your
allocation is for these studies?
Admiral Dunne. I do not, sir. My office is not supervising
that contract.
Senator Burris. Is not supervising the contract.
Admiral Dunne. I will also find that answer out, sir.
Senator Burris. I would appreciate that.
I am concerned with some of my other colleagues' questions,
too, because I am looking at TBI. I wanted you to talk about
the challenges in rating TBI and how is the VA attempting to
improve diagnosis, diagnostics of some of the signature
diseases of this war. I mean, there is going to be something
else coming up. So, can you give me some insight on how we are
attempting to improve diagnosis of Traumatic Brain Injuries?
Admiral Dunne. Senator, I have no medical background and do
not supervise the medical portion of VA, but I can certainly
make arrangements for a briefing for you from our medical
experts.
Senator Burris. OK, because that seemed to be the latest
thing, PTSD, which is really the biggest thing on our veterans,
then TBI, which is very hard to diagnose. So, I would assume
that there are just different levels for different individuals
because individuals are going to react differently to various
circumstances. I would assume, Dr. Kettner, that those are some
of the problems that would come out in your study, would they
not? How do you really get a norm in reference to what would be
applicable to a compensated situation for a person. I would
assume all of these criteria come into effect, you know, age
and education, family life. Are some of those criteria what you
put into your analysis?
Mr. Kettner. Yes. We controlled for human capital
differences, such as education, age, whether or not the veteran
was an officer versus an enlisted, and to the best of our
ability, we controlled for those differences.
I might also mention that we did analyze TBI as a separate
diagnosis and found that they were being--in those instances,
there was undercompensation for TBI cases.
Senator Burris. I assume, or I understand I heard General
Scott say that most of those were underestimated, is that
correct? A lot of those compensated amounts are just off-
kilter. I get all these veterans coming to me saying that they
are not really receiving enough money for what they really
suffered. Is that what you said in your testimony, General
Scott?
General Scott. The analysis that was done for the VDBC
regarding average earnings loss would indicate that the average
earning loss for mental disabilities does not--that the average
loss is in excess of the compensation. And the second part--the
study that Dr. Kettner referred to that was done also for the
VDBC regarding quality-of-life--clearly indicated that the
quality-of-life for those veterans suffering from mental
disabilities was markedly lower than the quality-of-life
suffered for those with physical disabilities. So yes, sir. I
think the answer to your question is yes in both cases.
Senator Burris. Now, help me out here, because I am new to
the Senate and I wasn't here when Senator Burr and our
distinguished Chairman were here, but you mentioned something
about Social Security and having to get the data from Social
Security. So, is there an offset? If you are getting Social
Security or some disability under Social Security, is there an
offset for the veterans compensation? What does Social Security
data have to do with the veterans?
Mr. Kettner. We simply use the Social Security
Administration earnings data for purposes of our earnings loss
analysis. We went to that source because it provides a
relatively accurate source of data on earnings as opposed, for
example, to using survey data or self-reported data. You don't
get data as accurate. But when you----
Senator Burris. Pardon me, Doctor. You mean you are not
going to Social Security to see whether or not these veterans
are collecting Social Security, but you are just trying to get
basic information and the Social Security Administration
wouldn't give you that basic information for you to continue
your study? Is that what you are saying?
Mr. Kettner. They gave us data aggregated to a certain
level. We couldn't get the data at the individual level for
privacy reasons. Now, since our study was----
Senator Burris. Pardon me. Why would you need----
Mr. Kettner. We have uncovered another possibility of
getting at this data, which would be that we could instruct
the--we could give instructions to the Social Security
Administration on exactly how to run the analysis at the
individual level and thereby that would be an avenue that could
be taken to circumvent the problem we have talked about--the
Social Security Administration not
releasing----
Senator Burris. Well, I am still not clear on why you need
Social Security data, and my time has expired, Mr. Chairman. I
don't know whether I am going to have time to pursue that or
not, but I am not clear on the need for the Social Security
data for comparison. It is not--may I have a couple extra
minutes, Mr. Chairman?
Chairman Akaka. If you pursue that, yes.
Mr. Kettner. OK. Let me try this again.
Senator Burris. Please.
Mr. Kettner. We measure the actual earnings of veterans
with disabilities and compare them to the earnings of veterans
without disabilities, OK. So, the veteran over here, he has a
disability, he makes $20,000 a year. Another veteran over here
that we have matched in terms of the same education level and
age and other characteristics, his income is $30,000 a year.
His earnings are $30,000 a year. So that is a difference of
$10,000. That is what we are trying to find out.
We go to the Social Security Administration because we know
they have accurate data. It has to be accurate. It is reported.
The earnings data is reported by employers to the Social
Security
Administration.
Senator Burris. Wouldn't the IRS have the same data?
Mr. Kettner. Well, yes, IRS is another possibility, but
there are certain issues involved as to how best to get the
data. There are bureaucratic obstacles always involved in
getting the data. We only had 7 months for our study and we had
to move very quickly on this, so we took certain courses to----
Senator Burris. Well, I am with Senator Burr. I don't see
how you could have 7 months and not know that you are going to
need this, then get caught up and now there has got to be
another study which you may have to spend another $3 million.
Mr. Kettner. Well, part of the study was discovery. We
didn't know all of this at the beginning. We did ask for
individual data at the beginning, so we knew from the beginning
that we would be facing a certain obstacle. But in the course
of our study, we discovered more things than we knew when we
first started.
We feel very confident in a lot of our studies. For
example, on tinnitus, tinnitus is a 10-percent rating. I can
say unequivocally that there is no earnings loss for tinnitus
veterans. Whether or not you want to--we are just reporting our
result, our statistical result. Whether or not you want to
change their rating from 10 percent to 0 percent, that is a
value judgment that others in government have to make. We are
not making that judgment. We are just reporting on the
statistical results.
At the same time, we can say that those veterans rated at
100 percent are not getting enough compensation. They are, on
average, 9 percent below what they should be getting. We are
very confident about that. We would not say we need to do more
studying for that.
Where our confidence starts to decline is when we have to
look at different combinations of disabilities. We have
tinnitus there, hemorrhoids, and diabetes. When you put them
all together, you get a certain combined rating. We are very
confident that the VA is overcompensating at the lower levels,
but you would have to look at--to get even more accurate, you
would have to look at what are the exact combinations of
different disabilities to really fine-tune this as accurately
as possible, and that is where our hands are tied behind our
back in terms----
Senator Burris. Thank you, Doctor. My time has expired.
Thank you, Doctor. Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Burris.
Dr. Kettner, the question of whether to compensate for loss
of quality-of-life has the potential to change veterans
disability compensation considerably. Let me ask you this
question, and I am going to ask General Scott to also comment
on this. Do you believe that VA should work on changes to the
rating schedule before addressing whether loss in quality-of-
life should also be compensated?
Mr. Kettner. Absolutely. They should get the VASRD in
better alignment before adding on quality-of-life, because you
could be compounding current inequities in the system right
now.
When we look at quality-of-life, you know, there is a
tremendous amount of variation across ratings. It jumps around
quite a bit. We believe part of the reason is that the rating
schedule itself--the regular schedule ratings schedule--is so
misaligned that when you try to line up quality-of-life loss
analysis, it is more of a random kind of thing, and there is
more variation than you would expect to see. So, we strongly
recommend fixing the VASRD first before taking on quality-of-
life.
Chairman Akaka. Thank you for that. When I asked about what
are your priority of any change, you mentioned the rating
schedule.
General Scott?
General Scott. Sir, you did indeed ask for a priority and
that is what each of us gave you. I think it is a good thing in
terms that we all have the same priority when we talk about it.
I guess my perspective on working quality-of-life would be
that an assessment of the different models for determining how
to compensate for quality-of-life can go on in parallel with
the updating and revision of the VASRD. But the application of
dollars, if you will, to a quality-of-life model might want to
wait until we had been through the VASRD and the updated
revision done.
So, that may be an equivocal statement, sir, but I think
that you can work the model, which I believe is what the VA is
doing. They are working--they are taking the input from us,
they are taking the input from the studies that have been done
and from the other advisory efforts that are ongoing to try to
develop a model or models for quality-of-life compensation, and
I think that can go on in conjunction with updating the VASRD.
But again, you might want to wait to put the dollars against it
until the VASRD is updated. Thank you, sir.
Chairman Akaka. Admiral Dunne and General Scott, last year,
Congress passed the Veterans' Benefits Improvement Act of 2008,
which became law. It was Public Law 110-389. This law required
VA to establish an Advisory Committee on Disability
Compensation. Congress intended that the committee would be
composed of individuals with experience with VA's disability
compensation system or who are leading experts in fields
relevant to disability
compensation.
My question to both of you is how are the requirements of
the Congressionally-chartered committee met by the Advisory
Committee that General Scott now chairs? Stated differently,
which members are experts in which fields of expertise? General
Scott, will you begin, and I will ask Admiral Dunne to comment.
General Scott. Well, let me start by saying that I will
send you the bio sketches of the members of the committee for
the record. The previous Secretary selected the current Members
of the Committee. The legislation offered the opportunity, as I
recall, for 18 members; and the Secretary at the time chose not
to fill it entirely, leaving the opportunity for the new
Secretary or the Veterans Committees in the House and Senate to
offer candidates.
The legislation, as I recall, requires the Committee to
report out to the Congress on a biennial basis, and in my
statement, I told you that we are submitting interim reports to
the Secretary twice a year, semi-annually, and that we are
obviously providing copies to the Committees. So, we are
probably over-reporting in terms of what the law required, but
not in terms of what we think we should be doing in terms of
keeping both the Secretary and you
informed.
As a matter of fact, I remarked to Admiral Dunne this
morning that this committee is reaching its 1-year anniversary
next month; that he and the Secretary might want to consult
with you and the House to offer some additional recommendations
for putting more people on it so that we don't all expire at
the same time next year, at the end of the 2-year mark. The
appointments of the people that are on it now were for 2 years
and so far no one has indicated they weren't going to serve out
the 2 years. What I would propose to do is, again, at the end
of the 2 years, is have the Secretary ask the Committees if
they would have recommendations regarding what should occur.
In response to one of the staffers who asked essentially
the same question, was there proper expertise there and all
that. At the time, my answer was I really don't know, because I
haven't gotten to know the members that well. I also told them
that if the Committees wanted to make changes, it was available
in terms of adding people now. So that would be my basic
response to your
question.
I will say this. There are some distinguished members on
that committee. I don't necessarily include myself in that, but
there is a former Surgeon General who is a true expert in the
transition from military to veteran and who thoroughly
understands the medical side. There is a medical doctor whose
background is psychiatry who is very, very helpful. There is
also a Ph.D. from Johns Hopkins on it.
So, this is a committee made up of people with a wide
variety of experiences and talents, and as I said, sir, at the
beginning, I will furnish copies of the bio sketches of all the
members, and perhaps your staff can take a look at them. Then,
I believe, sir, that the Committee can make up its own mind of
whether the people that you more or less intended or
anticipated would be involved are on it or not; and then the
opportunity is there to change the make-up of the committee as
we go along, sir.
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka
to LTG James Terry Scott, Chairman, Advisory Committee on Disability
Compensation
Chairman Akaka. Thank you, General. I would like the
Committee to have your request and would also like to know what
else you may need for the record.
General Scott. Yes, sir.
Chairman Akaka. Admiral Dunne?
Admiral Dunne. Mr. Chairman, first, I would offer that
General Scott is one of the distinguished members of the
Advisory Committee. Beyond that, I would say that the
circumstances as he presented them are as I understand them,
and I have nothing to add, sir.
Chairman Akaka. Thank you.
Let me pass it on to Senator Burr for his questions.
Senator Burr. Thank you, Mr. Chairman. And Admiral, I don't
think you took my last comments personally. I hope you didn't.
They were not intended to be personally directed to you. I
don't suggest to you or to the VA that we move on important
decisions before we have all the information we need to get it
right.
But I do want to try to present for you why there is a
level of frustration on my part. You very clearly said in your
testimony--being critical of the study for several reasons, you
said, and I quote, ``It did not provide the detail and
longitudinal analysis to warrant significant policy changes,''
yet my interpretation of Dr. Kettner's testimony reflects that
the information that he provided is reliable and accurate
enough to be the basis for policy decisions.
So, I hope that VA, company, contractor, will have some
conversations that better lay out what the clarity is we need
to make the important policy decisions before we begin the next
study.
Now, the VA report on the Economic Systems study, and I
quote, said ``consideration could be given'' to addressing the
loss of quality-of-life for additional disabilities through
special monthly compensation, and you mentioned it, as well.
There are currently 260,000 veterans that receive special
monthly compensation. Is the VA planning to send the Congress
proposed legislation to expand special monthly compensation?
Admiral Dunne. As we look through the ratings schedule and
come up with changes, if legislation is required to implement
that, sir, we certainly would do that. I have been talking with
the folks at Compensation and Pension Service right now on the
mental health side. There is some discussion about mental
health versus coverage under SMC. What I am not certain of
right now is modifications to that. If we determine they are
necessary, can we make them simply through regulation, or is
legislation required? So, we may have the capability to do it
right now.
Senator Burr. But we are in agreement, mental health is not
currently covered under special monthly compensation and it is
just a question of whether we need to make some changes
legislatively----
Admiral Dunne. Yes, sir----
Senator Burr [continuing]. Correct?
Admiral Dunne. I am not an expert in SMC, but to the best
as I understand it----
Senator Burr. That is my understanding. I may be wrong,
but----
Admiral Dunne. Yes, sir. To the best of my understanding,
it is not covered right now.
Senator Burr. I think we all agree that the VA rating
schedule is probably the cornerstone of the entire disability
compensation system. In its first report to the Secretary, the
Advisory Committee on Disability Compensation indicated that
the VA has not dedicated sufficient full-time employees to
keeping the VA Schedule for Rating Disabilities up to date.
Would I take it that the comment you made about the addition of
two new clinicians is part of that review process?
Admiral Dunne. Yes, sir, that is correct. As we go through
this, there may be the need to have different experts,
depending upon which part of the ratings schedule we are
looking at. So, in some cases, we are contracting for an expert
for a period of time to support that.
Senator Burr. Admiral, how many full-time employees are
hired to continually look at this rating schedule and update
it?
Admiral Dunne. I would have to get you the exact number,
sir. I am aware of the addition of two, and I know several of
the senior members of Compensation and Pension Service work on
it periodically, but are not dedicated to it 100 percent of
their time. However, those individuals, in my mind, are key and
essential to making this happen. For instance, the Director and
the Deputy Director, who will be involved all day tomorrow, are
not working on it 100 percent of the time, but they are
essential to the success of tomorrow's event.
Senator Burr. How important do you believe keeping this
schedule up to date is?
Admiral Dunne. Very important, sir. I am not sure how to--
--
Senator Burr. You know, clearly, I think it is. I think
that is part of the problem, that we haven't regularly updated
it. Until I know the number of folks, I couldn't make an
assessment as to where it shows the level of commitment to
continuing. To me, two new clinicians is not a major additional
commitment. It may be if there are 500 people that look at it
all the time--if there are two people that look at it all the
time and we are doubling, two to four, then we might both look
at it and say that is not indicative of the type of commitment
that we should have.
What role do you believe the Advisory Committee on
Disability Compensation should play in making sure that the
rating schedule is updated?
Admiral Dunne. Sir, they have the opportunity to, first
off, look at and evaluate what we are doing. General Scott and
the Director of Compensation and Pension Service are in routine
communication. The committee looks at what we are doing and
makes recommendations based on that, and we try to act on those
recommendations.
Senator Burr. Now, the VA report on the Economic Systems
study, and again I quote, said, ``We believe that recurring
studies of earning loss relationships should be conducted on a
regular schedule to ensure that the changes to the ratings
schedule accurately compensate to the extent practical, for
earnings loss.''
Admiral, do you know of any significant study that has been
done since the 1970s on that earnings loss relationship?
Admiral Dunne. I am aware of a study which is referred to
as the ECVARS study, which I believe was done in the early
1970s. I have not read that, sir, but I believe it took a look
at the economic parameters of the ratings schedule.
Senator Burr. But there hadn't been a--General, do you have
anything to add that you might be able to shed some light on
that from the standpoint of how long it has been?
General Scott. The Center for Naval Analysis did a study
for the Veterans Disability Benefits Commission that
essentially validated the relationship between the average
earnings loss and the compensation schedule, broadly speaking.
Now, with the exceptions that we discussed off and on here
today--age of entry, seriously disabled, mental versus
physical, et cetera.
So, in the sense that has any economic validation been
done, I would say that the ECVARS study, which was mentioned by
Admiral Dunne, is one. The CNA study done on behalf of the VDBC
is a second one. And significant parts of the study done by
Economic Systems recently all address sort of the economic
foundation of the VASRD.
Now, one can conclude that it is generally on the mark, but
has variations that should be fixed and can be fixed mostly in
the VASRD; or one can conclude that it is off by some small
percentage and more studying should be done to determine
exactly what and exactly how. I am of the view that sufficient
information has been provided by those three studies to enable,
as I mentioned before, the continuing revision and updating of
the VASRD, which should fix a lot of these problems. So yes,
sir, I think that those three studies are relevant.
Senator Burr. But to dig just a little bit deeper, are you
at odds with the VA relative to the conclusion you have come to
that there exists enough data to proceed with review and
update, or is there less light in between the two of you than I
interpret?
General Scott. I think you will have to ask the VA
representative whether the VA believes that adequate economic
analysis had been done, but clearly from my comments, I think
we can proceed with what we have here.
Senator Burr. Admiral?
Admiral Dunne. Sir, I don't think there is disagreement on
the fact that we need to take a look at the mental health part
of the ratings schedule. But I would disagree with saying, just
based on 2006 data, that we should do something specifically
like take a 10 percent disability rating to a 0 percent
disability rating. I would want to go back and take a look at
more years' worth of data to see what it is.
I believe we need to take a look at it. We need to evaluate
it. I am just not ready to say that every conclusion in here is
one that should be acted on precisely.
Senator Burr. General, one last question. The Chairman has
been incredibly accommodating to me this morning. You stated
that you felt that updating the ratings schedule was a very
high priority task. Do you believe that the VA agrees with that
being a very high priority task?
General Scott. Well, I believe that they agree that it is a
high priority task. I am not sure that the level of concern
that I have regarding how quickly we need to move on it is
reflected in what I have seen come out of the VA so far. But
again, you have obviously read this report that we submitted to
the Secretary where we--in no uncertain terms--not only told
them what they should do, but probably in too much detail told
them how to do it. We may have been a bit out of bounds by
saying they should hire nine people to do this, et cetera.
But the point was, we felt--the committee felt that it was
important that the VA focus full-time effort on updating the
ratings schedule and we fully understand that it will take
about a year to do a body system. The committee's position is
that we ought to be doing about three or four of these at a
time so that it doesn't take 15 years to get from 1 through 15.
I can't speak to whether the VA agrees with that approach
or not, but that is the committee's recommendation, unanimous
as a committee, to forward that to the Secretary and suggest
that that is the way we should go on it. So, we believe it is a
very high priority and it will fix so many of the small things
that we talk about--not small in terms of impact on veterans,
but all the second- and third-order issues that we are all
confounded by, in my judgment, can be fixed inside that.
Senator Burr. I thank you for your observations, and more
importantly, your involvement on the Advisory Committee. I hope
all of you understand that what I am trying to do is establish
points that we can begin to move forward from. If we can't do
it on all of them, we can't. Let us know that up front. If we
can, then let us find the agreement to move forward. I tend to
look at agency issues in 4-year segments. There are some
natural things that cause me to do that, and I know that when
you get on the downhill side of the 4 years, you are less
likely to get agencies to make major changes because all of a
sudden you have individuals that have been there a long time
that say all I have to do is wait out until this happens and I
don't have to go through the tough decisions and the tough
work.
So, we have a very short window to accomplish high priority
tasks. And I hope if you, as chair of the Advisory Committee,
see it as a high priority task, then I want to understand up
front, is that where the VA sees it or is it seen as a lesser
task, and if there is a difference, can we work this out to all
come up with a common timeline. I think my expectations and
hopes are that we are not talking about 15 years to accomplish
many of these things. Hopefully we are looking at studies in
the future that don't require follow-up studies, because I
think it does play into the hands of some that would prefer to
see this carried from 4 years to 4 years to 4 years.
Admiral, Doctor, General, thanks.
Chairman Akaka. Thank you very much, Senator Burr.
I want to thank Admiral Dunne, Dr. Kettner, and General
Scott for your responses. We continue to look to working
together with you in trying to resolve this as quickly as we
can. So, thank you very much for your time.
[Pause.]
Chairman Akaka. I want to welcome our second panel this
morning. Our first witness is Katy Neas, who is Vice President
of Government Relations for Easter Seals; Susan Prokop, who is
Associate Advocacy Director for the Paralyzed Veterans of
America; and retired Air Force Colonel John L. Wilson, who is
Associate National Legislative Director for the Disabled
American Veterans.
Thank you all for being here this morning. Your full
testimony will be, of course, in the record.
Ms. Neas, will you please present your testimony first.
STATEMENT OF KATY NEAS, VICE PRESIDENT,
GOVERNMENT RELATIONS, EASTER SEALS
Ms. Neas. Sure. Certainly. Thank you, Mr. Chairman. It is
an honor to be here today to give Easter Seals' perspective on
the Department of Veterans Affairs' disability compensation
system.
Easter Seals is a 90-year-old organization that works with
all people of all ages with all types of disabilities and our
goal is to help them live, learn, work, and play in their
communities. We work with each individual in the context of
their families and in the context of their communities and we
can't address each individual's needs in isolation.
My goal today is to provide some insights on Federal policy
affecting people with disabilities that hopefully can inform
you as you consider your work ahead.
Americans with disabilities have made great strides over
the past three decades and it is essential that the VA build on
these gains. I would like to list just three of the main
victories we have witnessed.
In 1973, thanks to Section 504 of the Rehabilitation Act,
all programs funded by the Federal Government need to be
accessible and usable by people with disabilities. In 1975,
with the passage of the Education for All Handicapped
Children's Act, children with disabilities secured the right to
an appropriate public education. And in 1990, all children and
adults with disabilities won the right to be free from
discrimination in employment services provided by State and
local governments, public accommodations, transportation, and
telecommunications, thanks to the passage of the Americans with
Disabilities Act.
As a result of these important laws, people with
disabilities expected to be fully included in their families
and in their communities and have the supports they need to
live the lives that they choose. There is a rallying cry within
the disability rights movement about ``Nothing about us without
us,'' and I think, if anything we learned from the first panel,
that that is something that we hope the VA takes to heart.
Again, nothing about us without us.
I would like to provide some specific recommendations about
how veterans with disabilities should be helped by the VA. Most
importantly, veterans with disabilities and their lives need to
be considered holistically. A veteran with a disability is
likely to have increased expenses through their years beyond
medical and therapeutic care. For instance, they may have
additional out-of-pocket expenses such as assistive technology,
transportation, home modification, and other supports to
maintain their independence.
One of the things that was racing through my mind during
the first panel was an individual's quality-of-life is
something that only that individual can determine for
themselves. Some people like to play rugby. I am not a rugby
player. If you see people who play wheelchair rugby, they are a
different breed of person who like risks and things. There are
a lot of other people that we have served that are farmers that
simply want a lift on their tractor so they can go back to
work, or a home modification.
A lot of our folks come from rural areas, and as Senator
Tester commented, they just want to go fishing. That is all
they really want to do. That is what they enjoyed in life
before their service and when they go home after their service,
they want to go fishing. Can they get into their boat? Is there
a dock that will accommodate their wheelchair? Can they do the
things that they wanted to do before they acquired their
injury? I think those are the kinds of things that only an
individual can say for themselves, and no rating system can be
complete if it doesn't accommodate that individual's
perspective on what is important to them as an individual.
I would like to ask you to keep in mind some basic
disability policy precepts that affect certainly our work and
the work that we try to have Congress consider, that whenever
you make a decision, that those decisions are based on fact,
objective evidence, state-of-the-art science, and a person's
needs and preference, not based on administrative convenience
and generalizations, stereotypes, fear, and ignorance. Again, a
quality-of-life is something that is very personal.
I have met thousands of families over the 20 years I have
been working in this field. When they have a child with a
disability, at the beginning, they think their world has ended.
And if you ask them at a later point in their life, they will
tell you having that child was the best thing that ever
happened to them because that child gave them perspective they
wouldn't have otherwise had.
I think a person who acquires a disability through their
service to our country needs to be afforded that opportunity to
determine for themselves what is important for them and not
have the rest of us dictate what their life should be all
about.
I think providing the supports for a person to have
independent living skills--what is it going to take for them to
go back to their homes and their families, to go back to being
a dad or a brother or a son? Those things need to be
accommodated.
We need to allow people to be in the most inclusive setting
based on what they want. We need to recognize economic self-
sufficiency as a legitimate outcome of public policy. And we
need to provide support systems for employment-related
supports.
In conclusion, Easter Seals recommends that revisions of
the disability compensation system should take into account the
totality of a person's potential ability as well as future
supports that they may need to maintain independence. Thank you
very much for the opportunity to be here today.
[The prepared statement of Ms. Neas follows:]
Prepared Statement of Katy Neas, Vice President,
Government Relations, Easter Seals
Good morning Chairman Akaka, Ranking Member Burr, and Members of
the Committee. I am indeed honored to be here today to provide Easter
Seals' perspective on the Department of Veteran's Affairs (VA)
disability compensation system. Thank you for the opportunity to speak.
My goal today is to provide some insights on Federal policy
affecting people with disabilities that can inform how you consider
compensation for veterans with disabilities. Americans with
disabilities have made great strides over the past three decades, and
it is essential that the VA build on these gains. I'd like to list just
three of the main victories we have witnessed:
1. In 1973, thanks to section 504 of the Rehabilitation Act, all
programs funded by the Federal Government needed to be accessible to
people with disabilities.
2. In 1975, with the passage of the All Handicapped Children's
Protection Act, children with disabilities secured the right to an
appropriate public education.
3. In 1990, all children and adults with disabilities won the right
to be free from discrimination in employment, services provided by
state and local governments, public accommodations, transportation and
telecommunications, thanks to the passage of the Americans with
Disabilities Act.
As a result of these important laws, America has a new outlook on
where people with disabilities belong. People with disabilities expect
to be fully included in their families and in their communities and
have the supports they need to live, learn, work and play.
Military servicemembers and veterans are a major focus for Easter
Seals. In communities nationwide, Easter Seals is being asked to help
meet the needs of America's military servicemembers and veterans with
disabilities and their families. Our goal is to promote their successes
by helping them attain their personal and family goals while becoming
full participants within their own communities. We have utilized our
nationwide network of accessible camps to provide therapeutic
recreation and camping experiences to veterans with disabilities and
their families. Easter Seals has also partnered with the National
Military Family Association to host week-long Operation Purple
experiences for children of deployed parents at five Easter Seals
affiliate camp sites. Later this year, the partnership will stage
Operation Purple Healing Adventure for servicemembers and veterans with
disabilities and their families at Easter Seals Camp ASCCA in Alabama.
And finally we provide a significant amount of adult day services and
other supports to the Nation's older veterans through the Nation's
largest network of adult day service centers.
In addition to these nationwide efforts, in our headquarters city
of Chicago, with generous funding from the McCormick Foundation, Easter
Seals has launched two programs that benefit servicemembers, veterans
and their families:
Operation Employ Veterans provides training to employers
on effective methods to recruit, employ, and retain veterans with
disabilities.
Community OneSource provides information, system and
resource navigation and personalized follow-up supports for
servicemembers, mobilized Guard and Reserves and veterans with
disabilities and their families as they reintegrate back into their
home communities. This is an initiative we hope to take national very
soon.
For 90 years, Easter Seals has been the leading non-profit provider
of services for individuals with autism, developmental disabilities,
physical and mental disabilities, and other special needs. Through
therapy, training, education and support services, Easter Seals creates
life-changing solutions so that people with disabilities can live,
learn, work and play in their communities. Based on this wealth of
experience, we are able to make some recommendations today about how
veterans with disabilities should be viewed by the Department of
Veterans Affairs when calculating compensation.
First, veterans with disabilities and their lives need to be
considered holistically when considering compensation.
Calculations of potential lost earnings do not account for the
reality of many veterans with disabilities lives. A veteran with a
disability is likely to have increased expenses through the years
beyond medical and therapeutic care. For instance, they may need
assistive technology, transportation, housing modification and other
supports to maintain health and independence. In most cases many of
these expenses, even when subsidized, are out-of-pocket expenses that a
veteran without a disability would not have.
In addition, a veteran with a disability may be able to work with
supports like those listed above and may not have as much in lost
earning, but the increased costs of the supports needed could still
financially devastate the veteran. For instance, advances in prosthetic
technology help veterans with lost limbs do work related tasks that
were not conceivable when compensations policies were set so earnings
potential can be very different for this generation of veterans with
disabilities. However, even a veteran with a disability who is a
relatively high earner could still be devastated financially by the
supports needed to remain independent.
As decisions are made about potential changes to disability
compensation systems and other decisions affecting veterans with
disabilities, I urge you to keep in mind some of the basic disability
policy precepts that we in the broad disability community always try to
infuse into legislation:
A. Equality of Opportunity
Individualization--Make decision affecting an
individual based on facts, objective, evidence, state-of-the
art science and a person's needs and preferences; not based on
administrative convenience and generalizations, stereotypes,
fear and ignorance.
Effective and Meaningful Opportunity--Focus on
meeting the needs of all persons who qualify for services and
supports, not just the ``average'' person by providing
reasonable accommodations and reasonable modifications to
policies, practices, and procedures.
Inclusion and Integration--Administer programs in
the most integrated setting appropriate for the individual
(i.e., the presumption is that a person who qualifies for a
public program must receive services in an inclusive setting
with necessary support services and the burden of proof is on
the government agency to demonstrate why inclusion is not
appropriate to meet the unique needs of the individual) and
administer programs to avoid unnecessary and unjustified
isolation and segregation (i.e., do not make a person give up
his/her right to interact with nondisabled persons in order to
receive the services and supports).
B. Full Participation
Provide for active and meaningful involvement of
persons with disabilities and their families in decisions
affecting them specifically as well as in the development of
policies of general applicability i.e., at the systems/
institutional level. (``Nothing about us without us'')
This means policies, practices, and procedures must
provide for real, informed choice; self-determination,
empowerment; self-advocacy; person-centered planning and
budgeting.
C. Independent Living
Recognize independent living as a legitimate outcome
of public policy.
Provide for independent living skills development.
Provide necessary long-term services and supports
such as assistive technology devices and services and personal
assistance services.
Provide cash assistance.
D. Economic Self-Sufficiency
Recognize economic self-sufficiency as a legitimate
outcome of public policy.
Support systems providing employment-related
services and supports.
Provide cash assistance with work incentives.
In conclusion, Easter Seals recommends that revisions of the
disability compensation system should take into account the totality of
a person's potential ability as well as future supports that may be
needed to maintain independence. Thank you very much for this
opportunity to testify today.
Chairman Akaka. Thank you very much, Ms. Neas.
Ms. Prokop?
STATEMENT OF SUSAN PROKOP, ASSOCIATE ADVOCACY DIRECTOR,
PARALYZED VETERANS OF AMERICA
Ms. Prokop. Thank you, Mr. Chairman. On behalf of the
Paralyzed Veterans of America, we appreciate this opportunity
to share with you some observations about Federal disability
policy as it affects veterans with disabilities.
As you requested, our testimony today focuses on several
areas of Federal disability policy affecting our members as
people with disabilities: Social Security; employment; and
housing. You have the details in our written statement. Though
not intended as exhaustive, this information should, we hope,
prompt you and other policymakers to ask in future disability
policy deliberations, how might this affect veterans with
disabilities.
What I will do in my remarks this morning is highlight
several principles recently expressed by the National Council
on Disability for evaluating disability programs and how the VA
disability system stacks up against those principles.
NCD urges the Federal Government to ensure that its
programs and services for people with disabilities are
consistent with the overarching goals of the ADA, promoting
equality of opportunity, full participation, independent
living, and economic self-sufficiency. NCD criticizes policies
that force individuals with disabilities to impoverish
themselves, give up jobs, and otherwise limit their freedom in
order to obtain the basic necessities of life.
As you know, veterans with service-connected disabilities
receive a wide array of services and supports from the VA. The
same can be said for veterans with catastrophic non-service-
connected disabilities. All of these benefits are provided
regardless of income. Compare these VA benefits to those
available to non-veteran people with disabilities on SSDI or
SSI in which benefits are limited by earnings and many services
and supports are provided only under certain restricted
circumstances. What separates veterans with disabilities who
receive Social Security benefits from their non-veteran
counterparts is their access to the VA health care system and
its ancillary supports and services, regardless of their
income.
As PVA has stated in past testimony, VA compensation is
meant to offset more than economic loss. It reflects the fact
that even if a veteran works, the disability doesn't stay at
the office when he or she goes home at the end of the day. In
many respects, VA compensation and its ancillary benefits, and
even the benefits for veterans with non-service-connected
catastrophic disabilities, reflect many of the standards
embodied in the first principle outlined by NCD.
NCD's second principle says that ensuring sound fiscal
policy in disability programs should be based on long-term
human costs and benefits. Here, NCD cautions against policies
that fail to take into account the overall cost to society or
to other programs when cost shifting occurs. A case in point is
the VA pension program cash cliff, which limits the ability of
low-income veterans to reenter the workforce, unlike their
counterparts on SSI.
A related perverse aspect of public policy involves VA
benefits interaction with civilian disability systems. As noted
in our statement, some married veterans eligible for
compensation and pension elect to receive only pension because
their service-connected benefits would knock their spouses off
SSI and cost them their
Medicaid.
Third, NCD notes that there are gaps between many Federal
programs where there should be bridges. According to this
standard, veterans who clearly meet SSA's criteria for
disability should not have to undergo a second disability
determination after receiving their 100 percent rating from the
VA, nor should low-income veterans deemed permanently and
totally disabled by the VA have to obtain a separate doctor's
note attesting to their disability to receive assistance from
HUD.
The foregoing positive description of VA benefits is not
meant to dismiss the many challenges still facing the VA
system. It is merely to suggest that policymakers may want to
look to the VA system as a model that at least breaks the chain
between health care and poverty for people with disabilities.
Indeed, compared to other Federal disability programs and
systems, the VA system recognizes that there are factors beyond
someone's earnings capacity that call for ongoing supports and
services in order to maintain a decent quality-of-life.
I appreciate this opportunity to testify and would be happy
to answer any questions you may have. Thank you.
[The prepared statement of Ms. Prokop follows:]
Prepared Statement of Susan Prokop, Associate Advocacy Director,
Paralyzed Veterans of America
Mr. Chairman and Members of the Committee--on behalf of Paralyzed
Veterans of America, I thank you for asking PVA to share with you some
observations about Federal disability policy as it affects veterans
with disabilities. As the only Congressionally-chartered veterans'
service organization solely devoted to representing veterans with
spinal cord injury and/or dysfunction (SCI/D), PVA is uniquely
qualified to speak to these issues because our members include those
with service-connected disabilities as well as those who sustained
spinal cord injuries or illnesses after their discharge from the
military. Maximizing ``the quality of life for its members and all
people with spinal cord injury/dysfunction'' has been part of PVA's
mission since its founding. As part of that mission, PVA has been a
longstanding participant in coalitions to advance the larger cause of
disability rights and to improve government programs and policies that
support and assist Americans with disabilities.
Our testimony today focuses on three areas of Federal disability
policy that affect our members as people with disabilities--Social
Security, employment and housing. Each of these areas has been the
subject of considerable debate within disability policy circles over
the past several years. Yet, when policy debates arise or when changes
are proposed concerning programs affecting Americans with disabilities,
veterans with disabilities are often overlooked. Moreover, seldom is
attention given to the interaction between veterans' benefits and those
they receive from other Federal disability programs. These comments are
not meant to be exhaustive of the many ways VA and other Federal
disability programs relate to one another. Perhaps some of the
information presented here may stir enough interest so that
policymakers in future deliberations on disability policy might ask--
how will this affect veterans with disabilities?
VETERANS WITH DISABILITIES AND SOCIAL SECURITY
Veterans with significant disabilities are very often Social
Security disability beneficiaries as well.
According to the Social Security Administration's (SSA) latest
Annual Statistical Supplement--in 2007, there were 434,000 Social
Security beneficiaries who were service-connected disabled veterans
rated 70-100% under age 65. Another 153,000 beneficiaries of Social
Security were non-service-connected disabled veterans under age 65.
There were also 1,540,000 service-connected disabled veterans under age
65 whose disabilities were rated below 70%. These latter individuals
likely have other non-service related conditions or disabilities that
qualify them for Social Security disability benefits.
Veterans with disabilities on Social Security can fall into one of
several categories. They can be service-connected disabled veterans
getting compensation and Social Security Disability Insurance (SSDI).
They might be getting compensation and be eligible for SSDI but their
earnings are too high to receive Social Security disability benefits.
They might be veterans with catastrophic non-service-connected
disabilities--like spinal cord injury--which will qualify them for SSDI
as long as their earnings are limited. They can be low income veterans
with non-service-connected disabilities who are eligible for
supplemental security income--or SSI--under Social Security; or they
might be veterans who had a modest earnings record and who may receive
a small SSDI check supplemented by VA Pension. It's even possible that
a veteran, if injured before age 22, could get Social Security
Childhood Disability benefits based on his/her parents' earnings
records--if the veteran's parents are retired, disabled or deceased.
VA Compensation and Social Security Disability Insurance--There is
no offset between SSDI and Compensation benefits--nor should there be.
Compensation is earned through military service and SSDI is an earned
benefit based on a person's work record and payment of FICA taxes. Once
a veteran receives SSDI and compensation, few if any complications
arise between those two benefit programs. However, the process by which
veterans with significant disabilities obtain SSDI could be improved
through better coordination between SSA and the Department of Veterans
Affairs (VA).
While the Department of Defense and VA have taken steps to smooth
the processes between their disability systems, veterans with severe
disabilities must still undergo a second disability determination to
apply for SSDI. The Veterans Disability Benefits Commission has
reported that only 54% of veterans rated 100% are receiving SSDI and
has stated ``either these veterans do not know to apply for SSDI or are
being denied the insurance.''
Granted, some of those veterans may not be receiving SSDI because
they are working above the earnings limit for that program.
Nevertheless, PVA finds it mystifying that veterans with 100%
disability ratings from the VA and the requisite quarters of coverage
should have to go through another application process to receive SSDI.
Some policymakers contend that the reason for the two disability
determinations is related to the differing definitions of disability
used by SSA versus the VA. The Social Security Administration's Wounded
Warrior Program has been making efforts to reach out to newly-injured
servicemembers to inform them of and expedite applications for their
SSDI benefits. However, this SSA initiative applies only to
servicemembers injured after October 1, 2001 and resources often limit
the extent to which SSA can make its presence known in the VA system.
Legislation has been introduced in Congress to allow automatic
qualification for SSDI to 100% service-connected disabled veterans.
While there may be details that still require attention, PVA supports
this move and hopes Congress can find a way to advance this policy.
VA Pension, Supplemental Security Income and other low income
support programs--Typically, a low income veteran with a significant
non-service-connected disability--and without an adequate work record
to qualify for SSDI--may qualify for Supplemental Security Income or
SSI. As an income-tested program, SSI carries with it limits on other
income and assets or resources--but these are generally less generous
than the VA pension program. As a result, it benefits a veteran in
these circumstances to be on pension. Veterans' spouses, who meet
appropriate criteria, can also receive pension payments from the VA.
Some veterans may have had low paying jobs or not had an extensive
earnings history but receive a small SSDI benefit based on that work
record. These DI benefits will offset any VA pension payments up to the
allowed pension level. This dual eligibility can have ramifications for
the veteran if he or she attempts work, as described in the next
section.
Among the most complicated public policy interactions are those
involving VA pension and other Federal income assistance programs. As a
means-tested program, VA pensions count all income to reduce--or even
eliminate--the pension payment. However, the VA does not count as
income for pension purposes SSI, welfare, food stamps, Medicaid and
housing aid. On the other hand, SSI, welfare, and other Federal
disability programs do count VA pension as income. As a result, a
veteran can get in trouble with those programs if the VA pension is not
reported accurately. The VA Aid and Attendance payments that accompany
some pension benefits as well as homebound benefits are not counted as
income by Social Security. Unfortunately, sometimes these benefits are
questioned as income by Social Security offices causing major headaches
for the veteran on pension.
Although Federal policies sometimes make it difficult for veterans
with disabilities to navigate the programs to which they are entitled,
there have been occasions where Congress did account for veterans'
circumstances in larger programmatic changes. The Medicare
Modernization Act was one of those few times that policymakers
remembered veterans in crafting a piece of non-VA related legislation.
Medicare--as you know--is a benefit available to those on Social
Security. Individuals on SSDI get Medicare after a two year waiting
period. When Medicare Modernization passed, the law declared that VA
prescription drug coverage would be considered creditable coverage for
those not signing up for the Part D benefit right away. Thus coverage
under the VA immunizes a veteran from the late sign up penalty for Part
D.
VETERANS WITH DISABILITIES AND EMPLOYMENT PROGRAMS
Typically, discussions about veterans' employment center on
veteran-specific programs operated by the VA, Small Business
Administration or Department of Labor. Understandably, this is due to
the fact that most veterans, even those with modest service-connected
disabilities, are eligible for the VA's Vocational Rehabilitation and
Employment (VR&E) Program. For veterans with non-service-connected
disabilities, the DOL offers programs and services through its Veterans
Employment and Training Administration and SBA hosts a number of
programs tailored to veteran small business owners and service-disabled
veteran small business owners. PVA, through The Independent Budget, has
offered numerous recommendations for improvements to the VR&E and other
VA employment programs that need not be repeated in this testimony.
State vocational rehabilitation programs--Veterans with significant
disabilities are also eligible for and often seek services from state
vocational rehabilitation (VR) agencies. Many state VR agencies have
memoranda of understanding with their state department of veterans'
affairs to coordinate services to veterans with disabilities. Some
state agencies have identified counselors with military backgrounds to
serve as liaisons with the VA and veterans' groups.
There are significantly more state VR counselors than there are
VR&E counselors around the Nation. These numbers of vocational experts
can amplify the assistance available to veterans with disabilities if
appropriate outreach and partnerships are established and training
provided to improve cross-agency coordination.
For some veterans with service-connected disabilities, establishing
eligibility for state VR services may prove challenging. While most
veterans with ratings at 40 percent and below are unlikely to qualify
for state VR services, those with ratings between 50 percent and 70
percent might qualify depending on a state's admission criteria and the
ability of VR professionals to assess appropriately a veteran's
functional capacity.\1\ Participants at a May 2008 Department of
Education symposium on VR and returning veterans suggested that,
because of differing eligibility criteria among state VR systems, the
potential exists for veterans in some states to be bounced between
state VR & VR&E. One way to address this concern would be for the VA to
work with the Rehabilitation Services Administration (RSA) to establish
consistent criteria for state agencies' acceptance of veterans with
service-connected disability ratings.
---------------------------------------------------------------------------
\1\ Proceedings of the 34th Institute on Rehabilitation Issues, U.
S. Department of Education Rehabilitation Services Administration, May
5-6, 2008.
---------------------------------------------------------------------------
Social Security Work Incentives and VA Pension ``Cash Cliff''--The
Social Security Administration offers a variety of work incentives to
enable SSDI and SSI disability beneficiaries to go to work. The Ticket
to Work program provides beneficiaries with vouchers to buy vocational
services of their own choosing and rewards vocational service providers
for helping SSDI and SSI recipients reduce their reliance on benefits.
PVA realized that many of the veterans being served by its vocational
rehabilitation program were on SSDI. So, a little over a year ago, our
program became an employment network under Ticket to Work in order to
take advantage of the payments offered by SSA for successful
beneficiary employment outcomes.
Other Social Security policies enable those on SSI to gradually
work themselves off of benefits by reducing the amount of their
disability benefits as earned income rises. Although the VA pension is
often likened to SSI, unlike that latter program, VA pensioners face a
``cash cliff'' similar to that experienced by beneficiaries on SSDI in
which benefits are terminated once an individual crosses an established
earnings limit. Because of a modest work record, many of these veterans
or their surviving spouses may receive a small SSDI benefit that
supplements their VA pension. If these individuals attempt to use SSA's
work incentives to increase their income, not only is their SSDI
benefit terminated but their VA pension benefits are reduced dollar for
dollar by their earnings.
Over twenty years ago, under P. L. 98-543, Congress authorized the
VA to undertake a four year pilot program of vocational training for
veterans awarded VA pension. Modeled on SSA's trial work period,
veterans in the pilot were allowed to retain eligibility for pension up
to 12 months after obtaining employment. In addition, they remained
eligible for VA health care up to three years after their pension
terminated because of employment. Running from 1985 to 1989, this pilot
program achieved some modest success. However, it was discontinued
because, prior to VA eligibility reform, most catastrophically-disabled
veterans were reluctant to risk their access to VA health care by
working.
The VA Office of Policy, Planning and Preparedness examined the VA
pension program in 2002 and, though small in number, seven percent of
unemployed veterans on pension and nine percent of veteran spouses on
pension cited the dollar-for-dollar reduction in VA pension benefits as
a disincentive to work.\2\ Now that veterans with catastrophic non-
service-connected disabilities retain access to VA health care, work
incentives for the VA pension program should be re-examined and
policies toward earnings should be changed to parallel those in the SSI
program.
---------------------------------------------------------------------------
\2\ Evaluation of VA Pension and Parents' DIC Programs--VA Pension
Program Final Report, ORC Macro, Economic Systems, Inc., Hay Group,
Dec. 22, 2004, www1.va.gov/op3/docs/pension.pdf
---------------------------------------------------------------------------
Other Efforts to Improve Disability Work Incentives--Proposals to
modify SSI income, asset and resource limits to encourage work and
savings illustrate another way in which veterans with disabilities are
left out of public disability policy discourse. Many policy strategies
have been discussed over the years to raise resource limits under SSI
so that beneficiaries would be encouraged to work and save enough to
purchase a home, for retirement, or to open a business. Because low
income veterans with disabilities are likely to be on VA pension--with
its own asset/resource limitations--rather than SSI, they would not
benefit from such proposals. If efforts are made in the future to
remove work disincentives for low income people with disabilities, low
income veterans with disabilities should be part of the conversation.
HOUSING AND VETERANS WITH DISABILITIES
Obviously, accessible housing is vitally important to PVA members.
Unlike other people with disabilities, our members are fortunate to
have access to the VA's home modification grants that help overcome
architectural barriers in housing. At the same time, they also benefit
from the same fair housing laws that protect other Americans with
disabilities and from the same provisions in the Rehabilitation Act
that call for federally-assisted multi-family housing to serve people
with disabilities. Like other people with disabilities, they are also
adversely affected when the Federal Government fails to properly
enforce existing housing accessibility laws and regulations.
Low Income Housing Policy and Veterans with Disabilities--For low
income veterans with disabilities, however, Federal housing policy is
sometimes at odds with their status as veterans. A 2007 Government
Accountability Office (GAO) report noted that, in 2005, some 2.3
million veteran renter households were considered low income. Of those
households, 39 percent had at least one veteran member with a
disability. GAO reported that neither the VA nor other housing agencies
were reporting on specific housing conditions and costs of veterans who
rent.\3\
---------------------------------------------------------------------------
\3\ Rental Housing--Information on Low-Income Veterans' Housing
Conditions and Participation in HUD's Programs, GAO-07-1012, August
2007
---------------------------------------------------------------------------
Veterans who meet income and other eligibility criteria for HUD can
receive housing assistance, if they meet HUD's criteria for elderly
households or households with a member with a disability. In most
respects, HUD's treatment of various veterans' benefits in determining
household income and subsidy amounts is quite generous. Yet, even
though a veteran must be determined permanently and totally disabled by
the VA to qualify for VA pension, HUD will not accept documentation
from the VA attesting to a veteran's permanent and total disability.
Instead, veterans must obtain additional evidence of disability from a
medical doctor before they can be qualified for housing assistance. HUD
issued a notice on Dec. 13, 2004 indicating plans to reevaluate this
issue but has never followed up on that notice.
THE VA'S PLACE IN NATIONAL DISABILITY POLICY
``Quality of life'' has become the latest catch-phrase in
disability policy circles throughout government, academia and private
industry. In its annual communication to Congress this year, the
National Council on Disability (NCD) said that its report ``focuses on
the current quality of life of people with disabilities in America and
the emerging trends that should be factored into both the design and
evaluation of the Federal Government's disability policies and programs
in the coming years.''\4\
---------------------------------------------------------------------------
\4\ National Disability Policy: A Progress Report, National Council
on Disability, March 31, 2009
---------------------------------------------------------------------------
Describing future policy directions, NCD outlines several
principles that should ``guide the review of existing government
programs, as well as to serve as a road map for the design of new
government programs.'' These principles offer one framework within
which to evaluate VA disability policy and how it fits into the overall
disability paradigm.
Ensure that Federal Government programs and services for people
with disabilities are consistent with the overarching goals of the
ADA--promoting equality of opportunity, full participation, independent
living, and economic self sufficiency. NCD criticizes policies that
force individuals with disabilities to impoverish themselves, give up
jobs and otherwise limit their freedom in order to obtain the basic
necessities of life.
As this Committee knows, veterans with service-connected
disabilities receive a wide array of services and supports from the
Department of Veterans Affairs. Veterans with the most significant
disabilities receive disability compensation, highest priority
admission to the VA health care system, the VA prescription drug
program, durable medical equipment and prosthetics; home modification
grants, VA vocational rehabilitation and employment services; vehicle
modifications; and aid and attendance benefits.
Veterans with non-service-connected disabilities deemed
``catastrophic'' get high priority access to the VA health system;
smaller home modification grants; certain automobile modifications; and
aid and attendance benefits.
All of these benefits are provided regardless of income.
Compare these benefits to those available to non-veteran people
with disabilities on SSDI or SSI. For those on SSDI, Medicare is
available--after a lengthy waiting period during which their health may
have deteriorated. Durable medical benefits under Medicare that would
otherwise allow a person with a disability to live independently are
covered only if limited to a person's home. Personal attendant services
are available only to those on Medicaid and only if a state offers
those benefits under its state plan. Otherwise, a person with a
significant disability is consigned to a nursing home in order to
receive attendant care. And to receive services under Medicaid, a
person must be poor and have few if any assets or resources. Some
states have enabled working people with disabilities to buy into their
Medicaid program but they have to live in the right state to access
this opportunity. And as for home and vehicle modifications and other
long term services and supports that would enable people with
disabilities to live independently, fully participate in society and
seek economic self-sufficiency--these are sometimes--but not always--
available through inadequately funded public programs.
What separates veterans with disabilities who receive Social
Security benefits from their non-veteran counterparts is their access
to the VA health care system and its ancillary supports and services--
regardless of their income. Veterans with even modest service-connected
disabilities gain access to VA medical centers, outpatient clinics,
home health care services, durable medical equipment and pharmaceutical
benefits. Veterans with non-service-connected ``catastrophic''
disabilities are also eligible for VA health care. However stressed and
under-funded the Veterans Healthcare Administration may be, it is
available to most veterans with disabilities no matter how low or high
their income.
A December 2007 article in the American Journal of Public Health
examined numbers of uninsured veterans from 1987 to 2004. In
recommending expansion of VA eligibility to address this problem, the
authors note that the VA health system ``appears to offer more
equitable care of equivalent or higher quality compared with that of
private sector alternatives.''\5\ The article goes on to state that the
VA ``accounts for much of the advantage in insurance coverage that
veterans enjoy compared with non-veterans.''\6\
---------------------------------------------------------------------------
\5\ Lack of Health Coverage Among US Veterans from 1987 to 2004,
December 2007, Vol. 97, No. 12, American Journal of Public Health,
Himmelstein et al, p. 4
\6\ Ibid
---------------------------------------------------------------------------
As PVA has stated in past testimony, disability compensation is
intended to do more than offset the economic loss created by a
veteran's inability to obtain gainful employment. It also takes into
consideration a lifetime of living with a disability and the every day
challenges associated with that disability. It reflects the fact that
even if a veteran holds a job, when he or she goes home at the end of
the day, that veteran does not leave the disability at the office.
In many respects, VA compensation and its ancillary benefits--and
even the benefits for veterans with non-service-connected catastrophic
disabilities--reflect many of the standards embodied in the first
principle outlined by NCD.
Protect the cost benefits of government programs or policies for
people with disabilities based on long term human costs and benefits.
Here, NCD cautions against policy decisions based mainly on costs and
which fail to take into account the overall costs to society or to
other programs when cost shifting occurs.
As outlined in this testimony, elements of the VA pension program
are obviously grounded in cost control rather than the long term well
being of low income veterans with disabilities. A case in point is the
cash cliff imposed on recipients of VA pension unlike their
counterparts in SSI and which limits their ability to reenter the
workforce.
Another perverse aspect of public policy related to this principle
involves VA benefits and their interaction with civilian disability
systems. Some veterans are married to spouses whose only access to
health care coverage comes through Medicaid. At last year's training
conference for PVA's service officers, a senior benefits advisor
related how some married veterans eligible for compensation and pension
elect to receive only pension. Even though their benefits are
consequently lower, they decline the service-connected benefits to
which they are entitled because compensation would knock their spouses
off SSI and cost them their Medicaid. As NCD states in its report,
policies such as this force ``otherwise self-sufficient people to
resort to public safety nets.''
Build program bridges. NCD notes that there are gaps between many
Federal programs ``where there should be bridges'' and challenges
government agencies to ``work together to create seamless transitions
into and out of their programs, for example, by establishing
presumptive eligibility, transferring application records and
eliminating arbitrary waiting periods.''
According to this standard, veterans who clearly meet SSA's
criteria for disability should not have to undergo a second disability
determination after receiving their 100% rating from the VA. In
addition, veterans who are deemed permanently and totally disabled by
the VA should not be required by HUD to obtain a separate doctor's note
attesting to their disability.
The foregoing positive description of VA benefits is not meant to
dismiss the variety of changes PVA believes are needed to improve the
VA system. It is merely to suggest that policymakers may want to look
to the VA system as a model that, at least, breaks the chain between
health care and poverty for people with disabilities.
The VA disability system recognizes that there are factors beyond
someone's earnings capacity that call for ongoing supports and services
in order to maintain a decent quality of life. Rather than trying to
diminish the VA compensation program, it should be held up as a gold
standard for improving the inadequacies of other Federal disability
systems.
Thank you again for this opportunity to testify. I would be happy
to answer any questions you may have.
Chairman Akaka. Thank you very much, Ms. Prokop.
Colonel Wilson?
STATEMENT OF LIEUTENANT COLONEL JOHN L. WILSON, USAF (RET.),
ASSOCIATE NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN
VETERANS
Colonel Wilson. Thank you, sir. Mr. Chairman, Ranking
Member Burr, and Members of the Committee, I am pleased to have
this opportunity to appear before this Committee this morning
on behalf of Disabled American Veterans to address the report
by the Advisory Committee on Disability Compensation.
The Advisory Committee focused on three general parts. Part
one, the necessity and methodology of updating the Veterans
Administration Schedule of Rating Disabilities, or VASRD. Part
two, physician compensation adequacy and sequencing for
servicemembers moving to veteran status. And finally, part
three, quality-of-life compensation.
In reference to part one, we agree with the importance of a
systematic review and update of the VASRD as it is the source
of all disability compensation ratings. It has a ratings scheme
that addresses illnesses and conditions that run into the
hundreds and should reflect the most recent medical findings in
each and every case.
DAV agrees with the Advisory Committee's assessment that a
systematic process is lacking and one is a necessity. We also
agree with the Committee's recommendations that, one, the
Deputy Secretary of the VA provide oversight of the VASRD
process with the VHA and Office of General Counsel fully
integrated into this VBA process.
Two, immediately increase staff at the VBA to nine full-
time employees, per the committee's specifications.
And three, VHA must be allowed to establish a permanent
administrative staff for this VASRD review. At least one
permanent party medical expert must be on this team and have
authority to liaise with VBA, assign VHA medical staff to
participate in VBA body system reviews and to coordinate with
medical experts. The experiential expertise that VHA
professionals will bring to the discussion should prove
invaluable and well worth the additional staffing.
We also agree with the Committee's body systems
prioritization, beginning with mental health disorders. It is
essential that different criteria be formulated to evaluate the
various mental disorders under appropriate psychiatric
disorders. Criteria for evaluating mental disorders under Title
38, Code of Federal Regulations, Section 4.130 are very
ambiguous. One veteran service-connected for schizophrenia and
another veteran service-connected for another psychiatric
condition, such as an eating disorder, should not be evaluated
using the same general formula.
Moving to part two, transition compensation adequacy and
sequencing for servicemembers moving to veteran status. DAV
supports legislation that offers limited dual entitlement to
vocational rehabilitation and employment under Chapter 31 and
the Post-
9/11 Education Assistance Program under Chapter 33 to ensure
disabled veterans are not forced to choose the lesser of two
benefits. Such a disparity will ultimately force service-
connected disabled veterans with employment handicaps to either
utilize less financially supportive programs than their non-
disabled counterparts; or even more tragically, opt out of
vocational rehabilitation for the more financially beneficial
Post-9/11 G.I. Bill.
An area where Congress could act now without having to wait
on the next study is by providing increased funding for the
Transition Assistance Program and Disabled Transition
Assistance Program, TAP and DTAP, respectively. TAP and DTAP
were created with the goal of furnishing separating
servicemembers with vocational guidance to aid in obtaining
meaningful civilian careers. Their continuation is essential to
easing some of the problems associated with transition.
Unfortunately, the level of funding and staffing is inadequate
to support the routine discharges of all the services in a
given year.
Congress could enact legislation to eliminate employment
barriers impeding the transfer of military job skills to the
civilian labor market by requiring the DOD to take appropriate
steps to ensure that servicemembers be trained, tested,
evaluated, and issued any licensure or certification that may
be required in the civilian workforce.
Last, part three addressed quality-of-life compensation.
Although close family members are often willing to bear the
burden of being primary caregivers for severely disabled
veterans, thus relieving VA of that obligation or the cost of
institutionalization, they seldom receive sufficient support
services or financial assistance from the government. The DAV
believes these informal caregivers should receive a
comprehensive array of support services, to include respite
care, financial compensation, vocational counseling, basic
health care, relationship, marriage, and family counseling, and
mental health care to address multiple burdens they face.
A caregiver tool kit should be provided to family
caregivers to include a concise recovery road map to assist
families in understanding and maneuvering through the complex
systems of care and Federal, State, and local resources
available to them. Policy and planning to better service such
caregivers could include statistically representative data from
a periodic national survey and individual assessments of family
caregivers of severely injured and disabled veterans to address
their quality-of-life concerns.
There are other action items that are listed in the
Advisory Committee's work. We look forward to working with the
VA and Members of Congress on them.
It has been a pleasure to appear before this honorable
Committee today, sir.
[The prepared statement of Colonel Wilson follows:]
Prepared Statement of John L. Wilson, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman, Ranking Member and Members of the Committee. I am
pleased to have this opportunity to appear before you on behalf of the
Disabled American Veterans (DAV), to address the report to the
Secretary of the Department of Veterans Affairs (VA) by the Advisory
Committee on Disability Compensation.
The Advisory Committee focused on the necessity and methodology of
updating the VA's Schedule of Rating Disabilities or VASRD; transition
compensation adequacy and sequencing for servicemembers moving to
veterans' status; and quality of life compensation.
The importance of a systematic review and update of the VASRD, in
our view, is a priority, as it is the source of all disability
compensation ratings. It is a rating scheme that addresses illnesses
and conditions that run into the hundreds, and as such, should reflect
the most recent medical findings in each and every case. DAV agrees
with the Advisory Committees' assessment that a systematic process is
lacking and that one is a necessity. The Committee offered the
following recommendations, with all of which we agree:
(1) The Deputy Secretary of the VA should be tasked with providing
oversight of the VASRD process, and of ensuring that the Veterans
Health Administration (VHA) and Office of the General Counsel (OGC) are
fully integrated in the Veterans Benefits Administration's (VBA's)
process;
(2) Immediately increase staff at the VBA to 9 full-time employees
(FTE) for the purpose of continuously reviewing and updating the VASRD.
The staff should include a coordinating administrative person and two
sub-teams comprised of one medical expert, two legal specialists, and
one administrative support staff each. This staff should be assigned to
the Compensation and Pension Service (C&P) for administrative purposes;
and
(3) As part of its new role as full partner in the VASRD review
process, VHA must establish a permanent administrative staff to
participate in VASRD review. The VHA administrative staff should
include at least one permanent party medical expert. This staff member
should have the authority to liaise with VBA, assign medical staff from
VHA to participate in VBA body system reviews, and to coordinate with
other medical experts as appropriate.
Staffing within the VHA and VBA must be allocated toward this task.
It is a positive step to include the medical expertise from the VHA
into this process. Although previous sources of expertise such as the
Institute of Medicine contributed to this body of work, the
experiential expertise that VHA professionals will bring to the
discussion, with a decades-long role in providing medical care to
veterans, should prove invaluable to this endeavor and well worth the
additional staffing.
The various stakeholders must also have a voice in this process.
Such a collaborative effort by all parties helps to dispel any
misperceptions and missteps.
Additionally, VA's leadership must ensure oversight and successful
implementation of this important recommendation. It was anticipated
that VA's commitment to the systematic updating of the VASRD would have
carried forward and been reflected in its strategic plan. Is not the
VASRD the key source of all disability ratings? However, a search of
VA's fiscal year (FY) 2006-2011 Strategic Plan finds no mention of the
VASRD. The need for an update of the VASRD is instead referenced in the
FY 2008 Performance and Accountability Report, as a result of a U.S.
Government Accountability Office (GAO) update to its High-Risk Series
(GAO-07-310), GAO High-Risk Area #1: Modernizing Federal Disability
Program.\1\ The VA would be well served to add the very language of
this section of the Advisory Committee's report to its Strategic Plan
as its map for the systematic updating of the VASRD.
---------------------------------------------------------------------------
\1\ High-Risk Series (GAO-07-310), GAO High-Risk Area #1:
Modernizing Federal Disability Program, pages 307 and 309.
---------------------------------------------------------------------------
As noted earlier, while we agree that a rewrite of sections of the
VASRD is appropriate, DAV would oppose an approach that required a
complete revamping of the 1945 Rating Schedule. Generally, the VASRD
has served America's disabled veterans quite adequately. It
incorporates a policy of ``average impairment,'' and that policy has
treated all veterans with like disabilities equally and fairly, in
spite of age, education or work experience. It also encourages disabled
veterans to seek vocational rehabilitation training in order to become
a more productive wage earner without penalty for doing so.
Understandably, the VASRD has been modified and upgraded many times
when advances in medical science dictates a change in a particular
disability rating might be necessary, or additions to the Schedule have
been incorporated to cover injuries, infirmities and illnesses unique
to some theatre of operations.\2\ We agree with the Advisory Committee
that the VASRD be updated in a systematic fashion, based on sound
medical principles, provided there are no wholesale changes and, when
change is necessary, it is based on the above principles.
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\2\ DAV Legislative Program 2010, DAV Resolution No. 098, Oppose A
Complete Revamping of the 1945 Rating Schedule.
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We also agree with the body system prioritization the Committee
offers, beginning with mental health disorders. It is essential that
different criteria be formulated to evaluate the various mental
disorders under the appropriate psychiatric disorder.\3\ Criteria for
evaluating mental disorder under title 38, Code of Federal Regulations,
Section 4.130, are very ambiguous. For example, schizophrenia and other
psychotic disorders, delirium, dementia, and amnestic and other
cognitive disorders, anxiety disorders, dissociative disorders,
somatoform disorders, mood disorders, and chronic adjustment disorders,
are all evaluated using the same general rating formula for mental
disorders. The Diagnostic and Statistical Manual for Mental Disorders
(DSM IV) specifically lists different symptoms for Post Traumatic
Stress Disorder, schizophrenia, and other psychiatric disorders. One
veteran service-connected for schizophrenia and another veteran
service-connected for another psychiatric disorder should not be
evaluated using the same general formula. Therefore, the DAV supports
amendment of title 38, Code of Federal Regulations, section 4.130, to
formulate different criteria to evaluate the various mental disorders
under the appropriate psychiatric disorder and is pleased to see the
Advisory Committee place mental disorders as the first to be considered
in this systematic review.
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\3\ DAV Legislative Program 2010, DAV Resolution No. 135, Support
Amendment of Title 38, Code of Federal Regulations, Section 4.130,
Schedule of Ratings, to Formulate Different Criteria to Evaluate the
Various Mental Disorders Under the Appropriate Psychiatric Disorders.
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The next area the Advisory Committee addressed was Quality of Life
(QOL). While the VASRD focuses its ratings and subsequent compensation
as a result of loss of income when compared to civilian contemporaries,
QOL is a separate but related category. The Advisory Committee's
recommended definition of ``An overall sense of well-being based on
physical and psychological health, social relationships, and economic
factors,'' is acceptable. Given an acceptable definition, the next
question is should a loss of QOL be compensated? We believe the answer
is yes. A veteran's quality of life generally decreases as the severity
of their disabilities increases. The Advisory Committee reasons that
the VA's providing additional monetary assistance through Special
Monthly Compensation (SMC) is, at a minimum, an inferred QOL
compensation program.
SMC is a rate paid in addition to disability compensation (i.e.,
SMC (K)). And this compensation can be viewed as an inferred payment
for a decrease in quality of life. To qualify, a veteran must be
disabled beyond a combined degree percentage or due to special
circumstances such as the loss or loss of use of specific organs or
extremities. SMCs are referred to by the letters (K) through (R.2).
These alphabetic designations follow the paragraph numbering system in
title 38, United States Code Sec. 1114.
While following the Advisory Committee's recommendation to change
the reference from ``Quality of Life'' to ``non-economic loss,''
clarifying the definition may prove helpful, DAV agrees that additional
benefits/compensation should be provided to veterans. Eligibility
criteria for non-economic loss should be clear, precise, and objective
in order to reduce uncertainty about the benefit's purpose,
inconsistent application of eligibility criteria and perceptions of
unfairness. We look forward to working with VA and Congress to create
legislation and a framework for controlled growth of this program.
The Advisory Committee has also recommended the use of
International Classification of Diseases (ICD) codes being added to the
VASRD where there is a direct correlation between an ICD code and a
VASRD diagnostic code. The DAV has no resolution on this issue.
The next area for future study has to do with reporting on the
inadequacies of the Vocational Rehabilitation and Employment Program.
According to a January 2009 GAO report, the ``program [has] not
fulfilled its primary purpose, which is to ensure that veterans obtain
suitable employment.''
The GAO Report summary noted:
``In 2004, the Veterans Affairs' Vocational Rehabilitation
and Employment (VR&E) program was reviewed by a VR&E Task
Force. It recommended numerous changes, in particular focusing
on employment through a new Five-Track service delivery model
and increasing program capacity. Since then, VR&E has worked to
implement these recommendations. To help Congress understand
whether VR&E is now better prepared to meet the needs of
veterans with disabilities, GAO was asked to determine (1) how
the implementation of the Five-Track Employment Process has
affected VR&E's focus on employment, (2) the extent to which
VR&E has taken steps to improve its capacity, and (3) how
program outcomes are reported. GAO interviewed officials from
VR&E, the 2004 Task Force, and veteran organizations; visited
four VR&E offices; surveyed all VR&E officers; and analyzed
agency data and reports.''
``By launching the Five-Track Employment Process, VR&E has
strengthened its focus on employment, but program incentives
have not been updated to reflect this emphasis. VR&E has
delineated its services into five tracks to accommodate the
different needs of veterans, such as those who need immediate
employment as opposed to those who need training to meet their
career goal. However, program incentives remain directed toward
education and training. Veterans who receive those services
collect an allowance, but those who opt exclusively for
employment services do not. While VR&E officials said they
believed it would be helpful to better align incentives with
the employment mission, they have not yet taken steps to
address this issue. VR&E has improved its capacity to provide
services by increasing its collaboration with other
organizations and by hiring more staff, but it lacks a
strategic approach to workforce planning. Although there have
been staff increases, many of VR&E's regional offices still
reported staff and skill shortages. The program is not
addressing these workforce problems with strategic planning
practices that GAO's prior work has identified as essential.
For example, VR&E officials have not fully determined the
correct number of staff and the skills they need to serve
current and future veterans. VA does not adequately report
program outcomes, which could limit understanding of the
program's performance. Specifically, it reports one overall
rehabilitation rate for veterans pursuing employment and those
trying to live independently. Computing each group's success
rate for fiscal year 2008, GAO found a lower rate of success
for the majority seeking employment and a higher rate of
success for the minority seeking independent living than the
overall rate. GAO also found that VR&E changed the way it
calculates the rehabilitation rate in fiscal year 2006, without
acknowledgments in key agency reports. VA noted the change in
its fiscal year 2006 performance report, but did not do so for
its fiscal year 2007 and 2008 reports, or for its fiscal year
2008 and 2009 budget submissions. Such omissions could lead to
misinterpretation of program performance over time.'' \4\
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\4\ VA Vocational Rehabilitation and Employment: Better Incentives,
Workforce Planning, and Performance Reporting Could Improve Program,
GAO-09-34 January 26, 2009.
While VA has contracted a study with Economic Systems, Inc. to
review the VRE program and plans to complete a study workforce planning
study in FY 2010, DAV and others have commented previously that the
VR&E subsistence allowance is insufficient, which causes veterans to
avoid entering the program or exiting it prematurely.
DAV supports legislation that offers limited dual entitlement to
vocational rehabilitation and employment chapter 31, and the post-9/11
education assistance program under chapter 33 in order to ensure that
disabled veterans are not forced to choose the lesser of two
benefits.\5\ Our nation established veterans' programs to repay or
reward veterans for their extraordinary service and sacrifices on
behalf of their fellow citizens, especially those veterans disabled as
a result of military service. These programs include the VR&E program
for service-connected disabled veterans with employment handicaps as
well as the post-9/11 GI Bill under title 38, United States Code,
chapter 33 (GI Bill). The GI Bill currently provides a more financially
lucrative subsistence allowance than does the current VR&E Chapter 31
program. Such a disparity will ultimately force service-connected
disabled veterans with employment handicaps to either utilize a program
less financially supportive to them and their families than their non-
disabled counterparts, or opt out of vocational rehabilitation for the
more financially beneficial post-9/11 GI Bill.
---------------------------------------------------------------------------
\5\ DAV Legislative Program 2010, DAV Resolution No. 002, Support
For Limited Dual Entitlement To Vocational Rehabilitation And
Employment Chapter 31, And The Post-9/11 Education Assistance Program
Under Chapter 33 In Order To Ensure That Disabled Veterans Are Not
Forced To Choose The Lesser Of Two Benefits.
---------------------------------------------------------------------------
Subsistence allowances must be comparable, regardless of program,
to ensure maximum participation and maximum benefit, whether it is
assisting veterans in finding employment, participation in vocational
rehabilitation or other services. The basis of that decision must never
be based on its financial incentives when compared to various VA
programs.
The issue of the transition from active duty status to veteran
status is also a subject of future study and we look forward to
participating in these discussions as well. DAV notes that there are
existing programs that prove invaluable during this transition period,
but are in need of additional funding. An area where Congress could act
now is by providing increased funding for the Transition Assistance
Program (TAP) and the Disabled Transition Assistance Program (DTAP).\6\
The transition from military service to civilian life is very difficult
for most veterans, who must overcome many obstacles to successful
employment. TAP and DTAP were created with the goal of furnishing
separating servicemembers with vocational guidance to aid them in
obtaining meaningful civilian careers and their continuation is
essential to easing some of the problems associated with transition.
Unfortunately, the level of funding and staffing is inadequate to
support the routine discharges per year from all branches of the Armed
Forces.
---------------------------------------------------------------------------
\6\ DAV Legislative Program 2010, DAV Resolution No. 258, Provide
Increased Funding for the Transition Assistance Program and the
Disabled Transition Assistance Program
---------------------------------------------------------------------------
Additionally, Congress could enact legislation supporting licensure
and certification of active duty personnel.\7\ The Department of
Defense (DOD) provides some of the best vocational training in the
Nation for its military personnel. DOD establishes, measures, and
evaluates performance standards for every occupation within the Armed
Forces. There are many occupational career fields in the Armed Forces
that can easily translate to a civilian occupation but there are many
occupations in the civilian workforce that require a license or
certification. The Armed Forces occupational standards meet or exceed
the civilian license or certification criteria yet many former military
personnel, certified as proficient in their military occupational
career, are not licensed or certified to perform a comparable job in
the civilian workforce. This situation creates an artificial barrier to
employment upon separation from military service. A study by the
Congressional Commission on Servicemembers' and Veterans' Transition
Assistance identified several military professions in which civilian
credentialing is required for employment in the private sector.
Congress could enact legislation to eliminate employment barriers that
impede the transfer of military job skills to the civilian labor market
by requiring the DOD to take appropriate steps to ensure that
servicemembers be trained, tested, evaluated, and issued any licensure
or certification that may be required in the civilian workforce.
Simultaneously, Congress could amend legislation and make GI Bill
eligibility available to pay for all necessary civilian license and
certification examination requirements, including necessary preparatory
courses to increase the civilian labor market's acceptance of the
occupational training provided by the military.
---------------------------------------------------------------------------
\7\ DAV Legislative Program 2010, DAV Resolution No. 046, Support
Licensure And Certification Of Active Duty Service Personnel
---------------------------------------------------------------------------
Another area for Congressional action could come with modification
of the Omnibus Budget Reconciliation Act of 1982 (Public Law 97-253,
now title 38, United States Code 511), which currently prohibits
disability compensation payments until the first day of the second
month after the VA grants a disability rating. A rewrite would allow
the newest veterans to receive disability compensation at the end of
the first month after discharge.
In reference to family care-giver support, the Advisory Committee
noted the Veterans Disability Benefits Commission (VDBC) cited gaps in
services when servicemembers leave active duty and transfer to VA under
title 38, United States Code. The VDBC recommended that Congress should
authorize and fund VA to establish and provide support services for the
families of severely injured veterans similar to those provided by DOD.
In a separate but related issue, under the issue heading Services as a
Disability Benefit, it noted that VA could directly provide respite
services for family members of severely disabled veterans who provide
daily aid and attendance and indirectly provide services such as seed
or grant money to encourage individuals, groups, and/or non-profit
organizations to develop and implement programs for veterans and their
families. Additionally, VA could establish a clearinghouse for
identification, referral, and support of existing and newly emerging
programs.
DAV supports legislation to create a comprehensive program through
which family members of severely wounded veterans can receive VA
training, certification, counseling, respite, a family allowance and
health coverage under CHAMP VA. The Advisory Committee is focusing on
two aspects of disability compensation as it pertains to family care-
giving. These are the impact on families when the servicemember
transfers from DOD to VA, and the long-term roles and needs of family
caregivers.
DAV has testified before the House Veterans' Affairs Subcommittee
on Health on June 4, 2009 \8\ and on February 28, 2008 \9\ regarding
the issue of family caregivers. Informal caregivers play a critical
role in facilitating recovery and maintaining the veteran's
independence and quality of life while residing in their community, and
are an important component in the delivery of health care by the VA.
These family members, relatives, or friends are motivated by empathy
and love, but the very touchstones that have defined their lives--
careers, love relationships, friendships, and their own personal goals
and dreams--have been sacrificed, and they face a daunting lifelong
duty as caregivers. Research has found that all too often the role of
informal caregiver exacts a tremendous toll on that caregiver's health
and well-being.
---------------------------------------------------------------------------
\8\ Meeting the Needs of Caregivers, Statement of Adrian Atizado,
Assistant National Legislative Director of the Disabled American
Veterans before the Subcommittee on Health Committee on Veterans'
Affairs, U.S. House Of Representatives June 4, 2009
\9\ Providing care, support and mental health programs for
caregivers of seriously disabled veterans, Statement of Joy J. Ilem,
Assistant National Legislative Director of the Disabled American
Veterans before the Subcommittee on Health Committee on Veterans'
Affairs, U.S. House Of Representatives, February 28, 2008
---------------------------------------------------------------------------
Family caregiving has been associated with increased levels of
isolation, depression and anxiety, higher use of prescription
medications, compromised immune function, poorer self-reported physical
health, and increased mortality. Research also suggests that caregiver
support services can help to reduce adverse health outcomes arising
from caregiving responsibilities and can improve overall health status.
Despite these documented physical and psychological hardships and
knowledge of effective interventions against caregiver burden, family
caregivers of disabled veterans receive little support from VA,
compromising their ability to provide care to their loved one.
Accordingly, the delegates to our most recent National Convention, held
in Denver, Colorado, August 22-25, 2009, approved a resolution calling
for legislation that would provide comprehensive supportive services,
including but not limited to financial support, health and homemaker
services, respite, education and training and other necessary relief,
to immediate family member caregivers of veterans severely injured,
wounded or ill from military service.\10\
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\10\ DAV Legislative Program 2010, Resolution No. 242, Support
Legislation to Provide Comprehensive Support Services for Caregivers of
Severely Wounded, Injured and Ill Veterans
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The last area to be addressed has to do with the relationship
between level of Individual Unemployability (IU) and VR&E. Modern
concepts of disability largely preclude the concept of ``unemployable''
except in the case of the most catastrophically disabled. For that
reason, the Committee is considering whether a finding of IU should
occur only after or in conjunction with some level of the VR&E
services. DAV's position is that determinations of IU are the province
of medical professionals familiar with their patients' history. VR&E
personnel, although skilled in their areas of expertise, do not have
the medical perspective essential to the proper determination as to
whether a veteran should be diagnosed as unemployable.
CONCLUSION
DAV looks forward to a continuing dialog on the issues of the
necessity and methodology of updating the VASRD, transition
compensation adequacy and sequencing for servicemembers moving to
veteran status and QOL compensation that were the focus of the Advisory
Committee. As we move forward it is a necessity that a transparent
process be set in place to address each of these sensitive issues. We
should not have to offer reminders this late in the game about the
important perspective that veterans service organizations bring to
discussions on topics such as these. Talking openly and discussing
potential changes will help resolve the understandable angst about
these complex and important questions. The time to act is now--our
Nation's veterans deserve no less than our best effort.
Thank you, Mr. Chairman and Members of the Committee for allowing
DAV to share our views on this critical topic.
Chairman Akaka. Thank you very much, Colonel.
You heard General Scott state that the Advisory Committee
is now of the opinion that quality-of-life loss should be
limited to those with serious disabilities. I am posing this to
all of our witnesses on this panel. Quality-of-life loss should
be limited to those with serious disabilities. Do you agree?
Let me ask Ms. Neas to begin.
Ms. Neas. You won't be surprised that I don't agree. I
think we have seen with these last conflicts that people with
Traumatic Brain Injury and PTSD have had very challenging times
returning to the workforce. In our own work at Easter Seals, we
are working with employers to help them understand what it
means to have these conditions and how it affects the veteran's
work. Someone who may have lost several limbs might be
considered as having a much more significant disability than
one who had a brain injury.
I also think that from our experience in working with
returning veterans--those that didn't have a formal diagnosis
of brain injury, because so many of these individuals have been
exposed to explosions that have affected their brains, for lack
of a more likely term--that we are going to see more people
needing help down the line who may not have had a formal
diagnosis of a brain injury but who, in fact, have had a brain
injury.
So, I think limiting these to people who have what is only
considered at a moment in time a serious disability would be
very inappropriate.
Chairman Akaka. Thank you.
Ms. Prokop?
Ms. Prokop. I think--well, I would echo Ms. Neas's comments
and note that the exchange that occurred earlier about asking
the veterans themselves for a perspective of what their
consideration of quality-of-life is is probably a key
ingredient in ascertaining that. I got the impression that that
sort of came late in the process in this study in terms of
actually--and echoing the ``Nothing about us without us''
philosophy of the broader disability movement, that you would
really need to talk to or gain a sense from a wide variety of
veterans with disabilities as to what exactly they feel
quality-of-life loss is for them, because it can be very
subjective.
Chairman Akaka. Colonel Wilson?
Colonel Wilson. Thank you, Senator. I would have to say
that Ms. Neas certainly said it quite well, I think, and I
would agree with her comments. I think the current situation of
economic loss that deals with things such as how this is going
to impact your capability to earn a living over an extended
period of time does not--the quality-of-life loss--does not
deal with the current economic compensation; and it does not
factor in pain and suffering, changes in lifestyle as a result
of being placed into a wheelchair, having to have hooks now in
order to manipulate a door, to drive a vehicle, to play
baseball, or fishing with my child.
I think Senator Tester was absolutely correct. You ask a
number of veterans and they will tell you exactly what they
think about an appropriate level of compensation or what is
not; and they should be actively involved in the process from
the very beginning.
Chairman Akaka. Thank you.
Colonel Wilson. Yes, sir.
Chairman Akaka. This next question is for everyone on the
panel. Do you have any suggestions for outside expertise that
VA should engage with while contemplating reform of the system?
Ms. Neas?
Ms. Neas. Absolutely. I think our three organizations,
which are in communities working with individuals every day,
are people who should be involved in this, though first and
foremost, veterans and their families. They know what they
need. They are the only ones who can dictate the quality of
their lives. They are the only ones who can tell you what it
was like to try to get a job and be turned down because you
look different or you act different than you did before you
were injured.
One of the things that has been wonderful about working for
Easter Seals all these years is many of the families that come
to us have been told by a variety of different systems and
professionals what they can't do. Until they came to us, no one
was asked what they want to do and have us figure out a way to
make it happen. I think that is a perspective that is really
important to have go forward with this. Let us not talk to you
about all the things you are never going to be able to do,
because quite frankly, no-
body knows what that is. What we need to do is help veterans
figure out what they want to do and what is going to be
necessary to get them there. And unless you talk to them
directly and know the communities from which they come, we are
not going to be
successful.
Chairman Akaka. Thank you.
Ms. Prokop?
Ms. Prokop. One of the benefits that PVA has is that it has
joined Easter Seals and other disability advocacy organizations
in a broader coalition, the Consortium for Citizens with
Disabilities, that enables us to see disability issues from a
broader perspective, and from that coalition we are able to
talk with our allies in the disability community and learn from
them about quality-of-life issues and studies and evaluations
of disability programs that are often tailored to or focused on
the Social Security disability system, but at the same time
raise many of the same issues that were being talked about in
this context.
So, there are studies, there are reports and evaluations--
such as from the National Council on Disability and elsewhere--
that speak to broader disability program features and issues
that the VA committee might be able to learn from, as well.
Chairman Akaka. Thank you.
Colonel Wilson?
Colonel Wilson. Just briefly, sir, I would think that the
Veterans Health Administration professionals who have been
doing such a fine job of taking care of veterans for these past
many decades certainly have an excellent perspective to
provide. They will be beneficial to updating the VASRD and
moving this whole process forward. And, of course, the Veterans
Service Organizations are pleased. We look forward to working
with this particular committee and the VA to move ahead on this
particular process.
Chairman Akaka. Thank you.
This question is also for all of the panelists. The
question of whether to compensate for loss of quality-of-life
has a potential to change veterans disability compensation
considerably. Do you believe that VA should work on changes to
the rating schedule before addressing whether loss of quality-
of-life should also be
compensated?
Colonel Wilson. If I could, Mr. Chairman, I would say,
absolutely, yes. The first priority is to address the VASRD,
look at it. The Disability Committee offered a viable option on
how to go about doing this. I would like to see it adopted as
soon as possible. I will believe that the VA is serious about
moving ahead on this particular issue once I see it appear in
their strategic plan. Being 33 years in the military, I find
them very useful to determine where an organization is going. I
look for that; I will review it.
The new administration has inherited this product from
previous years, but I have yet to see this issue--which has
been discussed by this Committee in other studies that the
Ranking Member talked about earlier--but has never been
incorporated into a change plan. There is no mention of the
VASRD being reviewed in the strategic plan. There is no
tactical application of how to go about doing this strategic
business to the tactical level of making it happen at all,
despite the many discussions, despite the many committee
hearings, despite the many publications. Once I see that
happen, then I know the leadership--and this new
administration, I am sure, will move in that direction--will be
moving properly to update the VASRD, followed closely by the
quality-of-life issues.
Chairman Akaka. Any other comments? Ms. Prokop?
Ms. Prokop. Mr. Chairman, I don't feel qualified to answer
that question because that is an issue that many of my other
colleagues at PVA have dealt with and worked on over many, many
years. If there is something specific you would like us to
answer on that question, we would be happy to do so in writing.
Ms. Neas. Yes. And Mr. Chairman, I don't feel qualified to
answer that question, either.
Chairman Akaka. Thank you. This question, again, is for the
panel. If VA compensation is modified to incorporate a specific
element for quality-of-life, do you believe that each disabled
veteran would require an individual assessment that was
mentioned, or would it be feasible to develop averages for the
impact on quality-of-life of specific disabilities? Ms. Neas?
Ms. Neas. I think you really--quality-of-life is such a
personal issue. I don't know how you could do that without
having maybe some broad criteria from which you could gain that
information. But, I think really making that determination
would have to be left up to each individual.
Chairman Akaka. Ms. Prokop?
Ms. Prokop. Based on what I have heard from our folks in
PVA's Veterans Benefits Department, I suspect they would say
that would need to be an individual assessment--that you really
do need to consider each person's specific circumstances.
Ms. Neas. Mr. Chairman, if I could add, I used to work for
a Member of the Senate who had a brother who was deaf. His
brother was told that deaf people could only be printers,
cobblers, or bakers, because at the time when he went to our
State School for the Deaf, that was what was determined for
someone who was deaf; those were the choices that were
appropriate to that disability.
I use that sort of extreme example because we don't want to
have the VA have a system that says, if you have a spinal cord
injury or if you have Traumatic Brain Injury, the only things
you can do or the only things you should consider being
available to you are a limited set of jobs or circumstances or
support. So, I really do think it needs to be individualized
and we don't need to go back to those days where, if you had a
specific disability or condition, that that put you on a track
that you could never otherwise get off.
Chairman Akaka. Colonel Wilson?
Colonel Wilson. I will be glad to provide a comment in
writing on that rather complex question, sir.
Chairman Akaka. Thank you.
I want to thank you for your responses. As you know, we
specifically asked you to join us here in this hearing so that
we could get responses from groups outside of VA, and I want to
thank you very much for providing responses from your
experiences. So, thank you very much for appearing today.
We know that there are many challenges to providing
disability benefits in the 21st century. Deciding how to best
compensate our Nation's disabled veterans is a sensitive and
complicated issue. We heard many options on how to calculate
and implement disability compensation for the future and we can
all agree that reforming the current system is imperative.
My goal is to ensure that this is done in an accurate and
timely manner.
The Committee, along with the administration and those who
advocate on behalf of veterans, intend to do all we can to
improve the current system. To bring optimal change to a
process as complicated and important as this, we must be
deliberative, focused, and open to input from all who are
involved in this process.
The Committee has held a number of hearings on this matter
in the past and will continue to work diligently until this
issue is resolved.
I want to again thank you all for being here today. This
hearing is adjourned.
[Whereupon, at 11:42 a.m., the Committee was adjourned.]