[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]



 
          EXAMINING VA'S PROCESSING OF GULF WAR ILLNESS CLAIMS

=======================================================================

                             JOINT HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                               joint with

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        THURSDAY, JULY 13, 2017

                               __________

                           Serial No. 115-23

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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         Available via the World Wide Web: http://www.fdsys.gov
         
         
                                 _________ 

                     U.S. GOVERNMENT PUBLISHING OFFICE
                   
 30-369                       WASHINGTON : 2018              
         
         
         
                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                    JACK BERGMAN, Michigan, Chairman

MIKE BOST, Illinois                  ANN MCLANE KUSTER, New Hampshire, 
BRUCE POLIQUIN, Maine                    Ranking Member
NEAL DUNN, Florida                   KATHLEEN RICE, New York
JODEY ARRINGTON, Texas               SCOTT PETERS, California
JENNIFER GONZALEZ-COLON, Puerto      KILILI SABLAN, Northern Mariana 
    Rico                                 Islands

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                     MIKE BOST, Illinois, Chairman

MIKE COFFMAN, Colorado               ELIZABETH ESTY, Connecticut, 
AMATA RADEWAGEN, America Samoa           Ranking Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
JIM BANKS, Indiana                   KILILI SABLAN, Northern Mariana 
                                         Islands

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

                            C O N T E N T S

                              ----------                              

                        Thursday, July 13, 2017

                                                                   Page

Examining VA's Processing Of Gulf War Illness Claims.............     1

                           OPENING STATEMENTS

Honorable Mike Bost, Chairman....................................     1
Honorable Ann Kuster, Ranking Member.............................     2

                               WITNESSES

Mr. Bradley Flohr, Senior Advisor, Compensation Service, Veterans 
  Benefits Administration, U.S. Department of Veterans Affairs...     4
    Prepared Statement...........................................    29

        Accompanied by:

    Patrick Joyce, MD, MPH, Chief, Occupational Health Clinics, 
        Washington VA Medical Center, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

Ms. Melissa Emrey-Arras, Director, Education, Workforce and 
  Income Security, U.S. Government Accountability Office.........     5
    Prepared Statement...........................................    30

Mr. Zachary Hearn, Deputy Director for Claims, Veteran Affairs 
  and Rehabilitation Division, The American Legion...............     7
    Prepared Statement...........................................    35

Mr. Michael S. Figlioli, Deputy Director, National Veterans 
  Service, Veterans of Foreign Wars..............................     8
    Prepared Statement...........................................    38

Mr. Anthony Hardie, National Board Chair & Director, Veterans for 
  Common Sense...................................................    10
    Prepared Statement...........................................    40

                             FOR THE RECORD

Ronald E. Brown, President, National Gulf Warsource Center 
  (NGWRC) & Gulf War Veteran.....................................    55
Mr. Paul Sullivan, Gulf War Veteran, Director of Veteran 
  Outreach, Bergmann & Moore, LLC................................    66
Mr. Kirt Love, former member of the Veteran Affairs Advisory 
  Committee on Gulf War Veterans.................................    71
Denise Nichols, MAJ, RET, USAF, RN RET, BSN, MSN, National 
  Vietnam and Gulf War Veterans Coalition........................    73

                        QUESTIONS FOR THE RECORD

HVAC to VA.......................................................    78


          EXAMINING VA'S PROCESSING OF GULF WAR ILLNESS CLAIMS

                              ----------                              


                        Thursday, July 13, 2017

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                  Subcommittee on Oversight
                                        and Investigations,
                                                   Washington, D.C.
    The Subcommittees met, pursuant to notice, at 10:30 a.m., 
in Room 334, Cannon House Office Building, Hon. Mike Bost 
[Chairman of the Subcommittee on Disability Assistance and 
Memorial Affairs] presiding.
    Present from the Subcommittee on Disability Assistance and 
Memorial Affairs: Representatives Bost, Bergman, Coffman, 
Radewagen, Banks, Esty, Brownley, and Sablan.
    Present from the Subcommittee on Oversight and 
Investigations: Representatives Bergman, Bost, Dunn, Kuster, 
and Sablan.
    Also Present: Representative Roe.

       OPENING STATEMENT OF HONORABLE MIKE BOST, CHAIRMAN

    Mr. Bost. Good morning, and welcome everyone. This joint 
hearing of the Subcommittees on Disability Assistance and 
Memorial Affairs and Oversight and Investigations will now come 
to order.
    I first want to thank my colleagues, Chairman Bergman, 
Ranking Member Esty, who should be along shortly, and Ranking 
Member Kuster for holding the hearing here with me today on the 
important issue that we are facing. And that is helping Gulf 
War veterans get the benefits that they have earned.
    It should go without saying that we have a duty to take 
care of the men and women who have been wounded while serving 
in our military. Unfortunately, too many injured Gulf War 
veterans are not being taken care of. VA estimates that 44 
percent of Gulf War veterans develop Gulf War Illness. Yet, 26 
percent of these veterans are receiving benefits. Something 
does not add up.
    On March 15, 2016 during a similar joint hearing on GWI 
claims, VA testified that it was taking steps to improve 
service for Gulf War veterans. Yet one year later GAO found VA 
is still only approving 17 percent of the claims of Gulf War 
Illness, which is about a third of the approved rate for other 
claims. For example, a GAO report says that only 13 percent of 
the claims of veterans that were diagnosed with the illness are 
approved. I cannot understand that at all. VA regulations state 
that if veterans have certain symptoms, such as headache, 
fatigue, or joint pain, VA is supposed to presume that these 
symptoms are related to the veteran's service in the Gulf area. 
Yet 87 percent of these claims are denied.
    GAO found that one of the problems is that the VA 
physicians are applying the wrong standards during the exams. 
Another issue is that the VA employees are not ordering the 
exams when necessary. I appreciate that recently the VA 
retrained all of its employees on GWI claims and I am looking 
forward to hearing whether retraining these employees made a 
difference.
    I am also frustrated because GAO pointed out that the VA's 
decision letters are not clear. This issue keeps coming up. As 
you know, my Appeals Reform Bill, H.R. 2288, would require VA 
to make its decision letters more clear and useful for the 
veterans. But it should not take legislation to force the VA to 
act. I would like to see the VA change its decision letters now 
so that the veterans understand why VA made the decisions it 
did.
    So GAO also found several other problems that may be 
keeping the approval rate for GWI claims low, such as the lack 
of a single case definition for GWI. I am looking forward to an 
honest discussion about the VA's need to do so and how to 
ensure that they do. None of us want to come back here next 
year to find the same problems. After this hearing I intend to 
work with my colleagues to keep on VA to make sure these 
changes are made and made this time where we will not have to 
do it again.
    I ask unanimous consent that written statements provided 
for the record be placed into the hearing record. Without 
objection, so ordered.
    I also want to thank the witnesses for being here today. 
With that, I want to call on the Oversight and Investigations 
distinguished Ranking Member Ms. Kuster for her opening 
statement.

        OPENING STATEMENT OF ANN KUSTER, RANKING MEMBER

    Ms. Kuster. Thank you, Chairman Bost. And to General 
Bergman, and Ms. Esty when she arrives, and to the witnesses 
for being here today.
    It has been 26 years since the beginning of the Persian 
Gulf War and since that time 44 percent of veterans who served 
in that conflict have suffered from Gulf War Illness. Sadly, 
these veterans struggle to receive accurate diagnoses for their 
symptoms, access to needed health care, and compensation for 
their service-connected conditions, even with the presumptions 
that should result in more veterans receiving benefits and not 
denied claims.
    Last year our Subcommittee held a hearing, as the Chairman 
said, on access to treatment for Gulf War Illness and how more 
research is needed to develop treatments and get our veterans 
the health care they need. Now we are back here again. And by 
the way, this is entirely bipartisan across our Committee, to 
determine why 83 percent of Gulf War Illness claims are denied 
by the VA and what we can do to ensure that our Gulf War 
veterans receive the benefits that they have earned. Gulf War 
Illness is a chronic, painful, often debilitating disease and 
veterans suffering from Gulf War Illness deserve disability 
compensation and to have their condition recognized and treated 
by VA providers.
    Now just this past Monday, the State Veterans Advisory 
Committee in my home state of New Hampshire, whom I meet with 
on a quarterly basis, were criticizing the VA's process for 
adjudicating Gulf War Illness claims. In fact one of the 
members of our State Advisory Committee had his own claim for 
Gulf War Illness denied. And for the veterans in my state and 
across the country, the VA's process is poorly run and fails to 
adequately train personnel.
    This latest GAO report confirms what our constituents 
suffering from Gulf War Illness continue to tell us on a 
regular basis. Their claims continue to be denied because 
medical examiners do not know how to diagnose Gulf War Illness 
or the VA fails to apply the presumption that Congress intends 
to grant this service-connection disability. When these claims 
are denied, VA does not communicate to veterans, as the 
Chairman said, the reasons for the denial, leading to veterans 
becoming frustrated, losing faith in the VA, and filing 
appeals.
    The GAO report found that 90 percent of medical examiners 
that the VA relies upon to assess veterans' disabilities have 
not completed the elective training on Gulf War Illness so they 
can better assess veterans' disability levels. I would like to 
know why this training is not a mandatory requirement and when 
it will become mandatory. I would also like to know if this web 
based training is sufficient to train medical examiners and if 
claims processors need better training requirements as well.
    I also wish to hear from the VA on its plan to improve the 
way in which it communicates decisions made on claims. When 
veterans are not provided the reason that the claim was denied, 
they become frustrated and angry and they end up in our appeals 
process, which is already swamped. If they do not know why the 
claims were denied, they can often spend years attempting to 
obtain their benefits through a lengthy appeals process.
    Finally we know that the VA continues to conduct and 
support research on Gulf War Illness. However, the VA lacks a 
single case definition, and as I understand it has no plan to 
develop one. A uniform case definition for Gulf War Illness was 
recommended in 2014 by the VA's Research Advisory Committee and 
the National Academy of Medicine. A single case definition is 
needed to improve research, diagnosis, and treatment of Gulf 
War Illness and I would like to see a plan put in place to 
develop a single Gulf War Illness definition. The number of 
Gulf War Illness claims doubled from 2010 to 2015 and we can 
expect that more veterans will file claims and will 
subsequently appeal denied claims. It is imperative that the VA 
implement the GAO's recommendations now so that Gulf War 
veterans receive the treatment and disability benefits that 
they deserve without having to fight the VA every step of the 
way.
    Thank you, Chairman Bost. I yield back.
    Mr. Bost. Thank you, Ms. Kuster. And I am going to ask that 
all Members waive their opening remarks, as per the Committee's 
custom. I understand that Chairman Bergman and Ranking Member 
Esty will give their statements at the end of the hearing.
    Now I would like to welcome our witnesses again and thank 
you for taking the time to be here today. Our first witness is 
Bradley Flohr, Senior Advisor for Compensation Services. He is 
accompanied this morning by Dr. Patrick Joyce, the Chief, 
Occupational Health Clinics of the Washington VA Medical 
Center. We are also joined by Melissa Emrey-Arras--is that 
correct? Well, now see with a name like Bost, where people say 
Bost, I want to make sure that we get everybody's right. Who is 
Director of the Education, Workforce and Income of the GAO. 
Zachary Hearn, the Deputy Director for Claims for the Veterans 
Affairs and Rehabilitation Division of the American Legion; and 
Michael Figlioli, correct? The Department Director of National 
Veterans Services of the VFW; and finally Anthony Hardie, the 
National Board Chair and Director of Veterans for Common Sense.
    I want to remind the witnesses that your complete written 
statement will be entered into the hearing record. And with 
that, Mr. Flohr, you are recognized for five minutes.

                   STATEMENT OF BRADLEY FLOHR

    Mr. Flohr. Thank you, Chairman Bost, Chairman Bergman, 
Ranking Members Esty and Kuster, and Members of the Committee. 
Thank you for the opportunity to discuss how VA processes Gulf 
War veterans' compensation claims for undiagnosed illnesses or 
medical unexplained chronic multi-symptom illnesses. For 
purposes of my testimony, I will refer to these categories of 
illness as Gulf War Illness. Today I will provide an overview 
of VA's processing of Gulf War Illness claims and some of our 
training and quality assurance efforts.
    Service connection may be awarded for Gulf War Illness when 
a veteran has service in the Southwest Asia Theater of 
operations after August 2, 1990 and has a qualifying disability 
in accordance with 38 C.F.R. 3.317. VA recently revised this 
regulation to extend the date for which service-connection may 
be awarded for Gulf War Illness from December 31, 2016 from 
December 31, 2021.
    In fiscal year 2016, 18,681 veterans received a decision 
for a claim specifically for Gulf War Illness. From this 
number, 4,594 veterans were awarded service-connection for one 
or more undiagnosed illness or chronic multi-symptom illness. 
Thirteen percent of these awards were for an undiagnosed 
illness and 31 percent for a medical unexplained multi-symptom 
illness.
    VBA continues to strengthen its training program for Gulf 
War Illness claims. We have developed 13 related courses for 
claims processors and over the last year VBA headquarters 
mandated ten hours of training for rating veteran's service 
representatives. In addition, we are currently developing a new 
training module which will focus on the proper development of 
Southwest Asia Gulf War claims. This module is scheduled to 
launch to fiscal year 2018.
    VA has implemented a number of other initiatives to improve 
Gulf War claims processing, to include improvement of the 
notification process, specifically to include a more thorough 
explanation when a claimed issue is denied. In recent years VA 
has developed special tracking to specifically account for Gulf 
War claims. VA has also amended its Gulf War general medical 
examination template to include important information for 
examiners when address undiagnosed and chronic multi-symptom 
illnesses, as well as information on various environmental 
exposures in the Gulf War.
    VA is constantly looking for ways to improve benefits and 
services it provides to veterans who served in the Gulf. VBA 
works closely with the Veterans Health Administration in 
reviewing the research done by its Offices of Public Health and 
Research and Development, as well as the National Academy of 
Medicine's biennial updates on Gulf War issues. VBA also works 
with VHA and the Department of Defense in joint work groups 
that research environmental exposures coincident with military 
service. VBA collaborates with VHA to update training for its 
medical examiners, as well as VBA's contract medical examiners. 
And finally, VBA's national quality review staffs, as well as 
local quality reviewers in our regional offices, continue to 
ensure employees correctly process and decide claims for Gulf 
War Illness.
    As agreed upon with the National Gulf War Resource Center, 
VBA conducted two distinct special focus reviews of decisions 
on claims for Gulf War related illnesses in December, 2015 and 
September, 2016. The review in 2015 focused on fiscal year 2015 
Gulf War Illness cases and showed a 94 percent accuracy rate. 
The 2016 review expanded the review to cases that involve 
claims from medical unexplained chronic multi-symptom illnesses 
over a four-year period, starting from fiscal year 2011. This 
review showed an 89 percent accuracy rate.
    VA continues to improve the efficient, timely, and accurate 
processing of claims involving service in the Gulf War. 
Although the science and medical aspects of undiagnosed 
illnesses and chronic multi-symptom illnesses are complex, VA 
continues to review scientific and medical literature to gain a 
better understanding of the impact of these illnesses on our 
Gulf War veterans.
    This concludes my opening statement. I am pleased to 
address any questions you or Members of the Committee may have.

    [The prepared statement of Bradley Flohr appears in the 
Appendix]

    Mr. Bost. Thank you, Mr. Flohr. Ms. Emrey-Arras, you are 
recognized for five minutes to give testimony for the GAO.

                STATEMENT OF MELISSA EMREY-ARRAS

    Ms. Emrey-Arras. Thank you, Chairman Bost, Chairman 
Bergman, Ranking Member Kuster, and Members of the 
Subcommittees. I am pleased to be here today to discuss our 
recent report on VA's evaluation of Gulf War Illness disability 
claims.
    The exact causes of Gulf War Illness are not always known 
and veterans' symptoms vary widely. Veterans with Gulf War 
Illness may experience symptoms such as fatigue, headaches, 
joint pain, indigestion, insomnia, respiratory disorders, skin 
problems, and memory impairment. They may also have infectious 
diseases, like malaria or West Nile Virus. VA refers to claims 
for Gulf War Illness as undiagnosed illness, medically 
unexplained chronic multi-symptom illness, and infectious 
disease claims. We refer to these three types of claims as Gulf 
War Illness claims.
    My testimony today will focus on our findings related to 
three key areas. One, recent trends in Gulf War Illness 
disability claims. Two, challenges VA faces. And three, VA's 
Gulf War Illness research.
    In terms of claims trends, we found that the number of Gulf 
War Illness claims processed has increased in recent years. In 
fiscal year 2015, VBA completed processing about 11,400 claims, 
which was more than double the 4,800 claims it processed in 
fiscal year 2010. Many of these claims included multiple 
medical issues or symptoms related to Gulf War Illness. On 
average, we found that Gulf War Illness claims took four months 
longer to process than other claims. We also found that Gulf 
War Illness claims were approved at lower rates than other 
types of disability claims. We found that approval rates for 
Gulf War Illness medical issues were about three times lower 
than for all other claimed disabilities. Specifically we found 
that 17 percent of Gulf War Illness medical issues were 
approved compared to 57 percent for all other types of medical 
issues.
    According to VA, several factors may contribute to the 
lower approval rates, including that these claims are not 
always understood by VA staff. Additionally, veterans sometimes 
file for Gulf War Illness benefits but according to some VA 
staff we spoke with do not provide sufficient evidence that 
their symptoms have existed for at least six months as 
generally required by VA regulations.
    In terms of challenges VA faces, we found that there is 
inadequate training for VHA medical examiners. VBA claims 
rating staff often rely on these medical examiners to assess a 
veteran's disability before they make a decision on a claim. 
Medical examiners we interviewed said that conducting Gulf War 
medical exams is challenging because of the range of symptoms 
that could qualify as Gulf War Illness. The VHA has offered an 
optional 90-minute web based Gulf War Illness training for its 
medical examiners since 2015, but according to VHA, training 
data only showed ten percent of the examiners had taken this 
training as of this past February. We recommended that VA 
require its medical examiners to complete training on Gulf War 
Illness and VA agreed with this recommendation.
    We also found that decision letters VA sends to veterans 
denying benefits for Gulf War Illness claims do not always 
clearly explain to the veteran how their claim was decided, 
which can leave a veteran uncertain about how the claim was 
evaluated and potentially lead to unnecessary appeals. We 
recommended that VA require decision letters to clearly explain 
how the claim was evaluated and VA agreed with our 
recommendation.
    In terms of Gulf War Illness research, we found that VA 
does not have a plan to develop a single case definition of 
Gulf War Illness. VA advisory groups have emphasized that 
establishing a single definition could further improve the 
research, diagnosis, and treatment of veterans. VA's advisory 
groups recommended that in the near term VA analyze data from 
its existing datasets and in the long term conduct research 
projects to contribute to the establishment of the single case 
definition. VA included in its 2015 Gulf War Research Strategic 
Plan an objective to establish a single definition, but the 
agency has no action plan in place to achieve it. Without a 
plan VA risks engaging in research that is not targeted towards 
its goal. We recommended that VA prepare a plan to develop a 
single definition and VA agreed with this recommendation.
    Thank you. This concludes my remarks.

    [The prepared statement of Melissa Emrey-Arras appears in 
the Appendix]

    Mr. Bost. Thank you. Mr. Hearn, you are recognized to begin 
the testimony for the American Legion, please.

                   STATEMENT OF ZACHARY HEARN

    Mr. Hearn. Thank you. It is like deja vu, all over again. 
Ranking Member Kuster, you made this assertion in your opening 
remarks during the March, 2016 hearing regarding Gulf War 
Illness. 486 days, one damning GAO report, and thousands of 
injured veterans and impacted dependents later, we are here 
again to discuss the adjudication of Gulf War Illness claims by 
VA. And yes, Ranking Member Kuster, it definitely feels like 
deja vu all over again.
    Chairman Chairmen Bergman and Bost, Ranking Member Kuster, 
and distinguished Members of the Subcommittees on Oversight and 
Investigations and Disability Assistance and Memorial Affairs. 
On behalf of National Commander Charles E. Schmidt and the over 
two million members of the Nation's largest veteran's service 
organization, the American Legion appreciates the opportunity 
to testify regarding the adjudication of Gulf War Illness 
claims.
    Gulf War Illness claims are inherently complicated. 
Veterans must tread murky waters to gain service-connection for 
many Gulf War related undiagnosed illnesses. An undiagnosed 
illness is just as it sounds, a cluster of symptoms that are 
unexplained and undefined. Veterans seeking treatment for these 
symptoms are often treated for years and often have multiple 
diagnoses before VA will acknowledge that the symptoms are 
related to an undiagnosed illness. It is terribly frustrating 
for veterans and as seen by a recent GAO report, overwhelmingly 
denied by VA when service-connection is sought.
    VA has previously acknowledged its frustrations with Gulf 
War Illness. With that in mind, one would think that there 
would be mandatory training to improve its workforce's 
understanding of the conditions. However, the GAO report 
indicated only about ten percent of VA's medical examiners 
successfully completed an optional course related to Gulf War 
Illness. This is pathetic. Only one of ten medical examiners 
have taken the optional course, but yet the other nine of ten 
are equally qualified to conduct Gulf War related examinations?
    Let us also not forget that many examinations are now being 
conducted by private sector contractors. If VA is not providing 
mandatory training regarding Gulf War Illness to its own 
employees, what requirements are being made of those examiners?
    The American Legion has over 3,000 accredited 
representatives located throughout the Nation. These dedicated 
individuals are the lifeblood for staff in Washington. They are 
the souls that provide the necessary feedback regarding issues 
our veterans face regularly. One service officer reported that 
a VA regional office employee stated that veteran's service 
organizations receive more frequent and higher quality training 
than RO employees. Training received as a web based training 
that often results in various interpretations, ultimately 
resulting in inconsistent decisions.
    Each service officer spoken to prior to this hearing stated 
that they have had to accept that claims sought for undiagnosed 
illnesses will have to go to the Board of Veterans Appeals if 
they expect the claim to be granted, costing the veteran not 
months, but numerous years to possibly result in a positive 
decision. Veterans will provide lay statements detailing 
symptoms and impacts of symptoms from family members and 
friends. These statements will have little, if any, impact on 
RO decisions. However, the service officers report BVA 
decisions are much more favorable for veterans and take into 
account those lay statements.
    The GAO report combined with American Legion findings paint 
a bleak picture of the development in adjudication of Gulf War 
related claims. Medical providers have optional training, of 
which only ten percent participate, and VBA personnel complain 
of a lack of adequate training on the subject. Three 
generations of veterans have potentially been impacted by Gulf 
War Illness and these concerns have been swirling for over a 
quarter of a century. Think about this. A 20-year-old deployed 
troop right now in Iraq was not even born when these symptoms 
arose and may one day suffer, and we have yet to discover, A, 
the cause and proper treatment for it, and B, how to properly 
adjudicate the claims that are associated with it.
    It is evident that there is need for improvement and the 
American Legion is willing to work towards achieving these 
goals. In the last year VSOs worked with VA in designing an 
appeals modernization plan that we collectively achieved. We 
have proven for substantial change to occur it takes VSO and VA 
collaboration. The American Legion is eager to work with VA and 
VSOs to accomplish this feat. This is a problem that will not 
be resolved strictly by finger pointing. It is a problem that 
will be resolved by agreeing on identified problems and 
arriving at sensible solutions.
    Again, on behalf of National Commander Charles E. Schmidt 
and the members of the American Legion, we truly appreciate the 
opportunity to speak with you this morning. I will be happy to 
answer any questions. Thank you.

    [The prepared statement of Zachary Hearn appears in the 
Appendix]

    Mr. Bost. Thank you, Mr. Hearn. Mr. Figlioli, you are 
recognized to present the position for the VFW.

                STATEMENT OF MICHAEL S. FIGLIOLI

    Mr. Figlioli. Thank you, Chairmen Bost and Bergman, Ranking 
Members Esty and Kuster, Members of the Subcommittees. On 
behalf of the VFW, I would like to thank you for the 
opportunity to testify on VA's disability claims process with 
respect to Gulf War Illness.
    As professionally trained accredited advocates, VFW service 
officers have work extraordinarily hard to ensure our veterans 
and their families receive the maximum benefit allowable by law 
from VA. All too often, however, this does not happen for a 
myriad of reasons. For today's hearing I will focus on the 
signature condition of the Persian Gulf War referred to largely 
across the veterans community as Gulf War Illness, or more 
commonly in VA as medically unexplained chronic multi-symptom 
illness.
    Unlike nearly all other claimed conditions, Gulf War 
Illness is intrinsically difficult to diagnose and treat. Gulf 
War Illness has no clear and concise set of rules. In other 
words, no one distinctive set of symptoms that allow for a 
single, unmistakable diagnosis. Gulf War Illness presents 
itself as a conglomeration of possible symptoms to which 
countless members of the general public with no military 
experience can also be subject. As such, Persian Gulf veterans 
have a steeper hill to climb in relating the symptoms to 
service, the most critical link in establishing service-
connection.
    None of this is remotely possible without the benefit of a 
VA exam. As VA continues to evolve on a number of fronts, such 
as electronic business management, VA developed disability 
benefits questionnaires, or DBQ, with an eye towards efficiency 
and timeliness. Last year the VFW strongly advocated for the 
elimination of the parsing out of symptoms and placing greater 
concentration on the clustering of these indicators of 
potentially one illness affecting multiple body symptoms as 
opposed to specific conditions related to each symptom. Put 
more simply, the VFW feels Gulf War Illness claimants would be 
better served by VA eliminating the assignment of multiple DBQs 
and posit from the outset that the evidence meets the criteria 
for Gulf War Illness. It remains our contentions that the 
current system of assigning separate DBQs for each symptom 
claimed in association with Gulf War Illness promotes 
incorrectly assigning a diagnosis to a condition linked to Gulf 
War Illness, which ultimately results in the veteran's claim 
being denied.
    More than a year ago these Committees met to discuss this 
topic and pressed VA to develop a single DBQ for GWI that would 
assist in establishing service-connection. Regrettably, VA has 
not reported any progress in developing this DBQ and veterans 
continue to have their claims denied. VA continues to rely on a 
Gulf War Illness general medical DBQ that is not singular in 
nature for claims for Gulf War Illness but instead rely on a 
subjective non-medically trained construal of a claims 
assistant to interpret a veteran's claimed conditions and 
schedule the appropriate VA exam. When asked about the 
possibility of a more favorable DBQ the response of record was 
that VA would look into the issue, and first we had to confirm 
that the lack of a single DBQ is a real problem. Mr. Chairman, 
let us stop mincing words. We know this is a problem and GAO 
agrees.
    This continued problem also has the downstream effect of 
the appellate process. VFW advocates at the Board of Veterans 
Appeals continue to find numerous inconsistencies when 
decisions are remanded to the VA regional office. In assessing 
pending appeals for Gulf War Illness, the VFW notes that VA 
appears to clearly favor finding a diagnosis for each reported 
symptom and thereby rule out Gulf War Illness rather than 
further developing and accurately applying the rating schedule 
with a diagnosis that is even a minimally supported one. The 
VFW urges VA to consider both possibilities as existential. 
Since the preponderance of evidence shows the possibility that 
Gulf War Illness may exist, the balance of evidence as to Gulf 
War Illness' non-existence is equal or in equipoise. Therefore, 
VA's own regulations show that VA should develop the claim for 
the potential grant of Gulf War Illness disability.
    The VFW suggested in prior testimony that inconsistencies 
in the application of the rating schedule is universal across 
the VA regional office spectrum with regard to claims for Gulf 
War Illness disabilities. While we are not in any way 
suggesting that this is deliberate, we continue to put forward 
that a grant for Gulf War Illness in Michigan should be exactly 
the same in New Hampshire, or any other VA regional office, 
based on the same evidence and fact pattern. VA's Office of 
Performance Analysis and Integrity has demonstrated their 
capability to track data nearly to the keystroke. This presents 
the perfect opportunity to identify and develop best practices 
across VA in properly adjudicating claims for Gulf War Illness 
and eliminate the disparities. At the very least with VA's 
national work queue, VA could easily distribute these 
specialized claims to the regional offices that have a proven 
track record in proper adjudication of Gulf War Illness claims.
    As one of the large Nation's VSOs responsible for providing 
direct assistance to veterans seeking their earned benefits, 
the VA thanks the Subcommittee for conducting oversight 
regarding Gulf War Illness claims. We ask that you join us in 
urging VA to adopt a single DBQ for all Gulf War Illness 
claims.
    Mr. Chairman, this concludes my testimony. I will be happy 
to answer any questions you or the Subcommittee Members may 
have.

    [The prepared statement of Michael S. Figlioli appears in 
the Appendix]

    Mr. Bost. Thank you, Mr. Figlioli. Mr. Hardie, you are 
recognized for five minutes.

                  STATEMENT OF ANTHONY HARDIE

    Mr. Hardie. Good morning, and thank you, Chairmen Bergman 
and Bost, Ranking Members Kuster and Esty, and distinguished 
Members and staff for this hearing and the opportunity to speak 
with you today. Thank you, Gulf War veterans, we know you are 
watching live from all over the country and what happens here 
today matters to you most of all.
    I am Anthony Hardie, National Chairman and Director of 
Veterans for Common Sense, and a U.S. Army veteran of the Gulf 
War and Somalia. We appreciate last year's Gulf War hearings 
and today's follow-on hearing to try and fix these many 
unresolved issues. Included in our written statement are many 
identified issues and recommendations and pages of heartfelt, 
painful stories from Gulf War veterans from all over the 
country, written in their own words, just a few of the tens of 
thousands whose denied VA claims left them hurting, bewildered, 
distraught, and angry.
    A Maryland veteran describes what it is like to actually 
live with the chronic fatigue of Gulf War Illness, saying, ``I 
slept fourteen and a half hours, woke up for three, slept for 
another eight and a half. This is right off my Fitbit. Yet I 
have been denied each time. How am I supposed to work when I 
literally cannot get out of bed? This is not how I saw my life 
at 47 years old.''
    They write about losing their health, their jobs, their 
finances, and even their homes. All write about VA improperly 
denying their presumptive Gulf War claims, exactly what GAO 
writes about in their report. One from Louisiana even writes 
about having to instruct a VA supervisor who had it wrong, and 
calling the White House seeking resolution. A Kentucky veteran 
wrote, ``I filed for a constellation of neurologic symptoms and 
was denied for each symptom of my undiagnosed illness.'' Others 
say the same thing or their symptoms being attributed to 
diagnosed conditions and then denied. That is the crux of the 
problem.
    It is now 23 years since Congress enacted the well-
intentioned 1994 law that created a presumption for undiagnosed 
illness symptoms. A written statement details later fine-tuning 
by Congress and VA. Today we have heard about GAO confirming 
VCS' earlier findings, that VA denies Gulf War Illness at a 
rate of greater than 80 percent. We see in their report that is 
three times the denial claim of any other claim, that the 
denial rates for undiagnosed illnesses are the worst of all, 
and that these trends are worsening over time and are now 
actually 87 percent overall, and get this, 90 percent for 
undiagnosed illness.
    We see from their report that these claims also take 50 
percent longer than other claims, meaning veterans who are the 
worst off suffer the longest, and that VA underreported Gulf 
War Illness claims by 57,000 issues, masking the true scope of 
this already egregious problem. The fact that VA developed 
evidence that led to these denials leaves the door open for 
potential litigation.
    Given GAO's findings that VA has not heeded external or 
even internal recommendations, a finding that mirrors our 
exasperated experiences, we are glad VA leaders seem to be 
stepping up to the plate to fix GAO's three basic 
recommendations. However, in reviewing VA's disability benefits 
questionnaires using claims processing, many if not most for 
diagnosed health conditions begin with this first basic 
question, does the veteran have this diagnosis? But that basic 
question obviously does not work for undiagnosed illness 
claims. And when GAO reports that some claims examiners will 
never find in favor of an undiagnosed illness, and will always 
attribute a veteran's symptoms to a diagnosable illness, that 
is most damning, showing that it is inevitable these claims 
will continue to be denied at near total rates no matter how 
much training is conducted.
    Collectively this decades-long body of evidence makes it 
clear. Undiagnosed illness as a judicable VA claim simply does 
not and cannot work. It is now beyond clear what we need to do. 
A statutory fix along the lines of what we propose in our 
written testimony is needed or we are going to keep having 
these investigations and hearings that all say essentially the 
same thing, decade after decade. We ask that Congress work in a 
bipartisan manner with President Trump to enact legislation to 
once and for all fix Gulf War Illness claims and the many other 
Gulf War issues we raise in this and previous testimony. And if 
VA is serious about resolving these issues, and the ones that 
the veteran raises in the last paragraph I am about to read, 
then VA leaders should leap at the chance to work with 
stakeholders and Congress to craft this legislation together if 
for no other reason than the human impact of VA's denial of 
nearly all Gulf War Illness claims is all too real.
    Listen carefully to these words written by a fellow 
Wisconsin veteran. ``I was told there is a two-year wait before 
my appeal will even be opened, and that it's now up to four 
years. Over the last ten years I have lost two jobs and have 
lost my home and land due to bankruptcy. We have had to move 
twice and change schools, which is really tough for my kids. I 
feel like I am on the verge of losing another job and I am 
afraid I cannot rebuild things again. My VA psychologist told 
me Wednesday that it was an awful long time to hold onto life 
by my fingernails and I agreed. I have put a belt around my 
neck twice and told my doctor Wednesday that I would blow my 
brains out if I am denied again. Twenty-two per day do not kill 
themselves because of PTSD. It is for being continually denied 
and called a liar by the administration that is supposed to be 
helping us. Veterans, and particularly those of war like me, 
look at life very differently than most. If I have no hope, I 
will not continue to be a burden on myself, my family, or my 
country. I will, however, do my best to let them know I was 
destroyed by the VA.''

    [The prepared statement of Anthony Hardie appears in the 
Appendix]

    Mr. Bost. As soon as I turn my microphone on I will start. 
I do want to thank you all for being here and for your 
testimony. But I do want to start with a question. Mr. Hearn, 
do you think the VBA's adjudication manual provides useful 
guidance for VBA employees related to the Gulf War Illness?
    Mr. Hearn. When preparing for the testimony I was reviewing 
the manual and I think it is fairly clunky in the way that it 
is written. And I question as to whether to not aspects of 
Joyner or more recent cases is applied properly in there and 
alerts the staff.
    I understand why the raters, and more importantly the VSRs, 
are having difficulty understanding what to do. And I think 
when you look at the VSO, the VSO does not use the manual when 
advocating for a case. And you know else does not? The Board of 
Veterans Appeals. So it is funny that the one aspect that seems 
to be different is this manual and a VBA rater. So that 
certainly is a concern with the way that VA goes about dealing 
with these types of cases.
    Mr. Bost. Mr. Flohr, how do you respond to his statement 
about where we are at with this right now?
    Mr. Flohr. Thank you, sir. First of all, I would like to 
say that a week before last I had my 42nd anniversary working 
at the Department of Veterans Affairs, all of them here in 
Washington, D.C. All kinds of jobs, from a basic adjudicator to 
where I am now. And we used to have a very, you know, the 
manual, or adjudication procedures manual was all in paper, it 
took forever to make changes to get them to our adjudicators 
out in the field and our field stations. Now it is a live 
manual. We call it a live manual because it is live. It is 
online. We make changes easily, whenever we find a change that 
needs to be made, we can do it. We have a large staff that can 
do that. It is very much superior to what we used to have.
    Is it perfect? Now. Nothing is going to be really always 
perfect, because there are always changes. There is either a 
court decision, or new legislation that is going to require us 
to make changes to what we currently have. But we do a lot of 
training. We have a very large training staff that works very 
hard to train our adjudicators and our rating specialists in 
making the right decisions.
    These claims are difficult. For example, an undiagnosed 
illness. Any of you who are physicians know that when a veteran 
presents, or anyone presents, to you with a constellation of 
symptoms, the first thing you do is try to diagnose it. Because 
if you cannot diagnose it, you cannot treat it. If you treat 
it, you possibly could do some hard if you treat it with the 
wrong type of medication. So that is one reason why it is so 
difficult, undiagnosed illness claims. We request an 
examination. The examiners do all indicated tests to try and 
determine what the veteran has. And if they cannot, we ask them 
to report to use the veteran has an undiagnosed illness of the 
respiratory system, the cardiovascular system, whatever body 
system it may be. And when that gets relayed to us, we grant 
the claim.
    As I said, unfortunately a diagnosis often is made. And 
then when a diagnosis is made, then the direct service-
connection criteria of statute comes into play. We must find 
evidence that the veteran had that particular disability while 
they were in service, they currently have it now, and then 
determine how disabling it is.
    Mr. Bost. Mr. Flohr, I do not want to interrupt but I do 
have another question I have to get to while my time is 
limited. You know, the VA issued a training letter on February, 
2010 that details VA should develop a claim for Gulf War 
Illness. For example, the letter instructs VA employees on when 
to request a disability exam for Gulf War Illness. However, GAO 
found that employees have different interpretations of VBA's 
policy despite VBA's steps to clarify that with guidance. I 
think we can all agree that adequate exams, if one was 
requested, are critical to correctly process these claims. The 
Fast letter that was issued seven years ago, even despite the 
lack of additional clear guidance in the manual, so why is it 
that VA employees still have such difficulty knowing when to 
request an exam for these claims?
    Mr. Flohr. That is a good question. As I said, our live 
manual is pretty clear, at least in my view. But one of the 
other, it was not a recommendation made by GAO, but it was an 
expression that we should do perhaps a consistency study on 
when to schedule an examination.
    Mr. Bost. Maybe Ms. Emrey-Arras--I love just messing that 
up. I am so sorry.
    Ms. Emrey-Arras. Melissa is fine.
    Mr. Bost. Okay. Melissa, what do you think the reason is?
    Ms. Emrey-Arras. VA told us that they were in fact planning 
to do a consistency study to evaluate just this issue, about 
consistency in referrals for medical exams. And they told us 
that they would be doing it the third quarter of this fiscal 
year. So I think that is an excellent question to ask of VA, in 
terms of what is the status of that consistency study.
    Mr. Flohr. I am glad to tell you that it was completed in 
April, which was in the third quarter. We gave it to a lot of 
our VSRs, our veteran service representatives, when there was a 
wrong answer. And as with most consistency studies, you find 
some answers that are not quite right, and particular in Gulf 
War claims which are very complex. But after the exam was 
given, then the people who took the exam were taken to a room 
and provided post-examination training to ensure that they knew 
the right answer, what it is going forward, they would not make 
the same mistakes again. So that was completed.
    Mr. Bost. Can we get the results of those studies for the 
record, please?
    Mr. Flohr. Yes. I will be glad to provide those.
    Mr. Bost. Okay. Thank you. My time is actually expired, and 
I hate to do that to Ms. Esty when she first walks through the 
door. But Ms. Kuster did have to leave to another meeting. 
Ranking Member Esty is here, if she is ready for--I was going 
to hope to do that for you.
    Ms. Esty. Thank you all very much. I appreciate you being 
here. Sorry, this is the fourth or fifth--I started at six a.m. 
this morning. So it is just one of those days. It is going to 
be long. NDAA days are long with many different commitments.
    I really want to thank all of you very much for your 
efforts and for really partnering with us. This Committee 
prides itself on bipartisanship and on getting things done for 
veterans, and making sure the VA works well, and that we are 
serving people the way we need to. And as technology changes, 
and as the needs of our veterans change, and who that 
population is, that is going to change over time. And we will 
not always get it right but we are always going to try. And we 
count on you doing the same thing, too, and giving us a little 
nudge sometimes when we do not, and figuring out how we can all 
do this better.
    An issue I want to really look at it, because I hear about 
it all the time in my district, and we have talked about it 
before in hearings here, is on decision letters. And on the 
lack of clarity in decision letters. I am a lawyer. I read 
those decision letters, I cannot tell what they mean. How can 
our veterans know what they mean? It is disrespectful and it 
leads to appeals and leads to frustration and a feeling of 
disrespect. So if people could talk a little bit about what 
actually can we do? This is an incredibly high priority for me, 
not just because I am the Subcommittee Ranking Member and I 
want us to deal with those claims. Because it is just wrong to 
be sending out letters that do not have clarity. So what can we 
do to get greater clarity in average people speak? This should 
not, you should not have to have a Ph.D. to figure out what 
these letters mean. And I do think it is disrespectful, which 
is number one a problem. Number two, it leads to appeals. And 
it leads people to disengage. So we have to find a better way 
forward. So I would love to hear your thoughts on this, as we 
are moving forward to make changes here. Thank you.
    Ms. Emrey-Arras. This is Melissa Emrey-Arras, GAO. I would 
say that we found that the letters did not specifically inform 
veterans that their claims had been considered in terms of 
presumptive eligibility. And the language made it seem like 
only direct service-connection had been considered. So if you 
were a veteran expecting a presumptive claim, and you saw the 
letter, you would think that that was not evaluated 
appropriately.
    Mr. Flohr. And VA accepted that recommendation and we have 
plans to change our letters by the end of August to provide 
that information. But I think perhaps we need to look at it in 
more detail to see where we can make it even more clearer and 
we will do that as well.
    Mr. Figlioli. Ms. Esty, Mike Figlioli from the VFW. This is 
a great concern to our organization, as it is to the American 
Legion and the other VSOs. The number one thing about these 
letters, as you said, they are convoluted. They are not written 
in English. They are not written in plain language that the 
average citizen can understand. And it is not just related to 
Gulf War Illness. This is for every disability. This is for 
every communication with the VA. Every letter has to meet 
certain requirements. But they can outline in that letter, to 
prove your claim you need to provide, A, B, C, and D, not the 
standard cut and paste blurb that there is evidence of record 
but we had to deny the claim because there is no diagnosis that 
this was occurred or was caused by service. That tells the 
veteran nothing. We have been after the VA for a number of 
years to make them simpler, make them straightforward, and 
allow the veteran to understand the shortcoming and then 
correct the deficiency so that we can go ahead and approve the 
claim. Thank you.
    Mr. Hearn. Good morning, Ranking Member.
    One of the issues that we have noticed over time and 
especially in the appeals inventory is that the VA kind of shot 
themselves in the foot with these letters, right? Because a lot 
of veterans are appealing cases or appealing their claims, but 
they don't know what they are appealing, they don't know why 
they are appealing. They just know that they feel like they 
kind of got messed over by VA.
    And so, like Mike was saying, they will sit there and they 
will say to gain service-connection, you must have the 
following. Well, why don't they identify it? Okay, you have a 
diagnosis, you have an incident of service, but yet we don't 
have a doctor's note linking the two conditions. And I think 
that is what is creating a lot of confusion. Like you said, you 
know, you shouldn't have to have a PhD or some sort of advanced 
degree just to be able to figure this out.
    And, unfortunately, this has been a problem that we have 
been calling for years and years and years, and really in the 
appeals modernization, that was a caveat for this whole thing. 
And so we are very much looking forward to it.
    Ms. Esty. Can I respectfully suggest that when VA has a 
draft letter ready they circulate it to this Committee and they 
circulate it to the VSOs?
    And I fully agree, I think it ought to be broken out with a 
checklist with numbered, so you can actually visibly see this 
criteria must be met, the following was/was not met. These 
would be documentation.
    So it is really clear and it is really easy to do a 
checklist that is the military way. Don't bury it in the middle 
of a paragraph in lawyerese. Break it out so that you can 
easily understand what that means.
    So I would urge the VA to circulate that to us. I know I 
work with some behavioral economists, I want them to take a 
look at it, and I would like to have some actual veterans look 
at it and say, does this make sense to you? If you read this, 
what would you understand that you need to do? And I think that 
would help us all get to the objective we share.
    Thanks very much and I see I am over time.
    My apologies, Chairman Bergman. Thank you.
    Mr. Bergman. No apology is necessary. You know, quality, 
you should never put a time limit on good quality.
    Mr. Coffman, you are recognized for five minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    And I just want to say first, as a Gulf War veteran, how 
disappointed certainly I was in the aftermath of the war and to 
this day that the Department of Defense I think participated in 
a cover-up, and that cover-up was the exposure to chemical 
weapons.
    And that I can remember the Marine Corps limit of advance 
in the first Gulf War was kind of the northern end of Kuwait on 
the Iraqi border and I can remember in the aftermath of the 
fighting, and you have tremendous visibility in the open 
desert, seeing this white cloud close to the ground, not 
moving, and reported that in. And I didn't think there was a 
question at that time--well, we knew, I knew later on, years 
later on what it was, and it was that combat engineers of the 
United States Army were blowing chemical weapons in place 
because they didn't want to go through the hassle of all the 
decontamination stuff.
    And so we were fortunate, the Marines I was with were 
fortunate that we were not downwind from it, that the wind 
patterns were moving in the other direction. So none of the 
Marines I served with came down with Gulf War Illness.
    But the Department of Defense denied for I believe about a 
five-year period in the aftermath of the war that the U.S. 
troops were ever exposed to chemical weapons and it wasn't 
until, you know, they were forced to admit it later on that 
they in fact were, that they did blow chemical weapons in 
place.
    And so we got off to a very bad start in terms of research, 
that that was not one of the aspects that were researched, 
because the Department of Defense was so vehement in denying 
that that was in fact true. And so it certainly left a bad 
taste in my mouth as a Gulf War veteran in terms of the 
integrity of the United States Government relative to veterans.
    And so, but I think my question at this point is, in the 
training of these disability folks that do the processing, 
review the claims, there doesn't seem to be any uniformity in 
the training. And as I understand it, there is a course that is 
optional for them to take and I think it is online. And I guess 
let me ask the VA, why isn't there mandatory training for the 
folks that review these claims?
    Mr. Flohr. Thank you. Are you referring to the training for 
medical examiners who provide medical opinions or the people 
that make the decisions?
    Mr. Coffman. Well, I think that is a good question. How is 
it for both?
    Mr. Flohr. Well, for us, for VBA, every time we hire a new 
group of individuals, we have a very large training staff and 
they get sent away to either Baltimore or Denver, we have 
training academies there. They go through a lot of training, at 
least six weeks--
    Mr. Coffman. Relative to the Gulf War?
    Mr. Flohr. To all particular claims, all types of claims.
    Mr. Coffman. Okay.
    Mr. Flohr. So they get an initial group of training, then 
every year they are required to complete training as well and 
updates.
    Mr. Coffman. Okay. GAO, maybe you can respond.
    Ms. Emrey-Arras. The medical examiners are not required to 
take training specific to Gulf War Illness issues. It is 
elective and, because of their high caseloads and the fact that 
they don't have a lot of time for elective training, only about 
ten percent of the medical examiners have taken training on 
Gulf War Illness.
    Mr. Coffman. American Legion?
    Mr. Hearn. Thank you, Congressman. The training--and that 
is something that we have a lot of concerns about and I 
addressed it during my remarks was that on the medical side, I 
mean, you have to remember these are doctors and doctors are a 
lot like mechanics, right? You don't take your car in to the 
mechanic and say fix my brakes, and the guy comes out and says, 
I don't know what it is. That goes against their DNA, they 
naturally are going to create a diagnosis. I think that is just 
how they operate.
    So if the doctor comes back and says, I don't know, that is 
a pretty rare circumstance. But then what the big concern is, 
is that you have VA as a department has said this is a priority 
of ours, but then only ten percent have taken it? It kind of 
makes you wonder if there is just lip service being paid.
    And then the second aspect of it is that we have started 
going to these contracted examinations. If they can't get it 
right with their own employees, what is going to happen when 
QTC or one of these other providers in the private sector are 
having these examinations, are they getting the proper 
training? And so which Gulf War veterans are going to be 
impacted by these private sector physicians?
    Mr. Coffman. Thank you, Mr. Chairman. My time is up. I 
yield back.
    Mr. Bergman. Thank you, Mr. Coffman.
    Ms. Brownley, you are recognized for five minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    And thank you all for being here this morning. This is a 
very important topic.
    So the GAO presented VBA with a set of recommendations on 
this issue and you have said and agreed to all of those 
recommendations. Can you in a general way, can you give me an 
idea of when you might complete all of these recommendations 
and have them operating in a way that is more effective?
    Mr. Flohr. Yes. Thank you for that question.
    We did accept and concur with the three recommendations. We 
appreciate GAO's looking at this, they are always instrumental 
in helping us do a better job of what we do and we appreciate 
that.
    The recommendation to ensure that VHA medical examiners 
take this 90-minute training has been accepted by VHA, it is 
going to be made mandatory, and as--
    Ms. Brownley. Do you think 90 minutes is enough?
    Mr. Flohr. I will let Dr. Joyce answer that.
    Dr. Joyce. I would like to address that. The 90-minute 
training course described by others as being optional is a mere 
fraction of the training required to do a Gulf War examination 
or any other kind of CMP examiner. These physicians, nurse 
practitioners, or physician's assistants are first licensed, 
privileged, and experienced before they do Gulf War 
examinations.
    This additional course of 90 minutes will be mandatory and 
will be completed by November, but it is supplemental to their 
underlying training as health care professionals which allow 
them to address this very complex subject, a subject that is 
not easy to define and has challenged even the learned 
colleagues at the National Academy of Medicine.
    Mr. Flohr. As far as number two, I think I already said we 
concur with that as well and we will have our decision 
notification letters completed, changes made to them by the end 
of next month.
    And number three is the single case definition. We do have 
a plan to do that.
    Ms. Brownley. What is the plan?
    Mr. Flohr. The plan is to get a lot of smart people 
together and try and figure it out.
    Ms. Brownley. What is the timeline?
    Mr. Flohr. The timeline is March of 2018 right now. But, 
you know, we asked the National Academy of Sciences to do this 
several years ago, they couldn't do it. It was that difficult, 
so they threw it back to us, and we are going to try and do 
that. We are going to get people from DoD, people from the 
Veterans Health Administration, from VBA, from the National 
Academies, if we can, whoever we can get who is smart about 
this. People from our War-Related Injury and Illness study 
centers here in D.C. and New Jersey, Palo Alto, they see a lot 
of Gulf War veterans.
    So we really will appreciate their input in trying to come 
up with a single case definition, but we do have a plan and we 
have already started.
    Ms. Brownley. Well, certainly my expectation is that the VA 
would be the experts when it comes to Gulf War Illness and the 
VA should not have to look to other entities for that, the 
research. I mean, this is what it is all about is, you know, 
why the VA in its mission, is because they are serving our 
veterans with all kinds of illnesses, but there are specialty 
illnesses that are just not out in the world other than within 
the VA.
    And I think, you know, back to the medical training, yeah, 
I agree that the doctors that come to the VA are well-trained 
doctors, I don't dispute that for a second, but a 90-minute, 
Web-based course to me seems like it is really not deep enough, 
you know, to really understand, you know, sort of what veterans 
are going through and understanding it. But certainly it is a 
step in the right direction to require that everybody take the 
course, so I certainly agree with that.
    Dr. Joyce. I am in complete agreement with you: it is not 
sufficient to take that 90-minute course and to call yourself a 
Gulf War examiner. It is a mere supplemental course to make us 
better able to answer the technical questions from the Veterans 
Benefits Administration and I would be doing a disservice to my 
colleagues to suggest you could be certified that quickly.
    Ms. Brownley. So with regard to the manual has been spoken 
of and you talked about it being live, you can make changes as 
we go. The American Legion described it as clunky, you 
described it as clear. Do you really think the manual is 
fundamentally, absolutely clear?
    Mr. Flohr. It is large, it is very large and it is full of 
a lot of information. And I have not processed claims myself 
for many, many years, so I don't necessarily always use the 
live manual if I want to look up something. Like I looked up 
what was in there on Gulf War Illness before I came here and 
there is a lot of information there that needs to be digested, 
and it may at times lead people to be somewhat confused. I am 
not sure about that, again, but there is a lot there and when 
we need to change something, we can do it immediately, and that 
is what is the best part about it. Plus, everyone else can see 
it as well.
    Ms. Brownley. Well, I think that is good, the transparency 
piece is good.
    Mr. Flohr. Yes.
    Ms. Brownley. But, you know, clarity is also important. And 
I think that all goes back to the definition and other kinds of 
things, you know, that we are talking about.
    And I know my time is up, but I would just like to hear 
from VBA, not now but if you can get back to me. You know, the 
opening of this hearing started about a deja vu, that we have 
had this conversation, we had it a year ago, and I would really 
like to know the work that has been done since last year up 
until this point. Now we are talking about a year later, we are 
talking about meeting some recommendations yet into the future. 
But, you know, I would like to have that conversation offline.
    And I apologize, I yield back.
    Mr. Bergman. Thank you, Ms. Brownley.
    Dr. Dunn, you are recognized for five minutes, sir.
    Mr. Dunn. Thank you very much, General.
    I would like to channel a comment made by Mr. Hearn a 
little earlier where doctors don't like to say they don't know 
and you are absolutely right, we don't like that, but we can be 
trained to say that. And my next comment is directed to Dr. 
Joyce and Mr. Flohr.
    So I want to stipulate something just among us here. Can we 
agree we do not understand Gulf War Illness Syndrome is a 
disease? None of us do and there are no experts anywhere that 
have some comprehensive understanding of the pathology of this 
disease. Do you agree with that?
    Dr. Joyce. I do, Dr. Dunn.
    Mr. Dunn. You do. Okay, good.
    So, now we all agree that the claims are rising, the 
denials are rising as well. Clearly, some of our Gulf War 
veterans are not having their conditions properly recognized 
and treated, we can agree on that?
    Dr. Joyce. Yes.
    Mr. Dunn. Yes? We can agree clearly that some of the 
veterans are not being recognized and treated for Gulf War 
Illness Syndrome?
    Dr. Joyce. Some, but not all.
    Mr. Dunn. Some, some? Not all of them, some?
    Dr. Joyce. Dr. Dunn, using the word ``some'' as we medical 
doctors do, I will agree with you.
    Mr. Dunn. Thank you, thank you. In medical terminology. 
That's good, because I haven't been up here long enough to use 
anything other than that kind of terminology.
    So given that and we know that the DoD has spent between 
'94 and 2016 over $172 million on research in hopes of simply 
clarifying the presumptive list of conditions, sort of that 
basket of pathologies that fit into Gulf War Illness Syndrome, 
and we have made no new changes or additions in seven years, 
since 2010, you know, my question is this, that can we, can 
you, can we together promptly finalize some diagnostic criteria 
for Gulf War Illness Syndrome and then address the prompt 
rollout of administrative, financial, and medical action to 
help these deserving soldiers?
    Emphasis on prompt.
    Mr. Flohr. You are talking about prompt training for 
medical providers, examiners?
    Mr. Dunn. So you do have to. But just going back to Mr. 
Hearn's remark, you know, doctors don't like to say they don't 
know, but if you go to a doctor and say nobody knows, not just 
you in this clinic, nobody knows Gulf War Illness Syndrome, but 
here's this basket of symptoms that fit this criteria, use this 
Chinese menu of pathologies, and if your soldiers fit these 
criteria and they were in the Gulf War, then they presumptively 
have Gulf War Illness Syndrome and they get their financial 
disability, whatever, and medical treatment such as we know at 
the time going forward. And we know there will be advances. I 
spent my evening reading the proteomic and genomic and microRNA 
studies on Gulf War Illness Syndrome, fascinating stuff, but 
not clinically relevant just yet, but it is okay. I think you 
can go to your doctors, I have worked at a VA hospital, and say 
nobody knows, not just you. Can you make this diagnosis and 
help this soldier?
    Mr. Flohr. Well, you know, the Gulf War Illness is 
described in statute and regulations. If a veteran has a 
chronic, multi-symptom--medically unexplained, chronic, multi-
symptom illness, which is defined in the statute as, such as--
    Mr. Dunn. Pretty clearly, the system isn't working yet for 
them.
    Mr. Flohr [continued]. --fibromyalgia--
    Mr. Dunn. I mean, so defining it in statute, maybe getting 
the lawyers involved was the wrong group, maybe we need to get 
the doctors involved in it, you know.
    Mr. Flohr. That would be good, but if a veteran has one of 
those fibromyalgia, chronic fatigue syndrome, or functional GI 
disorders, if a veteran of the Gulf War--
    Mr. Dunn. Things we sort of understand.
    Mr. Flohr [continued]. --has one of those, that is 
presumptive and we should be granting those immediately. And if 
we are not, please let me know, if you can--
    Mr. Dunn. All right. So my charge I guess would be, you 
know, and I heard you suggest you might do this by March of '18 
to Ms. Brownley's question, is to roll this out really, really 
promptly. No more fooling around with it, we have been fooling 
around with it for a long, long time. We need to take some 
clear action to help these poor soldiers.
    And in my final 45 seconds I would like to ask, I guess 
you, Mr. Flohr, what would you have us say to our constituents 
who perceive that they have a medical condition, Gulf War 
Illness Syndrome, arising from their service in the Gulf War, 
and yet that is not being recognized by the VA? And that 
happens to us on a weekly basis.
    Mr. Flohr. Well, I would say--
    Mr. Dunn. All of us, not just my office.
    Mr. Flohr. Sure, I understand. I would say to them that if 
they have a disability they think resulted from their Gulf War 
service and if it has been diagnosed a chronic, multi-symptom 
illness, they certainly need to provide that medical evidence 
when they file their claim from their private provider or 
whoever it might be. If they only have symptoms, if they don't 
have a diagnosed illness, then we are going to do what we need 
to do, which is request an examination.
    And then under the law, if after all indicated tests are 
done the examiner cannot arrive at a diagnosis, we want--
    Mr. Dunn. But this should be cookbook, I mean, really, it 
should be cookbook, right?
    Mr. Flohr. Yes, it should.
    Mr. Dunn. Okay. Well, let's get the cookbook out there 
and--
    Mr. Flohr. But it is not easy. That's the thing, it is not 
easy.
    Mr. Dunn. That is why we went to med school. All right.
    Mr. Chairman, I yield back. Thank you.
    Mr. Bergman. Thanks, Dr. Dunn.
    Mr. Sablan, you are recognized for five minutes, sir.
    Mr. Sablan. Thank you very much, Mr. Chairman.
    Good morning, everyone. Thank you for joining us today.
    I am new to this Committee and I asked to join because I 
have seen a spike of veterans coming to the congressional 
office asking for help. They go see a doctor or a medical 
professional and they are told, no, nothing is wrong with them. 
And here we are discovering that nobody really knows the entire 
story or whatever it makes of some of the illnesses from the 
Gulf War. And I am talking about Gulf War veterans primarily.
    I had a week two months ago dedicated to just talking to 
veterans in a group setting, in a one-to-one basis, and all of 
these veterans have filed claims and they are still suffering. 
Some of them suffer in quiet, they quietly suffer because they 
are told nothing is wrong with them.
    Now, Dr. Joyce mentioned that a VA physician who usually 
examines a Gulf War syndrome or illness specializes in this 
issue. So let me ask you--and that the GAO reports that only 
ten percent do these Web service training--so let me ask you, 
contracted medical examiners, I mean private doctors who are 
contracted to do this, because I don't have a VA clinic in my 
district, what makes you determine that that doctor knows what 
they are doing, a general internist, internal medicine doctor?
    Dr. Joyce. So as a general rule Gulf War exams are an 
exemption to the regular contract exams done to these non-
specialist and CMP exams.
    Mr. Sablan. Okay, but if they go see a doctor and the 
doctor said nothing is wrong with them, they can't get a 
referral to go to Hawaii. Some of these people have no money to 
go to Hawaii, you know. It costs $2,000 to go to Hawaii. Plus 
you have to get a car, you have to rent a hotel, get lodging 
and everything, and you need an appointment. And the doctor is 
saying nothing is wrong with you. So someone has to make that 
appointment in Hawaii for them, they have to go to a doctor.
    Dr. Joyce. I think I am going to have to say that we are 
going to have to get back to you, because I am not personally 
familiar with the referral system in your area.
    Mr. Sablan. Well, I am sure that there are other private 
doctors in the Nation.
    And again, Mr. Flohr, thank you, sir, for your 42 years of 
service, but let me ask you. GAO recommends that there should 
be a requirement that medical examiners complete training 
courses before conducting these exams for Gulf illness or such 
a medical conduct--complete training, including such as the 90-
minute Gulf War Illness Web-based course, and only ten percent 
do it. What do you do to the 90 percent who won't do it? Do you 
give them a bonus? I heard you guys give out lots of bonuses.
    Dr. Joyce. I can address that. When the course is now 
mandatory, we will be required, myself included, to demonstrate 
on a computerized record list that goes all the way to the 
central office that we have completed the course and passed the 
test showing we took the course; no one will be exempt.
    Mr. Sablan. Thank you, Doctor. I am not pointing fingers, 
Doctor, I am making just statements because I come from a 
place, I represent a district where there is no VA clinic and 
to go to Guam, to go to Hawaii requires a lot of money, and 
these people don't have money. So they have absolutely no help 
and so they suffer in silence. And they come to me, and 
especially when they are told nothing is wrong with them, they 
come to me and say, what can I do? What can you do for me? And, 
you know, I can't file appeal papers for them, I don't have 
their documents.
    And does it take the GAO to tell you these things? You have 
42 years of service, sir. Do you really need the GAO to tell 
you some of these things that you have failed to do, that we 
have discussed a year ago?
    Mr. Flohr. That the medical--that is Dr. Joyce's claim but, 
you know, we work with VHA to make sure that we get all that we 
need to make proper decisions.
    Mr. Sablan. Yeah, I'm sorry, I don't mean to be, you know, 
very--if I appear critical, I don't mean to be. I am just 
expressing. And I took the stories of veterans word-for-word, I 
added nothing, I took out nothing, and I presented them to 
Secretary Kelly--I mean Shulkin, I'm sorry, I am mistaken.
    But I really need help in my district and I don't know what 
else to do. I joined this Committee trying to find help, not to 
be critical of anybody, and I appreciate that you guys are 
doing this. I thank GAO also.
    I am over my time, but I will tell you that some of the 
best information I have learned over this series of hearings 
have come from these people, the VSOs. Unfortunately, I only 
have the VFW in my district, many of them are Vietnam veterans. 
But I have put together a list of all VSOs in the Nation and it 
is going on my Web site, and I am telling these veterans join 
or go to these VSOs for help. I can't do your things for you, 
but they could be helpful.
    Mr. Chairman, I apologize for being out of time, General. 
Thank you, sir.
    Mr. Bergman. No apology is necessary.
    My parents raised me to be kind. As a Boy Scout, I was 
courteous. So I am going to try very hard to maintain my 
parents' and my scout master's values here in my questioning.
    You can tell by the questions from our Members, there is a 
sense of urgency in this panel, a true sense of urgency; I am 
not sure I feel that throughout the room.
    So, Mr. Flohr, Dr. Joyce, I am going to look at you first. 
Do you feel a personal sense of urgency in this?
    Mr. Flohr. Yes. And not just for Gulf War veterans--
    Mr. Bergman. Good.
    Mr. Flohr [continued]. --but all veterans.
    Mr. Bergman. Good enough. Yes, okay.
    So now, since you do, can you give me any examples at the 
VA over the last, pick your time, two years, ten years that 
actually would show a sense of urgency from the top on down to 
get some results?
    Let me try it in a different way. Can you give me an 
innovative program, innovative, that was based on a sense of 
urgency to shrink the timeframe to develop the capabilities for 
the individual practitioners necessary to begin to get a handle 
on this problem? Can you give me one example of innovation 
other than a 90-minute, optional, online training program?
    Mr. Flohr. I can give you an example of an innovation that 
is currently underway. It is called--
    Mr. Bergman. Underway?
    Mr. Flohr. Yes.
    Mr. Bergman. How about in execution phase? Is underway 
meaning we are working it up or does underway mean actually 
being--
    Mr. Flohr. It means that we are working with the Department 
of Defense, the Veterans Health Administration, to achieve an 
electronic availability of determining someone had an exposure 
while they were on Active duty.
    Mr. Bergman. That's it?
    Mr. Flohr. Yes, sir.
    Dr. Joyce. I would also add that in the testimony of Mr. 
Flohr so far the increase in number of claims for Gulf War 
Illness is a demonstrable manifestation that more have been 
accepted--
    Mr. Bergman. Great segue, thank you very much, because in 
the military we--and you have heard this term, in fact General 
Petraeus coined the term when he looked at changing how we were 
looking at Operational Iraqi Freedom and he talked about 
creating the surge, if you will, can you give me an example of 
surge operations that have been instituted within the VA? Not 
just asking for more money and more people, but taking already 
existing assets that you have and that you pay every day of the 
week, and redistribute those assets in a surge manner to begin 
to grab a handle on this?
    Mr. Flohr. I don't know if it meets what you are looking 
for, but we--
    Mr. Bergman. I am looking for a surge--
    Mr. Flohr [continued]. --over the past several years--
    Mr. Bergman [continued]. --of existing assets that you are 
refocus--
    Mr. Flohr. Yes, sir.
    Mr. Bergman. --based upon a perceived need. Again, in war 
fighting, it is real simple: if the enemy is over here, bring 
your stuff over here to go after them.
    Mr. Flohr. What we have done over the last several years 
now is develop training academies for newly hired employees 
where they get the training they need to make proper decisions 
in a group setting, they get tested. It is working out very 
well for us.
    Mr. Bergman. Is there a sense of urgency?
    Mr. Flohr. It is urgent that we get them trained, so they 
can--
    Mr. Bergman. Is there a sense of urgency?
    Mr. Flohr [continued]. --process claims, yes.
    Mr. Bergman. You feel a sense. Sensing is a feeling. 
Someone can write the word ``urgent,'' but unless you sense 
urgency, that is where I am going with this.
    And from the top down, if the leaders and the people in 
charge do not have a sense of urgency that is not going to 
filter down into the organization. It doesn't come from the 
bottom up, it comes from that leadership at the top.
    Mr. Flohr. I believe that Secretary Shulkin definitely has 
a sense of urgency and he is relaying that down to all of us.
    Mr. Bergman. It is too bad it took this long to get the 
Secretary, if you will. Now, I agree with you, Secretary 
Shulkin does have a sense of urgency. I am trying to reinforce 
our support for his efforts to develop that sense of urgency 
throughout the VA.
    Here's a question for you and I don't care who answers 
this. What is the single biggest challenge for us moving 
forward here? I am going to give you two of my choices: apathy 
or bureaucratic red tape?
    Mr. Hardie. Mr. Chairman, Anthony from Veterans for Common 
Sense. I would like to suggest that, again, the biggest 
challenge is that undiagnosed illness, since 1994, it doesn't 
work and all the training in the world isn't going to fix it, 
all the solutions, we can rewrite manuals all day long. It 
simply doesn't work because these conditions are diagnosed.
    I had a veteran this morning who contacted me and said, ``I 
was diagnosed with sleep apnea, it is one of those nine 
conditions that are listed under sleep disorders, why can't I 
get this done?'' And I explained to him, well, it was diagnosed 
and therefore doesn't qualify under undiagnosed illness. And he 
said, ``well, that makes no sense.'' And I said, ``That's the 
point.''
    Mr. Bergman. So is it apathy or is it bureaucratic red tape 
that is causing that? Anybody want to throw one out there? It's 
okay, there are no right or wrong answers here. It is what you 
perceive based upon your understanding and research into this 
issue.
    Mr. Figlioli. Mr. Chairman, Mike from VFW. I would say it 
is bureaucratic red tape, in my opinion, VFW's opinion, too 
many steps. The manual, as was said, is clunky, confusing. 
Training is not conducted in a way that they can recognize 
either it is or it is not Gulf War Illness and roadblocks 
abound.
    If it was made simpler, if the DBQ was developed to the 
point that said this is in fact Gulf War Illness, or if we 
started from Gulf War Illness and worked backwards, it might be 
less so.
    This has actually not been going on since last year, this 
has actually been going on since 1997, Mr. Chairman.
    Mr. Bergman. Thank you very much.
    Question for Mr. Flohr, probably, and Dr. Joyce. What would 
be the cost, dollar cost to just presumptively assume that all, 
all Gulf War veterans had a base level of Gulf War Illness, 
what would be the cost?
    Mr. Flohr. I would have no idea.
    Mr. Bergman. Would you take that for the record?
    Mr. Flohr. I could take it to our staff that works on those 
costs.
    Mr. Bergman. Good. And I don't care whether it is ten 
percent, twenty percent, I don't care--
    Mr. Flohr. Are you talking about any disability claim by a 
Gulf War veteran?
    Mr. Bergman. Get them into the system, presumptively assume 
that because they were there, they were exposed.
    Now, again, we are product of our own experiences. I am 
Agent Orange, I am Vietnam. Okay?
    Mr. Flohr. I can tell you that right now Gulf War veterans 
are service-connected for more than 14 million disabilities.
    Mr. Bergman. Give me a cost to presumptively assume, if it 
is on your DD214 that you were there in that specific 
timeframe. Because when we talk about, number one, what are we 
providing, what is the cost of providing it, and how quickly 
are we going to come to some resolution.
    Wait time, wait time is not--you know, wait time, as a 
friend of mine, one of my Vietnam squadron mates told me about 
a month ago, he is still grieving for the recent loss of his 
wife to cancer and he is writing a book on our experiences in 
Vietnam, but his quote he is going to use for all to know, and 
I think it relates to his grieving for the loss of his spouse, 
is you think you have time, but you don't.
    I would suggest to you that that sense of urgency and 
thinking about how much time you have, but you really don't, we 
need more. We need a lot more and we need it sooner, and you 
can do it with quality, I know you can.
    So I have gone over my time and, unless there are any other 
follow-ups, we are going to proceed here with a closing 
statement.
    First of all, I would like to thank all of the witnesses 
for participating in the hearing today. The panel is now 
excused.
    And as you heard Chairman Bost and Ranking Members Kuster 
and Esty say, you know, that our efforts as these Subcommittees 
on behalf of the veterans are an example of true bipartisan 
effort that we are all philosophically aligned that it is our 
job as the Committee to do the right thing for the veterans.
    These Subcommittees that we represent here will continue to 
set the example for our 115th Congress about doing the right 
thing for those involved. So I am very proud to be a Member of 
this Committee.
    For years this Committee has been working to address the 
root cause of the high denial rate for Gulf War Illness claims. 
In that time, we have been met with a list of excuses from VA 
for failing to improve the process for Gulf War claims.
    Last year, we held a hearing to assess the disability 
claims process for Gulf War veterans and highlighted, just as 
we have discussed here today, that VA's approval rate for Gulf 
War Illness claims is less than 20 percent. VA often seems to 
deny these claims because it demands to know the specific cause 
of an illness, yet under the law presumptive conditions do not 
require causality, because they are presumed to have been 
caused by service in the Gulf War.
    The Government Accountability Office report that we have 
discussed in detail here today further substantiated that the 
approval rates for Gulf War Illness claims are three times 
lower than all other claimed disabilities.
    The critical point to understand is that veterans cannot 
receive appropriate VA care for symptoms of Gulf War Illness 
when the majority of those claims have been denied by the VA. 
To make matters worse, the reason for claims denials are also 
not clearly communicated to veterans, we heard that in your 
testimony--it is not written in English, if you will--or their 
representatives. Failure to communicate the reason for denials 
often leaves veterans with confusing or insufficient 
information for a potential appeal, which further delays access 
to care and compensation for injuries.
    GAO's review of the medical examination process for Gulf 
War Illness also highlighted that VA's medical staff are not 
adequately trained to conduct the exam. And we talked about the 
90-minute optional course here.
    VHA medical examiners informed GAO that it is challenging 
to conduct Gulf War general medical exams due to the range of 
symptoms associated with the claims. Although their concerns 
are legitimate, there is limited evidence to support that VHA 
has taken the initiative to improve the examination process. 
Again, that sense of urgency.
    GAO reported that, as of February 2017, only ten percent of 
examiners participated in the optional online training for 
those examiners. This statistic is troubling, very troubling, 
because the VBA cannot consistently and accurately provide 
benefits ratings without a proper exam from VHA.
    Furthermore, GAO found that another contributing factor for 
claims denial was the lack of a single case definition of Gulf 
War Illness. Establishing such a definition could lead to 
improvement in diagnosis and treatment of Gulf War Illness.
    Over the years, Congress has appropriated millions of 
dollars for VA research programs and there is still strong 
resistance against establishing a single case definition for 
undiagnosed illness related to Gulf War service.
    I am also extremely concerned that VA does not have a plan 
to guide, to review of the existing medical data sets and 
integrated information from recent and ongoing research to 
identify areas of future research and establish a single case 
definition. Again, that sense of urgency when it comes to 
innovating and really coming together to move forward.
    I look forward to continuing to work with VA, Veterans 
Service Organizations, and other stakeholders to increase Gulf 
War Illness claims approval rates. Improve the medical 
examination process, prioritize research related to Gulf War 
Illness, and ensure the VBA is providing straightforward 
information to veterans regarding their benefits decisions.
    With that, I now yield to Ranking Member Esty for any 
closing remarks that you might have.
    Ms. Esty. Thank you, General, and thank you to all of you 
on the panel.
    And I particularly want to thank Mr. Hardie. I know this 
has been a passion of yours, and you have been a forceful and 
persistent and, sadly, necessary advocate to put a human face 
on what I know from my friend Mike Siccea, who has inspired me 
to introduce a burn pits bill to try to move this along 
further.
    So I in particular want to thank you for your advocacy and 
I don't think we would be here today if it were not for your 
efforts. And I am sorry for the reasons that it has brought you 
here, but I am glad that you are here and I want to thank you.
    As a newer Member of this Committee, I am struck by how 
much we need to learn the hard-earned lessons of Agent Orange 
and not do what was done then. And I think the level of 
frustration you are seeing from this panel is a deja vu that 
this is taking too long and not everybody has got time, nor 
should they have to wait.
    The most important of those lessons is that we have to be 
determined, we have to work together. The unwieldy and long 
research process, which again I would agree with my colleague 
Representative Brownley, the expert on Gulf War Illness, with 
all due respect, is not the National Academy of Sciences, it 
should be the VA. Nobody else actually should know--or DoD or 
working together--nobody else is actually going to know that 
other than, right here, the people who supervise.
    The difficulty medical examiners have understanding the 
multi-symptom health conditions of Gulf War, and these are 
getting in the way of identifying and quantifying toxic 
exposures on the front end, and providing timely, fair 
compensation, services, and most importantly top-quality health 
care for our Gulf War veterans on the back end. We owe it to 
them not to let this happen, as we continue to owe it to our 
Vietnam veterans and the Blue Water veterans who are still 
trying to find a way to get the care that they need and 
deserve.
    I think it is very clear, and I want to acknowledge and 
thank the VA for taking steps in a positive direction for 
veterans who have Gulf War Illness, but it seems to me these 
steps are too small; they are too incremental, they lack the 
urgency, and they lack the surge, the surge that we need.
    It has been 26 years since the first Gulf War started. Many 
of the veterans who were deployed are very sick and they have 
been beaten down by a claims process that is confusing, it is 
unclear, and in almost every case it seems to deny what they 
know to be true in their lives. That has undermined their faith 
in the system as a whole, and they have disconnected and they 
are discouraged, and that is, quite simply, wrong.
    So I want to say for my part, and I suspect I am not the 
only one on this panel, that if VA doesn't use its authority on 
its own initiative, Congress will begin to take steps. We will 
set timeframes, we will mandate training for all examiners, 
whether they are in the VA or whether they are contract. I 
think that has to happen. We will mandate timelines within 
which we have to have a single definition that everybody can 
use.
    And most importantly, we need to do better. The General and 
I were talking about this point about cost, which often seems 
to me to be really the reason behind the red tape. The point 
should be to care for our veterans and if we are spend so darn 
much time and expense and people dedicated to making people who 
are sick prove just how sick they are and how they got so sick, 
what about just taking care of the people who defended this 
country. What if we took those same resources that are deployed 
now on saying no and deployed them to saying yes to those who 
were deployed in the Gulf?
    And I think it is not just an academic exercise to answer 
the question that the General and I were talking about and he 
directly asked you, what would be the cost of truly, 
presumptively saying anyone who served, if you got any of this, 
we are going to get you better and back on your feet. That is 
our commitment to you. And not spend our time trying to 
determine what percentage, where were you exactly.
    The point is people served and they need help now. And we 
should be able to expect, and they should too, that they can 
get back on their feet and be productive members of society. We 
shouldn't ask them to prove how disabled they are, we should be 
helping them to get as abled as they could be.
    And I think that is a really serious thing we all need to 
be thinking about, because I am new to this Committee, but I am 
not new to hearing from the veterans in my district and the 
frustration that they feel, and the time and effort that goes 
into these fine hair distinctions, when instead I would rather 
see that money going to care for our veterans and get them back 
on their feet.
    So I would ask you all to think seriously about that and 
ask everyone on this panel if the time hasn't come to rethink, 
particularly when we are now at a point with a voluntary force. 
Our veterans are changing and we need to think about changing 
with them.
    Thank you for your service, thank you for working with us. 
And we look forward to seeing those letters in August and I 
hope they will be shared with the VSOs, so we can get this 
better and get this right.
    Thank you very much and, with that, Mr. Chairman, General, 
I yield back.
    Mr. Bergman. Thanks, Ranking Member Esty.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks, and 
include extraneous material.
    Without objection, so ordered.
    I would like to once again thank, sincere thanks to all of 
our witnesses and audience members for joining in today's 
conversation.
    With that, this hearing is adjourned.

    [Whereupon, at 11:05 a.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

                    Prepared Statement of Brad Flohr
Opening Remarks

    Chairman Bost, Chairman Bergman, Ranking Members Esty and Kuster, 
and Members of the Subcommittees, thank you for the opportunity to 
discuss how the Department of Veterans Affairs (VA) processes Gulf War 
Veterans' disability compensation claims for undiagnosed illnesses or 
medically unexplained chronic multi-symptom illnesses. With me today is 
Dr. Patrick Joyce, Chief, Occupational Health Clinics, Washington VAMC, 
VHA. My testimony will provide an overview of VA's processing of these 
claims and our training and quality assurance efforts.

Gulf War Illnesses

    Service connection for undiagnosed illnesses or medically 
unexplained chronic multi-symptom illnesses requires service in the 
Persian Gulf after August 2, 1990, and a qualifying chronic disability 
that rises to a compensable level of severity before December 31, 2021. 
To ensure Veterans who served in the Southwest Asia theater of 
operations continue to be entitled to benefits under the law, VA 
recently updated the regulation in 38 Code of Federal Regulations Sec.  
3.317 to extend the date for which service connection may be awarded 
for a qualifying Gulf War illness from December 31, 2016, to December 
31, 2021.
    A medically unexplained chronic multi-symptom illness means a 
diagnosed illness without conclusive pathophysiology or etiology. The 
objective signs and symptoms of these disabilities, as well as 
undiagnosed illnesses, include fatigue, skin conditions, headaches, 
muscle pain, joint pain, sleep disturbances, and cardiovascular 
symptoms, among others. The term ``medically unexplained chronic multi-
symptom illness'' also covers diagnosed illness defined by a cluster of 
signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and 
functional gastrointestinal disorders (excluding structural 
gastrointestinal diseases).
    Processing these types of claims requires a careful review of 
service treatment records, military personnel records, and post-service 
treatment records. Claims processors must carefully review the claimed 
disabilities and symptoms. Medical examinations are generally required 
where VA identifies these disability patterns to determine whether 
there is a medical explanation of the disabilities.

Gulf War Claims Processing

    In fiscal year (FY) 2016, approximately 18,681 Veterans who served 
in the Southwest Asia theater of operations received a rating decision 
for a claim for service connection for undiagnosed illnesses or chronic 
multi-symptom illnesses. From this number, 4,594 Veterans were awarded 
service connection for one or more undiagnosed illness or chronic 
medically unexplained multi-symptom illness. This equates to a grant 
(or approval) rate of 25 percent. When considering each type of claim, 
the approval rate for a medically unexplained chronic multi-symptom 
illness is 31 percent compared to 13 percent for an undiagnosed 
illness. It should be noted that when a Veteran claims an undiagnosed 
illness, if upon examination or if the medical evidence shows that 
symptoms can be attributed to a diagnosed condition, VA will service 
connect the diagnosed condition whenever possible rather than 
characterizing the claimed condition as undiagnosed. Therefore, the 
number of grants for undiagnosed illnesses or chronic multi-symptom 
illnesses do not reflect the actual number of Veterans service 
connected for known disabilities resulting from their Gulf War service.

Training

    VBA has developed a total of thirteen courses for claims processors 
that are focused on processing of claims for undiagnosed illnesses or 
chronic multi-symptom illnesses. Over the last year, VA Central Office 
mandated, as part of the FY 2017 National Training Curriculum for 
Rating Veterans Service Representatives, required training of four 
interactive lessons (eight hours) and one classroom-based course (two 
hours) for a total of 10 hours of training. For Veterans Service 
Representatives, a two-hour required class was mandated as part of the 
National Training Curriculum. In addition, a new lesson titled, 
``Southwest Asia/Gulf War Claims Development'' is currently being 
developed and is scheduled to launch in FY 2018.
    VA has implemented a number of other initiatives to improve Gulf 
War claims processing. VBA is making necessary changes to improve the 
notification process, specifically to require that decision letters 
indicate that claimed issues were evaluated under both presumptive and 
direct service-connection methods. This change is scheduled to go into 
effect by the end of August 2017. VA has developed special tracking to 
specifically account for Gulf War claims. VA has also amended its Gulf 
War General Medical Examination template to include information for 
examiners on undiagnosed and chronic multi-symptom illnesses, as well 
as information on environmental exposures in the Gulf War.

Quality

    The Veterans Benefits Administration (VBA) is constantly looking 
for ways to improve the service it provides to America's Veterans, 
including this cohort of Veterans. VBA works with the Veterans Health 
Administration (VHA) in reviewing the research done by its Offices of 
Public Health and Research and Development, as well as the National 
Academy of Medicine's (formerly the Institute of Medicine) biennial 
update on Gulf War issues. VBA also works with VHA and the Department 
of Defense in joint workgroups that research occupational and 
environmental hazards coincident with military service. VBA 
collaborates with VHA to update training for its medical examiners, as 
well as VBA's contract medical examiners. Finally, VA continues to 
collaborate with the National Gulf War Resource Center (NGWRC) in 
bimonthly meetings.
    VBA has a national quality review staff, as well as quality 
reviewers in its local regional offices, to ensure employees correctly 
process and decide claims for Gulf War illness. As agreed upon with 
NGWRC, VA conducted two distinct special-focused reviews of decisions 
on claims for Gulf War-related illnesses in December 2015 and September 
2016. The review in December 2015 focused on FY 2015 Gulf War illness 
cases and showed a 94-percent accuracy rate. The September 2016 review 
expanded the review to cases that involved claims for medically 
unexplained chronic multi-symptom illnesses over a 4-year period 
starting from FY 2011. This review showed an 89-percent accuracy rate.

Closing Remarks

    VA continues to improve the efficient, timely, and accurate 
processing of disability compensation claims involving service in the 
Gulf War. Although the science and medical aspects of undiagnosed 
illnesses and multi-symptom illnesses are complex, VA continues to 
review scientific evidence and medical literature to gain a better 
understanding of the impact of these illnesses on our Gulf War 
Veterans.
    This concludes my testimony. I am pleased to address any questions 
you or other Members of the Subcommittees may have.

                                 
               Prepared Statement of Melissa Emrey-Arras
        Additional Actions Needed to Improve VA's Claims Process
    Chairmen Bergman and Bost, Ranking Members Kuster and Esty, and 
Members of the Subcommittees:
    I am pleased to be here today to discuss our recent report on the 
process the Department of Veterans Affairs (VA) uses to evaluate Gulf 
War Illness disability compensation claims. VA estimates that among the 
nearly 700,000 veterans who served in the Persian Gulf War in 1990-
1991, about 44 percent experience chronic medical issues commonly 
referred to as Gulf War Illness. There are no similar VA estimates of 
the prevalence of Gulf War Illness among veterans who were deployed to 
the region after 1991. According to the Department of Defense, however, 
these veterans may have also been exposed to certain environmental 
hazards and many have developed similar medical issues upon their 
return. The exact causes of Gulf War Illness are not always known and 
veterans' symptoms vary widely, but include fatigue, headaches, joint 
pain, indigestion, insomnia, respiratory disorders, skin problems, and 
memory impairment, among others. VA refers to claims for Gulf War 
Illness as ``undiagnosed illness,'' ``medically unexplained chronic 
multisymptom illness,'' and ``infectious disease'' claims. For the 
purposes of this testimony, we collectively refer to these three types 
of claims as Gulf War Illness claims (see fig. 1).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Note: The symptoms of undiagnosed illness and the chronic 
multisymptom illnesses are examples-not an exhaustive list-of medical 
issues that VA associates with Gulf War Illness.

    (a) The symptoms listed below may be manifestations of either 
undiagnosed illness or medically unexplained chronic multisymptom 
illness. For simplicity, these symptoms are listed only once, under the 
category of undiagnosed illness.
    (b) Irritable bowel syndrome is one common type of functional 
gastrointestinal disorder.
    The VA provides disability compensation benefits to veterans with 
disabling conditions that were incurred or aggravated during active 
military service. \1\ Gulf War Illness claims are different in that VA 
can award benefits to certain veterans who served in a Gulf War 
conflict since 1990 and display any of the symptoms listed above 
without the veteran having to prove the symptoms are related to their 
military service. VA does require proof, however, of a veteran's 
service in the Gulf War region and existence of the claimed symptoms. 
Veterans Benefits Administration (VBA) claims raters review each claim 
to determine if relevant criteria are met, including verifying the 
veteran's deployment location; establishing whether the veteran's 
symptoms have lasted for a minimum of 6 months; and assessing the 
severity of the veteran's condition. \2\ As such, the VBA may request a 
medical examination from the Veterans Health Administration (VHA) to 
obtain additional information about the veteran's disability.
---------------------------------------------------------------------------
    \1\ See 38 U.S.C. Sec. Sec.  1110 and 1131. This does not include 
disabilities incurred by a veteran's own willful misconduct or abuse of 
alcohol or drugs.
    \2\ The minimum 6 month time period does not apply to claims for 
certain infectious diseases.
---------------------------------------------------------------------------
    From fiscal years 1994 through 2016, VA has funded more than $170 
million for Gulf War Illness-related medical research, including $12.3 
million in fiscal year 2016. According to the VA and a 2016 National 
Academy of Medicine report, while much progress has been made in Gulf 
War Illness research, more work is needed to better understand what 
Gulf War Illness is and how to treat it.
    My remarks today are based on our recent report, entitled Gulf War 
Illness: Improvements Needed for VA to Better Understand, Process, and 
Communicate Decisions on Claims. \3\ Accordingly, this testimony 
addresses (1) recent trends in Gulf War Illness disability claims, (2) 
challenges VA faces with accurately processing and clearly 
communicating decisions on Gulf War Illness claims, and (3) how VA uses 
Gulf War Illness research to inform its disability compensation 
program. In addition, I will highlight several key actions that we 
recommended in our report that VA can take to help address challenges 
with its Gulf War Illness disability claims process.
---------------------------------------------------------------------------
    \3\ GAO, Gulf War Illness: Improvements Needed for VA to Better 
Understand, Process, and Communicate Decisions on Claims, GAO 17 511 
(Washington, D.C.: June 29, 2017).
---------------------------------------------------------------------------
    For our report, we analyzed VBA data on disability compensation 
claims completed during fiscal years 2010 through 2015 and reviewed a 
non-generalizable sample of 44 Gulf War Illness claims that were 
completed in fiscal year 2015. \4\ We also visited 4 of VBA's 58 
regional offices (selected for high numbers of Gulf War Illness claims 
completed in fiscal year 2015 and geographic dispersion) and nearby VHA 
health care facilities where medical examinations take place. \5\ 
Throughout our work, we interviewed staff from VA headquarters and the 
4 regional offices we visited, as well as representatives from several 
veterans advocacy groups. We also reviewed relevant federal laws and 
regulations related to disability compensation benefits for Gulf War 
Illness. Additional information on our scope and methodology is 
available in our full report. We conducted the work on which this 
testimony is based in accordance with generally accepted government 
auditing standards.
---------------------------------------------------------------------------
    \4\ We determined these data were sufficiently reliable for the 
purposes of our reporting objectives and have noted in our full report 
any limitations that are associated with the data we present on trends 
in Gulf War Illness claims.
    \5\ We visited the Cleveland, Ohio; Seattle, Washington; St. 
Petersburg, Florida; and Waco, Texas regional offices and nearby VHA 
clinics.

In Recent Years, Completed Gulf War Illness Claims Have Risen, Included 
    More Medical Issues, and Been Approved at Lower Rates Than Other 
---------------------------------------------------------------------------
    Service-related Disabilities

    According to our analysis of VBA data, the number of Gulf War 
Illness claims has substantially increased in recent years and these 
claims often include multiple medical issues, which generally require 
more time to process. Specifically, in fiscal year 2015, VBA completed 
about 11,400 Gulf War Illness claims, which was more than double the 
4,800 claims for Gulf War Illness it completed in fiscal year 2010. \6\ 
Many of these claims included multiple medical issues-or, symptoms-
related to Gulf War Illness. \7\ On average, we found that Gulf War 
Illness claims had about twice as many medical issues per claim as 
other disability claims, and took 4 months longer to complete.
---------------------------------------------------------------------------
    \6\ VBA completed processing over 42,000 Gulf War Illness claims 
during the 6 year time period we reviewed.
    \7\ A medical issue is an illness or condition that a veteran 
alleges was caused or worsened by their military service and may 
entitle the veteran to disability benefits. A veteran may file multiple 
claims with VA, and each claim may include multiple medical issues.
---------------------------------------------------------------------------
    We also found that Gulf War Illness claims were approved at lower 
rates than other types of disability claims. During fiscal years 2010 
through 2015, we found that approval rates for Gulf War Illness medical 
issues were about three times lower than for all other claimed 
disabilities-17 percent of Gulf War Illness medical issues were 
approved over the 6-year time period we reviewed in comparison to 57 
percent of all other types of medical issues. \8\ According to VA, 
several factors may contribute to lower approval rates for Gulf War 
Illness medical issues including that these claims are not always well 
understood by VA staff. Additionally, according to some VA staff we 
spoke with, veterans sometimes file for Gulf War Illness disability 
benefits but do not provide sufficient evidence that their symptoms 
have existed for at least 6 months, as generally required by VA 
regulations.
---------------------------------------------------------------------------
    \8\ VBA makes a separate determination on each medical issue 
submitted by the veteran and, therefore, we analyzed approval rates for 
Gulf War Illness claims at the medical issue level.

Accurate Processing of Gulf War Illness Claims Is Hampered by Confusion 
    about the Gulf War General Medical Exam, and Claim Decision Letters 
---------------------------------------------------------------------------
    Lack Key Information

    VBA has clarified its guidance and implemented additional training 
for its claims rating staff, but the agency's ability to accurately 
process Gulf War Illness claims is hampered by inadequate training for 
VHA medical examiners who conduct medical examinations. VBA claims 
rating staff often rely on medical examiners to assess a veteran's 
disability before they make a decision on a claim. Medical examiners we 
interviewed said that conducting Gulf War general medical exams is 
challenging because of the range of symptoms that could qualify as Gulf 
War Illness. The VHA has offered an elective 90 minute web-based Gulf 
War Illness training for its medical examiners since June 2015. 
According to a VHA official, as of February 2017, VHA training data 
show only 10 percent of examiners had taken this training. Federal 
internal control standards call for adequate training for staff so that 
they can correctly carry out an agency's procedures. Medical examiners 
who do not take this Gulf War Illness-specific training may not be able 
to provide information to VBA staff to correctly decide whether to 
grant or deny a veteran's claim. To help ensure that medical examiners 
are well prepared to conduct Gulf War Illness medical examinations, we 
recommended that VA require its medical examiners to complete training, 
such as the 90-minute web-based course developed by VHA, prior to 
conducting Gulf War Illness medical examinations. VA agreed with this 
recommendation and plans to require that all its medical examiners take 
the 90-minute training course.
    We also found that decision letters VA sends to veterans denying 
benefits for Gulf War Illness claims do not always clearly explain to 
the veteran how their Gulf War Illness claim was decided, which can 
leave a veteran uncertain about how the claim was evaluated and 
potentially lead to unnecessary appeals. VA regulations require that a 
clear statement be provided to the veteran regarding the agency's 
decision on each claim. \9\ Without VBA including clear language in its 
decision letters, veterans may be unable to make a fully informed 
decision on whether to appeal VBA's decision. To improve communication 
with and provide more complete information to veterans whose Gulf War 
Illness claims are denied, we recommended that VA require decision 
letters for Gulf War Illness claims to clearly explain how the claim 
was evaluated. VA agreed with our recommendation and is in the process 
of updating its guidance to the regional offices to clarify the 
language required for its Gulf War Illness decision letters.
---------------------------------------------------------------------------
    \9\ 38 C.F.R. Sec.  3.103(b).

VA Considers Research When Identifying Additional Disabilities Related 
    to Gulf War Service, but Lacks a Plan to Guide Its Work on A Key 
---------------------------------------------------------------------------
    Research Goal

    VA considers research findings when adding to the list of 
conditions it presumes are associated with Gulf War service for 
disability compensation purposes, but it does not have a plan to 
develop a uniformly used case definition of Gulf War Illness. Based on 
research evidence, in 2010, VA added nine infectious diseases to the 
list of recognized Gulf War Illness-related conditions in its 
regulations. \10\ Since then, VA has not identified any new conditions 
that it associates with Gulf War service, but agency officials say that 
they continue to explore whether additional conditions should be added.
---------------------------------------------------------------------------
    \10\ Presumptions of Service Connection for Persian Gulf Service, 
75 Fed. Reg. 59,968 (Sept. 29, 2010). In 1998, legislation was enacted 
that required VA to seek to enter into an agreement with the National 
Academy of Sciences to study Gulf War Illness related topics. See Pub. 
L. No. 105-277, Sec.  1603, 112 Stat. 2681, 2681-745 (1998). VA relied 
on findings from one of these studies when determining that it should 
provide disability compensation to Gulf War veterans who have these 
nine infectious diseases.
---------------------------------------------------------------------------
    Despite the progress made by VA's Gulf War Illness research 
program, VA advisory groups have noted the lack of a single case 
definition that can be uniformly used to study Gulf War Illness, and 
emphasized that establishing a single definition could further improve 
the research, clinical diagnosis, and treatment of veterans with Gulf 
War Illness. VA's advisory groups recommended that in the near-term, 
the agency analyze data from its existing datasets to better understand 
how they can be used to contribute to a single case definition. For 
example, VA has access to dozens of existing large-population datasets 
from federally-sponsored research studies and data contained in several 
federal Gulf War registries that include veterans' health information. 
According to VA, if these data were merged with its administrative 
datasets (for example, those containing clinical and benefits data), 
the information could be leveraged by VA researchers to improve 
understanding of Gulf War Illness and, ultimately, contribute to the 
development of a single case definition. Merging these datasets could 
provide researchers with additional information needed to develop a 
case definition, including information on veterans' service and onset 
of their symptoms. In addition, VA's research advisory groups also 
noted the need for VA to plan for future research that is likely to 
contribute to a single case definition in the long-term.
    VA included in its 2015 Gulf War Research Strategic Plan a 
strategic objective to establish a single case definition, but 
according to a VA official, the agency has no action plan in place to 
achieve it. Federal internal control standards call for agencies to 
have documented plans that include specific action steps associated 
with their objectives. VHA officials told us that they are considering 
how to use existing federal datasets and ongoing research to better 
understand Gulf War Illness but have not laid out specific actions, 
such as what data to use and how using these data would contribute to 
the development of a single case definition. VA officials attributed 
the lack of a specific plan to challenges with developing a single case 
definition and noted that it must be a slow and deliberate process. 
However, without a plan, VA risks engaging in research activities that 
are not cohesively targeted toward its goal of establishing a single 
case definition.
    To increase the likelihood of making progress toward developing a 
single case definition of Gulf War Illness, we recommended that VA 
prepare and document a plan to develop such a definition, including 
near- and long-term goals and specific actions needed to meet those 
goals. In response, VA agreed with this recommendation and will convene 
a group of subject matter experts to work on a plan.
    Chairmen Bergman and Bost, Ranking Members Kuster and Esty, and 
Members of the Subcommittees, this concludes my prepared statement. I 
would be pleased to respond to any questions you or other Members of 
the Subcommittees may have.

GAO Contact and Staff Acknowledgments

    If you or your staff members have any questions concerning this 
testimony, please contact me at (617) 788-0534 or [email protected]. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this statement. Individuals 
making key contributions to this testimony include Nyree Ryder Tee 
(Assistant Director), Nora Boretti (Analyst-in-Charge), David Barish, 
Deborah K. Bland, Alexander G. Galuten, Marcia A. Mann, Martin E. 
Scire, Walter K. Vance, and Kathleen L. van Gelder. Other staff who 
made contributions to the full report cited in this testimony are 
identified in the source product.

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                  Prepared Statement of Zachary Hearn
    In March 2016, The American Legion testified before a joint hearing 
of the Subcommittees on Oversight and Investigation, and Disability 
Assistance and Memorial Affairs to discuss the adjudication of Gulf War 
Illness claims for veterans that served in the Persian Gulf since 
August 2, 1990.
    These veterans are prideful based on their honorable service, but 
many remain frustrated due to their chronic and unexplained illnesses. 
They defeated an aggressor, liberated a nation, and defended American 
interests, but for some the cost of this service to our nation has 
resulted in many veterans suffering with debilitating symptoms since 
returning from the Persian Gulf. The specific etiology of the 
conditions are mysterious, and the granting of presumptive claims 
related to Persian Gulf service remains a painfully long process that 
could result in years of appeals before receiving the positive 
adjudication they have earned.
    Chairmen Bergman, Bost, Ranking Members Kuster, Esty, and 
distinguished members of the Subcommittees on Oversight and 
Investigations, and Disability Assistance and Memorial Affairs; on 
behalf of National Commander Charles E. Schmidt and The American 
Legion, the country's largest patriotic wartime service organization 
for veterans, comprising over 2 million members and serving every man 
and woman who has worn the uniform for this country; thank you for the 
opportunity to testify regarding The American Legion's position on 
"Examining VA's Processing of Gulf War Illness Claims".
                               Background
    The Department of Veterans Affairs (VA) currently identifies 
numerous medical conditions or symptoms that are presumptively related 
to Gulf War service. Presumptively awarding service connection for 
conditions due to environmental exposures is not a new concept for VA. 
Conditions such as diabetes, ischemic heart disease, and a variety of 
cancers are presumptively related to herbicide exposure in Vietnam. 
Additionally, veterans of radiation testing have had multiple 
conditions presumptively ascribed to radiation exposure in service.
    For Persian Gulf veterans, they face a unique set of challenges in 
their quest to gain benefits derived from their military service. 
Unlike herbicide and radiation exposed veterans, many Persian Gulf 
veterans must prove they suffer from symptoms, or clusters of symptoms, 
and endure years of medical tests to indicate that they suffer from an 
undiagnosed illness.
    "Undiagnosed illness" is a frustrating explanation to a complicated 
medical situation. Numerous medical studies have revealed that veterans 
who returned from Persian Gulf service face serious health concerns 
following their deployments. However, a generation removed from 
Operations Desert Shield and Desert Storm, the medical community is 
still uncertain of how to properly diagnose or treat these veterans 
resulting in VA routinely denying disability compensation to veterans 
seeking service connection for Gulf War related conditions.
    Due to the ambiguity in the application of presumptive conditions 
associated with Persian Gulf service and the uncertainty within the 
medical community, veterans have become increasingly frustrated while 
trying to get their claims properly adjudicated. A common problem The 
American Legion finds is that veterans who seek a claim for benefits; 
and because of the complexity of Gulf War Illness (GWI); find that the 
diagnosis may have changed multiple times. VA raters are not medical 
specialists and are often unaware and unable to detect that the rapidly 
changing diagnosis is essentially the same condition. Moreover, the 
situation is further complicated by the fact that if one medical 
professional renders a diagnosis, by definition it is no longer an 
undiagnosed illness; even if the veteran received a multitude of 
differing diagnoses related to the same symptoms; and is therefore no 
longer undiagnosed according to VA raters.
    The American Legion has over 3,000 accredited representatives 
located throughout the nation. Through their dedicated efforts, The 
American Legion represented over 800,000 veterans in Fiscal Year 2016. 
We are fortunate to have trained professional service officers in each 
of VA's 56 regional offices (VAROs) and were able to refer to our 
national network of service office in March 2016, while testifying 
about Gulf War Illness claims. Some of the veterans' experienced the 
following road blocks while seeking service connection ratings:

      Medical professionals hesitate to connect conditions to 
Persian Gulf service;
      Some veterans have elected not to pursue benefits because 
a perception exists that there is more desire to service connect 
veterans with service in Vietnam;
      Medical professionals will assign symptoms to aging; and
      Medical professionals suggest the veteran is malingering, 
stating they are too young for the symptoms.

    According to American Legion's Department Service Officers (DSOs), 
little if anything has changed regarding the development and 
adjudication of claims in more than a year since the March 2016 
hearing. Many DSOs report limited GWI research combined with 
adjudicators' denial of claims have led to many appeals that result in 
years of waiting and increased anguish for veterans and their families.
     The American Legion's concerns were confirmed in the recently 
released Government Accountability Office (GAO) report \1\. GAO concurs 
with years of complaints from veterans and veterans service 
organizations (VSOs) regarding the treatment, development, and 
adjudication of Gulf War Illness claims. GAO's report provides insight 
into VA's lack of providing training to medical staff and VARO 
employees. VA's lack of training has resulted in various 
interpretations of guidance provided by VA Central Office resulting in 
vastly different outcomes for veterans. Furthermore, GAO concludes that 
VA's lack of clarity in its decision letters pertaining to Gulf War 
Illness claims leads to more questions than answers.
---------------------------------------------------------------------------
    \1\ Gulf War Illness: Improvements Needed for VA to Better 
Understand, Process, and Communicate Decisions on Claims, GAO, June 
2017
---------------------------------------------------------------------------
     Many DSOs and veterans have discovered they may fare better if 
they ultimately appeal Gulf War related conditions to the Board of 
Veterans' Appeals (BVA). One DSO stated that he encourages veterans to 
submit lay statements from friends and family members detailing the 
symptoms the veteran has experienced to bolster the claim. He also 
states that a VA rater will likely ignore the lay statement that may 
detail the chronic symptoms; however, BVA veterans' law judges will 
take the lay statements into consideration when rendering a decision.
    Each year The American Legion visits VAROs to review recently 
adjudicated claims and meet with VA employees. It is not uncommon to 
hear VA employees tell us that BVA has greater latitude than VA raters 
in adjudicating claims. It was concerning when we heard these 
statements from raters and decision review officers (DROs), and it was 
alarming when we heard it from a veterans' service center manager, and 
it was stunning when we heard last year from a senior official within 
the Veterans Benefits Administration (VBA) that the BVA has greater 
authority. When asked to clarify the statement and cite a regulation or 
statute, the official simply stated, "They just do", when in fact - 
they do NOT. The VA and the Board both adjudicate from the same 
statute.
    Based on this common misconception The American Legion contacted 
VA's Office of General Counsel (OGC) for input. OGC agrees with The 
American Legion that no greater authority is given to a BVA judge than 
a VA rater or DRO adding, "It is not accurate to say that the Board has 
greater authority than the (VARO) to grant benefits, or any authority 
at all to circumvent the law and award benefits at will." In short, a 
rater has the ability to grant the same claim as the BVA judge.
    VBA has routinely stated that BVA's combined 75 percent grant and 
remand rate for all appeals is due largely to the submission of 
additional evidence or the passage of time. There is some truth to that 
statement - however when considering that at least one senior official 
at VA Central Office stated that the BVA has greater authority, and 
numerous individuals at VAROs employed in management, as well as front 
line employee concur with that belief - VBA must own its routine 
inadequate development and premature denial of claims.
    OGC's response to why the perception may exist that BVA has greater 
latitude sheds light on one of the issues that hamper VBA - its own 
manual. According to OGC, "One provision that may further misconception 
is 38 C.F.R. Sec.  19.5 which provides that the Board is not bound by 
Department manuals, circulars, or similar administrative issues." VBA's 
manual was designed to provide "procedures for the adjudication of 
claims for compensation, pension, dependency and indemnity 
compensation, accrued benefits and burial allowance." \2\ Considering 
the routinely different outcomes between VBA and BVA decisions, it 
stands to reason that VBA needs to reconsider the manual and its use of 
the document.
---------------------------------------------------------------------------
    \2\ VBA M21-1 Adjudication Procedures
---------------------------------------------------------------------------
    The use of lay statements in VBA decisions by VBA raters has become 
far less common. One reason for this is VA's implementation of its 
"Evaluation Builder" within the Veterans Benefits Management System. 
The Evaluation Builder tool was designed to provide uniform outcomes in 
decisions regardless of adjudicator. Discussions with line employees 
and VARO management at numerous offices have concluded that lay 
statements cannot be taken into account within the tool. This is 
further complicated by the fact that if a rater overrides the suggested 
decision, the quality review team (QRT) is notified and a review of the 
decision is initiated by QRT. Many employees report they will 
adjudicate in accordance with the Evaluation Builder tool's suggestion 
in order to avoid a QRT review. This lack of use of lay statements 
omits significant evidence, severely disadvantages veterans who submit 
this evidence, and causes significant harm to veterans who are denied 
benefits because raters refuse to consider all legal evidence. As an 
example, statements that support a continuity of symptoms could be 
evidence toward receiving a grant of benefits, or photographs would 
support the existence of an undocumented temporary duty assignment that 
wasn't properly documented in the veteran's official military record. 
It is absolutely critical that all levels of the VBA adjudication 
process fully support the use of lay statements, and The American 
Legion calls on VA to immediately cease the practice of largely 
ignoring this type of important legal evidence.
    The American Legion finds that training continues to be an issue at 
VBA. One of our DSOs tells us that according to a VARO employee "VBA 
employees receive less (GWI) training than (VSOs)." The employee 
further states that any training received has been through VA's Talent 
Management System (TMS) web-based training, and that TMS training is 
not typically treated with the same level of focus as classroom 
training which has led to frustration with GWI claims.
    DSOs also question the level of training that medical providers are 
receiving regarding Gulf War Illness claims and question if minimal, or 
if any training at all is being provided. VBA's expansion of contract 
compensation and pension exams is also raising concerns. Contractors 
may be hired with little to no training regarding GWI which will result 
in negative nexus statements and an ultimate denial by VBA.
    The American Legion understands and appreciates the challenges VA 
faces regarding GWI. Unlike Agent Orange related claims or radiation 
exposure claims, a decision has to be rendered on an undiagnosed 
illness creating an inherent ambiguity. The American Legion suggested 
changes to Disability Benefits Questionnaires (DBQs) in March 2016 
which have not been adopted. DBQs are a standardized form used by 
medical providers to evaluate the level of disabilities suffered by 
veterans; both VA and private sector medical professionals have the 
ability to access these forms.
    As previously stated, many veterans are denied compensation 
benefits for Persian Gulf related conditions upon receiving a 
diagnosis, even if the diagnosis changes over the course of months or 
years. This lack of access to benefits can result in unequal and 
extraordinary hardship to veterans and their family members - all while 
their health continues to deteriorate. The American Legion calls on VA 
to identify veterans with Persian Gulf service and allow medical 
professionals to opine on DBQs if the sought medical conditions could 
at least as likely as not be related to Persian Gulf service despite 
having a diagnosis. This would provide the necessary path for medical 
providers, VA, and most importantly, our veterans, to finally receive 
their VA disability compensation. Through this additional language 
examiners and VA would have the necessary latitude to provide proper 
benefits.
    The American Legion calls on this Committee to have ongoing 
roundtables regarding GWI between Congress, VA, and VSOs so that we can 
improve the delivery of benefits for those suffering GWI. The appeals 
modernization effort that began in 2016 is proof that when we 
collaborate on a common problem, we can arrive at a successful 
solution.
    The American Legion has been concerned about the effects of 
environmental exposure on our servicemembers, and the resulting health 
effects years following service for more than 20 years. During The 
American Legion's 98th National Convention, we called upon "the 
scientific community to focus its efforts on the most likely causes of 
Gulf War veterans' illnesses" and for VA to "closely monitor the 
implementation of changes to title 38, United States Code, section 
1117, to ensure proper application of the law at the Department of 
Veterans Affairs regional office(s)", through passage of American 
Legion Resolution 122. \3\ Additionally, the resolution states The 
American Legion supports a "liberalization of the rules relating to the 
evaluation of studies involving exposure to any environmental hazard 
and that all necessary action be taken by the federal government, both 
administratively and legislatively as appropriate, to ensure that 
veterans are properly compensated for diseases and other disabilities 
scientifically associated with a particular exposure."
---------------------------------------------------------------------------
    \3\ The American Legion Resolution No. 122 (Aug. 2016): Gulf War 
Illnesses
---------------------------------------------------------------------------
                              Conclusion:
    The American Legion appreciates the level of difficulty associated 
with claims pertaining to Persian Gulf service; however, veterans have 
now suffered for a quarter of a century. VA's continuous reliance on 
the medical community to discover the etiology for a syndrome they have 
yet to define has cost too many veterans years of disability 
compensation. We call for an immediate liberalization in the way Gulf 
War claims are adjudicated so as to provide an opportunity for our Gulf 
War veterans to finally receive the benefits they have earned through 
their honorable service. The American Legion thanks this committee for 
their diligence and commitment to our nation's veterans on this topic. 
Questions concerning this testimony can be directed to Derek 
Fronabarger Deputy Director in The American Legion Legislative Division 
(202) 861-2700.

                                 
                 Prepared Statement of Michael Figlioli
    Chairmen Bost and Bergman, Ranking Members Esty and Kuster and 
members of the Subcommittees, on behalf of the men and women of the 
Veterans of Foreign Wars of the United States (VFW) and its Auxiliary, 
I would like to thank you for the opportunity to testify on the 
Department of Veterans Affairs (VA) disability claims process with 
respect to Gulf War Illness.
    As professionally trained, accredited advocates, VFW service 
officers work extraordinarily hard to ensure our veterans and their 
families receive the maximum benefit allowable by law from the VA. All 
too often, however, this does not happen for a myriad of reasons and 
contributing factors. In relation to the topic of today's hearing, I 
refer to a signature condition of the Persian Gulf War referred to 
largely across the veterans' community as Gulf War Illness (GWI) or 
more commonly in VA, as ``Medically Unexplained Chronic Multisymptom 
Illness.''
    Unlike nearly all other claimed conditions, Gulf War Illness is 
intrinsically difficult to diagnose and treat. GWI has no clear and 
concise set of rules. In other words, no one distinctive set of 
symptoms that allow for a single, unmistakable diagnosis. Gulf War 
Illness presents itself as a conglomeration of possible symptoms to 
which countless members of the general public with no military 
experience can also be subject. As such, Persian Gulf veterans have a 
steeper hill to climb in relating the symptoms to service--the most 
critical link in establishing service- connection.
    None of this is remotely possible without the benefit of a VA 
examination (VAE), either at a VA medical facility or with a VA 
contracted provider. As VA continues to evolve on a number of fronts, 
mostly with regard to the transition to electronic filing and continued 
concentration on managing the current claims inventory, VA developed 
the Disability Benefits Questionnaire (DBQ) with an eye towards 
efficiency and timeliness.
    Last year, the VFW strongly advocated for the elimination of the 
parsing out of symptoms and placing greater concentration on the 
clustering of these indicators of potentially one illness affecting 
multiple body symptoms, as opposed to specific conditions related to 
each symptom. Put more simply, the VFW feels GWI claimants would be 
better served by VA eliminating the assignment of multiple DBQs for 
seemingly unrelated symptoms upon the receipt of a diagnosis, and posit 
from the outset that the evidence meets the criteria for Gulf War 
Illness, as opposed to its current form of considering the possibility 
as a last resort. It was and remains our contention that the current 
system of assigning separate DBQs for each symptom being claimed in 
association with GWI promotes the potential for incorrectly assigning a 
diagnosis to a condition linked to GWI. Thus, either improperly or 
inadvertently negating the requirements of section 3.317 of title 38, 
Code of Federal Regulation (CFR), which ultimately results in the 
veteran's claim being denied.
    Regrettably, in the 479 days since these distinguished committees 
last met to discuss this topic and pressed VA to develop a single DBQ 
for GWI that would assist in empirically establishing service-
connection, VA's Office of Disability Assistance, has not reported any 
progress in the development of a single Gulf War Illness DBQ as 
Congress suggested, and veterans suffering from these chronic 
conditions that may give the appearance of a confirmed etiology 
continue to have their claims denied. VA continues to rely on a ``Gulf 
War Illness General Medical DBQ'' that is not singular in nature for 
claims of GWI, but instead rely on the subjective, non-medically 
trained construal of a claims assistant to interpret a veteran's 
claimed conditions and schedule the appropriate VA examinations. When 
asked about the possibility of the creation of a more favorable DBQ, 
the response of record was that ``VA would look into the issue'' and 
``First, we have to confirm that [lack of a single DBQ] is a real 
problem.'' However, every Veterans Service Organization sitting at this 
table has offered data, verifiable stories, and written statements as 
to that very point, yet the problems in rating these claims continue.
    Beyond the VFW's continued concern with the illogical requirements 
of service-connection for Gulf War Illness, is the downstream effect of 
the appellate process. VFW advocates who represent those whose claims 
were denied continue to recognize the numerous inconsistencies when 
decisions from the Board of Veterans Appeals (BVA) are remanded to the 
VA Regional Office. In assessing pending appeals for GWI, the VFW 
professional staff at the BVA notes that VA appears to clearly favor 
finding a diagnosis for each reported system and, thereby, rule out 
GWI, rather than further developing and accurately applying the rating 
schedule to a diagnosis that is even a minimally supported one. The VFW 
urges VA to consider both possibilities as existential. Since the 
preponderance of evidence shows the possibility that GWI may exist, the 
balance of evidence as to GWI's nonexistence is equal or in 
``equipoise.'' Therefore, in accordance with section 3.102 of title 38, 
CFR, there exists enough ``Reasonable Doubt'' that VA should develop 
the claim for the potential grant of Gulf War Illness disability.
    The VFW suggested in prior testimony that inconsistencies in the 
application of the rating schedule is universal across the VA Regional 
Office spectrum with regard to claims for Gulf War Illness 
disabilities. While we are not in any way suggesting that this is 
deliberate, we continue to put forward that a grant for Gulf War 
Illness in Maine should be exactly the same in Ohio, Iowa, or any other 
VA Regional Office based on the same evidence and fact pattern. VA's 
Office of Performance Analysis and Integrity has demonstrated their 
capability to track data nearly to the key stroke. This presents the 
perfect opportunity to identify and develop best practices across the 
Veterans Benefits Administration in properly adjudicating claims for 
GWI and eliminate the disparities that currently exist. At the very 
least, now that the National Work Queue (NWQ) is in effect, VA could 
easily distribute these ``specialized'' claims to the regional offices 
that have a proven track record in proper application of section 3.317 
of title 38, CFR, with an eye toward the centralization of Gulf War 
Illness claims as is the case with claims for exposure to toxic water 
at Camp Lejeune, Lewisite, Spina Bifida and other ``non-routine'' 
issues.
    Over the past six years, much of VA's effort has been focused on 
the backlog of existing claims. In the attempt to reduce this inventory 
as efficiently and expeditiously as possible, VA has relied exceedingly 
further on the use of contract examiners to meet demand and relieve the 
burden from the Veterans Health Administration (VHA). While this has 
allowed VHA to direct resources to provide health care to those already 
service-connected or otherwise enrolled in the VA health care system, 
far too often we are alerted to contract exams that are hastily 
conducted, not performed to VA standard (not compliant with the DBQ 
required to evaluate the disability), or not properly scheduled. For 
this reason, the VFW believes that developing a single DBQ intended 
specifically for identifying and rating Gulf War Illness and accurate, 
continuous training on how to complete these exams will result in the 
proper application of the law and the veteran receiving the 
appropriately awarded benefit their service has earned.
    As one of the nation's largest VSOs responsible for providing 
direct assistance to veterans seeking their earned benefits, the VFW 
continues to urge Congress to employ its oversight authority regarding 
the development of a single use DBQ for Gulf War Illness, proper 
training for VA examiners and claims adjudicators, and the 
consideration of centralizing these claims through the NWQ to ensure 
consistency.
    Messrs. Chairmen, this concludes my testimony. I will be happy to 
answer any questions you or the Subcommittee members may have.

                                 
                  Prepared Statement of Anthony Hardie
    Thank you, Chairmen Bergman and Bost, Ranking Members Kuster and 
Esty, and Members of the Subcommittees for today's hearing and for the 
invitation to speak with you today.
    I'm Anthony Hardie, National Board Chair and Director of Veterans 
for Common Sense (VCS), and a U.S. Army veteran of the 1991 Gulf War 
and Somalia. VCS and I have provided testimony on many previous 
occasions, most recently in February and March 2016 for Gulf War health 
and benefits hearings.
    Today's hearing is focused on the latest Government Accountability 
(GAO) report related to Gulf War Illness (GWI) issues, with bottom line 
finding of an 87 percent overall denial rate that is three times worse 
than any other type of claim the Veterans Benefits Administration (VBA) 
adjudicates. However, the GAO report delves deeper into these GWI 
claims issues and their intertwined relationship with medical research.
    These serious issues have profound real-world impact on Gulf War 
veterans. Please see Exhibit 1, attached to this testimony, that 
provides a number of Gulf War veterans' accounts of how their own VA 
claims for GWI issues were denied. The negative impact on these 
veterans compels us today to seek to find solutions to favorably impact 
them and help to relieve their suffering however we can.

2017 GAO REPORT ON GWI CLAIMS

    Specifically for Gulf War Illness (Chronic Multisymptom (CMI) and 
Undiagnosed Illness (UDX)) claims, this new 2017 GAO report \1\ found:
---------------------------------------------------------------------------
    \1\ U.S. Government Accountability Office, ``Gulf War Illness: 
Improvements Needed for VA to Better Understand, Process, and 
Communicate Decisions on Claims'' (GAO-17-511), June 2017.

      TRIPLE THE DENIAL RATE: ``.the approval rate for Gulf War 
Illness medical issues was 17 percent (about 18,000 of 102,00 issues 
rated), which was about 3 times lower than all other medical issues at 
57 percent (about 14 million of 24.7 million issues rated).''; ``This 
approval rate was consistently lower than that of the non-Gulf War 
Illness medical issues.'' (p. 18)
      WORSE FOR UDX CLAIMS: ``.eight VBA regional offices had 
approval rates of 5 percent or less for undiagnosed illness medical 
issues.'' (p. 22)
      WORSENING OVER TIME: ``Approval rates . decreased from 
fiscal year 2010 to fiscal year 2015.'' (p. 18)
      VA UNDERREPORTED GWI CLAIMS: ``.the number of completed 
[GWI] claims . may be underreported due to unclear guidance and 
inconsistent data entry over time by VBA's claim rating staff.''; 
``.staff had not been consistently identifying these medical issues as 
Gulf War Illness-related.''; ``[GAO] tested the data to determine the 
potential magnitude of the underreporting [of GWI issues]. and found 
approximately 57,000.''; ``The number of veterans associated with 
claims for these medical issues was about 41,000.''; ``.VBA is not 
planning to correct these data from prior years.'' (pp. 15-16)
      GWI CLAIMS TAKE 50% LONGER: ``.[GWI] claims took about 4 
months longer for VBA to complete than all other types of claims, 
averaging about 1 year compared to about 8 months.'' (p. 17); And, 
``.[GWI] claims with eight or more medical issues took on average 1 
month longer to complete than Gulf War Illness claims with seven or 
fewer medical issue.'' (p. 17, footnote). This means veterans who are 
the worst off have to wait the longest for the help they need.
      DECISION LETTERS ARE FLAWED: ``.decision letters for 
denied claims do not communicate key information to veterans'', 
including, ``why the claim was denied'' (p. ii), and, ``.could lead the 
veteran to conclude that their claim was denied because . VBA had not 
considered it under the presumptive method of service connection.'' 
(pp. 24-25). This is despite a 2002 GAO report (GAO-02-395) that noted 
that ``unclear decision letters can confuse claimants.'' (p. 25, 
footnote).
      NO CONSISTENCY BETWEEN EXAMINERS: ``Medical examiners 
have different views on and approaches for how to assess veterans for 
undiagnosed illnesses, in part, because of the challenge of identifying 
something as an undiagnosed or unexplainable illness.'' (p. 22)
      UDX IS UNWORKABLE: ``Medical examiners at one clinic told 
us that they could nearly always attribute a veteran's symptoms to a 
diagnosable illness, which would mean the veteran does not qualify for 
benefits under the undiagnosed illness presumptive category.''; ``.two 
examiners said that to determine that a veteran should be categorized 
as having an undiagnosed illness, they would have to rule out all known 
diseases that could cause the veterans symptoms. Doing so, however, is 
beyond the scope of a medical exam for disability compensation 
purposes.'' (p. 22)
      INADEQUATE TRAINING IMPEDES ACCURACY: ``VA's ability to 
accurately process GWI claims is hampered by inadequate training''; 
``VA has developed elective GWI training for its medical examiners, but 
only 10 percent of examiners had taken the training as of February 
2017'' (p. ii), an ``.optional 90-minute web-based training course.'' 
(pp. 22-23). By contrast, ``.they must complete training courses before 
performing certain specialty medical exams, such as for traumatic brain 
injury or post-traumatic stress disorder.'' (p. 23)
      EXAMINERS' ERRORS MAY RESULT IN CLAIM DENIAL: ``.VHA 
medical examiners sometimes provide a medical opinion related to 
service connection when one is not necessary because the veteran has a 
presumptive condition.. This opinion may include language that 
indicates the veteran's presumptive condition may not be relate to 
their service.''; ``.if VBA claim raters do not recognize that the 
medical examiner has provided an unnecessary medical opinion about 
service connection for a presumptive condition, they may inadvertently 
deny a claim that should be presumptively granted.'' (p. 22)
      WITH AN 87% DENIAL RATE, TRAINING ISN'T THE ONLY ISSUE: 
This is evidenced by the finding that ``.98 percent of VBA's rating 
staff had completed . training.'' Despite this level of training, VA 
still denies GWI claims at extraordinary rates. (p. 21, footnote)
      NO CONSISTENCY BETWEEN REGIONAL OFFICES: ``VBA provides 
guidance to its claims staff regarding when to request this medical 
exam; however, we found different interpretations of the guidance among 
staff in the four regional offices we visited.'' (p. 20)
      VA STAFF DON'T UNDERSTAND GWI: ``These Gulf War Illness 
medical issues may be denied at a higher rate, in part, because 
according to VA officials, Gulf War Illness is not always well 
understood by VA staff..'' (p. 19)
      NO GWI CASE DEFINITION, NO ACTION PLAN TO DEVELOP ONE: 
``The National Academy of Medicine and VA's Research Advisory Committee 
on Gulf War Veterans' Illnesses both recognize that establishing a 
single case definition has been challenging and noted the risks of 
adopting one that is either too narrow or too broad. Nevertheless, they 
both identified steps VA can take toward this goal.'' (p. 30, 
footnote). ``In its 2015 Gulf War Research Strategic Plan, VA included 
an objective to develop a single case definition, but an official told 
GAO that VA had no action plan in place to achieve it.'' (p. ii); 
``.the persistent lack of a single case definition for Gulf War Illness 
contributes to many of the current challenges with the Gulf War Illness 
disability compensation program.'' . ``Without a documented plan to 
establish a single case definition, VA may miss opportunities to focus 
its efforts and advance knowledge about Gulf War Illness, and 
potentially improve the lives of hundreds of thousands of affected 
veterans.'' (p. 32)
      NO VA REPORTING: ``According to VBA officials, VA does 
not publicly report on the total number of Gulf War veterans who 
receive disability compensation benefits for Gulf War Illness.'' (p. 1)
      VBA CAN'T ADEQUATELY REPORT ON OTHER PRESUMPTIONS: ``VBA 
officials noted that it may be more useful to compare Gulf War Illness 
approval rates to those of other types of presumptive disability 
claims, such as those for presumptive illnesses VA associates with 
exposure to Agent Orange during the Vietnam War. However, the data 
provided to us by VBA did not allow us to conduct this analysis.'' (p. 
18, footnote)
      STILL NO CONSISTENT VA USE OF THE TERM ``GULF WAR 
ILLNESS,'' despite strong NAS recommendations to use this term. ``In 
2015, VA's Office of Research and Development officially adopted the 
term `Gulf War Illness presenting as chronic multisymptom illness' to 
describe symptoms of undiagnosed illness or medically unexplained 
chronic multisymptom illness.'' (p. 6, footnote)
      VA DOESN'T HEED RECOMMENDATIONS: ``According to a June 
2014 report published by [a VA] internal workgroup, VA had yet to 
implement many recommendations related to programs and services for 
Gulf War veterans made by internal task forces and external advisory 
committees to senior VA leadership over the years. In June 2014, this 
workgroup's environmental scan identified several deficiencies 
regarding VA's response to Gulf War Illness, including that there is: 
*no overarching Department-level strategy for Gulf War veterans; *no 
well-coordinated process for receiving recommendations or implementing 
plans to respond to recommendations; and *no clear consensus on a 
single case definition for Gulf War Illness.'' (p. 12)
      PROCESS FOR NEW PRESUMPTIVES FLAWED: GAO notes that some 
VA research, ``.is directly relevant to the disability compensation 
program; for example, it has been used to establish additional 
presumptive conditions.'' (p. 26). However, no examples are cited 
because, beyond nine infectious endemic diseases, VA has found none. 
``VA has not identified any new presumptive conditions that it 
associates with Gulf War service since adding the nine infectious 
diseases in 2010.'' (p. 29). ``Some presumptive conditions have been 
added through legislation. As we previously noted, in 1994 a 
presumptive service connection for ``undiagnosed illness'' for Gulf War 
veterans was established, and in 2001 legislation was enacted 
establishing ``medically unexplained chronic multisymptom illnesses'' 
as being presumptively service connected for these veterans.'' (p. 27, 
footnote)
      BRAIN CANCER PRESUMPTIVE DENIED: ``VA officials said the 
agency decided not to proceed, citing limited scientific evidence from 
a 2016 National Academy of Medicine report.'' (p. 29)
      GAO RECOMMENDED VA: ``.require medical examiners to 
complete training . before conducting these exams.''; ``. require that 
decision letters indicate whether Gulf War Illness medical issues were 
evaluated under both a presumptive and direct service connection 
method.''; and, ``...prepare and document a plan to develop a single 
case definition of Gulf War Illness.'' . ``This plan should include 
near- and long-term specific actions, such as analyzing and leveraging 
information in existing datasets and identifying any areas for future 
research to help VA achieve this goal.'' (p. 32)
      VA AGREED: ``VA said it plans to make its 90-minute web-
based training course mandatory for its medical examiners who conduct 
Gulf War Illness exams. VA also stated it will improve how it 
communicates decisions to veterans and is in the process of updating 
its guidance to the regional offices to clarify the language required 
for its Gulf War Illness decision letters. Finally, VA said it will 
convene a group of subject matter experts to work on a plan-as 
described in our report-to establish a single case definition of Gulf 
War Illness.'' (p. 33)
      GAO ADMONISHMENT - ACTION PLANS: ``According to federal 
internal control standards, an agency's objectives should be defined in 
specific terms, including clearly defining how the objective is to be 
achieved and who is responsible for achieving the objective, as well as 
establishing time frames for meeting the agency's goal. These measures 
allow agencies to track progress toward achieving their goals.'' (p. 
31, footnote)
      GAO ADMONISHMENT - COMPETENCE IS A BASIC PRINCIPLE: 
``Demonstrating a commitment to competence is a principle of federal 
internal control standards.'' (p. 23, footnote)

PREVIOUS INVESTIGATIONS

    This latest GAO report is just the latest in a long line of GAO, 
Congressional, and other investigations. In 1996, a GAO investigation 
found that VA had denied Gulf War veterans' undiagnosed illness (UDX) 
claims under the 1994 law at a rate of 95 percent. \2\ Additional 
hearings, legislation, advocacy, and major public outcry by the 
nation's ill Gulf War veterans eventually resulted in two major bills 
enacted in 1998 that sought to fix these issues with what appeared to 
be a clear, comprehensive framework for Gulf War veterans' healthcare, 
research, and disability benefits. \3\
---------------------------------------------------------------------------
    \2\ U.S. General Accounting Office, ``Veterans' Compensation: 
Evidence Considered in Persian Gulf War Undiagnosed Illness Claims'' 
(GAO/HEHS-96-112), May 1996, p. 3.
    \3\ As I noted in our testimony of February 23, 2016 to the 
Subcommittee on Oversight and Investigations (O&I), and our written 
submission for the record of March 6, 2016 for a joint O&I and 
Disability and Memorial Affairs subcommittees, these were the Persian 
Gulf War Veterans Act of 1998 (Title XVI, P.L. 105-277) and the 
Veterans Programs Enhancement Act of 1998 (P.L. 105-368, Title I-
``Provisions Relating to Veterans of Persian Gulf War and Future 
Conflicts'') were two landmark bills, that, ``for those of us involved 
in fighting for the creation and enactment of these laws, they seemed 
clear and straightforward, with a comprehensive, statutorily-mandated 
plan that would guarantee research, treatments, appropriate benefits, 
and help ensure that lessons learned from our experiences would result 
in never again allowing what happened to us to happen to future 
generations of warriors.''
---------------------------------------------------------------------------
    The next major update followed shortly thereafter. Legislation in 
2001 added signs and symptoms of undiagnosed illness, and ``medically 
unexplained chronic multisymptom illness (such as chronic fatigue 
syndrome, fibromyalgia, and irritable bowel syndrome) that is defined 
by a cluster of signs or symptoms.)''. \4\ This was the last 
significant legislative change to Gulf War Illness claims.
---------------------------------------------------------------------------
    \4\ Public Law 107-103, the ``Veterans Education and Benefits 
Expansion Act of 2001,'' was enacted December 27, 2001; Section 202, 
``Payment of Compensation for Persian Gulf War Veterans with Certain 
Chronic Disabilities,'' took effect March 1, 2002.
---------------------------------------------------------------------------
    However, as we described last year, the implementation of all of 
these Gulf War laws aimed at helping ill Gulf War veterans has been 
fraught with challenges. Myriad VA-contracted National Academy of 
Medicine (formerly the Institute of Medicine (IOM)) literature reviews, 
at a cost of millions upon millions of dollars, have resulted in no new 
presumptive conditions related to Gulf War Illness, no new case 
definition of Gulf War Illness, no better assistance for ill Gulf War 
veterans seeking VA healthcare or benefits.
    Last year, detailed testimony \5\ to the House Veterans' Affairs 
Subcommittee on Oversight and Investigations documented that the 
negative conclusions of these reports reflected the refusal of the NAM 
(with the blessing and at times collusion of VA) to follow the clear 
language of the statute requiring the reports as to the appropriate 
standard review.
---------------------------------------------------------------------------
    \5\ Statement of James H. Binns, U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Oversight and 
Investigations, hearing entitled, ``Persian Gulf War: An Assessment of 
Health Outcomes on the 25th Anniversary'', February 23, 2016, 
Washington, DC. http://docs.house.gov/meetings/VR/VR08/20160223/104497/
HHRG-114-VR08-Bio-BinnsJ-20160223.pdf
---------------------------------------------------------------------------
    Meanwhile, the challenges with VA continue, some specific to GWI 
and some more generally applicable. For example, in 2002, GAO found 
that VBA letters to claimants needed to be improved. \6\ However, this 
2017 GAO report - with its major findings related to flawed GWI 
notification letters to claimants - shows that these 2002 
recommendations to VBA were not fully heeded.
---------------------------------------------------------------------------
    \6\ U.S. GAO, ``Veterans Benefits Administration: Clarity of 
Letters to Claimants Needs to Be Improved'' (GAO-02-395), April 23, 
2002.
---------------------------------------------------------------------------
    Then, in two 2004 reports, GAO found that the federal GWI research 
strategy needed reassessment, \7\ and that federal GWI research efforts 
had waned. \8\ In FY06, Congress created the Gulf War Illness Research 
Program (GWIRP) within the Congressionally Directed Medical Research 
Program (CDMRP) portfolio that is managed by the U.S. Army Medical 
Research and Materiel Command (USAMRMC). Also in 2004, GAO found that 
DoD conclusions about Gulf War troops' toxic exposures couldn't be 
supported. \9\
---------------------------------------------------------------------------
    \7\ U.S. GAO, ``Department of Veterans Affairs: Federal Gulf War 
Illnesses Research Strategy Needs Reassessment (GAO-04-767) June 1, 
2004.
    \8\ U.S. GAO, ``Gulf War Illnesses: Federal Research Efforts Have 
Waned, and Research Findings Have Not Been Reassessed'' (GAO-04-815T), 
June 1, 2004.
    \9\ U.S. GAO, ``Gulf War Illnesses: DOD's Conclusions About U.S. 
Troops' Exposure Cannot Be Adequately Supported'' (GAO-04-821T), June 
1, 2004.

---------------------------------------------------------------------------
GWI CLAIMS DENIAL RATES

    Advocacy by Gulf War veterans brought limited attention to the 
ongoing issue of VA denials of these GWI claims. In 2007, analysis of 
publicly reported VA data showed a 74 percent denial rate of all GWI 
claims. \10\ Advocacy related to these continued denials of GWI claims, 
and in 2010, VA intervened to clarify that the CMI's listed in the 2001 
law were merely ``examples'' of, and not an exclusive list of CMI's. 
\11\
---------------------------------------------------------------------------
    \10\ As noted in my March 6, 2016 submission for the record, a May 
2007 report from VA's Gulf War Information System (GWVIS) showed that 
of 13,027 GWI claims, only 3,384 had been approved - a 74 percent 
overall denial rate.
    \11\ U.S. Department of Veterans Affairs, ``All VA Regional Offices 
Training Letter, SUBJECT: Adjudicating Claims Based on Service in the 
Gulf War and Southwest Asia'' (10-01), stated in part: ``The chronic 
disability patterns associated with these Southwest Asia environmental 
hazards have two distinct outcomes. One is referred to as ``undiagnosed 
illnesses'' and the other as `diagnosed medically unexplained chronic 
multisymptom illnesses'' that are without conclusive pathophysiology or 
etiology. Examples of these medically unexplained chronic multi-symptom 
illnesses include, but are not limited to: (1) chronic fatigue 
syndrome, (2) fibromyalgia, and (3) irritable bowel syndrome.''' 
[Emphasis added]
---------------------------------------------------------------------------
    Fast forward a few years, and VA once stopped its public reporting 
of GWI data. Data obtained in 2014 by a Congressional office from VA 
showed a nearly 80 percent overall denial rate of GWI claims. \12\ That 
data also showed that VA approved 52 percent of denied GWI claims for 
other conditions, demonstrating an implicit VA bias against approving 
GWI claims; however, two in very five (38 percent) of Gulf War veterans 
were denied in totality.
---------------------------------------------------------------------------
    \12\ U.S. Department of Veteran Affairs data, provided to the 
office of then-Representative Kerry Bentivolio, March 28, 2014. 
Analysis by VCS - Out of 54,193 GWI claims filed: 11,216 approved 
(20.7%), 42,977 denied (79.3%); 22,470 approved for other non-GWI 
conditions (41.5% of GWI claims filed, 52.3% of denied GWI claims), 
20,507 denied for GWI and all other conditions (37.8%); average 
disability rating granted for GWI claims was 67 percent.
---------------------------------------------------------------------------
    Rounded off, according to VCS analysis of VA data, this most recent 
data shows a 78 percent VA denial rate of Chronic Multisymtom Illness 
(CMI) GWI claims, an overall denial rate of these GWI claims of 87 
percent, and a staggering 90 percent denial rate of Undiagnosed Illness 
(UDX) GWI claims. Data shown in in this new GAO investigation \13\ is 
entirely consistent with the exceedingly high denial rates reported 
over the last two decades.
---------------------------------------------------------------------------
    \13\ U.S. Government Accountability Office, ``Gulf War Illness: 
Improvements Needed for VA to Better Understand, Process, and 
Communicate Decisions on Claims'' (GAO-17-811), June 2017.
---------------------------------------------------------------------------
    That UDX denial rate is approaching the 95 percent denial rate 
identified by GAO in a 1996 report that was part of the impetus for 
1998 Persian Gulf War veterans legislation.
    In more detail, the rates of VA denial of GWI claims continues to 
worsen. From a VCS analysis of VA data, for chronic multisymptom 
illness (CMI) \14\ claims, VA's denial rates were as follows: in Fiscal 
Year 2011 - 72.5%, in FY12 - 72.1%, in FY13 - 75.3%, in FY14 - 77.0%, 
and in FY15 - 77.5%, as shown by VCS's analysis of GAO's newly reported 
FY15 full year VA data.
---------------------------------------------------------------------------
    \14\ ``CMI = Chronic Multisymptom Illness (Fibromyalgia DC 5025; 
Irritable Bowel Syndrome, DC 7319; Chronic Fatigue Syndrome, DC 6354) 
in either the hyphenated or primary code. If condition is both UDX and 
CMI, it is included in UDX counts.''
---------------------------------------------------------------------------
    For undiagnosed illness (UDX) \15\ claims, veterans' odds of 
approval are even worse and that VA's denial of these UDX claims is 
worsening: in FY11 - 80.5%, in FY12 - 78.4%, in FY13 - 78.6%, in FY14 - 
83.1%, and in FY15 - 89.8%, again using the same methodology.
---------------------------------------------------------------------------
    \15\ ``UDX = Undiagnosed Illness, defined as diagnostic codes 
containing 88xx in either the hyphenated or primary code.''
---------------------------------------------------------------------------
    Combining these CMI and UDX data, VA's overall denial rates for GWI 
claims show a true downward spiral: in FY11 - 76.3%, in FY12 - 74.7%, 
in FY13 - 76.6%, in FY14 - 83.1%, and in FY15 - 86.7%, again using the 
same methodology.
    This data also shows that that the rate of denial for UDX claims 
was higher than that of CMI claims in all but five of the 58 VA 
Regional Offices for which GAO reported FY15 GWI claims data. This is 
also significant, and demonstrates the disparity between Gulf War 
veterans getting a UDX GWI claim approved versus a CMI GWI claim 
approved. It also suggests that the Congressional intervention in 2001, 
which introduced CMI's to GWI claims, improved the plight of Gulf War 
veterans.

VBA REGIONAL OFFICES VARY WILDLY WHILE BAD PERFORMERS ARE DOING MORE 
    CLAIMS

    One aspect of these denials of GWI claims that went unremarked upon 
by GAO in this 2017 report is that one-third (9,875) of all the 
adjudicated FY15 GWI claims (28,250) were in just six of the 58 VA 
Regional Offices: Muskogee, OK (2,431, 94% denied); Roanoke, VA (2,124, 
95% denied); Nashville, TN (1,763, 83% denied); Atlanta, GA (1,339, 93% 
denied); Columbia, SC (1,130, 90% denied); and Waco, TX (1,088, 92% 
denied). This implied that VA is sending claims from elsewhere in the 
country to at least these six offices, five of which have worse or far 
worse denial rates than the 86.7% national average.
    GAO also did not remark on the discrepancies between VA Regional 
Offices, which are profound and imply extreme variation in claims 
processing standards of these claims depending on location and local 
management. Overall FY15 GWI denial rates ranged from 47% at Boston to 
100% at Anchorage. CMI denial rates varied even more widely, ranging 
from 36% in Manila and 38% at Boston to 92% at Roanoke and 100% again 
at Anchorage.
    Since VA has this data (it is VA-provided data, after all), it is 
entirely unclear why there has not been an internal investigation not 
only of these discrepancies, but also why there hasn't been a complete 
overhaul of GWI claims adjudication at the worst performers like 
Roanoke and Muskogee. Given that it can be inferred that VA is sending 
GWI claims to these offices from elsewhere, and that the data shows 
these regional offices have far higher than average denial rates, a 
cynical person might conclude this consolidation of GWI claims 
processing to high-denying offices was intentional.

RECOMMENDATIONS FOR LEGISLATION

    In past testimony, we have provided numerous recommendations for 
legislative action. Today, we will focus on just a few.

    A) Fixing GWI Claims should be the centerpiece of a legislative fix 
to help Gulf War veterans. After years of critiques, recommendations, 
hearings, investigative reports, and bad press, VA has yet to fix the 
GWI claims problem. Despite enactment in 2001 of legislation that 
created the new CMI presumptive and fine-tuned the original 1994 UDX 
presumptive, VA still remains hampered by training issues and 
inconsistent implementation between locales. However, though GAO 
reported VBA assertions of a training rate of 98 percent of its claims 
examiners, the issues continue.
    In short, underlying these issues is that the ``Undiagnosed 
Illness'' claims adjudication framework utilized by VA simply doesn't 
work as Congress intended in 1994 and subsequent updates. This premise 
is supported by several factors, including the persistence of near-
total denial rates of UDX claims and GAO's 2017 finding that some 
claims examiners will in essence never find in favor of an 
``undiagnosed illness'' and ``always attribute a veteran's symptoms to 
a diagnosable illness''.
    However, there may be another option. First, we note that that 
Congressional intervention in 2001, with the introduction of CMI's, 
consistently shows a better approval rate over claims adjudicated as 
UDX under the 1994 law that instituted these claims.
    Next, we note that both PTSD and TBI claims have seen dramatic 
overhauls in recent years that made significant improvements over 
earlier processes. As a potential model of sorts for a future GWI 
claims schema, the current TBI rating system (DC 8045) uses a system of 
``buckets'' of symptom sets, scored for severity as mild, moderate, or 
severe. While not perfect, it's not hard to envision major GWI symptom 
sets as a parallel to these TBI symptom ``buckets'' under DC 8045.
    And, just like for TBI claims, it would be important to ensure that 
there are direct tie-in's for diagnosed conditions related to GWI. For 
example, sleep apnea, gastro-esophageal reflux disease (GERD), and 
chronic sinusitis are three of several commonly reported conditions 
among ill Gulf War veterans. However, due to epidemiological research 
inadequacies and the inherent requirements of undiagnosed illness 
claims, once diagnosed these conditions - more likely symptoms of the 
underlying GWI - no longer qualify to be rated under the UDX 
presumptive.
    Given VA's track record of failure on these issues, including the 
failure to heed recommendations as noted in this 2017 GAO report, the 
process to create this new GWI claims schema should also be statutorily 
mandated. It should include a statutorily-mandated panel to lead this 
process composed of VHA and VBA key personnel and subject matter 
experts (including those involved in the process to create the new TBI 
claims rating schedule), clinical and research experts on GWI including 
as identified by the Gulf War Illness Research Program within the DoD 
Congressionally Directed Medical Research Program, representatives of 
stakeholder veterans service organizations, and engaged Gulf War 
veteran advocate stakeholders.
    It should be given a timeline to conclude its work, as short as 
feasible given the many years ill Gulf War veterans have been suffering 
under the present unworkable UDX and CMI GWI claims system. And, with 
these medical experts included, a scientific case definition that may 
still be years in the future may not be needed to create a workable GWI 
claims adjudication mechanism favorable to ill Gulf War veterans. 
Finally, the new rating schedule developed under this process should be 
published by VA as regulation with sufficient opportunity for public 
comment.
    We want to work with VA to fix this. To that end, in collaboration 
with other veterans service organization we have requested a meeting 
with top VA officials to seek resolution. However, given that VA has 
had decades to find a solution on its own but hasn't, active 
Congressional involvement and statutory mandates seem likely to be 
necessary to mandate this process.
    Recommendation: As the centerpiece of a legislative package to 
right as many ongoing wrongs as possible for Gulf War veterans, 
Congress should statutorily mandate a process to create a new, more 
viable GWI claims adjudication rating schedule in as short a timeline 
as possible.

    B) Mandatory Training. In this new report, GAO identified areas of 
concern related to staff training as one probable cause of GWI claims 
denials. Therefore, it is worth referencing VA's new performance 
standards for claims rating staff (Rating Veterans Service 
Representatives, or RVSR's) that went into effect on July 1st. In these 
new performance standards, staff training was listed as a ``non-
critical element'' of performance. Similarly deemphasized in these new 
performance standards was ``Organizational Support - qualitative and 
quantitative measurement of positive internal and external customer 
service and organizational support.''
    By contrast, the ``critical elements'' of these new performance 
standards include only accuracy, speed, and output. And, it remains 
unclear how appropriately VBA measures accuracy, given the high rates 
of success among veterans who appeal their denied claims (not GWI-
specific).
    It is unconscionable that Gulf War (and other) veterans' disability 
claims rely upon being reviewed by untrained medical examiners and 
claims staff, and that VBA has deprioritized training and customer 
satisfaction over speedy output. These new performance standards help 
underscore how these negative GWI claims outcomes are, in part, 
systematically allowed to occur.
    And last year, we reported to your Subcommittees in our statement 
for the record that VA had amended Gulf War provisions in the M21-1 
``Veterans Benefits Manual,'' which is used by VBA for rating claims. 
However, the spiraling VA claims denial rates and GAO's most recent 
findings of untrained staff and an array of reasons underlying VA's 
denial of Gulf War veterans' claims suggest that this intervention had 
far too little positive effect, if any.
    Indeed, last year the Senate Appropriations Committee included the 
following proviso in report language accompanying the FY 2017 Defense 
Appropriations Bill: ``While the Committee commends VA on its efforts 
to revise the Compensation and Pension manual for ``Service Connection 
for Certain Disabilities Associated with Gulf War Service,'' concern 
remains that VA claims adjudicators are not consistently following 
these changes.''
    However, it is presently unclear whether there was any response by 
VA to this or any of the sixteen (16) Gulf-War veteran-related provisos 
included by the Senate Appropriations Committee or the several similar 
provisos included by the House Appropriations Committee and by the 
conference committee in its Joint Explanatory Statement.
    Recommendation: Specialized training related to the type of claim 
involved should be statutorily mandated for all VA claims staff, 
including medical examiners and rating staff.
    Recommendation: VBA should be statutorily mandated to report data 
to Congress that emphasizes and measures training, and the consistency 
of training and claims adjudication between each VBA regional office.

    C) Gulf War Veterans Who Aren't Gulf War Veterans to VA. The 
federal government has two different definitions for service in 
Southwest Asia (SWA), the geographic location of the Gulf War. The U.S. 
Department of Defense (DOD) uses a more expansive definition for 
military service with its criteria for awarding the Southwest Asia 
Service Medal (SWASM). Meanwhile, the U.S. Department of Veterans 
Affairs (VA) uses a narrower definition of SWA to determine eligibility 
for benefits.
    As a result of these two different definitions, a small number of 
U.S. service members who deployed to Israel, Egypt, Turkey, Syria, and 
Jordan, including airspace and territorial waters, are eligible to 
receive the SWASM as Gulf War veteran but are not eligible for Gulf 
War-specific benefits administered by VA.
    Recommendation: VA should be statutorily mandated to amend the 
definition of SWA at 38 CFR Sec.  3.317(e) to include the additional 
geographic locations in 32 CFR Sec.  578.27(b) listed above.

    D) VA Needs to Track, Analyze, and Regularly Report VA Utilization 
Data for 1990-91 Gulf War Veterans. In 2010, VCS testified, ``At 
present, VA has no idea how many UDX claims have been granted or 
denied.'' This 2017 GAO report makes it clear that VA has not been 
consistently tracking GWI claim denials and approvals, with about 
41,000 veterans' GWI claims not included in VA's data reporting.
    VA should have a statutory mandate to report quarterly and in 
perpetuity a comprehensive package of VBA and VHA usage and benefits 
data. These reports should include raw and analyzed data on the numbers 
and rates of claims filed, approved, and denied by era and actual war 
service (i.e., 1991 Persian Gulf War, etc.), and healthcare utilization 
also broken down by cohort. For 1991 Gulf War data, the recommendations 
adopted unanimously in 2012 by the Research Advisory Committee on Gulf 
War Veterans' Illnesses (RAC) should be implemented. These new 
quarterly data reports should be publicly accessible to enhance VA 
accountability.
    Recommendation: VA should have a statutory mandate to publicly 
report quarterly and in perpetuity a comprehensive package of VBA and 
VHA usage and benefits data that includes the 2012 recommendations 
adopted unanimously by the RAC.

    E) Other recommendations for legislation. Along with comprehensive 
reviews of the 1994, 1998, and 2001 laws, our numerous recommendations 
for legislative action made in previous testimony that should now be 
reviewed, including :

      Added Presumptives. As part of a tie-in with a new claims 
schema for GWI claims, there should be consideration of statutory 
mandates for presumptives for Gulf War veterans for brain cancer, lung 
cancer, migraines, GERD, chronic sinusitis, and the numerous other 
conditions shown in one or more VA epidemiological studies as occurring 
at higher rates than control populations.
      National Toxic Exposures Advisory Committee. Creation of 
a new, interagency (HHS, DoD including CDMRP, and VA including both 
VHA-ORD and VHA-PDHS) national advisory committee on toxic exposures, 
with a scope that spans quality of life measures from healthcare to 
benefits. Examples of toxic exposures include Agent Orange, 1991 Gulf 
War exposures, chemical warfare agent exposures, burn pits and airborne 
hazards, Camp Lejeune drinking water, and so on.
      WRIISC's. Expanding VHA's War Related Illness and Injury 
Study Centers to make them more accessible and for clinical treatment, 
not just one-time clinical evaluation and medical research.
      Gulf War Registry. Enhancing VA's Gulf War Registry to 
make it a meaningful medical surveillance tool to help identify 
emerging medical trends among Gulf War veterans.
      Gulf War Spouses and Children Registry. Consider 
restoring this former registry, also as a meaningful medical 
surveillance tool to help identify emerging medical trends.
      Reform of the relationship between VA and the National 
Academy of Medicine. Congress depends on the National Academy of 
Medicine for unbiased judgment medical issues involving veterans. 
Congress orders VA to contract with the NAM for reports on these 
issues. Too often, the reports fail to live up to this unbiased 
standard. VA routinely fails to contract for the report as specified by 
Congress. And NAM committees frequently include former VA officials and 
contractors in the areas addressed by the reports. Legislation is 
sorely needed to restore the impartiality of NAM reports on veterans' 
medical issues.
      RAC restoration. In 2013, the U.S. House passed 
legislation under unanimous consent that would restore the Research 
Advisory Committee on Gulf War Veterans' Illnesses (RAC) to its 
original intent, though it failed to be taken up in the Senate before 
the Congress ended. That legislation should be reviewed for potential 
revision and reintroduction.

EXHIBIT 1: GULF WAR VETERANS AFFECTED BY VA'S GWI CLAIMS DENIALS

    Collected July 2017

    The following are accounts from Gulf War veterans - in their own 
words--whose claims have been denied by VA for Gulf War Illness 
presumptives, including undiagnosed illnesses (UDX) and chronic 
multisymptom illnesses (CMI's) like fibromyalgia, chronic fatigue 
syndrome (CFS), and functional gastro-intestinal disorders (including 
irritable bowel syndrome (IBS)).

Arizona

    I just moved to Arizona from being in California for past 7 years. 
I was diagnosed with Multiple sclerosis and Lhermitte's while working 
up in Oregon. This was in Sept 2015. The VA kept me overnight to run 
more tests, and next morning the Neurology team came in and asked how 
long I had this disease, and I said 3 weeks. They said I had this at 
least 15 years or more. The main neurologist was surprised that I was 
not blind, paralyzed, or both by looking at my charts.
    * I filed my claim when I got back to Huntington beach CA. in July 
26th 2016.
    * After getting more exams from Long beach VA, and getting my Rep 
with Paralyzed Veterans of America, we filed a claim. My presumptive 
conditions are: Multiple sclerosis and Lhermitte's, Chronic Fatigue, 
Chronic Joint Pain, degeneration discs and right hip, shooting pain in 
feet.
    * I have a Nexus letter from my primary doctor from Salem OR, that 
was a specialist in MS. Stating that my condition was highly rated from 
being triggered from the Gulf War exposure of Oil well fires and 
possible Gas exposure. He had gone through my records to confirm of my 
unit and locations. I have x-rays of my joints, spine, and hip to 
confirm degeneration. I have multiple MRI's to confirm of the lesions 
on my brain and my spine for Multiple sclerosis and Lhermitte's. 
Paralyzed Veterans of America have my first contact info from 1994 of 
the first Gulf War Registry of me having the same issues that I have 
today, only now they are more extreme. I have letters/statements from 
veterans, current military servicemen, and family members. I have 
followed the book on preparing my case to file my claim only to be 
denied. I have a mountain of evidence and doctors to back my claim up. 
Doctors have been actually shocked that I am not on disability.
    *The only reason I have from the VA for being denied is ``Not 
service connected''.
    * My next step as of Monday July 10th, 2017, is getting my Rep with 
Paralyzed Veterans of America to get me answers and sent a letter of to 
an Accredited Claims Agent to see my next step.
    *Not sure what an appeal would do except wait another 2-5 years for 
a response.
    *Impact on me is that now that I have heard the stories of the VA 
and now that I am in the process of being pushed aside is appalling. It 
is completely amazing how bad the process is for all of us Veterans. 
Just disgusted.

Arkansas

    I was diagnosed with a myoclonus (research this condition, it is 
the perfect example of an undiagnosed condition) a few weeks (May 1991) 
after I spent 8 months during desert shield/storm. I was told it was a 
seizure disorder and prescribed seizure medication. Not knowing that 
the medication side effects would cause me to get discharged, I was 
told at the time I did not have a claim. This diagnosis was re-affirmed 
in 1992, 2007, and 2010. And I'm still fighting the validity of the 
claim of ``Gulf War Illness'' and seizure disorder, as the V.A. has 
denied both and reworded my claim. That is a small example of the many 
medical conditions that I have that fall under GWI that I am fighting 
since 2007 when GWI was recognized by congress.

California

    Around 1990 I was invited to attend SFOD-D, during the selection 
process I was given a flight physical which I passed with no issues and 
was given a class date in March of 1991. Desert Storm kicked off not 
long after this and I was cross-levelled to 2nd ACR for Desert Storm 
where I served as a Bradley Cmdr. Upon my return I was ordered to the 
101st. Where I was seen for rash, heart rhythm disturbances and 
tachycardia (POTS) and vertigo, also present was persistent flu like 
body aches after physical exertion. I was informed these issues were 
psychological. I left the Infantry in 1994 and filed a claim which was 
denied. I filed another claim in 2007 which was denied.
    I filed another claim in 2009 for IBS which was granted.
    In 2015 I had a serious flair which again brought the heart rhythm 
disturbances (NSVT, PSVT and POTS) along with many of the issues 
associated with GWI:

      Neuropsychological deficits (documented by exam)
      Cardiovascular signs or symptoms (documented by exam with 
no explanation or identifiable pathology)
      CFS, (documented by WRIISC) and recently Dr. Baraniuk.

    These and a few others were included in a claim filed in May of 
2015, all of which were denied.
    It was not until [VSO's] took my case before the director did I 
receive a partial award for CFS, all other issues are on appeal with no 
end in sight.
    There is no way I can cover everything, I am too cognitively 
compromised and intend to hire an attorney to engage the VBA from this 
point forward.
    [VSO's] have some of these documents but I assure you there is 
evidence to back up each of these claims. The VBA has it in their 
files.
    Most, if not all denials were ``Not service connected `` per the 
VBA.

Florida

    I live in the Tampa bay area in Florida. I made a claim for CFS in 
2008 and subsequently in 2010 pointing specifically to the presumptive 
law. Both were denied for lack of evidence. I included doctors' notes, 
and diagnosis from the VA primary care and chronic pain clinics. I did 
not appeal as I was at my wits end at this point given the VBA denied a 
claim with diagnostics from the VAMC. (The VA denied a claim based on a 
diagnosis for a presumptive condition by the VA) I am contemplating 
reopening the claim and adding more evidence in terms of diagnosis and 
treatment records however the previous two attempts were denied 
specifically because there was no evidence in my service medical 
records. At least I presume that given ``lack of evidence'' is a broad 
statement. At the time I was being treated for chronic fatigue and 
chronic pain. This again is for a presumptive...
    I was informed by a claims examiner that if they can offer a 
diagnosis then undiagnosed illness is out the window given it is then 
diagnosed. This leaves a veteran suffering with a now known condition 
that the VA can comfortably deny any claim against. That is a huge 
loophole given often a diagnosis may not be well grounded and based 
solely on symptoms presented. Often the symptoms may fit many diagnosis 
and they pick one. I claimed CFS specifically along with physical 
symptoms that were at the time present but undiagnosed.
    The impact of the denial has both a psychological and a physical 
impact. It makes you feel like you are being brushed away and are 
wasting energy and time on an impossible brick wall of bureaucratic red 
tape. This seems to encourage you to abandon hope of any successful 
claim. I do not have the resources to mount a legal challenge and 
frankly do not have the energy to either. Physically this leaves me 
paying out of pocket often to treat the conditions if I seek treatment 
outside of the VA. The medical supports would be wonderful but seem out 
of reach. The compensation would assist in support of life in general 
that tends to revolve around managing chronic conditions first and 
working when and where one is able so as to survive without becoming 
homeless.
    This feeds stress generally which exacerbates said chronic 
conditions. Ultimately if we are really dedicated to the care and 
wellbeing of our veterans then it is Congress that must act to clarify 
title 38 and end this debacle. It is Congress that as well needs to 
properly fund the VA or other programs that will provide care and 
compensation. It is a cost of war and it is hard to define... how much 
is a Semi-normal life worth over what time span and by how many 
hundreds of thousands of impacted persons? We stood up... we are still 
paying a price... help please.

Indiana

    I live in Indiana (Jeffersonville) and I filed in 2015 for 
gastrointestinal issue and IBS problems. I submitted a direct 
questionnaire from my personal doctor on these issues.
    The VA denied saying that it was not service related. I appealed 
and got denied again.
    Without the meds I take I couldn't do the job I do every day with 
an approved claim I could go back to school and do something easier on 
my body.

Iowa

    I am a retired Army MSG. I am also disabled through the VA. I 
served in the Gulf War from October 1990 through June 1991. I served 
all over the theater from Saudi Arabia, Southern Iraq, Kuwait, and 
Northern Iraq. I am a combat veteran. I currently live approximately 45 
miles from Des Moines Iowa.
    I originally filed with the VA for Gulf War Illness in the summer 
of 1998 while living in NC, just after I retired at the end of May. I 
was just getting my notices for exams when my Gulf War veteran wife 
took her own life. Due to circumstance and the severe depression and 
other health issues I was unable to comply with those notices. The VA 
denied everything due to that failure.
    My second filing was in Iowa in 2008. I filed for the same issues. 
I had been seeing medical professionals continuously since retirement. 
All of that information was either directly obtained by myself or 
provided or the VA obtained it through permission from me. My first 
compensation and pension examination was right after Memorial Day 2009. 
I was unable to comply because I was hospitalized with pancreatitis 
during that weekend.
    Even though my physician notified the VA my file was pulled for 
non-compliance. I fought and involved my congressman and eventually the 
file was returned and I was examined the first time in 2009 and other 
times into 2010. None of the exams were for GWI specifically. That exam 
was referred to Public Health.
    However, I had claimed Chronic Fatigue Syndrome/Fibromyalgia, 
Irritable Bowel Syndrome, as well as sleep disorder/sleep apnea and 
much more symptomology that was unexplained and still is. All was 
denied except 10% for IBS. All were appealed and again IBS was approved 
at 30% and all other denied. IBS was not approved as a GWI presumptive. 
All denials were stated to be unrelated to my service although most if 
not all were recorded on my retirement physical. The appeal awarded me 
100% P&T with only one GWI related issue. Due to the huge backlog in 
claims I was advised not to pursue at that time.
    I still suffer all the symptoms I had following the GW and they 
have progressively worsened. The lack of diagnoses prohibits possible 
treatments. The entire merry go round of seek and deny exasperates the 
depressive disorder I share with my PTSD.

Kentucky

    I am in Louisville, Kentucky.
    I filed for a constellation of neurological symptoms with no 
diagnosis in 2013, and was denied for each symptom of my undiagnosed 
illness.
    I appealed in 2014 with a new diagnosis of cramp fasciculation 
syndrome on the argument that I should have been approved for 
undiagnosed illness, but now should be approved for an idiopathic 
chronic multisymptom illness. I was then denied for no service 
connection.
    I appealed that decision citing the presumptive in 2015. My appeal 
has been reviewed by the Star team twice and sent back to the regional 
office and denied each time. The examiner's opinion, a nurse 
practitioner, seems to carry more weight than my VA neurologist who 
diagnosed me, and the Chief Examiner in DC. The last statement of the 
case said the nurse practitioner's opinion was more compelling.
    The claim is now awaiting a hearing with the board of appeals.
    I filed for IBS in 2016. The same examiner stated it could not be 
service connected. I was denied for no service connection. The Star 
team sent it back for correction. The examiner literally described my 
severe symptoms, and stated I experience them moderately. I am 
currently rated at 10%, and have appealed for 30%. This claim is also 
going to the board.
    I am facing an early retirement due to my health. The failure of 
the VA to provide me with adequate care, and then basing the rating 
decision on that same inadequate care is causing me an unnecessary 
amount of distress and financial hardship.

Louisiana

    I am in Louisiana and continue to be denied for fibromyalgia since 
2000. I have documentation signed by a rheumatologist in a Gulf War 
exam in 1994 with that diagnosis. I am currently on Cymbalta with VA 
medical records stating that I declined Lyrica because it has not 
worked for me in the past. An NP at a C&P exam recently told me that I 
was never diagnosed with fibromyalgia, and I am not on any medications 
to treat fibromyalgia. I received a call last week from a VA employee 
at the central office stating that there was enough evidence in my file 
for service connection, and that I need to get my case out of my 
regional office.
    There is more to the story. I was sitting in my VSO's office on 27 
March 2017, discussing which conditions we would forward to DC on 
appeal, when my phone rang, it was an employee from legal at the RO. He 
told me there was enough evidence for a CUE. As he was talking, my VSO 
was typing. That too has been denied. After several calls, to include 
one to the White House complaint line, a supervisor from the RO called 
me and told me that the VBA judges have ``more leniency'' than she has, 
and that she would need a nexus letter. I informed her that it was my 
understanding that for presumptive conditions, with a diagnosis, no 
nexus was needed.
    I came home from vacation today and this was in my mail. I might 
find the irony in this funny if they had not been denying me since 
2000. ``Dear [Veteran's name], We received your correspondence 
indicating that you would like to file a claim for benefits. VA 
regulations now require all claims to be submitted on a standardized 
form. What Should You Do? In order for us to begin processing your 
claim, you must submit an application for benefits.'' [From the U.S. 
Department of Veterans Affairs]

Maryland #1

    I have been diagnosed with fibromyalgia, CFS, IBS, and migraines. 
VA states I'm only eligible for migraines and Fibromyalgia. They sent 
my appeal to board without a review. Stating all my symptoms are 
fibromyalgia related.
    This case was done at the Baltimore RO, it was expedited to clear 
the backlog. The VBA's Star Team review, but only looked at the IBS and 
agreed it was separate from the fibromyalgia and recommended that a 
claim for IU be submitted. They didn't look at the Chronic Fatigue 
Syndrome diagnosis. The case was denied because supposedly [the] 
diagnosed condition of CFS isn't related to military service, the 
decision is in violation of the statute.
    The RO never communicated that they received diagnosis of IBS, they 
did in fact communicate receiving diagnosis and DBQ for Chronic Fatigue 
Syndrome, but stated that the CFS wasn't related to military service.

Maryland #2

    I now live in Maryland. I filed for the first time in 1991 three 
months after coming home for headaches and fatigue and was denied. 
There are other issues that I have filed for over the years that fall 
under the Presumptive Illness List but I will concentrate on these two 
diagnoses.
    I never had a migraine in my life until 3 months after I returned 
from the Gulf. The headaches over the years went from here and there to 
daily occurrences that included migraines thrown in every few days. I 
am on daily medication to help keep the headaches from turning into 
migraines on a daily basis.
    The fatigue is just as bad. Some days it hits me out of the blue 
and I literally can't get out of bed for days on end. I just sleep. As 
an example, I just went through a phase this week: I slept 14 1/2 
hours, woke up for 3 hours, slept for another 8 1/2. This is right off 
my Fitbit.
    Yet, after filing in 1991 again in 2012 and again last year I have 
been denied each time. How am I supposed work when I LITERALLY can not 
get out of bed? I wish I could work EVERYDAY! This is not how I saw my 
life at 47 years old. But I would go and serve all over again knowing 
where I am now. Because I know that I helped people while I served my 
time in the sandbox with my unit, Fleet Hospital 15.

Ohio

    I suffer from dizziness. It's constant, but comes with episodes of 
severe debilitating loss if muscle control. I call it dizziness because 
it feels like I don't have my balance, but it's more than that, I get 
unreasonably depressed, can't walk, feel like I'm falling all the time. 
It started years earlier, but being young I just wrote it off as being 
hungry or tired.
    When it became debilitating i went to the best neurologist at the 
Cleveland clinic. They have no idea what it is, but tried treating me 
with anti-seizure medicine, migraine and multiple other things. None of 
them worked. He believes they are caused by constant migraine headaches 
without aura or pain. He found the VA presumptive conditions and 
suggested I should pursue it because he couldn't solve it.
    In about 2013 I applied under the gulf war presumptive conditions 
first for dizziness. They denied me because in the 90s I had positional 
vertigo, they said it was the same thing. I appealed in 2014, they 
denied me.
    I then filed in 2015 for migraine induced dizziness, they denied me 
for chronic fatigue syndrome. You will note, I did not apply for 
chronic fatigue syndrome, I applied for migraine induced dizziness, 
which meant not only was I denied, I could not appeal it because I had 
no evidence for chronic fatigue. It was no mistake on my or my VSC 
representative's fault, they just changed it.
    So we refiled, with another note and more evidence from my 
neurologist, headache with a secondary condition of dizziness. They 
denied it because I once had a tension headache.
    We appealed with another note from my neurologist stating I was not 
having tension headaches, listing the clinical and medical definitions 
of both, and quoting the VAs presumptive description which didn't 
specify any particular type of headache anyway.
    It's been about eight months since that. I'm still disabled, 
employed by the grace of my employer that understands and gives me time 
off any time I am ill. I pass out randomly and have symptoms mimicking 
heart attack because of also having a rating for irritable bowel.
    I'm tens of thousands in debt for the bills I've incurred. My life 
is changed forever. There are days that I can't get out of my chair.

Pennsylvania #1

    I live in Pennsylvania. The following is my statement of claim for 
denial of CFS and Fibro:
    The AOJ provided a VA examination dated April 7, 2017 unfortunately 
the exam was inadequate. The exam was not based upon the medical 
record, specifically the Georgetown University Progress Notes dated 
March 02, 2017 in which James N. Baraniuk, MD (Professor of Medicine, 
Division of Rheumatology, Immunology and Allergy, Director of the 
Chronic Pain and Fatigue Research Center, Georgetown University) 
diagnosed me with Chronic Fatigue Syndrome using the Centers for 
Disease Control (Fukuda 1994) criteria, and he diagnosed me with 
Fibromyalgia using the 2010, & 2011 Modified American College of 
Rheumatology criteria (SEE: Georgetown University Progress Notes dated 
March 02, 2017). A medical examination is considered adequate ``where 
it is based upon consideration of the veteran's prior medical history'' 
(SEE: Ardison v. Brown, 6 Vet.App. 405, 407 (1994).
    The examiner falsified the April 7, 2017 exam; he never touched me 
on any area of my body to check for tenderness, in fact the only 
contact with this examiner was to shake my hand upon arrival and 
departure. He spent approximately half of the allotted time for the VA 
examination admiring my service dog which had nothing to do with my 
claimed conditions of fibromyalgia and chronic fatigue syndrome. He 
then leafed thru the Georgetown University progress notes and asked 
about Dr. Baraniuk's credentials, but apparently investigated no 
further because he stated that my condition (fibromyalgia) ``was never 
confirmed by a specialist.'' (SEE: VA Form 21-4138, statement 
concerning exam of April 7, 2017).
    If this examiner had taken the time to investigate the credentials 
of Dr. Baraniuk, he would have found with a simple search on the 
internet that James N. Baraniuk, M.D. is the Associate Professor of 
Medicine, Division of Rheumatology, Immunology and Allergy, at 
Georgetown University. He is the Director of Georgetown's Chronic Pain 
and Fatigue Research Center and is one of the nation's leading experts 
on both fibromyalgia and chronic fatigue syndrome (SEE: me-pedia.org 
James Baraniuk printable). He is also one of the nation's leading 
experts on disabilities occurring in Persian Gulf veterans. His 
curriculum vita (CV doc) is 41 pages long (SEE: James N. Baraniuk, 
M.D., curriculum vita).
    The examiner errored in his rational when he stated that because 
exposures to environmental hazards were about 25 years ago, he could 
not confirm any disability pattern that would be related to Southwest 
Asia service. The Department of Veterans Affairs' Employee Education 
System and the Office of Disability and Medical Assessment (DMA) offer 
a Gulf War General Medical Examination Course. If the examiner had 
participated in this training or referenced the notice to examiners in 
Southwest Asia claims, found in Part IV, subpart ii, 1.E. 19.g of the 
M21-1 manual he would have understood that the examiner is to provide a 
medical statement explaining the Veteran's disability pattern. 
Fibromyalgia and Chronic fatigue Syndrome are both diagnosable but 
medically unexplained chronic multi-symptom illnesses of unknown 
etiology, and they are disability pattern 2, a diagnosable but 
medically unexplained chronic multisymptom illness. The notice to 
examiners in Southwest Asia claims tells the examiner that he or she 
shall not provide a medical opinion (nexus) for disability pattern (1) 
or (2) as to whether the condition was incurred - caused by service. 
Clearly the notice to examiners in Southwest Asia claims was not 
followed as this examiner, in violation of the statue, imposed a nexus 
requirement.
    The AOJ's adjudicator failed to recognize that a Gulf War veteran 
does not have to prove any link to the veteran's service and the VA 
cannot impose a nexus requirement under the provisions of 38 CFR Sec.  
3.317. Fibromyalgia and chronic fatigue syndrome are presumptive 
illnesses for Gulf War veterans; VA presumes that these conditions were 
caused by military service. The decision of May 12, 2017 is clearly and 
unmistakably erroneous as it is in violation of statue, VA regulations 
and VA procedures.
    This C&) was done April 7, 2016. Denial was dated May 26, 2016. 
Less than 32 days. (working days)

Pennsylvania #2

    I am a 20 year Marine Corps Veteran (1984-2004) who served in the 
Persian Gulf from August 1990 - April 1991.It was mandated that I 
receive the Anthrax Vaccinations (Series of 6 shots) but I only 
received 5 shots because the program was Temporarily halted prior to my 
6 shot and at a later date restarted. No explanation! I was also 
required to take the progesterone Bromide Pills (3 weeks) while serving 
in country during Operation Desert Storm.Prior to and since my 
retirement from Active Duty, I have reported numerous medical problems 
that have not been adequately treated or document to include:I am from 
Pennsylvania (Pittsburgh VA Healthcare System).
    2006 - MAJOR DEPRESSIVE DISORDER: I was diagnosed and medicated for 
the treatment of Major Depression. I filed a claim through the VA that 
was DENIED and the examiner inappropriately diagnosed me, based off of 
personal opinion as being an Alcohol Abuser. I never drank in the 
military and have only been a Social drinker since being discharged. I 
have NEVER abused Alcohol or any other Illegal drugs.
    On February 6-9, 2017, because of the intense pain and Fatigue that 
I suffer from among other things on A DAILY BASIS, I applied for, was 
accepted and participated in a DOD Gulf War Illness Research Study 
conducted at Georgetown University by Dr. James N. Baraniuk M D. My 
decision to participate in the aforementioned study was based off of 
the fact that Dr. Baraniuk is an Associate Professor of Medicine, 
Director of Rheumatology, Immunology and Allergy, Director of Chronic 
Pain and Research at Georgetown University. He is also one of the 
Nation's leading experts on both Fibromyalgia and Chronic Fatigue (SEE; 
me-pedia.org James Baraniuk). I found this information through a simple 
search on the internet.
    Through this intense 4 day study Dr. Baraniuk spent more than 15 1/
2 hours with me, one on one, after the testing. I also had my service 
Medical Records and Deployment Records with me for review. As a result 
of the study, I received a POSITIVE diagnosis for GWI (per the Kansas 
Criteria), Fibromyalgia (per the 1999, 2010 & 2011 standards), IBS-C 
and Chronic Fatigue. The doctor also noted, utilizing my VA treatment 
records, PTSD, DEPRESSION and SLEEP APNEA.
    Upon completion of the study, I spent the next 3 Months conducting 
follow up appointments through the Pittsburgh VA for testing evaluation 
and treatment. I also filed claims through the VA.
    The Medical Examiner, who lacked the specialized credentials that 
Dr. Baraniuk possesses, proceeded to discredit Dr. Baraniuk's progress 
notes by stating ``that study is done for research purposes only... Not 
for diagnosis proposes'' the Medical Examiner, a Nurse Practicioner... 
NOT an MD, wow these remarks in her notes.
    My claims for IBS and Fibromyalgia were DENIED under the Chronic 
Multisymptom Illnesses (CMI) because the medical examiner noted that I 
have clear and diagnosable illnesses.
    I clearly have a Medical diagnosis for IBS and Fibromyalgia (both 
are Gulf War Presumptives seperate from CMI) From Dr. Baraniuk and also 
from the VA since 2016 yet both were DENIED by the VA 's Rating 
Specialist.
    The constant delay and deny and the Lack of understanding of the 
Gulf War Symptoms cause me daily anguish and pain. As a result of the 
lack of a proper diagnosis and treatment, my conditions have 
continually worsened to the point that I had to quit working at the age 
of 49 due to my mental and physical conditions yet the VA has still not 
recognized the importance of training their medical staff to understand 
and identify the issues that we, Gulf War Veterans, suffer from even 
though there is medical knowledge and research that has confirmed these 
issues that has been paid for and conducted by the Department of 
Defense!
    I was also Service Connected at 0% from the VA in June 2017 for the 
frequent headaches that I suffer from (another Gulf War Presumptive). 
I've also had my CFS and Sinus (respiratory) claims denied twice. I 
have Sinusitis all through my Service Medical Records but the VA calls 
it Sinus Rhinitis

South Dakota

    South Dakota, 1994 CFS, degenerative disease of the joints, memory 
issues, headaches Denied for not being noted on Service Records, same 
story on the Appeal. ``filed as joint pain, headaches, memory issues, 
and being tired constantly'' x-rays, lab work, Doctors reports 
submitted. 2001 Doctors claim it is arthritis, and not degenerative 
disease of the joints. New Claim, denied, Appeal Denied. Did not appear 
in Service. Doctors notes submitted. 2006 Doctor said I have CFS, New 
Claim, New Evidence denied again, Appeal Denied. Did not appear in 
Service. All records were forwarded with all claims from V.A. Doctors 
since 1993. Presumptive Laws never applied for my claims, I asked. 
Frustration with the whole V.A. claims system!

Texas

    I'm writing this letter on behalf of my recently deceased husband, 
whose death took almost 26 years to complete, and waiting for 
compensation took a chunk of years as well. My husband came back from 
Dessert Storm with several symptoms, ranging from burning eyes, chronic 
fatigue, rashes, sore throat and various other flu like symptoms. 
Within 3 months of coming back while doing an exercise with the unit, 
was flipped over in his kayak. He came home pretty sore.
    The next day his leg was swollen and very painful, he was rushed to 
Walter Reed and diagnosed with Antiphospholipid Syndrome, sticky blood? 
He had many other illnesses pop up such as a parathyroidectomy, scalp 
cysts removed, anemia and with these came much suffering. He was 
adamant about pushing forward, not complaining, being a soldier. His 
commander had a special meeting with a board at NSA regarding the need 
to keep this soldier because he was necessary for the missions due to 
his extensive language abilities. he was to stay stateside and work 
from here. During this time he had many bouts of illness without much 
complaining. In 2001 he retired after 21 years' service. At discharge 
he was giveb 30% disability.
    By 2003 my husband had an attack of Retroperitoneal Fibrosis. Then 
Rhabdomyolysis and again the chronic fatigue was taking its toll. He 
applied to VA again, was denied and we presented more evidence taking a 
year to finally receive 60%. In the meantime we were in Fort Lewis and 
Madigan felt they could not help this man with such complicated 
problems so gave him the ability to use a private doctor. Then things 
got worse, he was diagnosed with Raynaud's Syndrome, toe removed, 
Sympathectomy surgery, and we were having to pay out of pocket up 
towards the thousands. The Autoimmune diseases seemed to cascade to 7 
active diseases. My husband's dream was to move to New Braunfels, Texas 
and I researched the doctors in San Antonio. The trek across country 
began. This time I realized we had to have a doctor that would 
understand GULF WAR SYNDROME. This doctor did. My husband applied again 
in 2015 and by Jan. 2016 he was awarded 100% with the help of the 
doctor advocating for him. Twenty-six years of suffering and one year 
of that time he was 100% . He died, and written on the death 
certificate was pulmonary fibrosis as a result of Antiphospholipid 
Syndrome. He gave his all and had to fight to get just a piece of what 
was rightfully his!

Wisconsin

    I am a Gulf War Veteran from Wisconsin. Entering the Marines out of 
High School, I was very experienced long distance runner at the peak of 
my health. In basic training, I very proudly placed second in the 
``Company Iron Man''. Ultimately out performing all but one of 402 
other Marines from all over the United States. Little did I know at the 
time however that within two years of that performance and my return 
from the Persian Gulf, I would never run or regularly participate in 
athletics again without debilitating consequences. Ultimately I left 
the Military Reserves directly due to my inability to physically 
perform. Despite a written request for legal support and medical 
testing, I was denied this examination and given a General Discharge. I 
still had my honorable discharge from active duty and the war so I 
didn't really care.
    I have fought my physical battle completely on my own for the last 
thirty years until visiting the VA for the first time about 5 years ago 
at the urging of my former company Gunny and other members of my Unit. 
I first applied for connected disability in May of 2014. If there ever 
was a text book case of Gulf War Illness, it is me. Due to a VSO error 
my claim was not placed until November of that year. Approximately one 
year later, I was denied all issues claimed to include Chronic Fatigue, 
Gastrointestinal Issues, Sleep Deprivation, Joint and Tendon Issues 
(Fibromyalgia), Depression, and a chest injury which occurred while in 
active service.
    Evidence provided was my SRB, and all of my medical records from 
the VA to that point which included all labs and imaging. I had also 
participated in a War Related Illness Study which I also provided 
records of. It was the conclusion of this VA Department that all of my 
current medical conditions and symptoms ``are consistent and meet the 
VA Case definition of Gulf War Illness. I have now been invited to 
participate in no less than four gulf war illness studies through the 
VA.
    While some aspects of my initial denial were from ``conveniently'' 
missing components of my service records, the common thread across 
nearly all denials was a ``lack of diagnosis''. I had also tested 
positive for RA so they were able to apply that to anything else that I 
claimed. I was being treated for all of these issues but apparently 
none were diagnosed? I was amazed one arm of the VA could conclude I 
met the criteria while the disability governing body could not. I 
brought this up to a doctor at the VA Hospital and he explained they 
treat symptoms and do not diagnose! I thought to myself this ultimately 
would make it impossible to ever be granted anything!! This seemed to 
defy sanity that one department of the VA was demanding diagnosis and 
the hospitals were saying they could not be provide any! It is very 
apparent to me the hospital staff has been groomed to very carefully 
stay away from the issue of Gulf War Illness. Every time I bring it up 
to this day, I have never been provided any written or even oral 
connection from the Hospital to Gulf War Illness. It was finally eluded 
to me in confidence that hospital staff could get into trouble for 
referencing Gulf War Illness in their treatment records and that they 
could not provide that nexus.
    With this apparent and deliberate conflict of my interests for my 
VA Doctors to provide me the diagnosis I needed, I ultimately decided 
to leave the VA and go to a third party provider. I applied for copies 
of all of my medical records from the VA and traveled with them at my 
own very significant expense to the Mayo Clinic in Rochester MN for 
some real answers. I got a hotel and stayed there for three days in 
hopes of finally finding out what was so wrong with me.
    Within three days, YES ONLY THREE DAYS I had the following 
diagnosis. This is something I have been unable to get at the VA in the 
four years I have been going there for treatment.

    DIAGNOSES #1 Rheumatoid arthritis #2 Bilateral peroneal 
tendinopathy #3 Subpatellar degenerative arthritis of the left foot #4 
Chronic fatigue, fibromyalgia #5 Gastroesophageal reflux disease #6 
Chronic diarrhea #7 Prior chronic lower abdominal pain #8 Major 
depressive disorder, recurrent, moderate symptoms #9 Obstructive sleep 
apnea #11 Insomnia
    So now in addition to the War Related Illness Center, I have 
diagnosis of all of the above from the Mayo Clinic. Clearly a 
connection right?? WRONG. While I considered this the smoking gun 
evidence I needed, I have still have not been awarded any connected 
disability to this day. ZERO PERCENT.
    I have since resumed my treatment at the VA. I was told from my VSO 
there is approximately a two year wait before my appeal will even be 
opened. I have heard more recently that this wait is now up to four 
years. Over the last ten years I have lost two jobs and have lost my 
home and land due to bankruptcy. We have had to move twice and change 
schools which was really tough for my kids. I feel like I am on the 
verge of losing another job and I am afraid I can't rebuild things 
again. I am very fortunate to work from home where I have been able to 
hide and disguise my fatigue and sleep from my employer. My prayer is 
that I am granted some partial disability (50%+) so I can be honest 
with my employer and try to reduce my hours to accommodate the severe 
fatigue.
    My VA psychologist told me Wednesday that it was an awful long time 
to hold onto life by my fingernails and I agreed. I have put a belt 
around my next twice and told my Doctor Wednesday that I would blow my 
brains out if I am denied again. 22 per day don't kill themselves 
because of PTSD-it's for being continually denied and called a liar by 
the administration that is supposed to be helping us. Veteran's and 
particularly those of war like me look at life very differently than 
most. If I have no hope- I will not continue to be a burden on myself, 
family, or country. I will however do my best to let them know I was 
destroyed by the Veterans Administration.

BRAIN CANCER (Not yet presumptive) - Missouri

    My husband passed away from Glioblastoma Brain Cancer stage 4, 
three Brain tumors on March 21, 2013. He was diagnosed on January 20, 
2013 with the tumors. Although this is not a presumptive, this is to be 
examined on a case by case bases. The claims examiner is to evaluate 
the available evidence to determine if it is at least likely that the 
Veteran's Brain Cancer is related to his or hers exposure to 
environmental hazards while Serving in the Gulf War.
    Environmental hazards include but are not limited to reports of 
chemical alarms sounding of in Saudi Arabia as early as Jan 1991 and 
Sabotage of Kuwait Oil Wells in Jan 1991.
    I have provided the Veterans Affairs Office and claims examiner 
over 59 medical files for review, However, the Denial determined by the 
V. A. Compensation claim examiner was denied with a review of only TWO 
medical files. I must say I have felt like a dog and pony show jumping 
through Circus hoops chasing down medical records, faxing. Following 
up, hand delivering notices. The V.A. faxed a small Death Certificate 
that was not legible and I had to hand carry the document to the 
Physicians and Providers. This did stir up much emotion, to say the 
least.
    I reside in Missouri, a small town close to Whiteman Air Force 
Base. I laid him to rest on our Wedding Anniversary. The most precious 
gift I could give him, His Military Honors.
    My husband suffered with many illnesses for over nine years prior 
to the Glioblastoma Brain Cancer, some would have been presumptive, the 
headaches, undiagnosed neurological disorder, irritable bowel syndrome, 
degenerative disc disease, many surgeries. He had seven shots in his 
hands every four months. He immediately went to the V.A. and was put on 
the Gulf War Registry when his illnesses first started in 2002. We 
never ever thought he would pass away. It all happened so fast. I 
didn't have time to process anything. I lost the Love of my life. I was 
mentally and completely broken. I went to Therapy, eventually was 
treated with in- patient therapy as the Loss was so great I couldn't go 
on with my life. I never thought of contacting the VA until a little 
over a year of his passing. I made the funeral arrangements and paid 
for the marker myself. I wasn't aware he could be laid to rest in the 
National Cemetery just 20 minutes away with a Proper Military Marker. 
Although I Love the marker I purchased, I feel a bit cheated that His 
Air Force isn't displayed. I called the VA after getting my Gulf War 
Newsletter, to tell them in case they were keeping track and they told 
me to file a claim. I filed in July 2014. I provided so much medical 
evidence and proof, there is no way any Medical person could deny this. 
I am a common housewife and I can see the evidence clear as day. I have 
had two denials. I am currently collecting more Medical Evidence. I was 
asked to get Buddy Letters. Now that's impossible. The government 
admits the exposure, admits it causes Cancer of the Brain, yet throws 
ridiculous and impossible task on the Surviving Spouse. I can't ask my 
husband who his Buddies were now can I ? The ongoing fight for Justice, 
I am HIS VOICE is a Daily struggle for me. I have panic attacks, I want 
to give up at times. Then I think about Him. His Strength. His Love for 
me. He fought to stay with me when he was suffering because I was 
crying and weeping and couldn't let him go.
    Now it's my turn to fight for Him.
    He wanted to take care of His Wife. He fought hard on His Death Bed 
for me. Now it's time for me to fight for him. I am His voice. May 
Justice and Truth Prevail for Our Hero's.

                                 
                       Statements For The Record

                            RONALD E. BROWN
    Thank you, Chairman Bergman, Bost, Ranking Members Kuster, Esty all 
other members of the House Veterans' Affairs Subcommittee on Oversight 
and Investigations and Disability Assistance and Memorial Affairs. I 
thank you for holding this joint investigative hearing on the VA's 
Disability Claim Process with Respect to Gulf War Illness claims.
    My name is Ronald Brown; I'm President of the National Gulf War 
Resource Center (NGWRC). The NGWRC is a small 501 (c) (3) non-profit 
veteran service organization, which is comprised of sick Persian Gulf 
War veterans who volunteer our time to advocate for our fellow veterans 
suffering from the complexities of modern warfare. We specialize in 
Gulf War Illness claims, we work with veterans to educate and assist 
them in the claims process. We also work with policy makers inside the 
VA, to accomplish two goals: first, to insure clinicians are better 
trained about conditions facing this group of veterans to insure the 
veterans receive the best health care possible.econdly, we are working 
to address and correct issues affecting this group of veterans, such as 
the high denial rate of Gulf War illness related claims.
    We, the NGWRC have been working on addressing problems within the 
Gulf War Illness-related disability claim process with senior VA 
leadership for over the past three years. Everything in this GAO report 
has been addressed, corrective recommendations have been offered, but 
corrective action promised by the VA clearly wasn't carried out. I'm 
left scratching my head on exactly what has been accomplished, Our 
brain cancer presumptive has come to a standstill, those affected 
veterans and their families still can't obtain service connection, Gulf 
War presumptive claims are still denied at 80% plus rate, Examiners are 
still not trained on Gulf War related C&P exams. Adjudicators from 
around the country are poorly trained on Gulf War Illness-related 
presumptive conditions; the priority is to clear the claims backlog, 
causing many wrongfully denied veterans to wait years for a long drawn 
out appeals process.
    After last year's hearing (PERSIAN GULF WAR: An Assessment OF VA's 
Disability Claim Process with Respect to Gulf War Illness) we was 
contacted by the Government Accountability Office (GAO) concerning an 
investigation Congressman Coffman had initiated on Gulf War claims. We 
provided data the Veterans Benefit Administration (VBA) had shared with 
us on these claims to GAO representative Nora Boretti. This data 
Ssuggested to us that the VBA has a serious problem with presumptive 
Gulf War Illness claims. The data provided Gulf War presumptive claims 
denial and approval rates from 2001-2017. In addition to the VBA data, 
we also provided actual blacked out presumptive condition claims that 
had been wrongfully denied. These claims had actual language the VBA 
used in its denial, and showed that the examiners and adjudicators had 
failed to follow statue, regulations (38 CFR Sec.  3.317), and VA 
procedures. With each claim, we also provided blacked out medical 
evidence that proved that the veteran suffered from a medically 
unexplained chronic multisymptom illness. We also provided C&P exams, 
some in which the examiner failed to follow the guidance in the notice 
to examiners and provided an unnecessary medical opinion which caused 
the claim to be denied. Prior to providing these claim examples to the 
GAO, we first highlighted the errors and sent them to senior VBA 
leadership, who had them reviewed by VBA's quality control (Star Team) 
and the decisions had been overturned.
    As previously stated, the NGWRC has been working to address the 
problems adjudicating Gulf War Illness-related disability claims for 
over three years. One of our first meetings was with Under Secretary 
Allison Hickey which led to a special focus review Gulf War Illness-
related disability claims. VBA was instructed to randomly pull a 
statistical sample from claims dated 2011-2015 and have the Star Team 
review them. The findings of this Special focus review follows:

Special focus review overview:

    During the period of August through December 2015, Compensation 
Service (the Quality Review staff) conducted a special focus review 
(SFR) of Gulf War (GW) cases. This review was the result of a meeting 
that took place on August 17th, 2015 with Under Secretary for Benefits, 
Allison Hickey; Tom Murphy, Director of Compensation Service; and Brad 
Flohr, Senior Advisor, Compensation Service, along with Ron Brown, 
President, National Gulf War Resource Center. It was noted that the 
National Gulf War Resource Center had numbers that reflected GW cases 
were not being decided correctly. From this meeting, a decision was 
made to have Compensation Service (the Quality Review staff) do a SFR 
on GW claims that were denied.
    This review involved Veterans of the earlier Gulf War period that 
served between August 1990 and July 1991.
    A total of 311 cases from the first two quarters of Fiscal Year 
2015 were reviewed. Although some of these cases included claims for 
other disabilities that were not related to Gulf War, this review was 
restricted to the Gulf War related illnesses on each claim. The 
findings below are presented based on a claim based review. This means 
that if an error was found with a specific issue denied, the entire 
case was erroneous.

FINDINGS:

    Of the 311 cases reviewed, 291 were properly denied, and 20 were 
improperly denied. This corresponds to a 94% accuracy rate within our 
sample.
    The VBA testified as to the special focus review findings at last 
year's hearing. After the hearing we (NGWRC) received the special focus 
review findings from the VBA. After reviewing the findings we 
determined that the VBA had not done the review as was agreed upon in 
the meeting with Under Secretary Allison Hickey, only claims from the 
first two quarters of Fiscal year 2015 were reviewed instead of claims 
from Fiscal years 2010-2015 as agreed upon. We contacted Secretary Bob 
McDonald who instructed the VBA to do a second Special focus review in 
which claims from Fiscal years 2011-2015 would be reviewed. The VBA 
drew 111 less claims than what was agreed upon (311) in this second 
special focus review. The findings are listed below:

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    From the fairly small numbers of veterans the NGWRC has helped with 
the claims process, it is abundantly clear that the VBA has a systemic 
problem with Gulf War Illness-related disability claims. Adjudicators 
are not well trained, the emphasis isn't on accuracy; rather, on 
clearing the backlog of claims. The statue, VA regulation and VA 
procedure (M21-1 manual) often aren't followed. To complicate the issue 
C&P examiners aren't properly trained on these types of claims, despite 
VAs insistence that they are, this GAO report found the examiners 
training on these types of claims is optional, not mandatory as we were 
led to believe, and only about 10% of VA's examiners have completed the 
optional Gulf war Illness course. In the claims we have reviewed, got 
the VBA to overturn, and provided to the GAO (15 - 20 claims), it is 
abundantly clear that most examiners who preform Gulf War exams don't 
understand guidance in the Notice to Examiners in Southwest Asia claims 
(below) that they are to provide a medical statement, and not a medical 
opinion about service connection for disability type (1) an undiagnosed 
illness, and (2) a diagnosable but medically unexplained chronic multi-
symptom illness. As pointed out in this GAO report, adjudicators often 
fail to recognize that the examiner has provided an unnecessary medical 
opinion concerning service connection, and the veterans are wrongfully 
denied.

j. Notice to Examiners in Southwest Asia Claims

    Please examine this Veteran, who has service in Southwest Asia, for 
any chronic disability pattern. Please review the claims folder as part 
of your evaluation and state, with your findings, that it was reviewed. 
The Veteran has claimed a disability pattern related to [insert 
symptoms described by Veteran].
    Please provide a medical statement explaining whether the Veteran's 
disability pattern is:

    (1) an undiagnosed illness

    (2) a diagnosable but medically unexplained chronic multi-symptom 
illness of unknown etiology

    (3) a diagnosable chronic multi-symptom illness with a partially 
explained etiology, or

    (4) a disease with a clear and specific etiology and diagnosis.

    If, after examining the Veteran and reviewing the claims file, you 
determine that the Veteran's disability pattern is either (1) an 
undiagnosed illness; or (2) a diagnosable but medically unexplained 
chronic multisymptom illness of unknown etiology, then no medical 
opinion or rationale is required as these conditions are presumed to be 
caused by service in the Southwest Asia theater of operations.
    If, after examining the Veteran and reviewing the claims file, you 
determine that the Veteran's disability pattern is either (3) a 
diagnosable chronic multi-symptom illness with a partially explained 
etiology, or (4) a disease with a clear and specific etiology and 
diagnosis, then please provide a medical opinion, with supporting 
rational, as to whether it is ``at least as likely as not'' that the 
disability pattern or diagnosed disease is related to a specific 
exposure event experienced by the Veteran during service in Southwest 
Asia.
    Many of veterans that we assisted in the appeals process were 
wrongfully denied because the Regional Benefits office imposed a nexus 
requirement. The decision letter stated that the claim was denied 
because ``your service treatment records are silent for complaints, 
treatment, or a diagnosis for your claimed condition of [Fibromyalgia, 
Chronic Fatigue Syndrome or Irritable Bowel Syndrome]''. These types of 
denials are direct violations of U.S.C. 38 Sec.  1118 which states that 
these conditions (diagnosable but medically unexplained chronic multi-
symptom illnesses) are presumptions of service connection associated 
with service in the Southwest Asia theater of operations and ``shall be 
considered to have been incurred in or aggravated by service 
notwithstanding that there is no record of evidence of such illness 
during the period of such service.'' The United States Court of Appeals 
for Veterans Claims upheld the statue when it ruled in the case 
Gutierrez v. Principi, 19 Vet.App.1 (2004), that a Gulf War veteran 
does not have to prove any link to the veteran's service and the VA 
cannot impose a nexus requirement under the provisions of 38 CFR Sec.  
3.317. The Courts ruling follows:

Gutierrez v. Principi:

    ``In this case, the Board finds that the veteran's initial claims 
for VA compensation, the initial VA evaluations, and the veteran's 
initial statements to the VA following his discharge from active 
service (in which he fails to mention any disability associated with 
joint and muscle pain, fatigue, dizziness, decreased vision, memory 
loss, and loss of concentration) provides affirmative evidence that the 
undiagnosed illnesses were not incurred during his active military 
service. It further fundamentally undermines the veteran's credibility 
in that it is his central contention that he has had these disabilities 
over an extended period following his discharge from service. If this 
was the case, the Board finds no rational reason to believe that there 
would not be at least some evidence or indications in support of the 
veteran's contention or that the veteran would not have noted these 
difficulties earlier or during his initial examinations. The Board 
finds that these facts do not support the veteran's case. The only 
evidence of record before the Board specifically linking the veteran's 
current alleged disabilities to his service or to Gulf War syndrome 
consist[s] of the veteran's own evidentiary assertions. Such evidence 
is of limited probative weight. While the veteran is competent to 
describe manifestations perceivable to a lay party, he is not competent 
to diagnose himself with disabilities and then associate those 
disabilities with his active service or with any form of Persian Gulf 
syndrome R. at 14-15 (emphasis added). If this were a claim for direct 
service connection, a nexus between Mr. Gutierrez's disabilities and 
his period of active service would be required. See Caluza, supra. In 
this case, however, evidence is not required ``specifically linking'' 
Mr. Gutierrez's disabilities to his service or the Gulf War. See Brock, 
supra. Congress has decided as a matter of policy, stemming at least in 
part from difficulty of proof, that, even though a Persian Gulf War 
veteran's symptom may not at this time be attributed to a specific 
disease, the symptoms may nonetheless be related to conditions in the 
Southwest Asia theater of operations and, for that reason, are presumed 
to be service connected. See 38 U.S.C. 1117; 38 C.F.R. 3.317 (a)(1)(i). 
Thus, Mr. Gutierrez was not required to provide evidence linking his 
current conditions to events during service and the Board erred by 
imposing such a nexus requirement. Further, as stated above, section 
1117 and 3.317 require that undiagnosed illnesses become manifest to a 
degree of 10% or more during the presumption period that ends on 
December 31, 2006. See 38 C.F.R. 3.317(a)(1)(i).
    Accordingly, the Board erred by failing to account for that, as 
well as the other factors discussed below, in determining that Mr. 
Gutierrez's complaints were not credible because he had not sought 
treatment for these conditions earlier or did not complain about them 
during his initial medical examinations. The Board also found that, 
although Mr. Gutierrez had complained of joint and muscle pain, 
fatigue, dizziness, and loss of concentration, the objective medical 
evidence failed to show any such disabilities. R. at 15. The evidence 
of record reveals that Mr. Gutierrez consistently complained during VA 
medical examinations about fatigue, muscle and joint pain, neurologic 
signs or symptoms (loss of concentration and memory), and sleep 
disturbances. See R. at 98, 106-108,125-28, 228-29, 329, 348-53, 423, 
426-27. These symptoms are specifically identified by VA in its own 
regulation as possible manifestations of an undiagnosed illness in Gulf 
War veterans. See 38 C.F.R. 3.317(b).''
    Another troubling and frequent problem we see in Gulf War Illness-
related disability claims is that often the examiner, usually a Nurse 
Practitioner, will override the diagnoses from a medical specialist. 
Medical specialists are the ones who have run all the necessary testing 
to rule out all other clinical diagnosis that could produce symptoms 
before they diagnose a CMI such as fibromyalgia. The specialist often 
is the one treating the veteran or at least advising the veteran's 
primary care provider. As recently as two weeks ago, we assisted a 
veteran whose claim for fibromyalgia and chronic fatigue Syndrome was 
denied because the examiner stated that the veteran's diagnosis wasn't 
confirmed by a specialist. Ironically the veteran was diagnosed by 
James N. Baraniuk, MD (Professor of Medicine, Division of Rheumatology, 
Immunology and Allergy, Director of the Chronic Pain and Fatigue 
Research Center, Georgetown University). Dr. Baraniuk is one of the 
nation's leading experts on disabilities occurring in Persian Gulf 
veterans.
    We have also seen exams where the veterans have a clinical 
diagnosis of Fibromyalgia, Chronic Fatigue Syndrome, and Irritable 
Bowel Syndrome and the Adjudicator's try and lump the veteran's 
conditions under one rating even though all three conditions carry 
their own rating criteria in 38 CFR Sec.  3.317. Generally this hurts 
the veteran as they are given a lower rating percentage.
    After three years of trying to get the VA to correct issues with 
Gulf War Illness-related disability claims; I honestly feel that the 
only way to a viable fix is thru legislative action. I believe that 
Congress needs to reevaluate the statue; I don't think it was 
congressional intent for a process in which most Gulf War Illness-
related disabled veterans are denied service connection for their 
illnesses. In the last hearing in March of 2016 Representative Kuster 
had mentioned that perhaps Congress needs to go back and look at the 
legislation they did to create Undiagnosed Illness and I agree I think 
this desperately needs to happen.
    I also think that Congress needs to reevaluate USC 1117 and 1118. 
It is almost impossible to add presumptive conditions for Gulf war 
veterans in part because this stature requires positive proof 
concerning exposures. How's this possible, Gulf war veterans were 
exposed to a variety of environmental and chemical hazards, unlike our 
Vietnam veterans whose main exposure was herbicides? I honestly believe 
Congress needs reevaluate this legislation and change the positive 
proof wording to benefit of the doubt since there are so many exposure 
variables that will never be known.
    Without, guidance from Congress, I do think that the VBA or VA will 
take action to address problems within the Gulf War Illness-related 
disability claim process. I say this because I have spent the last 
three years addressing the same issues identified in this GAO report 
with Senior VA, VBA and VHA leadership with very little to show for it. 
They have had 26 years to get this correct and it's still not even 
close. So, I honestly hope Congress can assist in providing legislative 
help for Gulf War veterans. Below are the same recommendations I 
provided at the last hearing, with a new recommendation highlighted in 
yellow.

Recommendations:

    Have VA report back to Congress quarterly with the type of training 
being conducted and with proof the Gulf War medical and adjudicator 
training has indeed been done by all required VA employees. Make it 
mandatory and ongoing!!! ONE AND DONE TRAINING ABSOLUTLY HAS NOT WORKED 
ON GULF WAR MEDICAL AND AJUDICATOR TRAINING (NEW Recommendation).

    Training. Training the front-line adjudicators concerning Gulf War 
illness related claims would be the most effective tool in solving the 
high denial rate of Gulf War illness related claims.ulf War illness 
related claims make up 29% of the current back log.his training would 
further serve to reduce the growing number of appeals.f the policy 
makers in the Central office are serious about fixing the high denial 
rates of Gulf War illness related claims, they need to ensure that each 
regional office around the country is doing mandatory training. The 
upper management in the Central office should direct the directors of 
each Regional Benefits Office to ensure their front-line adjudicators 
are using the M21-1 manual.his manual provides the adjudicators all the 
references needed to accurately adjudicate claims.eferences in this 
manual include U.S. code, VA Regulation (CFR) and related U.S. Court of 
Appeals for Veterans' Claims cases.his manual is an excellent tool if 
used.
    Transparency, the VBA must continue to provide Veteran Service 
Organizations with data on these types of claims.his ensures that VSO 
organizations can monitor and keep tract of denial and approval rates 
as well as provide critical information to the veterans they represent. 
Have VA report back to Congress quarterly with the type of training 
being conducted and with proof the Gulf War medical and adjudicator 
training has indeed been done by all required VA employees.
    In closing, below is the Data VBA furnished the NGWRC on Gulf War 
presumptive claims from Fiscal years 2002-2017 This data covers more 
years than the GAO's report and paints an even darker picture of the 
systemic problems VA has with Gulf War presumptive claims!!

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Respectfully,

    Ronald E. Brown
    President
    National Gulf War Resource Center

                                 
                             Paul Sullivan
    Thank you, Chairmen Bergman and Bost, Ranking Members Kuster and 
Esty, and Members of both Subcommittees for your support of Gulf War 
Veterans and for holding today's hearing about the processing of Gulf 
War illness (GWI) disability compensation claims administered by the 
U.S. Department of Veterans Affairs (VA).
    My name is Paul Sullivan, and I am a disabled Veteran who served as 
a cavalry scout in the Army's 1st Armored Division during the first 
ground invasion of Iraq and Kuwait during the 1990 - 1991 Gulf War. I'm 
also the Director of Veteran Outreach at Bergmann & Moore, LLC, a 
national law firm based in Maryland representing Veterans with claim 
appeals before VA, including the Board of Veterans Appeals (Board) and 
the Court of Appeals for Veterans Claims (Court).
    Since becoming ill in the war zone and returning home, I've 
dedicated my professional life to assisting fellow Veterans. For more 
than two decades, I continue working closely with Veterans who were 
denied VA benefits, including fellow ill Gulf War Veterans.
    Since my first appearance on July 16, 1998, I've had the honor of 
testifying several times before the House and Senate with the goal of 
improving government policies regarding Veterans, including several 
hearings on GWI claims. My statement today again focuses on government 
policies and practices.
    However, there is an important addition in my statement for this 
hearing. For the first time, I am providing Congress with a description 
of VA errors, delays, inadequate exams, lost records, and retaliation. 
I am still waiting on VA to decide my GWI claim originally filed on 
July 28, 1992. It remains deferred and undecided at a regional office.
    The Subcommittees are rightfully concerned to focus on GWI claims. 
Congress acted properly in 1994, 1998, 2001, and 2010 with new laws to 
assist Gulf War Veterans with obtaining VA service connection in order 
to obtain free VA treatment (38 USC 1117 and 1118). Congress acted 
wisely and carefully based on the urgent needs of hundreds of thousands 
of ill Gulf War Veterans who reported ailments associated with toxic 
exposures after deploying to Southwest Asia during Desert Shield and 
Desert Storm.
    Many fellow Gulf War Veterans and family members worked diligently 
with Congress for years to help pass the laws because VA research 
indicates as many as 250,000 Gulf War Veterans remain ill. Your 
continued involvement is welcome and appreciated.
    With some exceptions, in order for Veterans to obtain free 
treatment at a VA medical center, Veterans need to be granted service 
connection via VA's highly complex and often adversarial disability 
compensation claim process. One of the most important exceptions is a 
law providing free healthcare for Veterans who deployed to a war zone 
for five years after discharge from active duty (38 USC 1710). The law, 
enacted as part of the landmark ``Persian Gulf Veterans Act of 1998,'' 
was expanded by Congress from an initial two years to five years in 
2008. Hundreds of thousands of Veterans who deployed to our current 
conflicts in and around Iraq and Afghanistan have used this new VA 
healthcare benefit, and I thank Congress for passing and expanding the 
law.

GAO FINDINGS

    Today's hearing was prompted by the new report issued by the U.S. 
Government Accountability Office (GAO) into VA's mishandling of GWI 
disability compensation claims (``Gulf War Illness: Improvements Needed 
for VA to Better Understand, Process, and Communicate Decisions on 
Claims,'' GAO-17-511, June 2017). Bergmann & Moore thanks Congress for 
requesting the GAO investigation into VA's processing GWI claims. 
However, GAO's conclusions raise serious concerns for Congress to 
address:

      Hundreds of thousands of Gulf War Veterans remain ill: 
``Nearly 30 years after the Gulf War conflicts began, hundreds of 
thousands of veterans continue to experience chronic medical conditions 
that may be related to a host of hazardous exposures they faced while 
serving our country..''

      Gulf War Veterans were exposed to toxins: According to 
the GAO, Gulf War Veterans were exposed to ``pesticides, smoke from oil 
well fires, and depleted uranium that could be linked to their medical 
conditions.'' Other hazardous exposures include pyridostigmine bromide 
chemical warfare agent pre-treatment pills and chemical warfare agents 
such as sarin and mustard gas.
      VA examiners lack training: Only 10 percent of VA medical 
professionals conducting Compensation and Pension (C&P) exams for 
Veterans seeking service connection for GWI were trained using VA's 
voluntary 90-minute video.
      VA examiners are confused: VA medical professionals 
conducting C&P exams for GWI expressed ``confusion'' on how to conduct 
and report a GWI C&P exam.
      VA lacks a case definition: VA has no case definition for 
GWI, and that hampers C&P exams, rating decisions, and treatment.
      VA remains fixated on identifying a diagnosis to make it 
fit: Some VA C&P examiners told GAO that ``they could nearly always 
attribute a Veteran's symptoms to a diagnosable illness, which would 
mean the Veteran does not qualify for benefits under the undiagnosed 
illness presumptive category.'' VA's action arguable defeats the 
purpose as it circumvents the law.
      VA issues unnecessary opinions: ``According to several 
[VA] claim rating staff we interviewed, [VA] medical examiners 
sometimes provide a medical opinion related to service connection when 
one is not necessary because the Veteran has a presumptive condition.'' 
Untrained C&P examiners thus ``inadvertently deny'' a claim that should 
be presumptively granted (Gutierrez v. Principi, 2004).
      VA issues incomplete rating decisions: When VA issued a 
Gulf War Veteran a GWI rating decision, VA often did not include key 
information on why it was denied. For example, when VA issued a Veteran 
a claim rating decision, VA may not have listed or considered both 
direct and presumptive service connection. VA's lack of clarity causes 
Veterans frustration when trying to determine the next step in the 
claim process, such as appealing VA's rating decision.

    According to GAO, the impact of VA's challenges cause severe and 
adverse consequences for ill Gulf War Veterans seeking service 
connection and healthcare:

      VA forces Gulf War Veterans to wait longer: VA takes four 
months longer to process a Gulf War illness claim than other claims 
because GWI claims involve multiple and complex medical conditions.
      VA denies Gulf War Veteran claims more often:

    -VA's Alaska regional office denied all GWI claims.

    -VA granted GWI issues ``about 3 times lower than all other medical 
conditions.''

    -VA granted service connection to only 10 percent of the Gulf War 
claims under Undiagnosed Illness in 2015 (the 1994 law, 38 USC 1117).

    -VA granted service connection to only 22 percent of the Gulf War 
claims under chronic multisymptom illness in 2015 (the 2001 law, 38 USC 
1118).

    While the GWI laws have provided tens of thousands of Gulf War 
Veterans with some relief and access to VA medical care and disability 
compensation, an unknown number still face unreasonable obstacles 
before obtaining VA treatment and benefits. GAO estimated the number of 
completed yet unreported GWI decisions to be in the tens of thousands 
because of underreporting ``due to unclear guidance and inconsistent 
data entry over time'' by VA.
    The bottom line for ill Gulf War Veterans is that we are often 
prevented from obtaining the VA treatment and benefits we earned and 
urgently need due to VA's problems confirmed by GAO. Thus, a large 
number of ill Gulf War Veterans continue suffering.

EXAMPLES OF VA CLAIM ERRORS

    Bergmann & Moore, managed by former VA attorneys, has assisted 
several thousand Veterans with VA claim appeals over the past 14 years. 
Here are common VA errors in GWI claims identified by Bergmann & Moore 
that go beyond those identified by GAO.

      War dates: VA denied a Veteran's GWI claim based on 
deployment to Southwest Asia during 1992, implying the war had ended. 
VA should have granted the claim because the Gulf War continues and 
existing laws apply to Veterans deployed to Southwest Asia starting on 
August 2, 1990, and continuing through the present (38 USC 101(33)).
      War locations: VA denied a Veteran's claim based on 
service aboard a ship in the Persian Gulf, mistakenly believing the 
nearby body of water was not part of the war zone. VA should have 
granted the claim because the Persian Gulf is considered part of the 
geographic area of Southwest Asia (38 CFR 3.317(e)(2)). VA should 
update the definition of Southwest Asia so the tens of thousands of 
Veterans who deployed to Turkey, Syria, Israel, Afghanistan, and other 
locations since August 2, 1990, can rightfully obtain VA healthcare and 
benefits.
      VA used the wrong DBQ: VA denied a Veteran's claim 
because the C&P examiner relied upon one or more incorrect Disability 
Benefits Questionnaires (DBQ) to evaluate the Veteran's condition(s). 
VA should use the more appropriate GWI DBQ for GWI claims and VA should 
train staff to use it.

    Some VA errors are simple to correct on appeal, such as knowing the 
correct dates and locations for the Gulf War. According to the GAO, 
other VA denials may require the Veteran to submit additional evidence.
    However, some VA errors appear to be harmful to Veterans, such as 
using the wrong DBQ or taking unreasonable and unwarranted steps to 
diagnose GWI. The GAO report indicates that VA appears to be 
inappropriately developing evidence or providing an unfavorable nexus 
in order to deny a Veteran's GWI claim. VA's adverse actions are 
counter to what Congress intended and Court mandate (Mariano v. 
Principi, 2003).
    In light of VA's high denial rate and errors, Bergmann & Moore 
encourages Veterans with situations similar to those listed above to 
consider appealing VA's rating decision. Veterans should seek an 
accredited representative to assist with filing a claim as well as when 
filing a Notice of Disagreement (Form 21-0958) or Substantive Appeal 
(Form 9).

VA USUALLY PERFORMS WELL IN OTHER AREAS

    For nearly two decades, I testified in person several times in 
support of new laws designed to improve VA so our Veterans would 
receive timely and quality VA care and benefits. Congress listened and 
took decisive action. My statement today is the first time I have 
provided Congress with information about how VA maliciously and 
incompetently mishandled my GWI claim for nearly a quarter century. My 
goal is for Congress to have a rare view into the extreme challenges 
Veterans face.
    Before I begin describing my VA claim nightmare, allow me to 
compliment VA medical professionals. As a former project manager 
working at VA's central office here in Washington, DC, and as Veteran 
who receives all of my care at VA, treatment for routine conditions is 
exemplary. VA staff are usually polite, caring, and professional. Yet 
my observation is that they are overworked with too many patients and 
not enough time, especially in order to provide care for Veterans with 
complex conditions. Although VA physicians continue trying, VA remains 
unable to provide me with an effective treatment for my GWI.
    Similarly, nearly all VA claims processors are doing the best they 
can under difficult circumstances. However, training, staffing, and 
oversight must improve at regional offices. VA regional offices should 
focus on quality rather than on speed and production quotas.

MY 25 YEAR VA CLAIM ODYSSEY

    My VA disability claim odyssey began on July 28, 1992. I walked 
into a VA medical center for the first time and sought care because I 
was suffering from several serious medical conditions. The previous 
day, I called and asked VA what to do in order to receive care as an 
ill Gulf War Veteran. The VA clerk advised me to arrive early in the 
morning, bring my DD 214 discharge papers, and ask to see a physician.
    Upon arrival at the VA medical center, VA refused to treat me. The 
VA clerk said I was not service connected and that I did not serve in 
the Gulf War. The clerk did not know that the military refers to the 
Gulf War combat zone as Southwest Asia. My DD214 confirmed I deployed 
to Southwest Asia and received the Southwest Asia Service Medal. The 
clerk insisted I was not in the Gulf War because my DD214 did not 
mention the Gulf War, Desert Shield, Desert Storm, Iraq, Kuwait, or 
Saudi Arabia. The clerk never mentioned the need to file and win a VA 
claim before receiving treatment.
    A second VA employee who happened to walk by asked me if this was 
my first visit to a VA medical center. I said yes, and the second VA 
employee suggested I meet with someone who could explain how to file a 
claim and obtain VA healthcare. I then met a Veteran Service 
Organization (VSO) representative who explained VA's complex claim and 
healthcare rules. That day, the VSO and I filed my original claim, even 
though I was visibly suffering from a fever, sinusitis, migraine, 
erythromelalgia, and other conditions. Like other Veterans, I filed my 
VA claim in order to obtain VA medical care.
    VA's poor handling of my claim could be summarized by saying, ``if 
something could go wrong at VA, then it did.'' VA's significant 
mistakes processing my GWI claim mirror the VA errors identified by 
GAO's investigation. Here are examples:

      VA transferred and lost my entire claim file: After 
Congress passed the 1994 Gulf War illness benefits law, VA sought to 
consolidate all Gulf War claims at four VA regional offices. That 
didn't work out well. Then VA tried consolidating all GWI claims at a 
single VA regional office. That failed as well. VA's repeated transfers 
of my paper claim file resulted in my file disappearing between 1995 
and 1999. My VSO advocate appealed and protested the transfer of my 
claim file to no avail. My medical conditions worsened, and my medical 
bills mounted. My paper records were eventually located by my VSO in 
1999.

      VA lost my C&P exams and medical records: VA lost C&P 
exams and medical records needed to process my GWI claim. As a result, 
even when VA had my file, VA issued partial rating decisions without 
deciding my GWI conditions. VA deferred portions of my claim related to 
GWI in 1995, 1999, and 2000.
      My VSO located my file and reported VA retaliation: 
During 1998 and 1999, attorney William ``Bill'' Russo searched for my 
claim file for several months. At that time, Mr. Russo was the director 
of benefits at the Vietnam Veterans of America (VVA), my VSO advocate. 
He found parts of my file in four different VA regional offices. My 
file inexplicably contained newspaper clippings about me, records of 
other Veterans, and duplicate copies of my records. Missing from my 
file were C&P exams and other salient DoD, VA, and private medical 
records. After spending an entire day reconstructing my claim file, Mr. 
Russo told VA's regional office director the situation was the worst 
case of VA retaliation and mishandling of a claim he had ever seen. Mr. 
Russo would go on to become the Deputy Director of Regulations at VA's 
central office in Washington, DC. I thank Mr. Russo for his tenacious 
advocacy. He died in 2016.
      VA used untrained C&P examiners: In one example in 1992, 
a VA physician conducted an exam without asking me any health 
questions. In the ensuring appeal, VA provided a new exam and granted 
the condition. In another example in April 2017, an untrained VA 
physician conducted a GWI C&P exam. The physician used the wrong DBQ, 
found a diagnosis, and provided a negative nexus opinion when none was 
required. This is exactly what GAO concluded was wrong with VA. The 
physician asked me to provide my military, VA, and private medical 
records because the physician had not reviewed them. In a related 
matter, VA sent me a letter asking me to call VA by a fixed due date 
for a GWI C&P exam. However, VA's letter was postmarked after the due 
date.
      VA ignored key evidence: When rating my claim in 1993, 
1995, 1999, and 2000, VA regional offices ignored probative evidence 
from military, VA, and private doctors. For example, my military 
records show the onset of my GWI while deployed to Southwest Asia and 
Germany during 1991. In another example, a 1999 VA Gulf War registry 
exam linked my GWI to toxic exposures.
      VA admitted CUE: In April 2000, VA made an admission of a 
Clear and Unmistakable Error, or CUE, in a November 1999 VA rating 
decision. VA erroneously established an effective date of November 
1999, instead of September 1991 (I filed my claim within one year of 
leaving Active Duty, so the effective date is retroactive to my 
discharge date). The silver lining in VA's April 2000 rating decision 
was that VA did grant some of my conditions and opened the door to VA 
treatment. The remaining dark cloud in VA's April 2000 rating decision 
was that VA again deferred my GWI claim for a third time.
      VA's failed Gulf War registry exam: During a Gulf War 
registry exam in 2017, the VA physician was unaware of any new Gulf War 
research or treatments. Furthermore, the physician, who regularly 
conducts GWI C&P exams, confided that VA provided no training for GWI 
C&P exams and that a supervisor issued orders to deny all GWI claims 
except in cases where the Veteran was diagnosed with fibromyalgia, 
chronic fatigue, or irritable bowel. The physician's comments confirm 
what the GAO reported. I wrote a letter and brought the physician's 
comments to the attention of the VA medical center's director, chief of 
staff, and C&P director. I have not yet received a reply.
      Other malicious VA acts - inexplicable change of my 
address and release of my medical records: VA changed my address in 
error to a location where I did not live. VA never explained how that 
happened. VA sabotaged a meeting with legislators by releasing my 
medical records without authorization. VA later apologized.
      VA improperly cancelled my deferred Gulf War illness 
claim: In the most egregious example of VA retaliation, VA improperly 
erased my deferred GWI claim from VA's computerized Pending Issue File 
(PIF) in September 2000. VA took action without notification or 
permission from my VVA advocate or me. Even though VA granted a portion 
of my claim and then deleted my claim from VA's electronic work queue, 
my GWI claim still remains pending and deferred because VA never 
decided it. I learned about VA's actions in July 2017 when VA provided 
me a copy of a VA letter dated September 2000 that contained hand 
written notes by VA employees improperly cancelling my deferred GWI 
claim.
      My appeals were timely and written: With the assistance 
of my advocate, all of my notices of disagreement and substantive 
appeals were timely and written. VA's actions described above are 
unacceptable and unconscionable. VA should have decided my pending and 
deferred claim at the regional office decades ago. My health continues 
worsening since 1991. The cost in my time and medical bills is 
staggering. I receive solace advocating for VA reform and assisting 
fellow Veterans. I am still waiting a VA rating decision from a 
regional office for my claim originally filed in July 1992, and in 25 
years, my claim has never reached the Board or Court.

LOOKING FORWARD: SUGGESTED REFORMS

    VA's concurrence with GAO represents a watershed step forward by VA 
in acknowledging and resolving the issue of tens of thousands of denied 
GWI claims. Bergmann & Moore agrees with GAO's recommendations. 
Specifically, VA agreed to begin mandatory VA training for medical 
professionals conducting GWI C&P exams, more detailed VA rating 
decisions provided to Veterans, and the development of a case 
definition for GWI.
    Going beyond the GAO's recommendations, GWI disability compensation 
claim laws and regulations need an urgent overhaul. Congress and VA 
should take advantage of the disturbing new information about GWI 
claims in order to collaborate with VSOs and other stakeholders to 
improve claims processes so Veterans can receive prompt and quality VA 
care and compensation for service-connected conditions.
    Congress should act swiftly based on the momentum created by the 
GAO report, VA's acknowledgement, and the testimony of advocates today. 
Any new legislation should provide for scientific research, medical 
treatment, training for claim processors at VA regional offices, 
training for claim examiners at VA medical facilities, an updated 
definition of Southwest Asia, and continued oversight through mandatory 
reporting of healthcare use and claim activity.
    The most critical component of any new legislation remains VA's 
willingness to embrace change and understand the reasoning behind a new 
benefits law. In the case of ill Gulf War Veterans, the main route to 
free VA treatment and disability benefits comes after VA grants the 
Veteran service connection.
    VA should work with VSOs so the training to implement any future 
laws and regulations meets the expectations of VA C&P examiners, VA 
claims processors, VSOs, and Veterans. As part of training VA claims 
processing staff about Gulf War illness claims, VA should share copies 
of VA's training materials with VSOs and Congress so that advocates, 
legislators, and Veterans have a better understanding of how to apply 
for and prevail on a GWI claim. This would also include describing the 
evidence needed, what to expect during a C&P exam, and what to look for 
in a VBA rating decision.
    In 1992, Congress mandated public reporting on the costs of the 
Gulf War. GAO described how VA stopped creating and distributing the 
reports. I was the person, while working at VA, who created the reports 
in 2000. VA should resume the reports on a quarterly basis. Such 
reports are consistent with the ``Veterans Health Care Act of 1992'' in 
identifying Gulf War Veterans and reporting on various aspects of their 
VA healthcare and benefit activity (Public Law 102-585).

CONCLUSION

    It is an uncomfortable truth, however, that the issue of GWI claims 
is here to stay for several more decades. As Gulf War Veterans age, we 
will file more claims, including GWI claims. This is because our 
conditions continue manifesting and worsening, thus revealing the true 
long-term cost of war and toxic exposures on our health.
    In the alternative, without reform legislation, Congress should 
mandate that VA train C&P examiners and claims processors on the proper 
processing of GWI claims, reopen all denied GWI claims, and then 
complete adequate C&P exams and new rating decisions with retroactive 
dates going back to the original date of the Veteran's claim. 
Otherwise, the only remaining recourse may be litigation.
    No Veteran should have to endure a lengthy, complex, and tortuous 
VA claims process. After working on this issue for 25 years, I am 
frequently confronted by countless Veterans who constantly share 
similar VA claim horror stories with me. Our goals as Gulf War Veterans 
remain the same today as they were in 1991, when we began falling ill 
due to toxic exposures while deployed to Southwest Asia or after 
returning home. Gulf War Veterans seek research to understand why we 
are ill, treatments to improve our health, benefits for those in need, 
training for those who assist us, and rigorous oversight and 
accountability of VA from our elected officials.
    I am available if the Subcommittee Members or staff have questions. 
Thank you.

                                 
                              Kirt P. Love
    Dear Subcommittee Members

    My name is Kirt P. Love, and Im a disabled Gulf War Veteran, 19 
year advocate, and former member of the Veteran Affairs Advisory 
Committee on Gulf War Veterans back in 2008.
    The nature of this hearing is a important one in what it can do, 
provided its given the right content to move forward with. So I hope to 
elude to points that Ive also covered with the committee the last 3 
years.
    Much of the 1990's there were various committees that set in motion 
a flawed methodology that really never got corrected. From 1995 on even 
with the GAO's involvement - recommendations mostly fell flat on ways 
to steer VA. By 1998 the veteran community ( and myself ) rallied 
around PL 105-368 and PL 105-277 hoping to steer things in a more 
positive direction. The laws got passed into sudden over time and with 
much of the content lost to the omnibus bill edits.
    VA promptly took advantage by dragging out implementation 2 years 
after it was signed. Only to take the clinical aspect and pervert it 
into the War Related Illness and Injury Study Center rather than the 
Gulf War Illness clinic we had set out for. Over the years it was made 
into a one time throw away visit you could not get a referral for. Once 
in, unless you knew what you wanted and demanded it - you got very 
basic exams coupled with a psyche evaluation. No follow-up exam or long 
term programs.
    Then VA taunted the very nature of the Research Advisory Committee 
and made it clear to them they could not operate on anything but 
research. So they were not vetted for healthcare or benefits. This 
later would become a ploy to eradicate vocal members and finally rig 
the committee for silent running in 2015.
    As the years passed, nothing was done about healthcare or benefits. 
VA played down the Gulf War Registry, and the independent efforts of 
the GWVIS to keep any kind of records of any trends not research 
related. After the passing of Helen Malaskiewicz as the senior 
coordinator of the program, it fell into silence and disrepair. The 
Austin Automation center would no longer share any information with 
outside sources.
    VA was so glib that it altered the GWVIS reports outright to play 
down the numbers, and my committee set up a task force to get answers. 
Yes, VA was white washing the numbers to under report them by 11% or 
more. VA's answer, get rid of the report. Then back the one time 
printing of the pre and port 911 reports that show nothing of value.
    Years would pas with no annual public data tracking.
    Other borderline programs fell into disarray. The Spouse and 
Children Registry of GW vets never got support, and it died quietly in 
2003. Vaccine tracking, exotic diseases,
    and such fell upon the Armed Force Institute of Pathology. The AFIP 
refused to catalog the samples in such a way researcher could request 
them at the time brain tumors surfaced in there vaults. It to took the 
thousands of Gulf War tissue samples it collected them and buried them 
at its new location once the staff was disbanded.
    The National Academy of Science was tasked to provide reports 
sanctioned by VA. The very nature of that was perverted, and the 
committee never allowed anything but peer reviewed materials for 
review. What was peer reviewed at that time wasn't helpful to the vets, 
and volumes where left out on a technicality. By the time it came to 
the ALS in Gulf war vets, the very name of the report was changed to 
``ALS in the military'' to diffuse the situation as Gulf War vets 
became part of the ``Deployment Health'' picture rather that helped 
make the number seem smaller.
    So by 2007 I pushed to get a federal advisory committee through 
congress to address the items others could not. Even managed to get on 
the committee. What I didn't allow for was this wasn't congressional 
mandate, so VA put a very short tenure on the committee of 18 months 
and then set it with ringers that would not oppose VA openly. The 
chairman waited till enough time had passed, and then mocked many of my 
issues - mostly the issue of 3.317. The very term UDX / MCI which VA 
showed was easily dismissible due to its title. When I pushed, I was 
shut down for ``telling VA how to suck eggs''.
    In 2008 the final report was not what I wanted, and it had taken a 
unpleasant turn groveling to the PDICI that Dr. Stephen Hunt headed up. 
The Post Deployment Initiative Care program was a scam, it was a 
psychiatric clinic looking for somatic issues which made me a instant 
critic. Enough so to I dissented on the committees final report, and 
make me a pariah in the VSO circles. Only to find out later the Gulf 
War Illness Task force had secret meetings at VA endorsing Dr. Hunt, 
and making none of this public for others to keep track of. The 
committee, and its report was all but hidden from the public. My letter 
of dissent never published by them on the page, and VA did its very 
best the last 9 years to pretend it never existed.
    The end result to all this is at the anniversary of the Gulf War 25 
years later, you cant even get a claim processed if you file under 
3.317 and you certainly have no where to go that isn't disposable or 
secretive. The WRIISC serves no value, and is nothing like what it was 
intended yet its massive and secretly funded between its locations. The 
funding diverted to ``Deployment Health'' projects and a less than 
savory person who stays with that behind the scenes to keep it going 
for her DOD comrades. All the while supporting a program in Seattle 
Washington that the vets have grown to despise.
    Everything about this is vile, to include the fact that 6 million 
records held by OSAGWI that should have been released last year are not 
going to made public any time soon. That 25 years after the war, NARA 
is going to keep these records beyond allotted storage time because of 
exclusion clauses towards ``Weapons of Mass Destruction'' and such. Of 
which 1.7 million are medically relevant to Gulf War veteran claims.
    What we need is a revision of Gulf War Public Laws, and a 
consolidation of the intent without having to recreate all this from 
scratch. That we need a 20 year review of how and what failed, and what 
can be repurposed. We also need to change CFR 3.317 and get rid to the 
bottleneck terminology that keeps it a obstacle. Get rid of terms like 
MCI and UDX that have no unique ICD 9, and link this to service, time, 
region just like VA spells out on its VA Gulf War web page.
    PL 105-368 is now a very flawed law that VA abuses in many ways. 
Its given them funding, leverage, and the ability to wait vets out on 
time. Its in desperate need of revision to not only make it more 
current, but get rid of the bastardization such as the WRIISC that 
insult its very purpose. To scale back, bring it all under one roof, 
and make it veteran friendly, and always visible. Getting away from the 
white washing terms of ``deployment health'' and start addressing the 
specifics VA wants to ignore. Make this very specific and ongoing for 
GW vets that need specialized long term follow-up such as myself.
    I apologize for the condensed format and seemingly vague points in 
this letter. What I really want to write is hundred of pages of extreme 
details since 1998 that would show a pattern. So if I dont keep this 
short, I loose the crowd to nap time. It is my wish that this be 
followed up, and that my committee also be reinstated in some other 
format with no termination date to deal with healthcare and benefits. 
Leave the defunct current RAC to not have to violate its charter. That 
3.317 is a dysfunctional code starting with its very
    terminology. That after 25 years we need to get this back on track 
to serve what little time I and my fellow vets have. As my own time is 
running out soon.
    Thank you for your time and consideration. Have good day.

    Sincerely

    Kirt P. love
    Director, DSBR
    Former member VA ACGWV

                                 
        Montra Denise Nichols, MAJ, RET, USAF, RN RET, BSN, MSN
            National Vietnam and Gulf War Veterans Coalition
    I am Montra Denise Nichols a Desert Storm Veteran and Gulf War 
Illnesses Advocate from 1992-2017 and giving testimony which gives the 
overview of the problem with gulf war illnesses claims. In order to 
cover this issue, one must understand it starts with when you walk in 
the door at VA seeking care and help. Our issue started with changes in 
our health and then progresses to benefits i.e. claims for compensation 
and answers and treatment which is now being found in research.
    Since 1991 when we return from our service in Desert Storm, our 
group of veterans have been suffering without adequate health care and 
effective claims service. This has continue for going into our 26 year 
of returning home despite hearings, legislation, advisory committee on 
benefits, advisory committee on gulf war illness research, IOM 
contracted studies, GAO studies, countless committee hearings, 
countless meetings and task forces, and legislative actions leading to 
public laws but here we are still feeling as though nothing has 
changed! It appears DOD has not totally been forth coming to help and 
VA care and benefits has us feeling like third class citizens. Many 
have tried, many have given up, many have died in a younger age group 
than should have normally occurred to a group of service members that 
went into service fully healthy and accepted physically the only 
intervening factor was our service in a war theater during Desert 
Storm. Many years ago we had a law put in place to cover the 
undiagnosed illness, the chronic multi-symptom illnesses, chronic 
fatigue syndrome, fibromyalgia, Irritable bowel syndrome and numerous 
other health complaints as presumptive conditions. Still after all 
these years the VA Benefits, Compensation and Claims process is broken 
as each GAO study has documented. Others today in person and in written 
for the record testimony will discuss in detail with examples given 
from members of our community of veterans.
    But in order to really understand the problem I believe you need an 
overview of the total problem that we Desert Storm Veterans have 
experienced because it all ties together one leads and impacts the 
other area of the VA. We in our overall community believe our 
government we swore to defend has not lived up to the due care and 
benefits earned by the giving of our services and our very lives. TOO 
MANY of our fellow veterans have died prematurely from Cancers 
especially brain cancers, heart disease i.e. Myocardial infarcts, 
pulmonary embolisms, and neurological conditions none of these have 
been added as presumptive conditions. They have been left without 
adequate care, no compensation for them or their surviving spouses, 
they have become homeless, families have broken over the health and 
financial distress, and some have given up leading to suicides. All of 
this has happened due to all portions of our government failing us the 
veterans of Desert Storm. This is totally UNACCEPTABLE and must have 
immediate real action no more promises, no more words, no more denial, 
no more ineffective responses, and no more excuses.
    Others today will testify in person and on submissions for the 
record on details of the claims for desert storm veterans situation I 
am here to provide a total overview of the problems that have occurred 
and the total interwoven situation from our service in theater to 
approaching the VA for care to seeking answers and effective, 
appropriate treatment, to getting research that should answer the 
physiological damage done and methods of real treatment, to how the 
total government system has failed, to how care and documentation from 
VA health has direct implications to our claims and benefits, and how 
legislative efforts have failed the Desert Storm Veterans. This has 
impacted 1/3 to + of us Desert Storm Veterans. Many veterans took the 
systems missteps and gave up. Many were suffering quietly having been 
trained not to be gold brickers and not to complain. They struggle 
valiantly and heroically to go on and try to reach their own personal 
professional goals and to maintain themselves and their families. They 
gutted up ignore the symptoms and did not want to appear weak. Those 
that spoke up or continued pushing faced huge odds against them. Many 
were left in the dark totally and did not know to question and keep 
seeking care and help. Most of all they wanted to live their lives and 
not to be disabled and warrant a compensation. Many wanted to stay for 
a full 20 years or more in military service to their country and hid 
their concerns in order to struggle on and serve in the intervening 
years and deployments into war time environments adding more exposures 
to their weakened physiological bodies.
    This whole situation starts with inadequate records, maintaining 
military active records from in theater, inadequate maintaining of logs 
from headquarters down to lowest level of units on location changes, 
vaccinations given, preventive medicines recorded in individual 
records, inadequate and erroneous measurement of exposures levels at 
multiple locations throughout the theater. Then inadequate 
documentation of medical concerns of the symptoms as they occurred both 
while on active duty status and upon leaving the service. The majority 
of troops were kept in the dark on information on exposures and what 
symptoms they needed to report i.e. any changes they had in pre-
deployment, deployment, redeployment home, and later throughout post-
deployment for 26 years.
    There was no SOPs to medical personnel to truly take complete 
physical history details, documenting locations and specifics of duty 
positions that may be factors to consider, no physical assessments were 
done completely in evaluation of exposures documented or undocumented, 
medical personnel were not educated on exposures potential or what 
symptoms to assess and report in medical records, vaccine records went 
missing, medical items were not documented, the standards and 
regulations of maintaining all documents from every level of command 
were neglected.
    Non-documented verbal directives seem quite realistically to have 
been given to turn a deaf and mute response to our concerns when we 
returned. Some doctors at the VA even said they could not help or their 
hands were tied. I know this lead to professional dissatisfaction to 
many of these health care providers. But MUM was the Standard operating 
procedure or else they were left totally uninformed due to the DOD 
actions. A few VA physicians and civilians researchers stood up for us 
since the beginning many were disciplined in many ways or found 
themselves out of jobs for speaking up.
    If they weren't told, or given written information, or given 
documentation from the DOD that VA accepted, or educated -then that was 
just it. WE as veterans would end up and continue to surmise the why. 
Was it money, budget, cover, negligence, geopolitical, personal 
reputations of our leaders, politics, just ignorance, or blind 
obedience to orders not valuing the service members health and 
wellbeing, or even our commanders in the field and supervisory ranks 
also affected by the ill effects of exposures that their abilities and 
common sense were affected and degraded their leadership and 
responsibility to their troops.
    Have no doubt they have suffered for 26 years now. They have been 
treated with no honor, no care, no celebration of their service. They 
have been treated as third class citizens not as valued service members 
and war time veterans. Their service is forgotten in every national 
veterans ceremony or memorial day ceremonies.
    Another factor is inadequate education and knowledge to health care 
providers both military, VA, and civilians in regards to each exposure 
or multiple exposures with synergistic and overlaying physical damage. 
( whether documented and acknowledged by DOD or not!) None of the 
doctors and health care providers have ever had education in medical 
schools, internships, residencies, continuing medical education, or 
medical conferences, or in VA employment as mandatory training on our 
exposures or the greater area of military toxic materials and the 
effects thereof to physiological body systems. The majority of health 
care providers are whole fully uneducated on even our presumptive 
conditions of chronic fatigue syndrome, fibromyalgia, Irritable bowel 
syndrome, or the mirage of our other health problems listed under ill 
defined chronic multi-symptom or un-diagnosable conditions. WE still 
get health care providers that get that look like a deer in the 
headlights, or how fast can They turf this to mental health and 
behavior medicine, or how can I avoid the veterans questions, or avoid 
real concerns, or avoid the good patient doctor communications, or how 
fast can I get them out the door. WE take in research articles and 
reports to help give them the info and tools but they are too busy and 
not required to receive and read and question. They do not even to seem 
to know what information is available if they pull up VA gulf war 
health, WRIISC, VA RAC GWIR, gulf war public health information on the 
computer sitting in front of them. They just follow the template as 
provided by VA on medical documentation for a health visit.
    The battle on a term for diagnosis for us and definition has been 
talked about for 26 years! Name it gulf war Illnesses or military 
toxics conditions define it by symptoms and findings so far in research 
and give it a code and use the code! Quit running around in circles and 
in the process denying our physiologic changes and symptoms and denying 
claims for whatever purpose or reasons. You disrespect the veterans 
service totally and do not give the veterans any benefit of doubt that 
was caused by all the factors I am covering in this testimony. You 
Dishonor our service and sacrifices. You do not give due trust in the 
honesty of each veteran. A result of that loss of trust it leads to 
future generations of civilians questioning joining the military if 
their health and lives are not protected and given full priority 
attention and benefit of the doubt!
    The first step was a Gulf War Registry that became a rushed 
questionnaire and very brief physical with very little physical 
assessment except yep breathing, pulse, Bp. No full physical, no 
complete detail history taking, no documentation of what the job was 
that the veteran did and what exposures needed to be documented i.e. 
fuels, tanks, flight duties, sanitation practice, noise levels exposed 
to, medicines, vaccines given in theater, where were they located from 
entrance to exit from theater, what unit and type of unit, what did 
they handle, did they handle dead bodies or injured EPWs or friendly 
casualties, or casualties showing symptoms, what symptoms no mater how 
slight occurred and when, what did they take note of in theater?, what 
did they observe as strange, what has changed head to toe.
    No neurological exam, no follow on consults re sleep study, no 
referral to dermatology for skin samples are just a few examples. No 
history taking on changes noted in memory, multitasking, comprehension, 
executive management tasking, change of IQ, school or duty performance 
impacts. They did not document exposures to oil fires smoke and follow 
up with complete respiratory function test and challenge substance 
respiratory functions. No EEGs, EMG, no assessments by specialties like 
immunology, endocrinology, infectious diseases, otologist(hearing) 
testing, no visual acuity testing were some of the items neglected.
    If you are going to do a registry then a full, complete, through 
history, complete physical, complete testing of blood hematological, 
immune factor, neurological transmitters testing, virus, infectious 
testing, viral testing, testing for endemic diseases, complete urine 
testing for Depleted uranium, metals and known toxins like a forensic 
toxicology screen must be done.
    These tests are needed in relation to confirmed, suspected, or 
unknown toxins.
    The registry records were never maintained from the start and data 
collection has been missing.
    The early specialty centers set up for gulf war veterans by the VA, 
the early CCEEP by the military, and the follow on VA WRIISC were more 
complete in this aspect but the majority of veterans who had symptoms 
were not able to obtain these services. These services would have 
provided much more in depth evaluations and testing and medical reports 
to assist in the later application for claims and compensation from the 
start.
    The health care within the VA for Gulf war illness and exposure 
assessment and medical reports is totally lacking on the physical 
symptoms and changes that occur after exposures to any military toxic 
exposures. The difficulty experienced in getting the diagnoses of 
Chronic Fatigue Syndrome, fibromyalgia, and irritable bowel syndrome 
that are so prevalent much less the other complaints and symptoms 
addressed in the regulations is another problem that has not been 
solved. Again the Doctors and health care professionals in the 
military, VA, and civilian health care areas do not receive education, 
continuing medical education, and training in military toxins. I wonder 
why when service members receive training in NBC why is the medical 
profession so lacking in knowledge? This is not covered in curriculums 
for medical schools, internships, or residencies.
    The total emphasis on claims should be focused on Desert Storm 
Veterans and gulf war illnesses because we happened prior to 911, OIF, 
OEF, etc, or the world trade center exposures. WE have waited too long! 
Where was the preparedness planning for medical professions? What if 
this happened within the continental US with massive civilians exposed? 
Would the medical professionals know what to do?
    In the GAO reports they state 1.1 million claims and 40% with 
claims. How many of those are Desert Storm Veterans? Many Desert Storm 
veterans were also Vietnam Era and mistakenly listed under Agent 
Orange, yes we have documented cases of that too! And why does the GAO 
not include every VARO in their reviews why only a small number of 
VAROs are reviewed to get a really complete review? Why not pick out 
those with high rates of approvals and find out the best practices?
    Without adequate Gulf War Registry Exams and with VA uneducated 
health care providers providing our health care then adequate medical 
records and medical progress notes and medical testing is interwown in 
the failure of successful claims adjudications ! The proof is in the 
medical records, progress notes, diagnoses lists, medications list, 
laboratory studies. Without proper mandatory training, education , CME 
and credentialing and Standard Procedures(SOP), standing orders it was 
destined to fail us the veterans in our claims process. The 
requirements of proof and documentation is the necessary steps for a 
successful claim. WE can not meet the requirements needed when we deal 
with VA Benefits/Claims.
    Without the right credentialed specialists Drs it is next to 
impossible to get the presumptive conditions diagnosed. Then the VA 
thru the Choice or fee basis programs for Desert Storm Veterans to get 
to experts in the civilian medical profession does not work. When the 
Desert Storm Veterans do go on their own expense to civilian experts 
i.e. Rheumatology, Immunology, Dermatology, Neurologist, Endocrinology 
with definite expertise and credentialed by specialty boards then the C 
and P examiners and VA adjudicators ignore these experts diagnoses, 
history, medical testing, and DBQs. The doctors at the VA may diagnose 
but out right refuse to fill out DBQs for the veterans to help aid in 
the claims process.
    The medical providers, C and P examiners, and VA adjudicators need 
mandatory and credential training to handle Desert Storm/Gulf War 
illness/ military toxins issues. We were told by VA headquarters 
personnel that all the adjudicators and examiners would receive 
mandatory training! They lied to several of us. The GAO study proves 
that fact!
    The WRIISC staff at Palo Alto has done some clinician training both 
in person and by web training. How many no one seems to have a full 
data collection on that aspect. This has been a very small number I am 
sure. Again No mandatory education has been done! The scheduled session 
by phone and computer web is not known about at all by medical 
professionals at each VA hospital much less the clinics. The VA care 
providers have no knowledge on what WRIISC is, what they provide, how 
to make referrals, how to find all the basic educational materials and 
brochures, pamphlets, newsletters, magazines that the WRIISC have 
developed. These materials are seldom if ever seen in the VA Waiting 
Rooms or Doctors offices! The veterans get educated by other veterans 
of where to find these materials and they hand carry the info to their 
doctors. Then if they are lucky and do get referred the doctors at 
their home VA have problems with follow thru with the results and 
suggested plan of care. Again the documentation by WRIISC can help 
significantly in the success of claims being approved due to their 
documentation.
    The VA RAC GWIRP since the turn over of committee members started 
under Secretary Shinseki, then McDonald has deteriorated that advisory 
group. The Presentations are not 100% applicable to what the mission of 
the RAC is. There are no short term and long term goals for each 
presentation made to the VA RAC GWIR. The RAC went to San Francisco a 
year ago but did not seek a presentation by Dr Golumb at UCSD and VA SD 
who is a prior committee member and gulf war illness funded researcher! 
When they went to Boston on their last meeting the funded DOD GWIRP 
Researchers at BU and Mass General were not invited to present past and 
current research findings on GWI.
    Personally, I have communicated in writing and verbally at each 
meeting and to their staff coordinator the shortfalls of the RAC as the 
veterans see them. They do not provide full interactive video 
conferencing of their sessions. The example role model would be the HHS 
Civilian CFS/ME Research Advisory Committee which has excellent web 
based audio visual interactive meetings. They do not provide printed 
notebook materials for the attendees to reference even on a back table.
    I have suggested and encourage the committee to consider and use VA 
facilities auditoriums like at Minneapolis VA where we have had MEG 
research studies done and hyper coagulation research and a treatment 
trial occurring! I suggested using Miami VA or the medical universities 
there to have DR Klimas and Roskamp Institute to review their funded 
gulf war illness research that is finished and ongoing. But no to that 
too. Then there is a Stanford University Researcher expert in civilian 
CFS/ME research and now funded at University of Alabama Birmingham for 
a gulf war treatment trial research. Then there is Salt Lake City VA 
funded studies on treatment trials for IBS. Then there is the gulf war 
illnesses researcher at Georgetown Medical University here in DC 
another expert in civilian CFS/ME that I recruited who has had funded 
GWIR studies on MRI DT, Spinal Proteomics who has not been invited to 
present to VA RAC GWIR when in DC for their meeting.
    Why are we not using VA hospital auditorium and the Medical 
Universities that are directly involved with VA hospitals as facilities 
for these RAC meetings. Certainly it would help cost wise much less 
drawn in more experts in the Medical Universities and their students! 
WE need the different locations throughout the country utilized so more 
veterans, Drs, researchers, and medical universities can be involved to 
further research and get answers and help to Desert Storm veterans. I 
would give the VA RAC GWIR at D in grade. All of us that fought for the 
introduction and passage of the law for the VA RAC GWIR and served as 
members of the committee or as attendees to the meetings have been 
distressed by its decline in productive goal and mission directed 
fulfillment. WE need a new RAC on a different set up model and covering 
military toxic exposures.
    The VA is still looking at our gulf war illnesses as a 
psychological and Behavior Problem or Mental health problem. They are 
treating with anti-depression medications and psychological 
medications. Many of these have side effects impacting further our 
immune system of the body. They frequently are using multiple anti-
depressant drugs at a time for a patient. And to use these drugs as 
pain control is not appropriate. Some of our Desert Storm veterans have 
been diagnosed with bipolar disease but never evaluated by MRI DT or 
MEG or other advanced neurological techniques. Is it possible that they 
have been misdiagnosed?
    Genomics is what is needed NOW. That is the direction we are headed 
in many areas of medicine to include Gulf War illnesses. Dr Klimas, 
Golumb, DR Baranuck(Georgetown) and the researchers at Minneapolis are 
headed now in that direction! The VA MVP could recruit more Desert 
Storm Veterans rapidly and make that a priority now on GWI. Then we can 
rapidly move to individualized genomic treatment and in the process 
have more definitive evidence for the claims proof.
    Serotonin and neurotransmitters have not been tested on Desert 
Storm veterans that would provide more definitive proof of 
physiological damage and symptoms of gulf war illnesses. Again this 
would provide more definitive proof for claims to be approved. Dr Terry 
at the VA has mention the neurotransmitters as being key to Gulf War 
illness but no testing or data is available because that has not been 
done.
    Again, areas that could provide proof of exposures and 
physiological damage that could help with diagnose, proof for claims, 
and treatment avenues has not been meeting the urgent need. The other 
is that of biomarkers coming from the animal models and correlated with 
biomarkers from a small sample size of ill Desert Storm veterans that 
matched! Again proof from the desert storm veterans physical bodies 
that show exposures and proof that could be used individually in claims 
or by extending the benefit of the doubt rule. These developments in 
biomarkers and genomics can lead to true treatment of Desert Storm 
veterans.
    There has been a lack of coalition forces' governments to interact 
in solving the medical problems and compensation issues. WE had UK 
veterans attend RAC meetings to take an active role by fellow Desert 
Storm veterans to set an example for the RAC but so far no action taken 
by the RAC to seek out known experts in coalition countries.
    There needs to be an urgent priority by all entities in the US 
government from legislative branch, to health care VA and Civilians, to 
researchers, and to VA Adjudicates on the Gulf War illnesses. WE have 
not learned from the past of WWI, Atomic Veterans, Agent Orange 
Veterans, Gulf War Illnesses Veterans, the WTC contaminated responders, 
Camp Lejune Environmental exposures, Pesticide exposed agriculture 
workers, and other toxic environmentally contaminated military bases. 
There has been no Standardized Operating Procedures, standing medical 
orders, regulations, education, training, credentialing of all that 
were needed to be involved. Failures in the areas of documentation, 
tracking mechanisms, effective leadership and management at all levels 
that have direct impact on the effectiveness of claims adjudication and 
thus failure approval of claims at a higher percentage.
    Who is hurt most? The Veterans! It has been evidence that 26 yrs of 
effort has failed not only in health care documentation but equally 
assuring the claims process is fair, rapid, and effective to serve tens 
of thousand, even hundred of thousands of Desert Storm Veterans.
    WE need Toxic Exposure centers in each region of the country 
located close to VAROs. If doctors give a presumptive diagnosis there 
is no excuse for denial of the claim!
    It seems to all of us Desert Storm veterans that it is the saying: 
Same ##### Different Day. What is need is SOPs, Leadership, Expertise, 
Outstanding Management, Creative thinkers and researchers to truly be 
effective and solve the problems for Desert Storm Veterans with Gulf 
War Illnesses.
    Enough delay has occurred!
    WE hold all US Representatives, Senators, DOD officials, VA 
officials from every VA area, VA Headquarters, VA administrators, each 
VA hospital administrator, chief of medical staff, VARO director, and 
VA claims adjudicators, each committee or entity that has been involved 
as failing to provide for the health and well being in all ways to 
those Desert Storm Veteran dealing with Gulf War illnesses both with 
presumptive categories and yet to come the diagnosable illnesses/
diseases that are leading to early age based diseases death rates.
    I say again it is all interconnected and interwoven failures that 
have led to the extremely high denial of claims for Gulf War Illnesses 
and to correct this problem all areas have to be reviewed and revamped 
now. I hope my testimony offers you the overview of the interconnected 
failures. One of the reasons I pushed to cover the overview is because 
US Representatives and Senators change every election cycle and many 
elected after 1991 do not have the institutional knowledge of the 
problems and delays we have faced. New doctors and health professionals 
enter the profession, the military, and the VA constantly and are not 
aware. New VA claims adjudicators and new C and P examiners get hired 
without adequate or mandatory training.
    WE need new legislation and laws now. No more delays fix this 
problem as the highest priority that it truly deserves.
    Look at our past lessons in exposures in war and compare 
presumptives by war and exposure similarities and really look to the 
urgent need to add Brain Cancers, other cancers, myocardial 
infarctions, pulmonary emboli , hyper coagulation resulting 
connections, neurological diagnoses, immune-endocrine related 
diagnoses, Parkinsons Disease, early appearing Althemizers Disease,, 
and many other diagnosed conditions.
    It is wrong to deny claims and leading to widows and widowers left 
high and dry after living thru their veterans deterioration and deaths. 
We veterans know each other and see those left with nothing due to 
serving this nation and having one of those life altering diagnosed 
illness in too early of an age group compared to like population of 
civilians at different age ranges. Maybe review the 911 workers at the 
World Trade center program and legislation as a model to follow.

                                 
                        Questions For The Record

                               HVAC to VA
    1. An analysis of data in the GAO's report shows that the grant 
rates for undiagnosed illness (UDX) claims are lower than for chronic 
multi-symptom illness (CMI) in most regional offices.
    a.Why is the grant rate for UDX claims below 10% at approximately 
half of the regional offices?

    VA Response: When comparing approval rate data between regional 
offices (RO), which GAO used in their study, it is not feasible to draw 
conclusions on the reasons for approval rates or any variations between 
ROs. As mentioned in the testimony, VA has conducted special-focused 
reviews of completed claims in the last 2 years, and the reviews showed 
94 percent and 89 percent accuracy rates. Further, the lower 
inventories of cases at certain offices also affect any comparative 
analyses conducted.
    When discussing approval rates, it is important to note, as the GAO 
report revealed, that Gulf War Illness claims have about twice as many 
medical issues per claim as other disability claims. Further, this 
category of Veterans has six conditions on average for which service 
connection has been awarded, which is more than any other era of 
Veterans.

    b.Does the grant rate at each regional office (RO) influence how 
work is assigned from the National Work Queue?

    VA Response: The grant rate at each RO does not influence how work 
is assigned by the National Work Queue.
    2. GAO's report showed that grant rates for Gulf War Illness (GWI) 
related medical issues varied across regional offices, from 0 to 64 
percent for medical unexplained chronic multi-symptom illness (MUCMI) 
issues and from 0 to 49 percent for UDX issues. Please explain the 
variation in grant rates among regional offices?

    VA Response: Please see response to Question 1(a).
    3. GAO's report noted that the grant rates of the oldest types of 
GWI related medical issues, UDX and MUCMI, have declined from 2010 to 
2015. Similarly, the 2015 grant rate for UDX is approximately 10% 
according to GAO. Why are the grant rates for these types of GWI-
related medical issues declining?

    VA Response: Based on VA's analysis of data, to include fiscal year 
(FY) 2016 data (which was not included in GAO's analysis), there is not 
a trending decline in grant rates for UDX and/or MUCMI claims. In fact, 
as noted in our testimony, 4,594 out of 18,681 Veterans were awarded 
service connection for one or more UDX or MUCMI conditions in FY 2016. 
This equates to a 25 percent approval rate, which is an increase from 
the 22 percent approval rate in FY 2015. When analyzing only UDX 
claims, VA's approval rate in FY 2016 was 13 percent compared to 12 
percent in FY 2015. For MUCMI's, the approval rate in FY 2016 was 31 
percent versus 29 percent in FY 2015.
    4. How much of the appeals backlog was the result of VA denials of 
GWI claims during the period reviewed by GAO, 2010-2015?

 
------------------------------------------------------------------------
            Fiscal Year                    GWI Appeals Established
------------------------------------------------------------------------
                   2010                                  162
------------------------------------------------------------------------
                   2011                                  160
------------------------------------------------------------------------
                   2012                                  151
------------------------------------------------------------------------
                   2013                                  125
------------------------------------------------------------------------
                   2014                                  205
------------------------------------------------------------------------
                   2015                                  356
------------------------------------------------------------------------

    a. How many GWI-related medical issues are currently in the appeals 
process?

    VA Response:
    Number of GWI issues on pending GWI appeals (as of 7/31/2017):

 
------------------------------------------------------------------------
         Number of Appeals                     GWI Issue Count
------------------------------------------------------------------------
                  1,242                                2,513
------------------------------------------------------------------------

    5. What is the grant rate of appeals filed by Gulf War veterans 
whose initial claim was denied?

    VA Response:
    Number of Grants (VBA and BVA), and Total Decisions (Grants, 
Denials, Appellant Satisfied with Decision, Remands, Withdrawn, 
Dismissed, Vacated)

 
------------------------------------------------------------------------
   Fiscal Year      Appeals Granted    Total Decisions     Grant Rate
------------------------------------------------------------------------
          2010                118               348             33.9%
------------------------------------------------------------------------
          2011                 90               259             34.7%
------------------------------------------------------------------------
          2012                 86               259             33.2%
------------------------------------------------------------------------
          2013                 86               274             31.4%
------------------------------------------------------------------------
          2014                 66               258             25.6%
------------------------------------------------------------------------
          2015                108               271             39.9%
------------------------------------------------------------------------
     2010-2015                554             1,669             33.2%
------------------------------------------------------------------------

    a. Does VBA track the number of appeals per veteran?

    VA Response: Yes.
    NODs Established (2010-2015):

 
------------------------------------------------------------------------
       Appeals per Appellant                 Number of Appellants
------------------------------------------------------------------------
                      1                                1,131
------------------------------------------------------------------------
                      2                                   14
------------------------------------------------------------------------

    Appeals Pending (7/31/2017):

 
------------------------------------------------------------------------
       Appeals per Appellant                 Number of Appellants
------------------------------------------------------------------------
                      1                                1,196
------------------------------------------------------------------------
                      2                                   20
------------------------------------------------------------------------
                      3                                    2
------------------------------------------------------------------------

    6. Given VA's research into a potential connection between brain 
cancer and service in the Persian Gulf War, is VA considering adding 
brain cancer as a presumptive condition for Gulf War Veterans?

    VA Response: Based on current science, VA has no immediate plans to 
pursue establishing presumptive service connection for brain cancer in 
Gulf War Veterans. VA will continue to review and evaluate any new 
science that might be sufficient to establish a presumption of service 
connection.
    a. If yes, what is the timeline and cost estimate?

    VA Response: N/A
    7. Given the complexity of Gulf War Illness-related claims and that 
only 10% of medical examiners had completed voluntary, supplemental 
training, what efforts are underway to make this training for medical 
examiners mandatory?

    VA Response: Currently, the Office of Disability and Medical 
Assessment (DMA) in conjunction with the Employee Education System 
(EES) has changed the status of the course to mandatory training for 
all Veterans Health Administration (VHA) clinicians who conduct 
compensation and pension (C&P) examinations.
    a. Are there any current proposals to make training mandatory?

    VA Response: All current VHA C&P examiners have been assigned a 
date of October 1, 2017, for mandatory completion of the training. The 
course is now a certification requirement for all new examiners before 
they can conduct C&P examinations. All VHA C&P examiners, regardless of 
what type of examinations they conduct, are now required to complete 
the ``DMA Gulf War Exam'' training.
    b. Is training mandatory for contract providers?

    VA Response: VHA does not currently have any contract staff 
performing C&P examinations. Historically, VHA contractors were 
excluded from conducting Gulf War examinations, thus the mandatory Gulf 
War training would not be applicable to them.
    c. How does VA plan to enforce compliance with training 
requirements?

    VA Response: VHA is monitoring and tracking the mandatory 
completion of the course through its C&P Certification Database; we are 
also working in concert with the Veterans Integrated Service Networks 
(VISN) and field facilities to ensure compliance with the established 
mandate to complete the training by October 1, 2017. EES is also 
providing assistance with compliance by requiring their Designated 
Learning Officers to assign this mandatory training to C&P providers in 
the field.
    8. GAO noted that MUCMI issues are only identified as being related 
to GWI if VBA employees identify them within a Veteran's claims file. 
Is VBA concerned that employees may not always accurately identify UDX 
and MUCMI claims, and what is being done to limit the effect of human 
error?

    VA Response: The Veterans Benefits Administration (VBA) has 
instructed field employees to carefully review claims and all other 
evidence of record to identify conditions for which service connection 
may be granted. This also includes reviewing the evidence of record to 
determine when and where a Veteran served, for example, because such 
service may warrant service connection on a presumptive basis. VA 
continues to improve its claims forms to solicit detailed information 
from the Veteran regarding his or her claim. In fact, VA is currently 
in the process of creating special environmental hazard form(s), which 
would allow employees to better identify claims related to Gulf War 
and/or other in-service hazards. VA Central Office will continue to 
provide information to the regional offices on various environmental 
hazards that may cause adverse health effects.
    9. What accountability measures should VA implement to ensure that 
claims from Gulf War Veterans are timely and accurately processed?

    VA Response: VA is committed to delivering benefits and services in 
a timely and accurate manner. This includes claims for disabilities 
received from Gulf War Veterans. The mandated training from and special 
reviews conducted by Central Office are examples of measures that will 
promote accuracy of processing and accountability in the field. VBA 
will continue these types of efforts, to include national and local 
quality reviews, which will ensure Gulf War Veterans receive a higher 
quality decision. In addition, VA Central Office will be mandating 
training for VHA examiners in response to the GAO recommendation. This 
measure will enhance the quality of examinations conducted for Gulf War 
Veterans.
    Additionally, in May 2016, VBA implemented the National Work Queue 
(NWQ), which allows VBA to prioritize and distribute claim inventory 
according to RO capacity to address each Veteran or claimant's claim 
based on date of receipt. This new functionality improves processing 
times by allowing VBA to assign the next right case for action by 
matching claims to available capacity; reducing the overall amount of 
time claimants wait to receive a decision on their claims.
    10. GAO reported that from 1994 to 2015, VA spent more than $160 
million dollars on research related to GWI, with two offices focused on 
VA GWI research. Please explain the reason VA has not yet adopted a 
single case definition for Gulf War Illness.

    VA Response: In 2014, after a year-long review, the Institute of 
Medicine (now National Academy of Medicine (NAM)) released a report on 
a case definition and Chronic Multi-symptom Illness, but could not 
decide on a single definition and recommended instead two research 
based definitions known as the Centers for Disease Control and the 
Kansas definitions. These definitions are difficult to use clinically 
or for benefits determinations. During that same year, a VA-Department 
of Defense (DoD) workgroup adopted a definition for their Clinical 
Practice Guidelines, but this definition was not research based or 
validated through research in clinical practice. Currently, VA is 
engaged in efforts to design a case definition that is explained below.
    a. Who is responsible for prioritizing VA's research program?

    VA Response: There are many entities that decide on research 
priorities.
    VHA's Office of Research and Development (ORD) provides research 
funds to investigators at VA medical centers, and the priorities for 
Gulf War research projects in ORD are described in the Gulf War 
Research Strategic Plan (https://www.research.va.gov/pubs/docs/
GWResearch-StrategicPlan.pdf). The strategic plan was developed by ORD 
with input from external advisory committees and internal experts. The 
highest priority is given to projects that deal with treatments and 
laboratory tests that could be used for diagnosing the condition. Each 
proposed research project is evaluated for scientific merit by a panel 
of subject matter experts (physicians and scientists) before a funding 
decision is made.
    b. Explain if and when VA plans to create a consensus, evidence-
based case definition for Gulf War Illness.

    VA Response: VA, in collaboration with DoD experts, is currently 
engaged in a concerted effort to develop a plan for an evidence-based 
consensus definition that could be used in the clinical setting, but 
would be validated by research as well. The effort includes a thorough 
search of the literature and expert deliberations using various subject 
matter experts and VA and DoD collaborators, including the 
Congressionally Directed Medical Research Programs and the Naval Health 
Research Center. The workgroup is targeting this effort to be done by 
March 31, 2018.
    11. Based on testimony received in connection to the hearing, how 
might VA's alleged lack of GWI-related research impact the current 
generation of Iraq and Afghanistan Veterans?

    VA Response: VA continues to perform and to fund GWI related 
research. This research will provide benefit to Veterans of more recent 
conflicts. As an example, VA is funding a special volume on Gulf War 
and Health by NAM to review possible intergenerational effects of 
various toxic exposures. Although the contract specifies this is 
targeting the first Gulf War, VA has encouraged the Committee to think 
broadly so that the findings might translate to the newer conflicts as 
well. Also, VA has the three War Related Illness and Injury Study 
Center sites (WRIISC-DC, CA, NJ) that fall under the Post Deployment 
Health Service. These specialty sites are doing research on health 
effects that translate across conflicts. Post Deployment Health 
Services currently has five Gulf War related research studies in 
progress.
    12. VA's testimony stated that VBA works with VHA and the DOD in 
joint work groups that address occupational and environmental hazards 
related to military service.
    a. When did these work groups begin?

    VA Response: The joint DoD/VA Deployment Health Work Group (DHWG) 
met for the first time in January 2003. DHWG reports directly to the 
joint DoD/VA Health Executive Council.
    b. How often do they meet?

    VA Response: The Work Group meets monthly and is made up of 
representatives from VBA/VHA/DOD Defense Health Headquarters and the 
Uniformed Services.
    c. What are some of the goals for these work groups?

    VA Response: DoD/VA DHWG was established to ensure coordination and 
collaboration to maintain, protect, and preserve the health of Armed 
Forces personnel. In order to improve force health protection efforts, 
DHWG focuses on the health of active-duty members, Veterans, and their 
families during and after combat operations and other deployments. 
Initially, the primary focus was on Service members returning from 
Operations Iraqi Freedom and Enduring Freedom. In addition, DHWG 
coordinates initiatives related to Veterans of all eras, going back to 
the 1940s. DoD and VA share information and resources in the areas of 
deployment health surveillance, assessment, follow-up medical care, 
health risk communication, and research.
    d. How do these groups and VA in general, track and record 
environmental exposure for the current generation of service members?

    VA Response: A millennium cohort study began in 2001 and will 
continue until 2022. Launched in the summer of 2001, the Millennium 
Cohort Study began enrolling a representative sample of US military 
personnel, both active duty and Reserve/Guard members, who agreed to 
participate in follow-up well past their time in service, for up to 21 
years. All participants provide important information on exposures and 
health through and beyond their time in service. Information is 
maintained confidentially and securely. The Millennium Cohort Study was 
designed to conclude in 2022.
    13. How many registries does VA maintain related to deployment and 
environmental exposure?

    VA Response: VA has six Congressionally-mandated registries.
    a. How are these records being used to improve the diagnosis and 
treatment of deployment related conditions?

    VA Response: VA and collaborators have built cohorts for research 
using these registries. However, a more important aspect of these 
registries is that they enable VA to provide clinical care, education 
as to issues that may arise, and assessments to Veterans. Examples are 
the Toxic Embedded Fragment Surveillance Center Program that does 
thorough workups on affected Veterans, and the Gulf War and Agent 
Orange Registries. Veterans benefit from a discussion of the results of 
their exams, specialty clinical consultations, and examinations when 
necessary. VA has a current multi-year, multimillion dollar effort to 
improve the utility of the registries and improve the data utility. 
Finally, VA has a concerted effort underway to train providers and 
environmental health coordinators on various aspects of environmental 
exposures and conducted several trainings and outreach. The newest 
registry, the Airborne Hazards and Open Burn Pit Registry is providing 
a service to both Veterans of the first Gulf War and also Veterans of 
the more recent conflicts in that area.
    Registries are self-reported ``opt-in'' lists, and these attributes 
have significant limitations for research. The Individual Longitudinal 
Exposure Record (ILER) may correct that concern. ILER is a VA/DoD 
effort funded with Joint Incentive Funding to develop an automatic 
recording of exposures from the time a person enters military service 
until discharge or retirement. This would allow VA to place a person at 
a specific place and time and know what exposures and at what levels 
the Servicemember was exposed, rather than relying on best 
recollection. VA has recognized the need and a pilot will be delivered 
in summer 2018.
    b. Please provide a list of registries

    VA Response:

      Agent Orange Registry
      Airborne Hazards and Open Burn Pit Registry
      Gulf War Registry
      Ionizing Radiation Registry
      Depleted Uranium Follow-Up Program
      Toxic Embedded Fragment Surveillance Center

    14. Much of the data that GAO used to conduct the review is easily 
available within VA's Performance Analysis and Integrity unit, but it 
is not reported publicly and reportedly not provided to Veterans' 
Service Organizations (VSOs).
    a. Will VA publicly report this data on a quarterly basis?

    VA Response: VBA is not routinely reporting specific trend data 
about GWI claims as there have been no significant changes in recent 
years.
    b. Is VA routinely tracking and publishing trend data about the 
characteristics of GWI claims. If not, please explain why not.

    VA Response: VBA is not routinely reporting specific trend data 
about GWI claims as there have been no significant changes in recent 
years. Two studies into the rating characteristics of GWI claims have 
been conducted in the past few years. Copies are attached along with a 
spreadsheet that correlates to the December 2015 report. In addition, 
we have included a spreadsheet that shows the trends through July 2017 
for UDX and CMI decisions.
    15. The GAO report states: ``VBA Officials noted that it may be 
more useful to compare Gulf War Illness rates to those of presumptive 
disability claims, such as those for presumptive illnesses VA 
associates with exposure to Agent Orange during the Vietnam War. 
However, the data provided to us by VBA did not allow us to conduct 
this analysis.''
    Does this analysis exist in any VA internal or independent reports 
or reviews? If so, please provide a copy of all such reports and 
reviews. If not, please explain why not.

    VA Response: VA is not aware of this analysis existing in any 
internal or independent reports or reviews. VBA believes there may be 
something to be gleaned from a comparison of grant rates for 
presumptive diseases across different eras and such a study is planned 
when competing requests of higher priority have been satisfied.
    16. Please provide detailed information regarding the consistency 
study completed in April on referrals for medical examinations. Such 
information should include the following:
    a. How the study was conducted.
    b. The results of the study.
    c. The results of the study specific to Gulf War Illness claims.
    d. The steps VA has taken to correct any issues with referrals 
revealed in the study.

    VA Response: In April 2017, Compensation Service conducted two 
computer-based consistency studies on the Southwest Asia exam 
requirements. The Veterans Service Representative (VSR) pre-test was 
comprised of three scenario-based questions assessing the following 
objectives: determining when it is appropriate to request exams in 
claims based on Southwest Asia service; determining the language 
requirements for exam requests based on Southwest Asia service; and 
recognizing which exam Disability Benefits Questionnaire (DBQ) is 
required for Southwest Asia service conditions. The Rating VSR (RVSR) 
pre-test was comprised of eight scenario-based questions assessing the 
following objectives: determining when it is appropriate to request 
exams in claims based on Southwest Asia service; recognizing which exam 
DBQ is required for Southwest Asia service conditions; and determining 
whether the exam is sufficient for rating purposes in cases based on 
Southwest Asia service.
    Compensation Service requires that any consistency study 
participant who incorrectly answered one or more questions in the pre-
test take the computer based training along with the post-test 
associated with the subject of the study. Participants must correctly 
answer all questions on the post-test to complete the study and receive 
credit.
    All questions on both the April 2017 VSR and RVSR Consistency 
Studies assessed the participants' competency with the Southwest Asia 
Exam requirements. There were a total of 3,151 participants that 
completed the VSR pre-test with an average score of 43.2 percent. Of 
these participants, 10.2 percent of the participants answered all three 
pre-test questions correctly and received credit without needing to 
take the Southwest Asia Exam requirements computer based training or 
post-test. Those participants who incorrectly answered one or more 
questions on the pre-test were required to immediately take the 
computer based training on the Southwest Asia Exam Requirements and the 
post-test. Of the VSR study participants required to take the computer 
based training and the post-test, 35 percent answered all the post-test 
questions correctly on the first attempt.
    There were a total of 3,484 participants that completed the RVSR 
pre-test with an average score of 56.4 percent. Less than one percent 
of the participants answered all eight pre-test questions correctly. 
Those participants who incorrectly answered one or more questions on 
the pre-test were required to immediately take the computer based 
training on the Southwest Asia exam requirements and the post-test. Of 
the RVSR study participants required to take the computer based 
training and the post-test, 14 percent answered all the post-test 
questions correctly on the first attempt.
    Both studies had a training portion based on the questions from the 
tests.
    17. Please provide the number of appeals that were completed from 
fiscal years 2010 to 2015, disaggregated by FY, that were related to 
UDX or MUCMI claims.

    VA Response:

 
------------------------------------------------------------------------
            Fiscal Year                        Total Decisions
------------------------------------------------------------------------
                   2010                                  348
------------------------------------------------------------------------
                   2011                                  259
------------------------------------------------------------------------
                   2012                                  259
------------------------------------------------------------------------
                   2013                                  274
------------------------------------------------------------------------
                   2014                                  258
------------------------------------------------------------------------
                   2015                                  271
------------------------------------------------------------------------

    18. For such appeals from fiscal years 2010 to 2015, please provide 
the following information, disaggregated by each FY:
    a. How many appeals were completed during that time period?
    b. How many appeals were approved?
    c. How many appeals were denied?
    d. How many appeals were remanded?

    VA Response:

 
----------------------------------------------------------------------------------------------------------------
                                                                                      Veteran
  Fiscal Year    Total Decisions      Appeals     Appeals Denied      Appeals     Satisfied with       Other
                                      Granted                        Remanded        Decision*      Decisions**
----------------------------------------------------------------------------------------------------------------
         2010              348             118              30             117              59              24
----------------------------------------------------------------------------------------------------------------
         2011              259              90              21              91              35              22
----------------------------------------------------------------------------------------------------------------
         2012              259              86              22              84              42              25
----------------------------------------------------------------------------------------------------------------
         2013              274              86              24              86              50              28
----------------------------------------------------------------------------------------------------------------
         2014              258              66              24              74              66              28
----------------------------------------------------------------------------------------------------------------
         2015              271             108              15              63              68              17
----------------------------------------------------------------------------------------------------------------

    * Appellant Satisfied with the decision on the Statement of the 
Case
    ** Includes appeals Withdrawn, Dismissed, or Vacated